Anesthetic management of pediatric patients undergoing thoracoscopy

Anesthesia management in neonatal congenital bronchobiliary fistula: case report and literature review

Background

There is very little published literature and none that discussed care in a neonate regarding anesthetic risk and management of neonate with congenital bronchobiliary fistula during thoracoscopy and thoracotomy. This article analyzes related risk factors and literature review from perioperative ventilation, circulation and other aspects of management.

Case presentation

A neonate diagnosed as congenital bronchobiliary fistula combined with severe chemical pneumonia, consolidation of the lungs, and infection was facing the risk of anaesthesia under thoracoscopy exploration surgery, who experiened more than 20 days diagnostic period before operation. Many risk factors have led to conversion from minimally invasive surgery to thoracotomy, including persistent hypoxemia, hypercapnia, difficult surgical exposure and extremly difficulty of intraoperative ventilation management. Anesthesia maintenance after conversion to open access remained problematic. Fortunately the patient showed no sign of any adverse CNS effects after 4 months of follow-up.

Conclusions

The most prominent anesthesia challenges are hypoxemia, increased airway resistance, impaired ventilation, and the risk of metabolic acidosis. Close cooperation among the entire neonatal medical team is the key factors in successful management of this rare case.

Cricoid and left bronchial diameter in the pediatric population

BACKGROUND

Lung isolation in the pediatric population can be problematic. The diameter and length of the right and left mainstem bronchi are not well described in young children. Information regarding these measurements may help determine the appropriate size of endotracheal tubes for endobronchial intubation as well as the development of lung isolation devices for the pediatric population. The present study is based on computed tomography (CT) measurements to evaluate airway dimensions. The goal of this study was to define the relationship between the diameters of the left mainstem bronchus (LMSB) and the cricoid ring, and to study the effect of age, weight, and height on these dimensions.

METHODS

The two-dimensional CT images of 102 children, ranging in age from 1 month to 10 years, undergoing radiological evaluation unrelated to airway symptomatology were examined. The cricoid dimensions (anteroposterior and transverse diameters) were measured using transverse plane images. The LMSB diameter was measured below the carina along the long axis of left main bronchus. Univariate regression analysis was used to determine whether one or more of the variables (age, gender, height, weight) had a predictable relationship with the cricoid and the LMSB diameters.

RESULTS

The cricoid as well as the LMSB diameters increase with age, height, and weight. The relationship between the cricoid diameter and the LMSB diameter remains constant across all ages with a ratio of 0.78 ± 0.14. This ratio was slightly larger for girls than boys (0.81 ± 0.16 vs 0.77 ± 0.13).

CONCLUSION

The cricoid to LMSB ratio (relationship) remains constant with respect to age, height, and weight.

Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years

BACKGROUND

One-lung ventilation (OLV) is frequently employed to improve surgical exposure during video-assisted thoracoscopic surgery (VATS) and thoracotomy in adults and children. Because of their small size, children under the age of 2 years are not candidates for some of the methods typically used for OLV in adults and older children, such as a double-lumen endotracheal (DLT) tube or intraluminal use of a bronchial blocker. Due to this, the clinician is left with few options. One of the most robust approaches to OLV in infants and small children has been the extraluminal placement of a 5 French (5F) Arndt endobronchial blocker (AEB).

AIM

The aim of this retrospective study was to examine and describe our experience with placement and management of an extraluminal 5F AEB for thoracic surgery in children <2 years of age.

METHODS

We retrospectively examined the anesthetic records for details of AEB placement, arterial blood gas (ABG) data, and intraoperative analgesic prescription in 15 children under the age of 2 years undergoing OLV with a 5F AEB for thoracic surgery at our institution from January 2010 through January 2016.

RESULTS

We were able to successfully achieve lung isolation in 14 of 15 patients using a 5F AEB that was bent 35-45° 1.5 cm proximal to the inflatable cuff. In 13 of 15 patients, we were able to place the AEB into final position with the aid of video-assisted fiberoptic bronchoscopy. In two patients, fluoroscopy was required to place the 5F AEB into the left mainstem due to poor visualization of the carina and rapid desaturation during bronchoscopy. In one of these patients, even though the blocker appeared to be correctly placed by fluoroscopy, adequate lung isolation was not observed. Intraoperatively, we observed significant degrees of hypercarbia in most patients without oxygen desaturation. Analgesic regimens lacked consistency and varied among patients. Open thoracotomy procedures tended to receive more aggressive narcotic regimens than video-assisted thoracoscopic surgery (VATS) procedures. Fourteen of 15 patients were extubated in the immediate postoperative period.

CONCLUSIONS

Our technique of placing a 35-45° bend in the AEB, extraluminal placement, and observed manipulation with a video-assisted flexible fiberoptic bronchoscope (FFB) within the trachea can be used to achieve consistent lung isolation in patients <2 undergoing thoracic surgery. When the use of a FFB proves unsuccessful, fluoroscopy can provide an alternative solution to successful placement. Significant respiratory derangements without long-term sequelae will occur in a majority of these patients during OLV. Several different approaches to intraoperative analgesia did not impede extubation in the early postoperative period.

