Methods for Single-Lung Ventilation in Pediatric Patients

Hypoxemia in School-age Children Undergoing One-lung Ventilation: A Retrospective Cohort Study from the Multicenter Perioperative Outcomes Group

BACKGROUND

Risk factors for hypoxemia in school-age children undergoing one-lung ventilation remain poorly understood. The hypothesis was that certain modifiable and nonmodifiable 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 yr of age undergoing one-lung ventilation. Patients undergoing vascular or cardiac procedures were excluded. The original cohort was divided into two cohorts: 4 to 9 and 10 to 17 yr of age inclusive. All records were reviewed electronically for the primary outcome of hypoxemia during one-lung ventilation, which was defined as an oxygen saturation measured by pulse oximetry (Spo2) less than 90% for 3 min or longer continuously, while severe hypoxemia was defined as Spo2 less than 90% for 5 min or longer. Potential modifiable and nonmodifiable risk factors associated with these outcomes were evaluated using separate multivariable least absolute shrinkage and selection operator regression analyses for each cohort. The covariates evaluated included age, extremes of weight, American Society of Anesthesiologists Physical Status of III or higher, duration of one-lung ventilation, preoperative Spo2 less than 98%, approach to one-lung ventilation, right operative side, video-assisted thoracoscopic surgery, lower tidal volume ventilation (defined as tidal volume of 6 ml/kg or less and positive end-expiratory pressure of 4 cm H2O or greater for more than 80% of the duration of one-lung ventilation), and procedure type.

RESULTS

The prevalence of hypoxemia in the 4- to 9-yr-old cohort and the 10- to 17-yr-old cohort was 24 of 228 (10.5% [95% CI, 6.5 to 14.5%]) and 76 of 1,012 (7.5% [95% CI, 5.9 to 9.1%]), respectively. The prevalence of severe hypoxemia in both cohorts was 14 of 228 (6.1% [95% CI, 3.0 to 9.3%]) and 47 of 1,012 (4.6% [95% CI, 3.3 to 5.8%]). Initial Spo2 less than 98% was associated with hypoxemia in the 4- to 9-yr-old cohort (odds ratio, 4.20 [95% CI, 1.61 to 6.29]). Initial Spo2 less than 98% (odds ratio, 2.76 [95% CI, 1.69 to 4.48]), extremes of weight (odds ratio, 2.18 [95% CI, 1.29 to 3.61]), and right-sided cases (odds ratio, 2.33 [95% CI, 1.41 to 3.92]) were associated with an increased risk of hypoxemia in the older cohort. Increasing age (1-yr increment; odds ratio, 0.88 [95% CI, 0.80 to 0.97]) was associated with a decreased risk of hypoxemia.

CONCLUSIONS

An initial room air oxygen saturation of less than 98% was associated with an increased risk of hypoxemia in all children 4 to 17 yr of age. Extremes of weight, right-sided cases, and decreasing age were associated with an increased risk of hypoxemia in children 10 to 17 yr of age.

EDITOR’S PERSPECTIVE

Co-axial Endotracheal Tube Technique for Achieving One Lung Ventilation in a Toddler With a Space Occupying Malignant Tumor of the Right Lung

Achieving one-lung ventilation in pediatrics is often challenging. In caring for these patients, the anesthesiologist must consider the child's age and size, underlying tracheobronchial anatomy, equipment availability, urgency of procedure, and as well as the experience level of the anesthesiologist. This report describes a "tube-inside-tube" technique that was adopted for providing one-lung ventilation in a toddler. The method described here involved railroading a smaller endotracheal tube over a flexible intubation video endoscope into the left mainstem bronchus coaxially through a larger endotracheal tube placed in the trachea. The technique achieved effective left-lung ventilation and isolation of the operative right lung during surgical resection of a malignant mesenchymal tumor. On completion of the procedure, double-lung ventilation could be established through the endotracheal tube in the trachea after the retraction of the video endobronchial tube.

