Use of Bronchial Blockers for Single-Lung Ventilation in Infants and Children

In their report of single- and double-lung ventilation for thoracoscopic lung resection in infants and children[1] as well as in the same group's report of single-lung ventilation in thoracoscopic pediatric surgery,[2] Dingemann et al describe techniques for single-lung ventilation in children. They advocate mainstem intubation for children under 6 years of age, use of the Univent Tube® for 6- to 12-year-old children, and double lumen tubes or the (9 French) Arndt Endobronchial Blocker® for children 12 years and older. We would like to draw attention to the ease of lung isolation with bronchial blockers even in younger children and infants as has been reported for infants and toddlers.[3] [4] [5] We use the 5 French Arndt Endobronchial Blocker® (AEB) (Cook Medical, Bloomington, IN, USA, or Limerick, Ireland); alternatively, Fogarty embolectomy catheters can be used as well. In smaller children, putting the blocker outside the endotracheal tube into the trachea allows a 2 mm fiberoptic bronchoscope (FOB) to pass through the endotracheal tube and to guide the blocker into the mainstem bronchus to be isolated. This technique has been safe and efficient with conversion to open thoracotomy less likely related to inability of lung isolation than to surgical reasons. We use the 5 French AEB outside the endotracheal tube up to approximately 4 years of age with cuffed endotracheal tubes up to an inner diameter of 4.5 mm. In children older than 4 years and with endotracheal tubes of sizes above 5 mm inner diameter, we use the 5 French AEB inside the endotracheal tube with a 2 mm FOB, and the 7 French AEB with tubes of 6 mm inner diameter and larger with a 2 mm or larger FOB. The Univent Tube® (LMA North America, San Diego, CA, USA), while available in pediatric sizes, reduces the available lumen due to its design of incorporating the blocker into its wall, and we prefer the use of isolated blockers over the use of the Univent Tube®. With appropriate caution in their placement, double lumen tubes starting with a size 26 French can be used in children older than 8 to 10 years and over 30 kg of weight. Even with successful lung isolation, gentle insufflation of CO₂ with a pressure of 2 to 3 cm H₂O improves surgical visualization and is usually well tolerated by the patients. In particular, right mainstem intubation can result in occlusion of the right upper lobe bronchus with difficulty maintaining oxygenation during single-lung ventilation, which is easily avoided by positioning a bronchial blocker in the left mainstem and ventilating the right lung via the endotracheal tube in the trachea.

• References

• 1 Dingemann C, Zoeller C, Bataineh Z, Osthaus A, Suempelmann R, Ure B. Single- and double-lung ventilation in infants and children undergoing thoracoscopic lung resection. Eur J Pediatr Surg 2013; 23 (1) 48-52
• 2 Bataineh ZA, Zoeller C, Dingemann C, Osthaus A, Suempelmann R, Ure B. Our experience with single lung ventilation in thoracoscopic paediatric surgery. Eur J Pediatr Surg 2012; 22 (1) 17-20
• 3 Wald SH, Mahajan A, Kaplan MB, Atkinson JB. Experience with the Arndt paediatric bronchial blocker. Br J Anaesth 2005; 94 (1) 92-94
• 4 Stephenson LL, Seefelder C. Routine extraluminal use of the 5F Arndt Endobronchial Blocker for one-lung ventilation in children up to 24 months of age. J Cardiothorac Vasc Anesth 2011; 25 (4) 683-686
• 5 Disma N, Mameli L, Pini-Prato A, Montobbio G. One lung ventilation with Arndt pediatric bronchial blocker for thoracoscopic surgery in children: a unicentric experience. Paediatr Anaesth 2011; 21 (4) 465-467