Procedures involving lung surgery in the pediatric population are relatively uncommon and tend to be centralized in a limited number of institutions. Anesthesia literature is also sparse. To have a clear overview of frequency, underlying pathologies, ICU and hospital stay, anesthetic techniques, one lung ventilation, and perioperative analgesia. We conducted a retrospective review in a single-center tertiary hospital, from January 2014 to 2023. We included children aged 0-16 years who underwent major lung surgery and received anesthesia managed by the pediatric anesthesia team. Patients with congenital diaphragmatic hernia, esophageal atresia, or those undergoing surgery for pectus excavatum were excluded. Our main outcome measures include the type of underlying pathology and surgical procedure, ICU and hospital stay, methods of one-lung ventilation, source of perioperative analgesia, and the incidence of (postoperative) complications. We included 73 patients, 55% male and 45% female. The median age was 2.8 years and the median weight was 12.9 kg. Congenital pulmonary airway malformation was diagnosed in 43%, and 45% underwent a (partial) lobectomy. The proportion of video-assisted thoracoscopic surgery was comparable to that of open thoracotomy. One-lung ventilation (OLV) was used in 81%, primarily facilitated by a bronchial blocker. Epidural catheterization with ropivacaine for perioperative pain management was used in 71%. The proportion of patients receiving intravenous morphine on postoperative Days 1, 2, 3, 4, and 5 was 40%, 34%, 19%, 15%, and 11%, respectively. Insufficient pain control was reported in 14%. 70% were admitted to the ICU for one night. The average length of hospital stay was 8 days. We addressed the anesthetic care of pediatric lung surgery procedures. OLV was required in the majority of the population and a bronchial blocker was the preferred method. Epidural analgesia was the preferred choice to tackle perioperative pain.

Pediatric one-lung ventilation (OLV) is always challenging for the anesthesiologist. Despite a plethora of options in the present era, there still remains a concern regarding the choice and success of the modality to isolate the lungs in the pediatric age group especially for thoracoscopic procedures. Bronchial blockers provide an effective way to achieve OLV in patients below 6 years. With smaller-sized endotracheal tubes (ETTs) being used in this age group, a physical check of the fit between the equipment (bronchoscope and the blocker inside the ETT) is strongly recommended. In the present case report of a 3.5-year-old child requiring lung isolation for robotic-assisted thoracoscopic surgery, we went a step ahead by using this entire assembly to intubate the patient. This innovative combo approach was chosen considering the anticipated struggle with manoeuvring the two components together. It was quick and safe in terms of decreased airway manipulation of pediatric airway.

Postoperative sore throat and hoarseness are common complications following lung isolation with double-lumen tubes (DLTs) in video-assisted thoracoscopic surgery (VATS). Laryngeal mask airway (LMA) combined with a visual bronchial blocker (VBB) may reduce airway trauma while maintaining effective lung isolation. This is a prospective, randomised, controlled, single-blind, multicentre clinical trial conducted at three major thoracic surgery centres in Shanghai, China. A total of 270 patients aged ≥18 years scheduled for elective VATS anatomical lung resection will be randomly allocated 1:1 to either the VBB group (n=135) using LMA combined with VBB or the DLT group (n=135) using conventional DLT (see Consolidated Standards of Reporting Trials diagram). The primary outcome is the incidence of sore throat and hoarseness at 24 hours postoperatively. Secondary outcomes include sore throat and hoarseness at 1 and 48 hours, intraoperative device performance, lung collapse quality, intubation time, haemodynamic changes, emergence quality, device-related complications and hospital length of stay. The study protocol was approved by the Ethics Committee of Shanghai Chest Hospital (KS24042). Results will be disseminated through peer-reviewed publications and conference presentations. ClinicalTrials.gov (NCT07117539).

