Use of Fogarty catheter as bronchial blocker for lung isolation in children undergoing thoracic surgery: A single centre experience of 15 cases

Abstract

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.

Full text

148 © 2022 Annals of Cardiac Anaesthesia | Published by Wolters Kluwer - Medknow
Use of Fogarty catheter as bronchial blocker for lung
isolation in children undergoing thoracic surgery: A single
centre experience of 15 cases
Bikram K Behera, Satyajeet Misra, Manoj K Mohanty1, Bikasha B Tripathy1
Departments of Anesthesiology and Crical Care and 1Pediatric Surgery, All India Instute of Medical Sciences, Bhubaneswar, Odisha, India
Original Article
INTRODUCTION
One lung ventilation (OLV) in children is indicated for
various intrathoracic procedures. The common indications
are decortication in suppurative lung disease, diaphragmatic
hernia repair, resection of tumour, and congenital
lung malformations. The American Thoracic Society
has suggested the use of video‑assisted thoracoscopic
surgery (VATS) in this group of patients as there is
less pain, better postoperative mobilization, and fewer
complications.[1] This has led to an increased request for
lung isolation in children and infants.[2] A double‑lumen
tube (DLT) is the gold standard for OLV in adults.[3]
However, no such gold standard exists in children for
lung isolation.[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
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DOI:
10.4103/aca.aca_219_20
ABSTRACT
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.
Keywords: Fogarty catheter, lung isolation, paediatric patients, thoracic surgery.
Address for correspondence: Dr. Bikram K Behera, Department of Anesthesiology & Crical Care, AIIMS, Bhubaneswar, Sijua, Patrapada ‑ 751 019, Odisha, India.
E‑mail: bikrambehera007@gmail.com
Submied: 31‑Aug‑2020 Revised: 12‑Apr‑2021 Accepted: 21‑Apr‑2021 Published: 11‑Apr‑2022
How to cite this article: Behera BK, Misra S, Mohanty MK, Tripathy BB.
Use of Fogarty catheter as bronchial blocker for lung isolation in children
undergoing thoracic surgery: A single centre experience of 15 cases. Ann
Card Anaesth 2022;25:148-52.
This is an open access journal, and arcles are distributed under the terms of the Creave
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Behera, et al.: Fogarty catheter as bronchial blocker in children
Annals of Cardiac Anaesthesia | Volume 25 | Issue 2 | April‑June 2022 149
were used for children up to 2 years, 2‑4 years, and
5‑8 years, respectively. Fogarty catheters were placed
into the desired bronchus under a exible bronchoscopy
guidance. 9 patients had desaturation (SpO2 <90%) during
the placement of the Fogarty catheter accompanied by
bradycardia, which responded to bag‑mask ventilation
with 100% O2, and both saturation and heart rate returned
back to baseline values in all patients. It took 2 attempts
per child on an average to place the Fogarty catheter. The
average time taken for successful Fogarty insertion and
lung isolation was 6.9 ± 1.3 minutes.
There was airway obstruction in 2 children, denoted by a
sudden increase in peak airway pressures, after assuming
lateral decubitus position, due to proximal migration of
the inated balloon into the trachea. The catheters were
repositioned successfully into the main stem bronchus
with the help of exible bronchoscopy without having to
change the position of the children.
Intraoperative desaturation (SpO2 <90%) occurred in
3 patients, which responded to increase in FiO2 and positive
end expiratory pressure (PEEP) to the ventilated lung.
There were no other serious adverse events during surgery,
and all the children tolerated OLV fairly. 7 patients were
electively ventilated for various indications and extubated
in the ICU. None of the patients developed any respiratory
or neurological complications during their stay in ICU.
Satisfactory postoperative analgesia was achieved in all
children with either caudal epidural or intercostal nerve
blocks.
DISCUSSION
In children, lateral decubitus position causes greater
ventilation and perfusion mismatch as compared to adults.
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. 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.[5] Thus, the twin challenges in paediatric OLV are
troubleshooting intraoperative hypoxemia and minimizing
contamination of the non‑operative lung. In addition,
provision of a quiet surgical eld with a well deated lung
remains the 3rd major challenge.
isolation and OLV even in very small children.[6,7] We
present our institutional experience in children undergoing
various thoracic procedures with lung isolation performed
by Fogarty catheters.
METHODS
This retrospective analysis was carried out after institutional
review board approval (T/IM‑NF/Anaesth/20/82) with
waiver for informed patient consent. Date:06/08/2020.
Children less than 8 years who underwent thoracic
procedures for various indications over the last 4 years at
our institute with a Fogarty catheter used as BB and had
complete records were included in this analysis.
