One-lung Ventilation In Children Research Articles

Error traps in pediatric one-lung ventilation.

With the advent of thoracoscopic surgery, the benefits of lung isolation in children have been increasingly recognized. However, because of the small airway dimensions, equipment limitations in size and maneuverability, and limited respiratory reserve, one-lung ventilation in children remains challenging. This article highlights some of the most common error traps in the management of pediatric lung isolation and focuses on practical solutions for their management. The error traps discussed are as follows: (1) the failure to take into consideration relevant aspects of tracheobronchial anatomy when selecting the size of the lung isolation device, (2) failure to execute correct placement of the device chosen for lung isolation, (3) failure to maintain lung isolation related to surgical manipulation and isolation device movement, (4) failure to select appropriate ventilator strategies during one-lung ventilation, and (5) failure to appropriately manage and treat hypoxemia in the setting of one-lung ventilation.

This Month in Anesthesiology

This Month in Anesthesiology

Hypoxemia in Young Children Undergoing One-lung Ventilation: A Retrospective Cohort Study.

One-lung ventilation in children remains a specialized practice with low case numbers even at tertiary centers, preventing an assessment of best practices. The authors hypothesized that certain case factors may be associated with a higher risk of intraprocedural hypoxemia in children undergoing thoracic surgery and one-lung ventilation. The Multicenter Perioperative Outcomes database and a local quality improvement database were queried for documentation of one-lung ventilation in children 2 months to 3 yr of age inclusive between 2010 and 2020. Patients undergoing vascular or other cardiac procedures were excluded. All records were reviewed electronically for the presence of hypoxemia, oxygen saturation measured by pulse oximetry (Spo2) less than 90% for 3 min or more continuously, and severe hypoxemia, Spo2 less than 90% for 5 min or more continuously during one-lung ventilation. Records were also assessed for hypercarbia, end-tidal CO2 greater than 60 mmHg for 5 min or more or a Paco2 greater than 60 on arterial blood gas. Covariates assessed for association with these outcomes included age, weight, American Society of Anesthesiologists (Schaumburg, Illinois) Physical Status 3 or greater, duration of one-lung ventilation, preoperative Spo2 less than 98%, bronchial blocker versus endobronchial intubation, left operative side, video-assisted thoracoscopic surgery, lower tidal volume ventilation (tidal volume less than or equal to 6 ml/kg plus positive end expiratory pressure greater than or equal to 4 cm H2O for more than 80% of the duration of one-lung ventilation), and type of procedure. Three hundred six cases from 15 institutions were included for analysis. Hypoxemia and severe hypoxemia occurred in 81 of 306 (26%) patients and 56 of 306 (18%), respectively. Hypercarbia occurred in 153 of 306 (50%). Factors associated with lower risk of hypoxemia in multivariable analysis included left operative side (odds ratio, 0.45 [95% CI, 0.251 to 0.78]) and bronchial blocker use (odds ratio, 0.351 [95% CI, 0.177 to 0.67]). Additionally, use of a bronchial blocker was associated with a reduced risk of severe hypoxemia (odds ratio, 0.290 [95% CI, 0.125 to 0.62]). Use of a bronchial blocker was associated with a lower risk of hypoxemia in young children undergoing one-lung ventilation.

Point-of-Care Lung Ultrasound to Evaluate Lung Isolation During One-Lung Ventilation in Children: Narrative Review.

This review focuses on the current technique and evidence regarding the use of point-of-care ultrasound (POCUS) to evaluate lung isolation for thorax surgery in infants and children. Previous reports in infants and children are presented. Figures and high-quality video are used to demonstrate the technique for POCUS in pediatric patients and to highlight differences between pediatric and patients. Lung sliding in B-mode and the seashore sign in M-mode suggest that the lung is ventilated. Pediatric anesthesiologists should be familiar with this technique as it is non-invasive and may also be more accurate when compared with auscultation.

An Update on One-Lung Ventilation in Children.

One-lung ventilation in children continues to present technical and sometimes physiologic challenges to the clinician. The rarity of these cases at any single institution, however, has led to very few prospective trials to guide best practices. As a result, most clinicians continue to be guided by local tradition and preference. That said, the development of new bronchial blockers such as the EZ-Blocker or blocking devices such as the Univent tube have continued to evolve the practice of lung isolation in children. Further, the development of a variety of extraluminal blocker techniques has led to innovations in practice through a relatively diverse landscape of published case series offering different approaches to one-lung ventilation during the past 15 years. The Arndt bronchial blocker continues to represent the most well documented of these devices. Additionally, recent advances have occurred in our understanding of the relevant anatomic constraints of the lower pediatric airway. This review is intended to provide a comprehensive and practical update to practicing pediatric anesthesiologists to further their understanding of the modern practice of one-lung ventilation for thoracic surgery in children.