Background and objectivesMinimally invasive coronary artery bypass grafting (MIDCAB) requires effective left lung isolation, yet evidence comparing video-imaging single-lumen tracheal tubes with bronchial blockers (VSLT + BB) and video-imaging double-lumen endotracheal tubes (VDLT) remains limited. This randomized controlled trial aimed to: (1) quantitatively compare time efficiency for device placement and lung isolation between VSLT + BB and VDLT; (2) evaluate perioperative airway complications; and (3) assess differential impacts on postoperative recovery, including postoperative sore throat, hoarseness, and Quality of Recovery-15 (QoR-15) scores.MethodsIn this single-blind randomized controlled trial, 97 MIDCAB patients were allocated to VSLT + BB or VDLT groups. Primary outcomes were tube positioning time; secondary outcomes included total intubation time, oxygenation parameters, hemodynamic variables, and postoperative complications.ResultsVDLT exhibited shorter tube positioning time (128 ± 37 vs. 159 ± 58 s; p < 0.001) but longer total intubation time (192 ± 40 vs. 159 ± 58 s; p < 0.001). VSLT + BB demonstrated higher PaO₂ at 10-min post-OLV (226.0 vs. 168.0 mmHg; p = 0.035) with lower airway pressures (p < 0.05). Postoperative sore throat (33% vs. 13%; OR 2.84, 95% CI 1.04, 7.71; p = 0.018) and hoarseness at 48 h (55% vs. 31%; OR 2.45, 95% CI 1.08, 5.59; p = 0.018) were higher with VDLT. Lung collapse quality, hypoxemia rates, pulmonary complications, and QoR-15 scores showed no significant differences (all p > 0.05).ConclusionsIn MIDCAB surgery, VDLT demonstrated significantly shorter tube positioning time compared with VSLT + BB. However, VSLT + BB exhibited shorter total intubation time than VDLT by avoiding postoperative tube exchange. Both techniques provided clinically acceptable lung isolation with comparable lung collapse quality and hypoxemia incidence. VSLT + BB exhibited lower airway pressures and higher oxygenation indices during early OLV, whereas VDLT was associated with higher rates of minor airway complications (sore throat, hoarseness). No significant differences were observed in pulmonary complications, hemodynamic stability, or recovery quality.Trial registrationChiCTR2300072124, 3/6/2023.

Abstract Background One-lung ventilation (OLV) in children is technically demanding due to small airway calibers, variable bronchial anatomy, and limited pediatric-specific devices. Challenges are greater in resource-limited settings where double-lumen tubes (DLTs) and fiberoptic bronchoscopes are not consistently available. Methods We retrospectively reviewed five consecutive pediatric patients (ages 4–13 years) who underwent thoracic surgery with OLV between 2022 and 2024. Case summaries highlighted device choice, confirmation method, and perioperative challenges. Variables included demographics, diagnosis, surgical side, isolation technique, OLV duration, ventilatory parameters, arterial blood gases, and defined outcomes (desaturation, hypercarbia, hemodynamic instability, device dislodgement, and postoperative complications). Results Lung isolation was achieved with DLTs in two older patients and bronchial blockers in three younger ones, guided by age and weight. OLV lasted 105–150 min. Two children developed transient desaturation (nadir SpO₂ 75%), one experienced hypercarbia (PaCO₂ &gt;50 mmHg), and two had hemodynamic instability. No tube dislodgement occurred. Median ICU stay was 17 h (IQR 8–19), and hospital stay 21 days (IQR 15–21). All patients were discharged in stable condition. Conclusion An age- and weight-based algorithm bronchial blockers for children &lt; 8 years or &lt; 30 kg, DLTs for older/heavier patients enabled safe OLV and preserved oxygenation, even without routine fiberoptic bronchoscopy. Vigilant ETCO₂ monitoring, careful device fixation, and close intraoperative assessment compensated for equipment limitations. This pragmatic workflow demonstrates feasibility in resource-constrained environments, provides practical guidance for clinicians, and is hypothesis-generating for future multicenter studies.

Airway Management in Thoracic Anesthesia.