Paediatric pulmonary echinococcosis: A neglected disease

Echinococcosis is a worldwide public health problem causing considerable paediatric morbidity and mortality in endemic areas. The presentation of cystic echinococcosis (CE) varies by age. Unlike adults, where hepatic involvement is common, pulmonary CE is the dominant site in the paediatric population. Pulmonary cysts are typically first seen on chest X-ray, either as an incidental finding or following respiratory symptoms after cyst rupture or secondary infection of the cyst. In children, pulmonary cysts have a broad differential diagnosis, and a definitive diagnosis relies on the combination of imaging, serology, and histology. In countries with high infectious burdens from diseases such as acquired immunodeficiency syndrome (AIDS) and tuberculosis (TB), the diagnosis is additionally challenging, as atypical infections are more common than in developed countries. Pulmonary CE is treated with a combination of surgery and chemotherapy.

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

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 FiO₂and 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.

Life-threatening complications of streptococcal sepsis: a PICU contemporary series

Background

Life-threatening streptococcal sepsis nowadays represents an uncommon event in previously healthy infants and children. Critically ill patients suffering from severe streptococcal sepsis complications may present with pre-antibiotic era clinical pictures and require a timely clinical approach to achieve restitutio ad integrum.

Results

We report a series of four patient groups affected by an uncommon life-threatening streptococcal sepsis, each of them exhibiting some distinct features. Streptococcus Agalactiae sepsis was associated with cerebral thrombotic/ischaemic lesions, whereas severe cardiogenic shock was prominent in the Streptococcus Viridans group; Streptococcus Faecalis and β-hemolytic group A Streptococcus patients mostly reported lung complications.

Conclusions

Previous antibiotic treatments should not delay aggressive treatment in the intensive care setting. Early diagnostic suspicion, as well as appropriate and aggressive treatment provided within an intensive care setting are crucial for the clinical outcome.

Endobronchial Intubation to Facilitate Extraluminal Bronchial Blocker Placement in Young Children: A Retrospective Case Series

OBJECTIVES

Extraluminal bronchial blocker placement has become a well-accepted approach to one-lung ventilation in young children. In some cases, technical issues with placement may require alternative approaches to correct bronchial blocker positioning. The primary aim of this study was to review the authors' experience with using endobronchial intubation to facilitate extraluminal bronchial blocker placement in young children.

DESIGN

Single-center case series of pediatric patients undergoing thoracic surgery and one-lung ventilation using a bronchial blocker.

SETTING

Tertiary academic medical center.

PARTICIPANTS

Pediatric patients < three years of age undergoing thoracic surgery and one-lung ventilation who underwent bronchial blocker placement using endobronchial intubation to facilitate blocker placement. In all patients, the bronchial blocker was inserted through a selectively mainstemmed endotracheal tube to facilitate blocker positioning.

INTERVENTIONS

No interventions were performed.

MEASUREMENTS AND MAIN RESULTS

Fifteen patients were identified after a query of the local electronic health record. There were five right-sided and ten left-sided placements in this cohort. Bronchial blocker placement was successful in 14 of 15 patients using endobronchial intubation to facilitate bronchial blocker placement. In one patient, the bronchial blocker was discovered in the nonsurgical bronchus, following placement with this technique. The bronchial blocker was repositioned manually into the desired mainstem bronchus prior to lateral positioning.

CONCLUSIONS

Mainstem intubation can be used to facilitate bronchial blocker placement in young children and represents an alternative approach to extraluminal bronchial blocker placement.

Case reports of one-lung ventilation using Fuji Uniblocker bronchial blockers for infants under one-year-old in uniportal video-assisted thoracoscopic surgery

INTRODUCTION

Uniportal video-assisted thoracoscopic surgery (VATS) for various pulmonary diseases provides advantages of less postoperative pain and earlier post-operative recovery over traditional open surgery. The inherent limitation of this surgical modality in manipulation of surgical instruments renders intra-operative one-lung ventilation a requisite to increase the substantially restricted working space and thus visibility of the surgical filed.