Lung separation in children: Options and impact on gas exchange and lung compliance.

One-lung ventilationis a challenging airway technique in the pediatric population. Multiple airway devices can be employed, but there is no consensus as to the most reliable and physiologically advantageous method. This report is a review of the methods of one-lung ventilationin children in our practice, as well as an analysis of the impact of airway device type, patient age, and duration of lung separation on respiratory mechanics and gas exchange. The records of all pediatric patients undergoing procedures requiring one-lung ventilation in a single center over an 18-month period were reviewed. Demographics, time required to achieve lung separation (anesthesia ready-time), and duration of one-lung ventilation were collected. Data from arterial blood gas analysis and ventilator parameters were collected at three time points: 15minutes prior to one-lung ventilation (pre-OLV), 15minutes after initiation of one-lung ventilation (during OLV), and 15minutes after one-lung ventilation was ended (post-OLV). Standard equations for calculating compliance, the ratio of arterial partial pressure of oxygen to the fraction of inspired oxygen, and the alveolar-arterial oxygen gradient were used. Forty-six patients were identified with a mean age of 9.3 (inner quartile range 3-15) years. All patients had significant changes in pulmonary function when comparing pre-OLV with during OLV and when comparing during OLV with post-OLV. There were no significant changes from pre- to post-OLV. On further analysis, there were more pronounced changes in compliance and gas exchange in older patients (P=0.003; 95% CI: -0.62 to -0.14). There was also a significant decrease in post-OLV compliance with a longer duration of OLV (P=0.018; 95% CI: -0.02 to <-0.01). Airway device type did not have significant impact on the parameters examined. Our report demonstrates significant changes in lung function during one-lung ventilation. One particular device does not seem to be superior. Though pre-OLV measures of pulmonary function correlate closely with post-OLV, older age and a prolonged duration of one-lung ventilation did impact compliance.

Point-of-care lung ultrasound to evaluate lung isolation during one-lung ventilation in children: A case report

Minimally invasive thoracic surgical techniques require effective lung separation using one-lung ventilation (OLV). Verification of lung isolation may be confirmed by auscultation, visual confirmation using fiberoptic bronchoscopy, or more recently, point-of-care ultrasound (POCUS). We describe anecdotal experience with POCUS to guide OLV during robotic-assisted thoracic surgery in a child. Techniques to confirm thoracic separation are reviewed and potential advantages of POCUS discussed.

A novel technique for endobronchial blocker placement for one-lung ventilation in children under 2 years.

The present study aimed to report our clinical experience with intraluminal calculated distance for endobronchial blocker placement (ICEB) and to find out whether ICEB could reduce the number of hypoxemia episodes during blocker placement compared with extraluminal blocker placement for one-lung ventilation in children under the age of 2years. The medical records of all children under the age of 2years with a 5 French (F) or 4F WeiLi (WeiLi medical Inc, Guangzhou, China) endobronchial blocker for one-lung ventilation in thoracic surgery from July 2015 through July 2016 were retrospectively reviewed. After November 2015, one-lung ventilation was achieved using the ICEB technique, while before November 2015, extraluminal blocker placement was used. The success rate of blocker placement, quality of lung deflation, number of hypoxemia episodes, blocker dislodgement, and successful reposition after dislodgement were compared between the two groups. The incidence of hypoxemia episodes during blocker placement was lower in the ICEB group compared to the extraluminal placement group. Moreover, the success rate of blocker reposition during the operation was higher in the ICEB group than the extraluminal placement group. The success rate of endobronchial blocker placement was similar between the two groups. Intraluminal calculated distance for endobronchial blocker placement is a feasible method to achieve lung isolation and could reduce hypoxemia episodes during blocker placement in children under the age of 2years.

