A written consent was obtained from the patient for reporting this case and images.

A 52-year-old man (173 cm, 58 kg, BMI 19 kg m−2) with multiple giant bullae was scheduled for video-assisted pulmonary resections, because of repeated infection of the cysts. Preoperatively, chest radiography and computed tomography indicated a giant bulla in the left upper lobe, occupying the one-third of the left thoracic cavity, multiple bullae in the right upper lobe, and diffuse emphysematous changes of both lungs (Fig. 1). Respiratory function tests were within the normal limits, although the patient had shortness of breath during walking. He underwent resection of a right-sided giant emphysema 5 years ago.

Pre-operative chest radiography (a) showing bulla on the left side (arrows). Horizontal slice (b) and sagittal slice (c) of computed tomography showing bilateral diffuse emphysematous changes, multiple bullae in the right upper lobe, and a giant bulla, in the left upper lobe (arrows)

On arrival at the operating room, routine monitors, such as a non-invasive blood pressure cuff, an electrocardiogram, a pulse oximeter, and bispectral index monitor, were applied. Before induction of anesthesia, the blood pressure was 147 / 99 mmHg, heart rate 80 beats·min−1, and oxygen saturation 99% on room air.

After preoxygenation of the patient via a face mask for more than 3 min, anesthesia was induced with propofol at target concentrations of 3 µg·ml−1 using a target-controlled infusion pump (TE-371, Terumo, Tokyo, Japan), fentanyl 100 µg, remifentanil at 0.25 µg·kg−1·min−1, and rocuronium 50 mg. Mask ventilation was easy. After confirmation of neuromuscular blockade, a 37-Fr left-side double-lumen bronchial tube (ShileyTM endobronchial tube, Covidien Japan, Tokyo, Japan) was inserted with some difficulty, mainly due to limited mouth opening (Fig. 2). The patient was turned to the right decubitus position, and one-lung ventilation was started with the pressure-controlled ventilation, with the peak pressure of 14 cmH2O, PEEP 5 cmH2O (generating tidal volumes from 280 to 320 mL), inspiratory to expiratory (I:E) ratio: 1:1.5, and a fraction of inspired oxygen (FiO2) between 0.6 and 0.75. Anesthesia was maintained with continuous administration of propofol in the range of target concentrations of 2.5–2.7 µg·ml−1, remifentanil 0.15–0.25 µg·kg−1·min−1, and intermittent administration of fentanyl and rocuronium. Thoracoscopic left upper lobectomy and left pulmorrhaphy were performed without notable events.

A fiberoptic bronchoscopy passing through an i-gel™, which was inserted while a double-lumen tube is still in place in an anesthetized patient, the size 3 i-gel™ inserted behind a double-lumen bronchial tube a. The view of a fiberscope which was inserted to the i-gel™ b. The double-lumen tube (arrows) is being inserted between the vocal cords in the center of the screen, indicating that the i-gel™ is inserted to the correct position

Considering the possibility of air leakage from emphysematous lung tissues around the sutured areas and the fragility of the remaining lung tissues, the thoracic surgeons requested us to avoid increased airway pressure such as by straining or coughing as much as possible during emergence of anesthesia.