In all cases, Fogarty catheters were placed under exible
bronchoscopy guidance following which the trachea
was intubated with appropriately sized tracheal tubes.
The proximal end of the Fogarty catheters was xed
with adhesive tape at the angle of the mouth to prevent
migration. Extubation was attempted after the reversal
of neuromuscular blockade was carried out with inj.
Neostigmine (50 microgram/kg) and inj. Glycopyrrolate
(10 microgram/kg) at the end of surgery.
The following parameters were noted; failure to
place Fogarty catheter into desired bronchus, sizes of
the Fogarty catheter, number of attempts and time
taken for lung isolation, incidence of complications
(desaturation, hypoxia, bradycardia) during lung isolation,
as well as incidence of intraoperative complications
(hypoxia, migration of the Fogarty catheter, inability to
ventilate the dependent lung).
RESULTS
A total of 15 children, below 8 years, who underwent
lung isolation with a Fogarty catheter and had complete
records were included in this analysis [Table 1]. Most of
the children underwent VATS decortication for empyema
thoracis. Satisfactory lung isolation for surgical access and
conduct of surgery was achieved in all patients. Fogarty
catheters were placed by same two anaesthesiologists in
all cases. Fogarty catheters of sizes 3, 4, and 5 French (Fr)
Table 1: Demographic and Clinical Characteristics
Characteristics Values
Age (years) 2.42 (5)
Weight (kg) 12.6 (10)
Gender (M:F) 10:5
VATS: Open thoracotomy 11:4
OLV (Right:Left) 4:11
Fogarty size (3 Fr./4 Fr./5 Fr.) 6/2/7
Values are Median (IQR) or number of patients; VATS (video assisted
thoracoscopic surgery; OLV (one lung ventilation); Fr (French)
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Behera, et al.: Fogarty catheter as bronchial blocker in children
150 Annals of Cardiac Anaesthesia | Volume 25 | Issue 2 | April‑June 2022
The use of single‑lumen tracheal tubes endobronchially is
the easiest and quickest method for lung isolation and OLV
and is practiced at many centres.[8] However, lung isolation
by single‑lumen tracheal tubes may not be always adequate
when uncuffed smaller size tubes are used endo‑bronchially.
They also fail to prevent aspiration into the dependent and
ventilated lung. Ventilation may not be adequate in the right
upper lobe when the right main bronchus is intubated, and
hypoxemia may occur. A specic endobronchial tube, the
Marraro Paediatric Endobronchial Bilumen Tube®, was
developed for OLV but is currently available only as a
special product and is not widely used.[9] Although DLTs
are ideal for OLV in adults, the smallest size DLT available
is 26 Fr left DLT and can only be used for children greater
than 8 years.[10]
BB is the technique of choice for lung isolation in children
6‑8 years of age.[5] An ideal BB should have low volume
balloon, stabilize in the bronchus, be exible, have a
channel for deation and suction distal to the blocker,
adaptable for use internally and externally to a standard
tracheal tube, and should be available in a variety of sizes.
No such ideal blocker exists for use in the paediatric
population.[4]
Wire‑guided endobronchial Arndt blocker® and UniventTM
tubes are used as BB in children.[11‑13] However, Arndt
blockers can only be used in children if the tracheal
tube is >4.5 mm internal diameter.[5] Cohen® Flexitip
Endobronchial Blocker, CoopdechTM endobronchial
blocker tube, EZ‑blockerTM, and Papworth BiVent ETT
are available for adults, but their use in paediatric age has
not been demonstrated.[14‑17]
Fogarty catheters have been used as BB in children.[6,7,18,19]
The Fogarty catheters provide adequate lung isolation
and protect the dependent lung from contamination
from the operative non‑dependent lung. However, they
have signicant limitations. Suctioning of the operative
lung is not possible with the Fogarty catheter in‑situ with
the balloon inated. The balloon must be deated for
intermittent suctioning and ventilation of the operative
lung when required during which may lead to the soiling
of the dependent lung.[20] The lung collapse after lung
isolation is not always complete and is generally achieved
due to the absorption atelectasis of the blocked lung. The
balloon at the tip of Fogarty is of high‑pressure type, and
there is always a risk bronchial rupture if the balloon is
inated with a higher volume of air.[21] Finally the balloon
can also migrate to the trachea and may lead to complete
airway obstruction. Despite this, various workers have used
it for lung isolation in children.