Lung isolation, one-lung ventilation and hypoxaemia during lung isolation

Lung isolation is being used more frequently in both adult and paediatric age groups due to increasing incidence of thoracoscopy and video-assisted thoracoscopic surgery in these patients. Various indications for lung isolation and one-lung ventilation include surgical and non-surgical reasons. Isolation can be achieved by double-lumen endotracheal tubes or bronchial blocker. Different issues arise in prone and semi-prone position. The management of hypoxia with lung isolation is a stepwise drill of adding inhaled oxygen, adding positive end-expiratory pressure to ventilated lung and continuous positive airway pressure to non-ventilated side.

One lung ventilation strategies for infants and children undergoing video assisted thoracoscopic surgery

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 children. This article aims to provide an updated and comprehensive review on one-lung ventilation strategies for infants and children undergoing VATS. Search of terms such as ‘One lung ventilation for infants and children’, ‘Video assisted thoracoscopic surgery for infants and children’, and ‘Physiologic changes during one lung ventilation for infants and children’ were used. The search mechanics and engines for this review included the following: Kandang Kerbau Hospital (KKH) eLibrary, PubMed, Ovid Medline, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. During the search the author focused on significant current and pilot randomized control trials, case reports, review articles, and editorials. Critical decision making on what device to use based on the age, weight, and pathology of the patient; and how to use it for lung isolation are discussed in this article. Furthermore, additional information regarding the advantages, limitations, techniques of insertion and maintenance of each device for one lung ventilation in infants and children were the highlights in this article.

Fluoroscopic guidance of Arndt endobronchial blocker placement for single-lung ventilation in small children

BACKGROUND

Thoracoscopic surgery may require single-lung ventilation (SLV) in infants and small children. A variety of balloon-tipped endobronchial blockers exist but the placement is technically challenging if the size of the tracheal tube does not allow the simultaneous passage of the fibreoptic scope and the endobronchial blocker. This report describes a technique for endobronchial blocker insertion using fluoroscopic guidance in children undergoing SLV.

METHODS

After approval from the local Medical Ethics Committee and parental consent, 18 patients aged 2 years or younger scheduled for thoracic surgery requiring SLV were prospectively included. Following induction of anesthesia, a 5 Fr endobronchial blocker (Cook) Arndt endobronchial blocker) was inserted first into the trachea under direct laryngoscopy. Correct placement in the main bronchus was assessed by fluoroscopy and tracheal intubation next to the endobronchial blocker. Optimal position and balloon inflation was verified using a fibreoptic scope. The duration and number of insertion attempts as well as age, weight and size of the tracheal tube were recorded.

RESULTS

Eighteen patients were studied. Median (range) age and weight were 12 (0.2-24) months and 11.2 (4-15) kg, respectively. SLV was successfully achieved in all patients using a 5 Fr endobronchial blocker outside a 3.5-4.5 mm ID tracheal tube within 11.2 (+/-2.2) min. No side effects were observed during the procedure.

CONCLUSION

Fluoroscopic-guided insertion of extraluminal endobronchial blocker is an effective and reliable tool to place Arndt endobronchial blockers in small children.

Pediatric thoracic anesthesia

PURPOSE OF REVIEW

Surgical interventions, including video-assisted thoracoscopic surgeries, are increasingly being performed in the neonatal and pediatric populations. Thoracic anesthesia in infants and children poses special challenges for the anesthesiologist. These include assessment of the patient's clinical condition, obtaining and maintaining single lung ventilation, and maintaining adequate ventilation and oxygenation while the surgery is in progress.

RECENT FINDINGS

This review will outline the anesthetic management of infants and children undergoing thoracic surgery, including preoperative assessment, and anesthetic induction and maintenance. The physiology and methods of single lung ventilation will be reviewed, including the use of bronchial blockers, Univent tubes and double-lumen tubes. Special considerations for video-assisted thoracoscopic surgery, pectus repair and mediastinal masses will be discussed.

SUMMARY

These techniques will provide the anesthesiologist with a number of strategies for assessing the pediatric thoracic patient and for managing pediatric single lung ventilation.

Single-lung ventilation in infants and children

During the past decade, the use of video-assisted thoracoscopic surgery (VATS) has dramatically increased in children as well as adults. Although VATS can be performed while both lungs are being ventilated, single-lung ventilation (SLV) is desirable during VATS. In addition, anaesthesiologists are performing (and paediatric surgeons are requesting) SLV more frequently for open thoracotomies in infants and children.

