Year : 2016 | Volume
: 3 | Issue : 2 | Page : 131--133
Pediatric single lung ventilation for lobectomy: Anesthetic challenge
K Ramakrishna Chaitanya, P Ravikanth, Suhasini Gazula, Nagarjuna Thakur
Department of Anaesthesia and Paediatric Surgery, ESIC Super Speciality Hospital, Hyderabad, Telangana, India
K Ramakrishna Chaitanya
Department of Anaesthesia, ESIC Super Speciality Hospital, Sanath Nagar, Hyderabad, Telangana
A 4-year-old male child, who was diagnosed as congenital cystic adenomatoid malformation of the right lower lobe of the lung, was scheduled for resection of the affected segment. Provision of lung isolation intraoperatively in children is more difficult due to anatomical and physiological differences from an adult. This case represents challenges encountered by the pediatric anesthesiologist to provide intraoperative single lung ventilation in a child, as there are limited options available, and also need for effective postoperative analgesia in the form of thoracic epidural which helped in early recovery.
|How to cite this article:|
Chaitanya K R, Ravikanth P, Gazula S, Thakur N. Pediatric single lung ventilation for lobectomy: Anesthetic challenge.CHRISMED J Health Res 2016;3:131-133
|How to cite this URL:|
Chaitanya K R, Ravikanth P, Gazula S, Thakur N. Pediatric single lung ventilation for lobectomy: Anesthetic challenge. CHRISMED J Health Res [serial online] 2016 [cited 2020 Aug 15 ];3:131-133
Available from: http://www.cjhr.org/text.asp?2016/3/2/131/177646
Congenital cystic adenomatoid malformation (CCAM) is a rare condition in children with an incidence of 1–4/100,000 cases. Children usually present with repeated respiratory tract infections since birth. Surgical resection of the affected segment often necessitates one lung ventilation (OLV) for adequate exposure. Provision of OLV is challenging in pediatric age group due to unique airway anatomy, physiology, and limited equipment available to isolate lung intraoperatively.
A 4-year-old male child presented with history of recurrent respiratory tract infections since birth. Chest X-ray showed cavitary lesions in the right lower zone and was treated initially as a case of pulmonary tuberculosis elsewhere. When symptoms and X-ray findings persisted even after complete course, the child was referred to our hospital. A thorough clinical re-evaluation and contrast enhanced computerized tomography chest revealed multiple cystic lesions in the right lower lobe of the lung, and the diagnosis of CCAM was made.
The child was scheduled for resection of the affected segment through right posterolateral thoracotomy.
On the day of surgery, peripheral venous access was secured on the left antecubital vein with a 20-gauge cannula, and anesthesia was induced. To facilitate intubation, 0.5 mg/kg of atracurium was administered. At laryngoscopy, 4 Fr Fogarty catheter modified by bending the tip was positioned in the trachea. The trachea was intubated with 4.0 size uncuffed endotracheal tube (ETT). After intubation, 2.7 mm flexible fiberoptic bronchoscope (FOB) (FUJINON FB120P™) was passed through ETT, and carina was visualized. Under fiberoptic guidance, the tip of the Fogarty catheter was manipulated externally so that it advanced into the right main bronchus and crossed the orifice of the upper lobe bronchus. The Fogarty catheter was secured to ETT.
Epidural catheter was inserted at T12–L1 level and the right internal jugular vein was cannulated with 4, 5Fr triple lumen central venous catheter. Radial arterial cannulation was done by using 22-gauge intravenous cannula.
Position of Fogarty catheter was rechecked by using fiberoptic guidance, before final positioning in left lateral for thoracotomy. The bronchial blocker (BB) was inflated before the pleura was opened. The Fogarty position was also confirmed by the surgeon by a deflated lower lobe.
BB was deflated after the lower lobe bronchus was divided and stump closed and bilateral ventilation was resumed.
Postoperatively, the child received 0.0625% bupivacaine with 1 μg/ml of fentanyl at the rate of 5 ml/h. Active chest physiotherapy and incentive spirometry were initiated on the 1st postoperative day (POD). Postoperative chest X-ray showed the right lung to have fully expanded. Epidural was continued until 5th POD until intercostal drain was removed. Later, analgesia was supplemented by oral paracetamol. The child had an uneventful recovery and was discharged on the 10th POD.
The child resumed full physical activity with active involvement in outdoor play by the 3rd week.
CCAM of the lung can be diagnosed by antenatal scan performed any time between 18 and 36 weeks of gestation. It is more common in male children and affects single lobe causing lung compression, hypoplasia and in severe cases causes mediastinal shift. The most common presentation in smaller lesions is occurrence of repeated respiratory tract infections.
Children are usually posted for resection of the affected lobe and often necessitate OLV. Provision of OLV improves surgical access and reduces lung contamination with secretions, but a deflated silent lung risks the children to dreadful complications of hypoxia.
Various equipment such as double lumen tubes, Univent tubes, and BB are available to provide OLV in adults. However, these cannot be used in pediatrics patients as the smallest available double lumen tube is 26F, which is used in children above 8 years of age., The smallest available Univent tube is 3.5 mm internal diameter and used for children more than 6 years of age.,
The most commonly used option for OLV in younger children is to use conventional ETT and advance into the desired bronchus using FOB. However, the disadvantage is it may not be able to provide a completely collapsed lobe.
BB are an effective way of lung isolation in younger children., They can be introduced alongside of conventional ETT and positioned to desired level using FOB. We have used 2.7 mm FUJINON FB120P™ FOB so that it can be easily passed through 4.0 ETT. The smallest available FOB is of 2.2 mm can be used in newborns and infants <6 months.
Historically, Vale and Lines described the use of Fogarty embolectomy catheter for lung isolation in small children and suggested appropriate size selection., We have used a 4 Fr Fogarty embolectomy catheter whose tip was modified by bending so that it eases the entry into the desired bronchus. After reaching the desired level, the cuff was inflated with 1 cc of air under vision. Caution should be excised while inflating the balloon as they exert high pressure on the airway.
After completion of the surgery, the child was electively ventilated for 12 h in dedicated pediatric surgical Intensive Care Unit. Provision of adequate analgesia in the postoperative period is a key to early recovery. Studies in children have suggested that epidural analgesia is better than intravenous morphine infusions. We have inserted a low thoracic epidural catheter which provided analgesia that helped in providing adequate analgesia and early recovery.
There is increasing need for lung isolation strategies in children, with increasing use of procedures such as video-assisted thoracoscopy. Provision of OLV is challenging and requires dedicated team and experienced personnel. The position of BB should be regularly checked as there are high chances of dislodgement.
Using a Fogarty embolectomy catheter seems to be a feasible and effective modality for intraoperative OLV in young children and provision of adequate analgesia in the form of thoracic epidural infusion helps in early recovery.
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Conflicts of interest
There are no conflicts of interest.
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