PATIENT CONCERNS

Patient 1, an 8-month-old, 9-kg, and 70 cm-in-height male infant was diagnosed as congenital pulmonary airway malformation (CPAM) over left lower lobe.Patient 2, a 9-month-old, 8-kg and 72 cm-in-height male infant was diagnosed as CPAM over right lower lobe.Patient 3, an 8-month-old, 8-kg and 67 cm-in-height female infant was diagnosed as CPAM over left lower lobe.This facilitating one-lung ventilation yet was rarely conducted in infants under one year of age for the extremely small body size, the unavailability of dedicated tools, and therein the very tough techniques demanded.

DIAGNOSIS

Infants with congenital cystic adenomatoid malformation.

INTERVENTIONS

Here we report three infants of less than one year of age in whom one-lung ventilation was successfully achieved by intraluminal use of 5-Fr Fuji Uniblocker Bronchial Blocker devices and in turn assisted the completion of uniportal VATS for congenital cystic adenomatoid malformation in unilateral lungs.

OUTCOMES

Three infants received VATS under uniblocker smoothly. Patient 1 had two episode of balloon dislodgement and desaturation and solved by re-insertion. And he had subglottic tracheal stenosis which treatment with laser coagulation. Patient 2 had overall blood loss 80 ml. Patient 3 had one episode of desaturation after stapling the bronchus and fiberoptic bronchoscope revealed obstruction by blood and secretion which solved by suction.

CONCLUSION

In conclusion, OLV in infants undergoing uniportal VATs could be successfully achieved by Fuji 5 Fr Uniblocker bronchial blockers for as long as 4 hours, as exemplified by our three cases, and balloon poor sealing and dislodgment can be immediately solved by bronchoscope-guided re-positioning without compromising surgical proceeding or outcome.

Simulated dimensional compatibility of uncuffed and cuffed tracheal tubes for selective endobronchial intubation in children

BACKGROUND

Cuffed tracheal tubes have recently been recommended for selective endobronchial intubation to establish single-lung ventilation even in smaller children. This implies that, compared with uncuffed tracheal tubes, the cuffed tracheal tubes selected will be smaller and therefore have a shorter length. We hypothesized that cuffed tracheal tubes might be of insufficient length for selective endobronchial intubation if the tube cuff were fully immersed in the left or right mainstem bronchus.

METHODS

The distance from the proximal end of the tracheal tube to the upper border of the cuff in cuffed tracheal tubes and to the upper margin of the Murphy eye in uncuffed tracheal tubes, respectively, was assessed in sizes 3.0-7.0 mm internal diameter. The raw data sets of two previously performed studies obtained from 337 children aged from birth to 16 years, including the distances "teeth to tracheal tube tip" and "tracheal tube tip to carina," were used to calculate age-, weight-, and height-related data for the distance from "teeth to carina." Tracheal tube dimensions were compared with age-related distances from "teeth to carina," applying published recommendations for the selection of uncuffed and cuffed tracheal tubes for selective endobronchial intubation in children.

RESULTS

The differences between the length of the age-related tracheal tube and the tracheal tube insertion length required to guarantee full insertion of the tracheal tube cuff or the Murphy eye within the mainstem bronchus ranged from -3.5 to 52.6 mm in cuffed tracheal tubes and from 42.3 to 83.3 mm in uncuffed tracheal tubes.

CONCLUSIONS

For many age groups of patients requiring selective endobronchial intubation, the lengths of cuffed tracheal tubes, in contrast to those of uncuffed tracheal tubes, were revealed to be critically short for safe taping outside the oral cavity with the cuff placed completely within the right or left mainstem bronchus.

Airway management of congenital pulmonary airway malformation resection in neonates and infants: A case cohort study

BACKGROUND

Anesthestic management of congenital pulmonary airway malformation has not been well described in the literature. It is not clear whether one-lung ventialtion is indicated during thoracoscopic lobectomy and if so, what is the best technique achieve it.

