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The advantages of video assisted thoracoscopic surgery (VATS) in children have led to its increased usage over the years. VATS, however, requires an efficient technique for one lung ventilation. Today, there is an increasing interest in developing the technique for lung isolation to meet the anatomic and physiologic variations in infants and childr...
Citations
... In the conventional surgical repair of CoA without cardiopulmonary bypass (CPB), routine endotracheal intubation and bilateral lung ventilation are usually used, which affects the surgical field of vision, easily causes lung injury, and increases the incidence of postoperative atelectasis [4,5] . In recent years, bronchial blockade for single-lung ventilation (SLV) technology has been applied gradually, which can improve the operation field exposure and has no apparent influence on hemodynamics [6,7] . At present, there is no large sample studies about the application of bronchial blockade SLV in the surgical repair of CoA in infants without CPB. ...
Objective
To investigate the effect of improving the operative field and postoperative atelectasis of single-lung ventilation (SLV) in the surgical repair of coarctation of the aorta (CoA) in infants without the use of cardiopulmonary bypass (CPB).
Methods
This was a retrospective cohort study. The clinical data of 28 infants (aged 1 to 4 months, weighing between 4.2 and 6 kg) who underwent surgical repair of CoA without CPB from January 2019 to May 2022 were analyzed. Fourteen infants received SLV with a bronchial blocker (Group S), and the other 14 infants received routine endotracheal intubation and bilateral lung ventilation (Group R).
Results
In comparison to Group R, Group S exhibited improved exposure of the operative field, a lower postoperative atelectasis score (P<0.001), reduced prevalence of hypoxemia (P=0.01), and shorter durations of operation, mechanical ventilation, and ICU stay (P=0.01, P<0.001, P=0.03). There was no difference in preoperative information or perioperative respiratory and circulatory indicators before SLV, 10 minutes after SLV, and 10 minutes after the end of SLV between the two groups (P>0.05). Intraoperative bleeding, intraoperative positive end-expiratory pressure (PEEP), and systolic pressure gradient across the coarctation after operation were also not different between the two groups (P>0.05).
Conclusion
This study demonstrates that employing SLV with a bronchial blocker is consistent with enhanced operative field, reduced operation duration, lower prevalence of intraoperative hypoxemia, and fewer postoperative complications during the surgical repair of CoA in infants without the use of CPB.
... It is achieved with bronchial blockers, double-lumen endobronchial tubes (DLT), single-lumen endotracheal tubes (ETT), and the Univent tube for infants and children. [1] Fiber optic bronchoscope is required for placing and confirming the correct position of these tubes. The objective of this report is to describe perioperative management of safe conduct of one-lung ventilation with two endotracheal tubes to a child in limited resource settings where pediatric-sized fiber optic bronchoscope (FOB) is unavailable. ...
One-lung ventilation (OLV) is essential for adequate visualization and exposure of surgical site during thoracic surgery. It is achieved with bronchial blockers, double-lumen endobronchial tube (DLT), single-lumen endotracheal tubes (ETT), and the Univent tube for infants and children. Fibreoptic bronchoscope is required for placing and confirming the correct position of these tubes. The objective of this report is to describe a perioperative management of safe conduct of one lung ventilation with two endotracheal tubes to a child in limited resource settings where paediatric-sized fibreoptic bronchoscope (FOB) is unavailable.
... Children represent a unique cohort, because unlike in adults, approaches to one-lung ventilation will necessarily change with age and size. 7,8 Additionally, the type of pathology requiring thoracic surgical intervention also changes with increasing age, with the most common procedure in older children being treatment for spontaneous pneumothorax compared to very young children, in which the most common thoracic procedure remains the excision of sequestrations and/or other intrapulmonary lesions such as congenital pulmonary adenomatous malformations. 9,10 In school-age children, the most common approaches to one-lung ventilation continue to be use of a bronchial blocker, use of a double lumen endobronchial tube, and endobronchial intubation, although this likely becomes less common above 7 or 8 yr of age. ...
