Anesthetic management of thoracoscopic resection of lung lesions in small children

Abstract

Summary 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.

Dimensional compatibility of balloon‐tipped bronchial blockers with the pediatric airway anatomy using different recommendations for age‐related size selection

“…The main finding of this study is that the maximal outer balloon experience is limited to retrospective case series using the Arndt endobronchial blockers, [13][14][15][16] Fogarty catheters, 8,17 or a combination of these. 18 Stephenson and Seefelder published on the successful use of the 5 F Arndt endobronchial blocker in 26 patients aged from 2…”

“…to 24 months using extra-luminal placement of the catheter and endoscopically controlled inflation. 13 18 Since they did not report insufficient bronchial sealing, it is likely that higher inflation volumes of air were used to achieve acceptable bronchial sealing. The outer diameter of the 5 F Arndt endobronchial blocker inflated with the maximum recommended volume of air (2 mL) has an outer diameter of 8 mm, sufficient to seal the right and left mainstem bronchi of a 4-or 6-year-old child.…”

“…This catheter has, however, been successfully used in patients from 2 to 10 years or even up to 16 years. 16,18 Again, it is likely that higher than recommended maximum volumes of air were used for inflation to obtain a sufficient seal. This is not Gender differences in the sizing of bronchial blockers have been discussed in the past, and some recommendations were developed specifically for girls or boys, but were given without obvious differences in the tables and sometimes with larger sizes for girls and in spite of negotiation of gender differences.…”

“…Prospective clinical studies investigating the effectiveness of the current recommendations for size selection of the three types of balloon‐tipped bronchial blockers are lacking. Reported clinical experience is limited to retrospective case series using the Arndt endobronchial blockers, 13–16 Fogarty catheters, 8,17 or a combination of these 18 . Stephenson and Seefelder published on the successful use of the 5 F Arndt endobronchial blocker in 26 patients aged from 2 to 24 months using extra‐luminal placement of the catheter and endoscopically controlled inflation 13 .…”

CT 3-Dimentional Airway Reconstruction-guided Intraluminal Placement of Endobronchial Blocker in Pediatric Patients: A Randomized Controlled Study

“…The insertion of the nest 5F endobronchial blocker requires a Tracheal tube with an internal diameter greater than 4.5 mm 14 . While applying OLV in pediatric patients, bronchoscopy cannot be used to guide intraluminal blocker placement if the insertion of a Tracheal tube with an internal diameter greater than 4.5 mm is not applicable.…”