AIMS

We describe the variables with the two commonly performed surgical techniques, thoracoscopic lobectomy and open thoracotomy, from our institutional database to assess the role of lung isolation and the preferable method of lung isolation technique for congenital pulmonary airway malformation resections.

METHODS

After institutional review board approval, fetal center records were reviewed retrospectively from January 2010 to July 2016 for patients who underwent congenital pulmonary airway malformation resection. The primary goal was to describe the anesthesia induction-airway management techniques with emphasis on one-lung ventilation techniques.

RESULTS

Among the 65 resections, one-lung ventilation was performed in 30 resections (46%) and was primarily achieved by endobronchial intubation in most cases (80%). One-lung ventilation was performed in a greater number of resections with thoracoscopic lobectomy (96%) compared to open thoracotomies.

CONCLUSION

From our institution cohort, one-lung ventilation was more commonly used during thoracoscopic resections and was most commonly achieved with endobronchial intubation. Most patients were induced with inhalational anesthesia (sevoflurane), nondepolarizing neuromuscular blocker, and gentle positive pressure ventilation for intubation.

Successful one-lung ventilation by blocking the right intermediate bronchus in a 7-year-old child: a case report

A 7-year-old child underwent surgical excision of a benign mesothelioma of the pleura near the right lower lung. Although insertion of a wire-reinforced endotracheal tube through the left main bronchus was attempted for one-lung ventilation to secure the surgical field of view, the attempt failed. Therefore, an endotracheal tube was inserted into the trachea, and an Arndt endobronchial blocker (Cook Medical, Bloomington, IN, USA) was placed in the right intermediate bronchus under bronchoscopic guidance to selectively block the right lower and middle lobes. The surgery was performed while ventilating the right upper lobe and left lung, and no specific intraoperative adverse events occurred.

Perioperative anesthetic management of children with congenital central hypoventilation syndrome and rapid-onset obesity with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation undergoing thoracoscopic phrenic nerve-diaphragm pacemaker implantation

BACKGROUND

Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation are rare neurocristopathies characterized by autonomic dysregulation including bradyarrhythmias, abnormal temperature control, and most significantly, abnormal control of breathing leading to tracheostomy and ventilator dependence as life support. Surgical advancements have made phrenic nerve-diaphragm pacemakers available, to eliminate the tether to a mechanical ventilator for 12-15 hours each day. The thoracoscopic approach to implantation has allowed for a less invasive approach which may have implications for pain control and recovery time. However, thoracoscopic implantation of these devices presents several challenges to the anesthesiologist in these complex ventilator-dependent patients, including, but not limited to, sequential lung isolation, prevention of hypothermia, and management of arrhythmias. Postoperative challenges may also include strategies to treat hemodynamic instability, managing the ventilator following lung derecruitment, and providing adequate pain control.

AIMS

We aimed to describe the anesthetic management of Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation patients undergoing thoracoscopic phrenic nerve-diaphragm pacemaker implantation and the nature and incidence of perioperative complications.

METHODS

A retrospective chart review was performed of 14 children with Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation undergoing phrenic nerve-diaphragm pacemaker implantation at a single academic pediatric hospital between 2009 and 2017. Demographic information, intraoperative management, and perioperative complications were analyzed from patient records.

RESULTS

Twelve of 14 patients (86%) underwent an inhalational induction via tracheostomy. Lung isolation was achieved via fiberoptic guidance of a single lumen endotracheal tube sequentially into the right or left mainstem bronchi for 12 patients (86%). Double lumen endotracheal tubes were utilized in two patients (7%) and bronchial blockers in two patients (7%) for lung isolation. Anesthesia was maintained using a balanced technique of volatile agents (sevoflurane/isoflurane) and opioids (fentanyl). Bradyarrhythmias developed in six patients (43%) during surgery, 5 (36%) responded to anticholinergics and one patient (7%) required backup cardiac pacing using a previously implanted bipolar cardiac pacemaker. Intraoperative hypothermia (<35.5°C) was present in five patients (36%) despite the use of warming devices. Hypercarbia (>50 mm Hg) during lung isolation was present in eight patients (57%) and hemoglobin desaturation (<90%) in four patients (29%). Postoperatively, oxygen desaturation was a common complication with nine patients (64%) requiring supplemental oxygen administration via mechanical ventilator or manual bag ventilation. Opioids via patient-controlled analgesia devices (12 patients, 86%) or intermittent injection (two patients, 14%) were administered to all patients for postoperative pain control. Phrenic nerve-diaphragm pacemaker placement was successful thoracoscopically in all patients with no perioperative mortality.

