An Update on One-Lung Ventilation in Children

Abstract

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.

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

“…22,23 Additionally, the increased compliance of the rib cage leads to reduced dependent lung volume. 5 These factors, combined with the increased rate of oxygen consumption and technical issues associated with lung isolation in small children, likely contribute to this increased risk of hypoxemia.…”

“…These secretions can cause partial and sometimes complete obstruction of the endotracheal tube. 5 Bronchial blockers, when used correctly, should completely occlude the mainstem bronchus as the balloon cuff conforms to the shape of the bronchus, preventing leakage of debris into the ventilated side. Also, complete occlusion of the operative lung via the occlusive balloon of the bronchial blocker may enhance hypoxic vasoconstriction as no air is entering the operative lung, thus improving ventilation/ perfusion matching overall.…”

Lung-protective Ventilation Combined With Pressure-controlled Ventilation Volume-guaranteed in Children Undergoing One-lung Ventilation: A Randomised Controlled Trial

“…Finally, the lungs were re-expanded manually with sustained in ation with 20-30 cmH 2 O of positive airway pressure for 10-15 s under direct observation. 9,10 Anaesthesia was maintained using propofol 5-8 mg kg − 1 h − 1 to maintain the BIS (Philips Healthcare, Andover, MA) at 40-60 and remifentanil 0.1-0.4 ug kg − 1 min − 1 to maintain haemodynamic stability, and rocuronium 0.3-0.6 mg kg − 1 h − 1 was maintained. Crystalloid solutions (6-8 ml kg − 1 h − 1 ) were used as maintenance uids intra-operatively.…”

“…The four levels of aeration in LUS examination were classi ed as follows: N = 0, B1 = 1, B2 = 2, and C = 3. 10,11 Statistical analysis Data are expressed as n (%), mean ± SD, or median (IQR) depending on the distribution of the data.…”

Congenital anomalies of the large intrathoracic airways

“…Patients with lobar emphysema should undergo a thorough pre- Pleuropulmonary blastoma is a very rare embryonic tumor of the lung or pleura predominantly observed in children. 3,20 The lesion is believed to be a manifestation of the DICER1 syndrome, a rare genetic disorder that predisposes individuals to multiple cancer types through mutations in the translation of genes encoding endoribonucleases. Four different types of pleuropulmonary blastoma have been characterized based on their appearance (cystic or solid) and degree of malignancy.…”