Volume relationships between cricoid and main stem bronchi in children using three-dimensional computed tomography imaging

There are limited data to guide the selection of the appropriate sized endobronchial tube for main stem intubation to provide one-lung ventilation in children. The relationship between the cricoid and the main bronchi (right and left) has been previously evaluated using two-dimensional computed tomography (CT) imaging and video-bronchoscopic images. The present study defines the three-dimensional, CT-derived volume-based relationships between the right main-stem bronchus (RMB), left main-stem bronchus (LMB), and the cricoid ring. The three-dimensional CT images of 35 children, less than 8 years of age, undergoing radiological evaluation unrelated to airway or mediastinal symptomatology were examined. The images of the airway column were evaluated at the level of the cricoid and main stem bronchi (right and left). Volumes were calculated and comparisons made between these levels. There was no statistically significant difference based on gender for the cricoid and main stem bronchi volumes. A statistically significant difference was observed between the cricoid and left main stem bronchi volumes as well as between the right and left main stem bronchi. The relationship (ratio) between the volumes of the cricoid and main stem bronchi remains constant by age. The cricoid dimensions can be used to predict the main stem bronchi dimensions.

Routine Extraluminal Use of the 5F Arndt Endobronchial Blocker for One-Lung Ventilation in Children up to 24 Months of Age

THORACIC SURGERY in neonates, infants, and small children increasingly is performed with minimally invasive techniques including thoracoscopy.1 One-lung ventilation (OLV) optimizes exposure during thoracoscopic surgery.1 The pediatric size 5F Arndt Endobronchial Blocker (AEB) (Cook Medical Inc, Bloomington, IN) has been used successfully for lung isolation in children. A removable loop protruding through its central lumen is used to guide it with a fiberoptic bronchoscope (FOB) into the mainstem bronchus.

Techniques and complications of one-lung ventilation in children with suppurative lung disease: Experience in 15 cases

Objective: To evaluate lung isolation with Fogarty catheters and to analyze respiratory consequences of one-lung ventilation (OLV) in children with suppurative lung disease. Dign: Prospective. Setting: University hospital. Participants: Fifteen children undergoing thoracotomy. Interventions: Bronchial blockade with a 7F Fogarty catheter was attempted. In case of incomplete blockade or failure in directing the catheter into the desired mainstem bronchus, endobronchial intubation was done. Volume-controlled ventilation was performed with fraction of inspired oxygen (FIO2), 0.5; inspiratory-to-expiratory (I: E) ratio, 1:2; and 10 mL/kg tidal volume during two-lung ventilation (TLV). FIO2 was increased to 1.0 by the initiation of OLV. If peak airway pressure exceeded basal values during TLV by 35%, tidal volume was reduced to 8 mL/kg, inspiratory pause was zeroed, and I:E ratio was increased to 1:1. Hemodynamic and respiratory parameters were recorded during TLV and 30 minutes after initiation of OLV. Peripheral oxygen saturation and end-tidal carbon dioxide tension were recorded every 5 minutes. Measurements and Main Results: Right lung isolation was successfully obtained by Fogarty catheters in 10 children undergoing right thoracotomy. Endobronchial intubation was performed in 2 children (40%) undergoing left thoracotomy. Three children (20%) developed episodes of severe hypercapnia and hypoxia requiring treatment during OLV. All of the parameters recorded at 30 minutes of OLV revealed statistically significant differences from TLV. OLV was transiently discontinued in 1 child. Conclusion: The use of Fogarty embolectomy catheters for lung isolation in children undergoing thoracotomy is recommended. Respiratory problems are not rare during OLV in children with suppurative lung disease and require immediate management. Copyright © 2001 by W.B. Saunders Company

New developments in the management of the paediatric airway: cuffed or uncuffed tracheal tubes, laryngeal mask airway, cuffed oropharyngeal airway, tracheostomy and one-lung ventilation devices

The use of a cuffed endotracheal tube should no longer be limited by the age of the child but by his or her clinical condition (e.g. poor lung compliance). To prevent pharyngeal damage, overinflation of the cuff of the laryngeal mask airway should be avoided by inflating it with the minimum volume required to maintain an effective seal and by monitoring intracuff pressure if nitrous oxide is used. Percutaneous tracheostomy in children is still in the experimental stage. New and older devices to perform one-lung ventilation in children are also described.

Anesthetic management of pediatric patients undergoing thoracoscopy

ECENT IMPROVEMENTS in the instruments for R and the technique of video-assisted thoracoscopy in adults have resulted in increased use of thoracoscopy.l Reported advantages of thoracoscopy include smaller thoracic incisions, reduced postoperative pain, and faster postoperative recovery.2 The descriptions of anesthetic techniques used for thoracoscopy pertain only to adults.2-4 Because thoracoscopy is now used in the pediatric population,5,6 the detailed anesthetic management for thoracoscopy in nine pediatric patients, with emphasis on methods of one-lung ventilation in children, is reported.