CONCLUSION

The main anesthetic challenges in patients with Congenital Central Hypoventilation Syndrome and Rapid-Onset Obesity with Hypothalamic dysfunction, Hypoventilation, and Autonomic Dysregulation include hemodynamic instability, the propensity to develop hypothermia, hypercarbia/hypoxemia, and the need to perform bilateral sequential lung isolation requisite to the thoracoscopic implantation technique. Most anesthetic agents can be used safely in these patients; however, adequate knowledge of the susceptibility to complications, coupled with adequate preparation and understanding of the innate disease characteristics, are necessary to treat anticipated complications.

Anesthetic management of thoracoscopic resection of lung lesions in small children

BACKGROUND

Video-assisted thoracoscopic surgery has dramatically increased over the last decade because of both medical and cosmetic benefits. Anesthesia for video-assisted thoracoscopic surgery in small children is more challenging compared to adults due to the considerable problems posed by small airway dimensions and ventilation. The optimal technique for one-lung ventilation has yet to be established and the use of remifentanil infusion in this setting is not well described.

AIMS

This study investigated the use of extraluminal bronchial blocker placement for one-lung ventilation and the effect of infusion of remifentanil in infants and small children undergoing video-assisted thoracoscopic surgery.

METHODS

We retrospectively reviewed the technique of one-lung ventilation and the hemodynamic effects of remifentanil infusion in 31 small children during elective video-assisted thoracoscopic surgery for congenital lung lesions under anesthesia with sevoflurane or isoflurane, oxygen, and air. Patients' heart rate, blood pressure, and endtidal carbon dioxide at baseline (after induction of anesthesia), immediately after one-lung ventilation, during carbon dioxide insufflation, and at the end of one-lung ventilation were extracted from the database and analyzed. The use of vasopressors or dexmedetomidine was also recorded and analyzed.

RESULTS

Extraluminal placement of a bronchial blocker alongside the tracheal tube was successfully performed in 90.3% of cases (28 patients) without any serious complications or arterial oxygen desaturation. There was no significant rise in blood pressure or heart rate even with the rise of endtidal carbon dioxide concentration during video-assisted thoracoscopic surgery. In 58% of patients (18 patients), phenylephrine was administered to maintain the blood pressure within 20% of the baseline value. There was no significant change in the heart rate of all patients at each time point.

CONCLUSION

One-lung ventilation with an extraluminal parallel blocker was used effectively in this series of young children undergoing thoracoscopic excision of congenital pulmonary lesions. Remifentanil infusion attenuated surgical stress effectively in infants and small children undergoing video-assisted thoracoscopic surgery.

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

BACKGROUND

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 2 years.

METHODS

The medical records of all children under the age of 2 years 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.

RESULT

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.

CONCLUSIONS

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 2 years.

Thoracoscopic Lobectomy for Congenital Lung Lesions

Congenital lung lesions (CLLs) comprise a heterogeneous group of developmental and histologic entities often diagnosed on screening prenatal ultrasound. Most fetuses with CLL are asymptomatic at birth; however, the risk of malignancy and infection drives the decision to prophylactically resect these lesions. The authors describe their approach to minimally invasive lobectomy in children with CLLs, postoperative care, and management of procedure-specific complications.