Camci et al.,[19] reported their experience with Fogarty
catheters in 15 children and recommended that these
catheters should be used for OLV in children undergoing
thoracotomy. However, the authors attempted bronchial
blockade in all patients with a 7 Fr Fogarty catheter
irrespective of the age of the patient. The median patient
age in their series was 9.9 ± 3.2 years. The rationale was
that a bigger catheter will be associated with successful lung
blockade in the rst attempt with less incidence of failure,
since a lower volume of air will be required.
Furthermore, the authors introduced the Fogarty
catheter blindly into the desired bronchus under direct
laryngoscopy.[19] This can cause tracheobronchial trauma
and may even take a longer time to place the Fogarty
catheter into the desired bronchus. The mean time taken for
lung isolation in their series was 11.7 ± 12 minutes, which
was considerably longer as compared to 6.9 ± 1.3 minutes
in our series.
Additionally, instead of using the “one size fits all”
approach, we individualized the selection of the catheters
as per age of the patients. This has been previously
recommended by Tan and Tankendrick who found that age
and not the weight of patients correlated with bronchial
diameters.[7] They recommended use of 3 Fr Fogarty
catheters up to 4 years and 5 Fr for 5‑12 years.[7] They did
not use 4 Fr catheters stating that there was only a 1 mm
difference between 4 and 5 Fr and that balloon pressure
may be lower with 5 Fr catheters, thereby increasing the
margin of safety against bronchial rupture.[7]
In our series, we used 4 Fr catheters in children 2‑4 years
and balloon ination was carried out under vision so as to
prevent over ination and bronchial rupture. 4 Fr catheters
would additionally require less ination as compared to 3
Fr catheters and thus, provide a greater margin of safety
in children 2‑4 years. 3 Fr catheters were used in our series
in only children less than 2 years.
Kamra et al.,[6] reported use of Fogarty catheter in
27 patients without any major complications. The authors,
however used rigid bronchoscopes for placement of the
Fogarty catheter. Anaesthesiologists have limited experience
in using rigid bronchoscope. Furthermore, as compared
to rigid bronchoscopy, a exible bronchoscope provides
better vision and ease of insertion with lesser hemodynamic
perturbations. With expertise in the technique and
good knowledge of tracheobronchial anatomy, exible
bronchoscopy is considered the best method to provide
optimal conrmation of device placement.[22] Moreover,
rigid bronchoscopy cannot be performed once the child is
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Behera, et al.: Fogarty catheter as bronchial blocker in children
Annals of Cardiac Anaesthesia | Volume 25 | Issue 2 | April‑June 2022 151
intubated, or when the need arises during the intraoperative
period for repositioning of the Fogarty catheter.
In our series, 20% of children had hypoxemia
intraoperatively. There are various options available for
the treatment of hypoxemia in OLV. Application of
continuous positive airway pressure and apneic oxygenation
insufation to the non‑ventilated lung are recommended
techniques, but are not possible with a Fogarty balloon
catheter in‑situ. Alveolar recruitment strategies and the use
of PEEP to the ventilated lung improves oxygenation and
lung mechanics.[20] In our patients, intraoperative hypoxemic
episodes were managed by increasing the FiO2 and PEEP
to the dependent lung.
The biggest disadvantage of a Fogarty catheter is the
absence of a hollow lumen, which prevents suctioning
of the non‑dependent lung. To avoid the soiling of the
ventilated lung, intermittent suctioning of the trachea
should be done intraoperatively, and patients should
be placed in supine 300 Trendelenburg position to aid
gravity‑dependent drainage of the secretions in an attempt
to minimize contamination of the healthy lung. However
tracheobronchial toileting can still remain a problem in this
cohort of patients.
There are some limitations in our study. This was a small
retrospective analysis which had only had 15 patients,
but we included only those with complete intraoperative
and postoperative records. However, all retrospective
studies suffer from inherent biases of patient selection,
non‑randomization, data collection and outcome reporting
which can be addressed only by well‑designed prospective
randomized trials. Only 2 anaesthesiologists were involved
in all the cases and thus, operator experience may play
a big role in the placement of the catheters which may
not be replicated by other workers. We did not evaluate
the impact of lung isolation with Fogarty catheters on
the gas exchange and lung mechanics. However, Hale
et al.,[2] have shown that older age and duration of OLV
but not the type of device were associated with decrease
in lung compliance and a poorer gas exchange. Finally,
we evaluated only Fogarty catheters and cannot comment
on other types of devices that are used in this age group
for OLV.
CONCLUSION
There is no “gold standard” method for lung isolation
in children less than 8 years. Fogarty catheters are widely
available and can be used as BB in this subset of patients
for conduct of OLV with a low incidence of complications.
However, suitable experience and practice may be needed
for using these catheters as BB.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conicts of interest.
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