Effects of Bronchial Blockers and Double-Lumen Tubes on Recovery Quality in Patients Undergoing Lobectomy: A randomized controlled trial

BackgroundApproximately one-third of patients who undergo bronchial blocker (BB) intubation in the conventional supine position suffer BB malposition. This trial aims to explore the efficiency and clinical application of BB intubation in the lateral position to reduce the incidence of BB malposition in patients undergoing video-assisted thoracic surgery (VATS).MethodsThis single-center, parallel-group, randomized controlled trial will enroll 110 patients aged 18–80 years who are scheduled for elective unilateral VATS with BB intubation under general anesthesia. Participants will be randomly assigned (1:1) to either the lateral BB intubation group or the conventional supine BB intubation group. The primary outcome is the incidence of BB malposition observed by fiberoptic bronchoscopy (FOB). Secondary outcomes include the duration of intubation, the frequency and duration of FOB usage, whether to re-intubate, intraoperative vital signs, and postoperative recovery.DiscussionThis trial will confirm the clinical efficacy and superiority of BB intubation in the lateral position to consolidate the lateral intubation pattern in thoracic anesthesia. We expect that performing lateral BB intubation can reduce the BB malposition rate and result in more stable intraoperative vital signs and fewer postoperative complications, which is in line with the concept of Enhanced Recovery After Surgery in thoracic anesthesia.Trial registrationChinese Clinical Trial Registry ChiCTR2400081961. Registered on March 18, 2024.Supplementary InformationThe online version contains supplementary material available at 10.1186/s13063-025-09287-7.

Robotic-assisted thoracic surgery (RATS) has emerged as a transformative approach in thoracic surgery, enabling enhanced precision and minimally invasive treatment for lung, esophageal, and mediastinal resections. These advances introduce unique anesthetic challenges requiring tailored strategies to ensure patient safety and surgical success. Key challenges include intrathoracic carbon dioxide insufflation, prolonged one-lung ventilation, and complex positioning. Special considerations apply to high-risk groups such as patients with myasthenia gravis, obesity, and frailty. Advances in anesthetic management include individualized lung isolation with double-lumen tubes or bronchial blockers, protective ventilation with permissive hypercapnia, and restrictive fluid strategies supported by invasive monitoring. Deep neuromuscular blockade is often needed to maintain stability during robotic manipulation. Multimodal regional anesthesia and enhanced recovery after surgery (ERAS) pathways are increasingly applied, improving analgesia, reducing opioid exposure, and facilitating early extubation and mobilization. Novel approaches such as subpleural anesthetic infusion, continuous airway visualization devices, and perioperative artificial intelligence (AI) applications are being explored. RATS present distinct anesthetic challenges and opportunities. Integration of tailored airway and ventilation strategies, vigilant hemodynamic management, regional analgesia, and ERAS principles is essential. Future priorities include AI-supported monitoring, simulation-based training, and global consensus frameworks to standardize anesthetic practice.

This article reviews the latest literature and discusses future guidance on airway management in thoracic surgery. It has been recommended for the preoperative assessment to use validated scales such as the Airway Risk Index combined with tools for predicting difficult lung isolation, especially in patients with chronic obstructive pulmonary disease, endobronchial tumors, or tracheal pathology. Preoperative imaging plays a crucial role in predicting and planning lung isolation in thoracic anesthesia, with computed tomography (e.g. three-dimensional reconstructions and virtual bronchoscopy) being very useful for identifying airway abnormalities and guiding the selection of appropriate lung isolation devices. One of the most reliable methods to achieve lung collapse with a bronchial blocker is the apnea-disconnection for improvate nonventilated lung collapse. Recent studies suggest that the adoption of videolaryngoscopes in thoracic surgery procedures involving double-lumen endotracheal intubation may enhance patient safety and outcomes by reducing the incidence of malpositioned tubes. In addition, the development of double-lumen tubes with integrated cameras enables real-time visualization of tube positioning, a growing trend that may partially replace conventional bronchoscopy. The field of airway management is constantly evolving, with new technologies and techniques emerging regularly, improving patient safety, reducing the risk of complications, and enhancing surgical conditions.

Lung separation for thoracic surgery is associated with varying degrees of difficulty depending on the age group. While the anatomical, physiological and technical requirements for the appropriate selection of bronchial blockers and double-lumen tubes in children > 12years of age are comparable to those for adults, this is not the case for newborns and infants; however, at 13% they constitute the second largest group of children requiring lung surgery. Lung separation in this age group is technically demanding. The rate of cardiopulmonary complications is many times higher than in older children and adults. These procedures are therefore an anesthesiological challenge that should only be performed in specialized pediatric anesthesiology centers with appropriate personnel and structural facilities. In infants extubation should also be attempted on table to shorten the recovery time. This requires sufficient and multimodal pain therapy. The development of an internal enhanced recovery after surgery (ERAS) protocol can be helpful for high-quality perioperative treatment.