Alternative methods of lung isolation in cases of pediatric bilateral thoracoscopic surgery

We compare airway management and lung isolation methods in two pediatric cases of congenital central hypoventilation syndrome undergoing bilateral throacoscopic phrenic-nerve-stimulator surgery. One child received lung isolation using a 7Fr bronchial blocker in conjunction with a 6.0 cuffed endotracheal tube; and the second received a technique of endobronchial intubation using a 3.5 microcuffed tube via the tracheostomy stoma in conjunction with 5.0 cuffed endotracheal intubation; a technique previously undescribed in pediatric patients.

Rigid Bronchoscopic Placement of Fogarty Catheter as a Bronchial Blocker for One Lung Isolation and Ventilation in Infants and Children Undergoing Thoracic Surgery: A Single Institution Experience of 27 Cases

One-lung ventilation (OLV) is a challenging task in infants and children as few techniques are possible because of narrow anatomy. The aim of this study is to evaluate and experience lung isolation with Fogarty catheters as a bronchial blocker placed by rigid bronchoscope for OLV in infants and children with lung pathologies requiring surgical management in an industrial hospital. This study is a prospective study carried out in J.L.N. Hospital and Research Centre, Bhilai (CG), from January 2011 to December 2014. The study was designed to place Fogarty catheter for achieving OLV using rigid bronchoscope in children. The patient and anaesthesia characteristics, placement and positioning of Fogarty catheters, intraoperative course, complications and recovery of the patient were studied. The data were then compared with the relevant and available literature. Over the study period of 4 years, 27 cases were included, out of which 22 (81.48 %) cases had suppurative lung disease, three cases (11.11 %) had hydatid cyst of the lung, whereas one case (3.7 %) each of congenital lobar emphysema and congenital cystic adenomatoid malformation of the lung, respectively. In all cases general anaesthesia was provided using single lumen endotracheal tube and one lung ventilation achieved by parallel placement of Fogarty catheter as a bronchial blocker with rigid bronchoscope. The surgical management included thoracotomy with decortication in 21 cases, thoracotomy with excision of hydatid cyst in 3 cases, video-assisted thoracoscopic surgery, thoracotomy with left upper lobectomy and thoracotomy with left lower lobectomy in one case each, respectively. There were no major intraoperative and postoperative complications. There was no mortality in our study. We conclude that rigid bronchoscope can be safely and effectively used to place Fogarty catheter in main bronchus in infants and children for achieving OLV.

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.

Anesthetic management for thoracic surgery in Rubinstein-Taybi syndrome

Rubinstein-Taybi syndrome (RTS) is a chromosomopathy associated to molecular mutations or microdeletions of chromosome 16. It has an incidence of 1:125,000-700,000 live births. RTS patients present craniofacial and thoracic anomalies that lead to a probable difficult-to-manage airway and ventilation. They also present mental retardation and comorbidity, such as congenital cardiac defects, pulmonary structural anomalies and recurrent respiratory infections, which increase the risk of aspiration pneumonia. Cardiac arrhythmias have been reported after the use of certain drugs such as succinylcholine and atropine, in a higher incidence than in general population. There is an increased risk of postoperative apnea-hypopnea in these patients. We report the anesthetic management in a RTS patient undergoing emergent thoracic surgery due to oesophageal perforation and mediastinitis. Lung isolation was achieved with a bronchial blocker guided with a fiberoptic bronchoscope and one-lung ventilation was performed successfully.

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.

The neonatal lung--physiology and ventilation

This review article focuses on neonatal respiratory physiology, mechanical ventilation of the neonate and changes induced by anesthesia and surgery. Optimal ventilation techniques for preterm and term neonates are discussed. In summary, neonates are at high risk for respiratory complications during anesthesia, which can be explained by their characteristic respiratory physiology. Especially the delicate balance between closing volume and functional residual capacity can be easily disturbed by anesthetic and surgical interventions resulting in respiratory deterioration. Ventilatory strategies should ideally include application of an 'open lung strategy' as well avoidance of inappropriately high VT and excessive oxygen administration. In critically ill and unstable neonates, for example, extremely low-birthweight infants surgery in the neonatal intensive care unit might be an appropriate alternative to the operating theater. Best respiratory management of neonates during anesthesia is a team effort that should involve a joint multidisciplinary approach of anesthetists, pediatric surgeons, cardiologists, and neonatologists to reduce complications and optimize outcomes in this vulnerable population.