Background
Risk factors for hypoxemia in school age children undergoing one-lung ventilation remain poorly understood. We hypothesize that certain modifiable and non-modifiable factors may be associated with increased risk of hypoxemia in school age children undergoing one-lung ventilation and thoracic surgery.
Methods
The Multicenter Perioperative Outcomes Group database was queried for children 4 to 17 years of age undergoing one-lung ventilation. Patients undergoing vascular or cardiac procedures were excluded. The original cohort was divided into two cohorts: 4-9 and 10-17 years of age inclusive. All records were reviewed electronically for the primary outcome of hypoxemia during one-lung ventilation defined as an oxygen saturation (SpO2)<90% for≥3 minutes continuously and severe hypoxemia, SpO2<90% for ≥5 minutes. Potential modifiable and non-modifiable risk factors associated with these outcomes were evaluated using separate multivariable least absolute shrinkage and selection operator regression analyses for each cohort. Covariates evaluated included: age, extremes of weight, American Society of Anesthesiologists Physical Status≥3, duration of one-lung ventilation, preoperative SpO2<98%, approach to one lung ventilation, right operative side, video assisted thoracoscopic surgery, lower tidal volume ventilation defined as tidal volume≤6ml/kg + positive end expiratory pressure ≥ 4cmH2O >80% of the duration of one-lung ventilation, and procedure type.
Results
The prevalence of hypoxemia in the 4-9 and 10-17 year old cohorts was 24/228 (10.5%, 95%CI[6.5%-14.5%]) and 76/1012 (7.5%, 95%CI[5.9%-9.1%]) respectively. The prevalence of severe hypoxemia in both cohorts was 14/228 (6.1%, 95%CI[3.0%-9.3%]) and 47/1012 (4.6%, 95%CI[3.3%-5.8%]). Initial SpO2<98% was associated with hypoxemia in the 4-9 year old cohort, OR 4.20 [95%CI(1.61 - 6.29)]. Initial SpO2<98%, OR 2.76[95%CI(1.69-4.48)], extremes of weight, OR 2.18[95%CI(1.29-3.61)], right sided cases, OR 2.33[95%CI(1.41-3.92)], were associated with an increased risk of hypoxemia in the older cohort. Increasing age (1 year increment), OR 0.88[95%CI(0.80-0.97)] was associated with a decreased risk of hypoxemia.
Conclusion
An initial room air oxygen saturation <98% was associated with an increased risk of hypoxemia in all children 4-17 years of age. Extremes of weight, right sided cases, and decreasing age were associated with an increased risk of hypoxemia in children 10-17 years of age.
... DLV can be achieved with a double-lumen endotracheal tube in adult patients with atelectasis; however, the double-lumen catheter is too large to be used in infants and small children. The smallest available Rusch double-lumen catheter is 26 gauge, and it can only be applied in children over 8 years of age [10,11]. DLV is rarely used in pediatric patients, and therefore, reports of experiences with DLV in small children and infants are limited in the published literature [12]. ...
It is very difficult to perform differential lung ventilation (DLV) in children with unilateral atelectasis, especially small children. We aimed to introduce a novel technique, one-lung ventilation with a single-lumen tube with a side hole (SH-SL-OLV), to perform DLV in this setting. This retrospective, observational, and analytic study enrolled 21 children with unilateral atelectasis admitted to the PICU. The children were treated with one-lung ventilation with a single-lumen tube (SL-OLV) or SH-SL-OLV.A total of 8 children underwent 45 SL-OLV sessions, and 13 children underwent 23 SH-SL-OLV sessions. Before treatment, no significant between-group difference was present in FiO 2 , P/F ratio, and PCO 2 . However, during OLV, FiO 2 and PCO 2 were significantly lower, while the P/F ratio and the duration hours of OLV were significantly higher in the SH-SL-OLV group than in the SL-OLV group. SH-SL-OLV is an innovative technique for the treatment of unilateral atelectasis in children. SH-SL-OLV can improve atelectasis and reduce the risk of hypoxemia and hypercapnia during OLV.
... A double lumen tube (DLT) can be used for OLV in children older than eight years. In younger children, a bronchial blocker (BB) is commonly used and is placed either inside (>two years) or outside (<two years) the endotracheal tube (ETT) [3,4]. However, the ETT with a BB may not be correctly placed, which prolongs the effective anesthesia and operation time [5,6]. ...
