one - lung ventilation ( olv ) for thoracic surgical procedures is usually achieved with a double - lumen endobronchial tube ( dlt ) or a bronchial blocker . earlier on , some reports have described the use of bronchial blockers for providing olv in patients with restricted mouth opening . ours is probably the first case report where olv was provided with an arndt blocker positioned through a nasotracheal tube under fiberoptic bronchoscopy guidance in a patient with both upper and lower airway abnormalities , ie , restricted mouth opening , minimal neck extension , and a distorted tracheobronchial anatomy . a 17-year - old girl with severe kyphoscoliosis presented with breathlessness and productive cough of one week duration . she was referred to our institute as a case of non - resolving left pneumothorax . significant history included open heart surgery for ventricular septal defect closure at 4 years of age and spinal instrumentation for correction of kyphoscoliosis at the age of 15 years . on examination , she was emaciated , weighing 35 kg , and had severe thoracic kyphoscoliosis and generalized muscle wasting . airway evaluation revealed limited mouth opening with inter - incisor distance of 1 cm , mallampati score was iv , and atlanto - occipital joint extension was grade iv ( < 12 ) . chest radiography and computed tomography displayed a large pneumothorax with complete atelectasis of the left lung and airway distortion with deviated trachea and bilaterally narrowed bronchi [ figure 1 ] . chest radiography displaying a large pneumothorax with complete atelectasis of the left lung and airway distortion with deviated trachea and bilaterally narrowed bronchi despite conservative management for two weeks , which involved insertion of intercostal drains , there was no improvement in the left lung status . the possible aetiology for the non - resolving left pneumothorax was multiple bullae in a hypoplastic lung . the hypoplasia of the left lung was probably due to the spinal deformity that the patient had . due to the non - resolving nature of the left pneumothorax , an informed consent was obtained and the patient was taken up for a pleurectomy . in view of anticipated difficult airway access , an awake fiberoptic tracheal intubation was planned . after premedication with oral midazolam , under standard american society of anaesthesia ( asa ) monitoring guidelines , the right radial artery was cannulated under topical anesthesia for invasive arterial pressure monitoring . despite topicalization of the upper airways with local anesthetic , after further sedation with intravenous fentanyl ( 50 g ) and midazolam ( 1 mg ) , general anesthesia was induced with titrated concentrations of sevoflurane taking care to maintain spontaneous breathing . a lubricated nasopharyngeal airway was inserted in the left nostril to administer oxygen and sevoflurane . a 7.0-size cuffed endotracheal tube was successfully introduced into the patient 's trachea through the right nostril under the guidance of a 4.0-mm diameter fiberoptic scope ( lf-1 olympus ) . once airway control was achieved , a muscle relaxant ( cis - atracurium ) was administered . in view of distorted trachea & bronchi it was decided to use an endobronchial blocker for achieving olv as was the request from the surgical side . using the special multiport adaptor provided , a five - size arndt wire - guided endobronchial blocker ( cook , inc . , bloomington , in ) was introduced coaxially through the nasotracheal tube . under fiberoptic guidance , pressure control ventilation with positive end expiratory pressure ( 4 cm h2o ) and peak airway pressures up to 24 cm h2o were used throughout the surgery . inspired oxygen concentration ( fio2 ) and the respiratory rate were adjusted based on serial arterial blood gas analysis , pulse oximetry ( spo2 ) and end tidal carbon dioxide concentration ( etco2 ) values during both lung ventilation and olv . after completion of surgery , the blocker balloon was deflated and the left lung was expanded . the blocker was then removed with the nasotracheal tube left in situ . in view of the chest deformities and difficulties with airway access , the patient was gradually weaned off artificial ventilation after four hours of elective mechanical ventilation in the post - cardiothoracic surgery intensive care unit . postoperative analgesia was provided with fentanyl infusion and the patient 's trachea was extubated successfully with satisfactory arterial blood gases . serial chest radiographs showed good left lung expansion and , after an uneventful postoperative course , the patient was discharged home on seventh postoperative day . bronchial blockers have been used to achieve olv in patients with restricted mouth opening and in paediatric patients for scoliosis surgery . bronchial blockers have an established role in patients with abnormal tracheobronchial tree and requiring thoracic surgery . however , the successful use of an arndt bronchial blocker for the provision of olv in a patient with difficult both upper and lower airway access has not been described , thus making this case report novel . as described by several authors as the technique of choice , we also secured the patients airway with a single - lumen nasotracheal tube under fiberoptic bronchoscope guidance . we opted for fiberoptic bronchoscope  assisted nasotracheal intubation , as it conforms to the natural airway passages and is relatively easier than orotracheal intubation in patients with restricted mouth opening . once the patient 's trachea was intubated , lung separation was achieved with a bronchial blocker . in clinical practice we did not prefer a dlt in our patient due to the following reasons : 1 ) nasal intubation is not easy with a dlt due to its large outer diameter and the distal curvature . 2 ) in patients with a difficult airway ( mallampati grade view 3 or 4 ) , restricted mouth opening , limited neck extension , etc , it is difficult to place a dlt as it is bulkier and more rigid than a single - lumen endotracheal tube . 3 ) in our patient , there was , in addition , distortion of the tracheobronchial tree ; hence , placement of a dlt would have posed additional difficulties . 4 ) lastly , as we planned for postoperative mechanical ventilation , a bronchial blocker through an endotracheal tube was ideal . usually , a dlt needs to be exchanged for a single - lumen tube at the end of the procedure , if the patient requires postoperative ventilatory support . apart from being the technique of choice , the selection of a wire - guided arndt bronchial blocker was appropriate in this case , as there were additional advantages : the set has a special airway adaptor and ventilation is easily maintained during placement of the blocker . as the arndt blocker requires a single - lumen endotracheal tube , it is more convenient to use in a difficult airway scenario as it maximizes the cross - sectional diameter of the airway . nasotracheal intubation and a bronchial blocker , both of which are performed with the aid of a fiberoptic bronchoscope in patients with distorted upper and lower airway passages , appear to be the best option for achieving olv . this technique would be useful in clinical situations where placement of double lumen endotracheal tubes is technically impractical or impossible .
one - lung ventilation for a thoracotomy procedure was achieved with the help of a endobronchial blocker in a young girl with limited mouth opening , minimal neck extension , and a distorted tracheo - bronchial anatomy . 
 as the patient would not cooperate for an awake nasotracheal intubation despite adequate preperation , an inhalational anesthetic was used to make the patient unconscious , taking care that spontaneous breathing was maintained . 
 nasotracheal intubation was done with the help of a fiberoptic bronchoscope . 
 a wire - guided arndt endobronchial blocker was placed coaxially through the endotracheal tube using a fiberoptic bronchoscope . 
 this case report highlights that in a scenario of both upper and lower airway distortion , a bronchial blocker positioned through a nasotracheal tube under fiberoptic guidance might be the best option when one - lung ventilation is required .