Severe desaturation while attempting one-lung ventilation for congenital cystic adenomatoid malformation with respiratory distress syndrome in neonate -A case report-

There are many methods for achieving one-lung ventilation (OLV) during thoracic surgery in neonates and the accuracy of OLV may affect postoperative outcome. The authors have performed OLV using a 5 Fr Arndt endobronchial blocker (AEB, Cook Inc., Bloomington, IN, USA) on a neonate diagnosed with congenital cystic adenomatoid malformation and respiratory distress syndrome (RDS) associated with marked mediastinal shift. In spite of sufficient preoxygenation, sudden and severe fall in oxygen saturation had occurred. Since neonates with RDS may develop sudden and severe desaturation, rapid intubation with anticipation of potential difficulty is necessary as well as sufficient preoxygenation.

CT features of lymphobronchial tuberculosis in children, including complications and associated abnormalities

BACKGROUND

Lymphobronchial tuberculosis (TB) is tuberculous lymphadenopathy involving the airways, which is particularly common in children.

OBJECTIVE

To describe CT findings of lymphobronchial TB in children, the parenchymal complications and associated abnormalities.

MATERIALS AND METHODS

CT scans of children with lymphobronchial TB were reviewed retrospectively. Lymphadenopathy, bronchial narrowing, parenchymal complications and associations were documented.

RESULTS

Infants comprised 51% of patients. The commonest site of lymphadenopathy was the subcarinal mediastinum (97% of patients). Bronchial compression was seen in all children (259 bronchi, of these 28% the bronchus intermedius) with severe or complete stenosis in 23% of affected bronchi. Parenchymal complications were present in 94% of patients, including consolidation (88%), breakdown (42%), air trapping (38%), expansile pneumonia (28%), collapse (17%) and bronchiectasis (9%), all predominantly on the right side (63%). Associated abnormalities included ovoid lesions, miliary nodules, pleural disease and intracavitary bodies.

CONCLUSION

Airway compression was more severe in infants and most commonly involved the bronchus intermedius. Numerous parenchymal complications were documented, all showing right-side predominance.

Congenital lobar emphysema in neonates: Anaesthetic challenges

Congenital lobar emphysema (CLE) is a potentially reversible, though possibly life-threatening, cause of respiratory distress in the neonate. It poses dilemma in diagnosis and management. We are presenting a 6-week-old baby who presented with a sudden onset of respiratory distress related to CLE affecting the left upper lobe. Lobectomy was performed under general anaesthesia with one lung ventilation. The details of anaesthetic challenges and management are described here.

Fluoroscopic-assisted endobronchial intubation for single-lung ventilation in infants

OBJECTIVE

Review our institutional experience with an alternative to fiberoptic-guided endobronchial intubation.

AIM

The aim of this retrospective cohort study was to present our experience with the use of fluoroscopy to facilitate endobronchial lung isolation in infants undergoing thoracoscopic procedures.

BACKGROUND

Anesthesiologists are more frequently being asked to anesthetize infants and small children for thoracoscopic surgery. Typically, endobronchial intubation or bronchial blockers are utilized to achieve lung isolation during these procedures. However, sometimes small and complicated anatomy can make this challenging.

METHODS

Respective chart review over a 13-month period of infants undergoing thoracoscopic excision of congenital lung lesions at the Children's Hospital of Philadelphia. Rate of success in achieving lung isolation along with time of fluoroscopy exposure were recorded.

RESULTS

Twenty infants had thoracoscopic lung surgery attempted during the period of the review. Lung isolation was successfully achieved in all of the patients. The average exposure to fluoroscopy was 83.7 s (range 20-320 s).

CONCLUSIONS

Fluoroscopic aided lung isolation is a reliable and effective alternative method to the use of fiberoptic bronchoscope for endobronchial intubation in infants.