Objectives:
One-lung ventilation (OLV) for children under the age of two years is difficult. The authors hypothesize that a combination of a supraglottic airway (SGA) device and intraluminal placement of a bronchial blocker (BB) may provide an appropriate choice.
Design:
A prospective method-comparison study.
Setting:
Second Affiliated Hospital of Xi'an Jiaotong University, China.
Participants:
120 patients under the age of two years undergoing thoracoscopic surgery with OLV.
Interventions:
Participants were randomly assigned to receive intraluminal placement of BB with SGA (n = 60) or extraluminal placement of BB with endotracheal tube (ETT) (n = 60) for OLV.
Measurements and main results:
The primary outcome was the length of postoperative hospitalization stay. The secondary outcomes were the basic parameters of OLV and investigator-defined severe adverse events. The postoperative hospitalization stay was 6 days (interquartile range, IQR 4-9) in SGA plus BB group compared with 9 days (IQR 6-13) in ETT plus BB group (P = 0.034). The placement and positioning duration of SGA plus BB was 64 s (IQR 51-75) compared with 132 s (IQR 117-152) of ETT plus BB (P = 0.001). The values of leukocyte (WBC) and C-reactive protein (CRP) of SGA plus BB group on the first day of post-operation were 9.8 × 109/L (IQR 7.4-14.5) and 15.1 mg/L (IQR 12.5-17.3) compared with 13.6 × 109/L (IQR 10.8-17.1) and 19.6 mg/L (IQR 15.0-23.5) of ETT plus BB group (P = 0.022 and P = 0.014).
Conclusion:
There were few if any significant adverse events in the intervention group (SGA plus BB) for OLV in children under the age of two years, and this method seems worthy of clinical application. Meanwhile, the mechanism for this novel technique to shorten the length of postoperative hospitalization stay needs to be further explored.
... For this reason, the anesthesiologist must be able to overcome the desaturation that may occur while instrumentation during the procedure or other manipulations of the patient's lungs. The anesthesiologist must also ensure adequate ventilation and oxygenation throughout the procedure [3]. ...
... One-lung ventilation (OLV) is common airway management in thoracic surgery where ventilation is carried out in one lung and leaves the other lung unexpanded or collapsed. The indications for OLV itself are to provide good access or operating field during the procedure, to provide lung protection from pus or blood contamination, and to ensure adequate ventilation and oxygenation of healthy lungs [2,3]. ...
... The use of a Forgarty Catheter as a bronchial blocker is aimed as an alternative to the absence of a double-lumen tube for infants and pediatrics. Forgarty Catheters, although commonly used in vascular surgery for thrombectomy, can function as bronchial blockers by utilizing their inflatable distal balloon cuff [3,4]. ...
... The reduced dimensions of the airway in neonates and very small children limit the airway management to two approaches, endobronchial intubation with a single lumen tube (SLT) to the non-operating lung or a bronchial blocker (BB) placed in the operating lung (3)(4)(5). There are limitations reported from the use of the first technique in children up to 2 years old since the use of a larger or cuffed tube can cause tracheobronchial mucosa damage (6)(7)(8)(9), and the use of a smaller tube can increase airflow resistance, create auto-peep, limit suctioning or be unable to provide adequate sealing (10,11). ...
Objective
Selective one-lung ventilation used to optimize neonatal and pediatric surgical conditions is always a demanding task for anesthesiologists, especially during minimally invasive thoracoscopic surgery. This study aims to introduce an ultrasound-guided bronchial intubation and exclusion technique in a pediatric animal model.Methods
Seven rabbits were anesthetized and airway ultrasound acquisitions were done.ResultsTracheal tube progression along the trachea to the right bronchus and positioning of the bronchial blocker in the left bronchus were successfully done with consistent ultrasound identification of relevant anatomical structures.Conclusion
The study provided a new application of ultrasound in airway management. More advanced experimental studies are needed since this technique has the potential for translation to pediatric anesthesia.