Efficacy of Arndt Endobronchial blocker and Left Double-Lumen tube in lung isolation for thoracic surgery: a randomized comparative study

BackgroundSurgical lung biopsy (SLB), performed via open lung biopsy or video-assisted thoracoscopic surgery, has traditionally been the gold standard for diagnosing interstitial lung disease (ILD) when histological confirmation is necessary. Transbronchial forceps biopsy, while less invasive, often yields small, artifact-prone specimens that are insufficient for conclusive histopathological analysis. Transbronchial lung cryobiopsy (TBLC) has emerged as a minimally invasive alternative, offering a higher diagnostic yield and superior tissue integrity due to the retrieval of larger, en bloc samples. International societies currently conditionally recommended TBLC as a potential first-line diagnostic tool for ILD, citing its favourable safety profile and diagnostic performance.Technique, procedural environment and complications.TBLC may be performed via flexible bronchoscopy with or without an artificial airway. When an artificial airway is used, general anaesthesia is administered, and a supraglottic device or endotracheal tube facilitates bronchoscope and blocker access. Without an artificial airway, the procedure is conducted under conscious sedation using an oral bite guard. A bronchial blocker is deployed to control bleeding, and biopsies are obtained under fluoroscopic guidance with freezing times of 6 - 10 seconds. At least four adequate samples (>5 mm) are collected. Post-procedure care includes positioning the patient with the biopsied lung in the dependent position and performing imaging to detect pneumothorax. While bleeding and pneumothorax are potential risks, they are generally manageable. Definitive exclusion criteria for TBLC have not yet been established, but characteristics such as severely impaired lung function, pulmonary hypertension and significant comorbidity are associated with adverse events.ConclusionAlthough TBLC yields marginally lower diagnostic rates compared with SLB, it remains a cost-effective and safer alternative, particularly in resource-limited settings. The South African Thoracic Society strongly advocates for TBLC as the first-line diagnostic modality in all cases of ILD, where histology is required, provided there are no contraindications. This recommendation is based on the lower cost and morbidity associated with TBLC compared with SLB. An exception is made for patients with non-diffuse or non-peribronchiolar disease who are suitable candidates for SLB and where the procedure is readily available. Strengthening local capacity and expertise in TBLC is crucial for improving ILD diagnostic accuracy in South Africa.

Comparison of Intubation-Related Complications Between Laryngeal Mask and Endotracheal Intubation with Bronchial Blocker for One-Lung Ventilation in Pediatric Patients.

Surgical correction is the definitive treatment for adolescent idiopathic scoliosis (AIS), but 25% of cases may experience screw migration, risking injury to thoracic structures. Video assisted thoracoscopic surgery (VATS) can visualise malpositioned screws and resolve injury. This report presents a case of an AIS patient who underwent prone VATS for simultaneous screw correction after posterior spinal fusion. While traditional VATS uses a double lumen tube (DLT) in the lateral decubitus position, DLTs are less ideal for prone surgery. Bronchial blockers (BB), like the EZ-Blocker (Teleflex, Wayne, Pennsylvania), can be used with a more stable armoured single lumen tube (SLT). The EZ-Blocker, a Y-shaped BB, offers stability and sequential lung isolation. Studies show EZ-Blocker performance is comparable to DLTs in lung isolation quality and surgeon satisfaction, though it requires longer placement time and offers limited suctioning. This case demonstrates that an EZ-Blocker with an armoured SLT is a safe, effective airway option for prone VATS.

