Departments of Anesthesiology and Surgery at the David Geffen School of Medicine at UCLA, Los Angeles, CA 90095, USA
* Corresponding author. E-mail: swald{at}mednet.ucla.edu
Accepted for publication August 26, 2004.
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Abstract |
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Keywords: children ; equipment, tubes endobronchial ; lung, bronchus ; surgery, thoracic ; ventilation, one-lung
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Introduction |
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Techniques for single lung ventilation in children have included the use of double lumen endobronchial tubes or Univent tubes, endobronchial intubation with a standard tracheal tube, use of a Fogarty catheter as a bronchial blocker, collapse of the surgical lung by insufflation of carbon dioxide (during thoracoscopy), or lung retraction. These options all have their individual limitations and none is entirely satisfactory.36
We report our experience with the use of a new device, the Arndt 5 French (Fr) paediatric endobronchial blocker,for single lung ventilation in the first large series of children.
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Case series |
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In each case, the blocker and the fibreoptic scope were placed through their respective ports in the multi-port airway adapter provided. The inner filament at the end of the blocker was then looped over the fibreoptic scope and the adapter was connected to the tracheal tube and breathing circuit. The fibreoptic scope was advanced under videoscopic guidance into the desired mainstem bronchus and then the blocker was advanced past the fibreoptic scope. The balloon was then inflated under fibreoptic visualization, the scope removed, and the bronchial port was tightened (Fig. 1).
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We were able to achieve single lung ventilation in 23 of the 24 patients. Seven bronchial blockers were placed in the right mainstem bronchus and 16 were placed in the left. Placement required approximately 515 min. In one patient the insertion was aborted because of rapid desaturation during attempts at placement. The patient was a 3-yr-old boy with a bilateral pneumonia undergoing lung decortication who was unable to tolerate any period of apnoea.
In three cases during surgical manipulation of the tracheo-bronchial tree, the blocker became dislodged into the trachea. This malpositioning caused an immediate increase in peak inspiratory pressure and decrease in end-tidal carbon dioxide. The blocker was simply advanced under fibreoptic guidance back into a mainstem bronchus.
Except for the child noted above, there were no immediate complications from blocker placement.
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Discussion |
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We have found several benefits in using the Arndt 5 Fr paediatric bronchial blocker and we were able to achieve consistent lung isolation using standard tracheal tubes in a short period of time. It has been useful in small children with a balloon designed for bronchial blockade and can easily be directed to either bronchus. Use of this bronchial blocker in young children may require a fibreoptic scope of less than 2.0 mm for use with a 4.5-mm I.D. tracheal tube; alternatively, a 2.2- or 2.8-mm scope may be used with larger tracheal tubes.
This paediatric bronchial blocker has its limitations. There may be a period of decreased ventilation during placement. The fibreoptic port is larger than the scope to allow easy advancement, however, this results in a significant leak during positive pressure ventilation. We suggest tightening the blocker port slightly during fibreoptic advancement to decrease any additional loss of tidal volume. To lessen the need for re-placement, the blocker may be inserted after the child is in the lateral position.
It may be difficult to block the right upper lobe with a right-sided blocker. The early take-off of the right upper lobe bronchus may be so high that the balloon would have to be partially in the trachea to block ventilation to that lobe and require a left mainstem bronchus intubation, instead.
Finally, the smallest tracheal tube recommended for use with this paediatric bronchial blocker is 4.5-mm ID, limiting the use of this technique in the very young (<1 yr). Some children may have an intrapulmonary disease process, which may not allow for any period of hypoventilation during blocker insertion or single lung ventilation.
Existing methods for single lung ventilation are either impossible to use in small children (double lumen endobronchial tubes) or inconsistently successful (Fogarty catheter, endobronchial intubation).4 The narrow airways of children under 8 yr old or less than 30 kg in weight preclude placement of a double lumen endobronchial tube as the smallest size available is a 26 Fr. The smallest Univent tube has a large outer diameter (8 mm OD) and narrow inner diameter (3.5 mm ID) limiting its use to an older age group. Endobronchial intubation may only inconsistently provide lung isolation, may only provide partial lung isolation, or may require re-adjustment to the trachea, risking extubation.3 A Fogarty catheter is not designed for use in the airway, as it is equipped with a high-pressure, low-volume balloon; it may be difficult to secure and does not have a lumen for application of continuous positive airway pressure.
Our experience suggests that the paediatric bronchial blocker can be used as a consistent, safe method of single lung ventilation in most young children.
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References |
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