Management of traumatic tracheobronchial separation in a teenager using a fabricated extra-long endotracheal tube

Tracheobronchial separation (TBS) due to blunt chest trauma in children is extremely rare. We report the case of a 14-year-old boy who fell 20 feet and developed respiratory distress, bilateral pneumothoraces, pneumomediastinum, and subcutaneous emphysema. Computed tomography imaging at the initial institution failed to detect tracheobronchial disruption, and the patient was managed conservatively. The patient's worsening condition prompted bronchoscopic examination which revealed complete separation of the right main bronchus from the trachea. Single-lung ventilation was instituted using a fabricated extra-long nasotracheal tube due to the patient's large size and mandibular fracture, and the airway was primarily anastamosed with an open thoracotomy approach. The clinical features of tracheobronchial separation as well as anesthetic, clinical and surgical management of this rare but life-threatening injury are described.

The design of pediatric tracheal tubes

Differences in the anatomy and physiology of the young child necessitate specialist equipment and anesthetic equipment is constantly evolving. We will review the factors influencing the design of pediatric tubes and highlight those areas of special interest. There have been pleas for more standardization of tube markings, as this would help with positioning of tubes, especially in small babies, and there are recent advances in this area. Anesthetists need to be aware that there are important differences between tubes so that they take this into account when choosing an appropriate tube. In addition, developments in the design of cuffed tubes are increasingly being used both for routine care and specialist surgery.

Thoracoscopic bleb resection using two-lung ventilation anesthesia with low tidal volume for primary spontaneous pneumothorax

BACKGROUND

We performed thoracoscopic surgery for pneumothorax using two-lung ventilation with low tidal volume and evaluated the feasibility and safety of this procedure.

METHODS

Forty-six patients (mean age, 23.6 +/- 10.47 years) each with a primary spontaneous pneumothorax underwent wedge resection with chemical and mechanical pleurodesis. Two-lung ventilation anesthesia was performed with a single-lumen endotracheal tube, and the tidal volume was reduced to 4 mL/kg; the respiratory rate was increased to 24 cycles/min. Airway pressure, end-tidal CO(2), and the results of blood gas analysis were obtained right after endotracheal intubation and during the operation, and were compared.

RESULTS

The tidal volume was 496.2 +/- 94.33 mL at anesthesia induction, which decreased to 243.9 +/- 34.43 mL during the two-lung ventilation. In 5 patients, the tidal volume was additionally decreased by 32.5 +/- 12.58 mL (p = 0.014) to obtain an optimal working field. The differences between the airway pressure, pH, partial pressure of carbon dioxide, and partial pressure of oxygen were significant between the two measurement times. However, all of the values of the arterial blood gas analysis were within normal range. The oxygen saturation (99.9% +/- 0.69% versus 99.8 +/- 0.72%; p = 0.160) and end-tidal CO(2) (33.2 +/- 3.74 mm Hg versus 34.1 +/- 4.19 mm Hg; p = 0.157) were not significantly different. The time from intubation before the incision was 17.1 +/- 4.18 minutes, the operation time was 31.9 +/- 14.48 minutes, and the total anesthesia time was 65.8 +/- 15.02 minutes.

CONCLUSIONS

Thoracoscopic surgery for primary spontaneous pneumothorax using two-lung ventilation with low tidal volume was technically feasible.

[Scoliosis surgery in children from the viewpoint of anaesthesiology]

Anaesthesia for scoliosis surgery in children is a challenge for the paediatric anaesthesiologist. The large range of underlying pathologies causing deranged physiology in an inhomogeneous patient group ranging from neonates to adolescents necessitates diligent and individual preparation for each case. Due to the invasiveness of the operation demanding anaesthetic care is necessary. This review highlights current approaches to monitoring, anaesthetic regimen, positioning of the patient, blood conservation and transfusion, age-related pathophysiology, ventilation and postoperative pain therapy. The introduction of neurophysiologic spinal cord monitoring requires certain adaptations of the anaesthetic regimen to suit technological advances.

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.