Pediatric thoracic anesthesia

The anesthesiologist caring for infants and children undergoing thoracic surgery faces many challenges. An understanding of the primary underlying lesion as well as associated anomalies that may impact perioperative management is paramount. A working knowledge of respiratory physiology and anatomy in infants and children is required for the planning and execution of appropriate intraoperative care. Familiarity with a variety of techniques for SLV suited to the patient's size will allow maximal surgical exposure while minimizing trauma to the lungs and airways. Finally, use of regional anesthetic techniques, including epidural anesthesia and analgesia, facilitates optimal postoperative pain control and pulmonary function.

Anaesthesia for minimally invasive surgery in children

There continues to be an increase in the applications of minimally invasive surgical techniques in infants and children. This increase includes their use for new surgical procedures as well as their application in younger patients including neonates. As with any new surgical procedure, specific modifications of the anaesthetic technique may be necessary. This chapter reviews (1) the pre-operative evaluation of infants and children scheduled for minimally invasive surgery; (2) techniques for pre-medication and anaesthetic induction; (3) intra-operative anaesthetic implications of laparoscopy, including the cardiorespiratory consequences of CO2 pneumoperitoneum; (4) intra-operative anaesthetic implications of thoracoscopy, including techniques for one-lung ventilation (OLV); and (5) post-operative issues, including pain management and monitoring of cardiorespiratory function as they apply to the patient of paediatric age.

Single lung ventilation in children using a new paediatric bronchial blocker

As video-assisted thoracoscopic surgery has become more common in paediatric patients, the use of single lung ventilation in children has also increased. Single lung ventilation in young children is performed by either advancing a tracheal tube into the mainstem bronchus opposite the side of surgery or by positioning a bronchial blocker into the mainstem bronchus on the operative side. Techniques for placing a variety of bronchial blockers outside the tracheal tube have been described. We describe a technique for placement of a new bronchial blocker through an indwelling tracheal tube using a multiport adaptor and a fibreoptic bronchoscope.

Video-assisted thoracic surgical procedures in children

The general principles and current applications of pediatric video-assisted cardiothoracic surgery (PVACTS) are reviewed. The purpose of PVACTS is to improve surgical quality and precision in selected operations. In the 1990s PVACTS has expanded to include the management of a variety of pulmonary, mediastinal, and cardiac lesions. Currently, PVACTS is carried out using a video camera connected to a low-profile scope and a specialized set of surgical instruments. PVACTS is an accepted modality for the diagnosis (by biopsy) of pleuropulmonary and mediastinal disease, and the treatment of pediatric empyema, spontaneous pneumothorax, and mediastinal cysts. Diaphragmatic plication, repair of chylous leak, and ligation of collateral vessels have all been done using PVACTS. PVACTS patent ductus arteriosus (PDA) ligation and vascular ring repair are being successfully carried out in several institutions. The technique at The Children's Hospital of Philadelphia is described. Indications and techniques for PVACTS lobectomy and pneumonectomy are less well established. Suggested anecdotal methods are described. Cardioscopy carries the hope of improving intracardiac repair, and has been applied to several lesions. The future of PVACTS depends on the surgeon's willingness to master it, industry's willingness to customize instruments for pediatric use, and developments in the fields of virtual imaging and augmented reality. Copyright 1998 by W.B. Saunders Company

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.

DESIGN

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 (F(I)O2), 0.5; inspiratory-to-expiratory (I: E) ratio, 1:2; and 10 mL/kg tidal volume during two-lung ventilation (TLV). F(I)O2 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.

Ventilation strategy for video-assisted thoracoscopic clipping of patent ductus arteriosus in children

Video-assisted endoscopic techniques have reduced operative trauma in adult thoracic and general surgery but its application in children with congenital heart disease has been limited. We report the use of video-assisted thoracoscopic (VAT) technique of clipping patent ductus arteriosus (PDA) in children. Forty patients with PDA were divided into two groups: during VAT surgery patients in group A [mean age=3.6 +/- 2.4 (SD) years] were managed with right main stem bronchial intubation and those in the group B [mean age=3.7 +/- 2.7 (SD) years] received low tidal volume-high frequency ventilation using a Siemens 900C ventilator. The mean oxygen saturation (SpO2) observed during the surgical intervention was significantly lower in group A (90%) compared to group B (96.8%) while the surgical convenience was not different. We conclude that a low tidal volume-high frequency ventilation is acceptable and safe in patients with PDA undergoing VATS.

Use of the laryngeal mask for placement of a bronchial blocker in children

For one-lind ventilation in children, a bronchial blocker (e.g. Fogarty catheter) is often used, but its insertion may not be easy. We report a new method of placement of a bronchial blocker in an infant, using the laryngeal mask.

The Univent tube for single-lung ventilation in paediatric patients

A Univent bronchial blocker tube was used in a ten-year-old patient undergoing videothoracoscopy. Paediatric Univent tubes offer an alternative to balloon-tipped catheters for providing single-lung ventilation (SLV) in children too small for adult size double-lumen tubes.