... [4] Balloon tipped bronchial blockers (BB) are used for OLV in children younger than 6 years of age, and various devices like Arndt's BB are commercially available for use in children. [5] But, they may not be available at all centres. Though not designed for use primarily as BB, Fogarty embolectomy catheters can be used for lung were used for children up to 2 years, 2-4 years, and 5-8 years, respectively. ...
... This is because the effects of the hydrostatic pressure gradient between the non-dependent and dependent lung on perfusion and ventilation in the lateral decubitus position are considerably less in children. [5] Furthermore, residual volume is closer to the functional residual capacity and thus, airway closure and atelectasis can occur even with appropriate tidal ventilation. [5] Thus, hypoxia during OLV is much more common in children than adults. ...
... [5] Furthermore, residual volume is closer to the functional residual capacity and thus, airway closure and atelectasis can occur even with appropriate tidal ventilation. [5] Thus, hypoxia during OLV is much more common in children than adults. In addition, thoracic surgery in children necessitating use of OLV is usually required for suppurative lung disease and there is a potential for contamination of the healthy lung during surgery. ...
Background and aim:
Various devices such as single lumen tubes, balloon-tipped bronchial blockers, and double-lumen tubes can be used for lung isolation in children, but no particular device is ideal. As such, there is a wide variation in lung isolation techniques employed by anaesthesiologists in this cohort of patients. This study aims to describe our experience with Fogarty catheters for lung isolation in children.
Methods:
This was a single centre, retrospective review of 15 children, below the age of 8 years, undergoing thoracic surgeries and requiring lung isolation. Demographic details, clinical parameters, complications during Fogarty catheter placement, number of attempts for placement, time taken for satisfactory lung isolation, and intraoperative complications were collected.
Results:
Successful lung isolation was achieved in all 15 children with Fogarty catheters of various sizes with the help of flexible bronchoscopy. Desaturation and bradycardia were the commonest complications seen during placement of the catheters but resolved with bag-mask ventilation. On average, 2 attempts were required for successful Fogarty placement. The mean time for successful lung isolation was 6.9 ± 1.3 minutes. The commonest intraoperative complication noted was desaturation, which resolved with an increase in FiO2 and positive end expiratory pressure. 2 children had migration of the device proximally to the trachea causing airway obstruction. The devices were successfully repositioned in both cases.
Conclusion:
Fogarty catheters can be used for successful lung isolation in children less than 8 years of age, undergoing thoracic surgery.
... This is because the diameters of the Univent™ 3.5 uncuffed tube (recommended for 6 to 8 year olds) and double-lumen endobronchial tube (recommended for 8 to 10 year olds) are not appropriate for the aforementioned age group. [6] For children, the Arndt endobronchial blocker is only suitable if the endotracheal tube to be used is greater than 4.5-mm internal diameter, as the available 5-Fr catheter has a diameter of 2.5 mm and requires a small bronchoscope of 2.2-2.8 mm for positioning. ...
... Marraro pediatric endobronchial bi-lumen tube has been reported to be effective for OLV up to 3 years. [1,[4][5][6][7][8] These are not easily available. ...
Video-assisted thoracoscopic surgery (VATS) is a frequently performed procedure in children which requires an efficient technique for lung isolation. Unavailability of appropriate size double-lumen tubes (DLT) for children and fiber optic scopes inspired us to create our own technique for lung isolation. This retrospective case series aims to describe our technique of C arm-aided endotracheal tube (ETT) placement for one-lung ventilation in these patients. 15 patients, aged 3 months to 10 years posted for VATS were recruited. Standard monitoring, general anesthesia and Lung isolation done as per the described protocol. Mean, standard deviation, and 95% Confidence interval was used. The mean age and weight was 43.93 months was 16.4 kg respectively. All right bronchus intubations were achieved in the first attempt. Of the 8 left bronchus intubations, 4 needed more than one attempt with a stylet inserted with a gentle J-shaped curve. Mild desaturation, seen in 2 patients during surgery was corrected with neck extension and increasing the FiO2. None of the cases required withdrawal of the tube into the trachea. One-lung anesthesia was achieved successfully in all the cases using C Arm with routine ETT.