In thoracic surgery, general anesthesia remains the standard approach. During the procedure, one-lung ventilation using double-lumen tubes or bronchial blockers is employed as needed. For postoperative pain control, a multimodal approach is taken, incorporating options such as thoracic epidural anesthesia, paravertebral blocks, intercostal nerve blocks, and intravenous patient-controlled analgesia (IV-PCA). These practices have remained consistent in recent years. However, anesthetics and anesthesia-related devices including physiological monitors and ultrasound machines have continued to evolve. As a result, anesthesia today differs significantly from that of a decade ago. This section highlights the latest advances in anesthetics and anesthesia-related technologies, including: (1) the use of artificial intelligence (AI) for monitoring and decision support, (2) robotic anesthesia systems with automated drug delivery, (3) remimazolam as a novel ultra-short-acting sedative, and (4) autologous blood recovery systems capable of platelet collection, improving hemostasis and reducing transfusion requirements. Although the clinical efficacy of these innovations remains to be established through future research, there is considerable anticipation surrounding their potential to enhance the quality of anesthesia management.

Lung isolation using retrograde intrabronchial Fogarty catheter: Experience from 35 cases

Intraoperative Ventilation and Anesthesia Issues During Thoracic Surgery.

In neonatal and pediatric thoracoscopy, two-lung ventilation is often used due to the size constraints of double-lumen tubes or selective bronchial blockers. Reducing the volume of both lungs to create surgical workspace requires moderation in the application of capnothorax insufflation pressures, and requires experienced anesthesiologists to manage ventilation. This balance was investigated in anesthetized pigs in theleft decubitus position with a capnothorax, using volume-guaranteed intermittent positive pressure ventilation. End-expiratory computed tomography scans were obtained in 10 pigs (median weight 21.5 kg, range 17.8 to 26.3 kg) during incremental CO2 insufflation pressures of 0, 3, 5, 6, 8 and 10 mmHg. Capnothorax, right lung and left lung volumes were measured. At an insufflation pressure of 10 mmHg, peak ventilation pressures had a median of 35 cmH2O. Insufflation pressures ≥ 6 mmHg had profound cardiorespiratory effects, requiring inotropic support. Capnothorax volume reached a median of 1503 (IQR 1465-1596) ml at 10 mmHg, at which diaphragmatic displacement contributed 79.5% to capnothorax volume, with smaller contributions from lung volume (16.1%) and thoracic expansion (4.4%). Thoracoscopic workspace during two-lung ventilation originates mainly from diaphragmatic displacement. In a porcine model the marked cardiorespiratory consequences of insufflation emphasized the need to minimize insufflation pressures.

Introduction: Pediatric thoracic surgery, particularly lung resection, has special difficulties due to anatomical and physiological differences compared to adults. One-lung ventilation (OLV) is often necessary to optimize surgical exposure while minimizing lung injury. Traditional methods, like double-lumen endotracheal tubes, can be difficult to use in children due to their smaller airways and the risk of trauma. Thus, alternative approaches, such as bronchial blockers like Fogarty occlusion catheters, have gained prominence. Objective: This case report aims to highlight the use of the Fogarty balloon in a pediatric patient undergoing lobectomy for organized pleural effusion linked to pneumonia. Case Report: A 5-year-old girl with recurrent pneumonia presented with persistent cough, intermittent fever, and respiratory distress. Physical examination revealed decreased breath sounds and mild cyanosis. Imaging confirmed a large organized pleural effusion, suspected to be empyema. The surgical team chose a right thoracotomy lobectomy to remove the affected lung tissue. Preoperative consultations included pediatric surgery, anesthesiology, and respiratory therapy to ensure comprehensive care. A multi-modal pain management strategy, emphasizing regional anesthesia through epidural blocks, was implemented. For OLV, the anesthetic team selected a Fogarty balloon catheter to minimize airway trauma. After intubating with a single-lumen endotracheal tube, the balloon was inserted into the right main bronchus and inflated to occlude it, allowing ventilation of the left lung. Discussion: The Fogarty balloon effectively provided lung isolation while preserving airway integrity, facilitating optimal surgical exposure and stable oxygenation. Continuous monitoring of oxygenation during OLV was crucial for patient safety. Conclusion: The use of a Fogarty balloon for bronchial blockade and epidural anesthesia was successful in this pediatric lobectomy case. These techniques enhanced surgical safety, efficacy, and postoperative recovery, suggesting that there must be ongoing research to establish standardized protocols for pediatric thoracic procedures.