One Lung Ventilation: Difference between revisions

Latest revision as of 23:55, 18 November 2024

Introduction

- Pediatric thoracic anesthesia is more challenging than Adults

- DLT is gold standard for children > 8 Yrs

- Available devices for Peds OLV: DLT, BB, Uninvent Tubes, SLT

- Caution with BB due to high pressure balloon cuffs - Many surgical procedures in the chest need OLV, but some can be done without it

ABC”D” OF Pediatric Lung isolation


ABC"D" of Pediatric Lung Isolation
A	Anatomy
B	Bronchoscopy
C	Chest imaging
D	Diameter change with age

Important measurements

- How to know if FOB fits in the Tube?

ODB/IDTT < 0.9

- To allow some ventilation during bronchoscopy

ODB/IDTT < 0.7

Example: smallest FOB in use has OD of 2.2 mm, placing this Scope through 2.5 SLT gives an ODB/IDTT ratio of 2.2/2.5 or 0.88

This ratio is <0.9 but >0.7, the bronchoscope will physically fit inside the TT, but no ventilation will be able to occur!

Tip: Bronchoscopes can become deformed from repeated use and cleaning, and the tip may have a larger diameter than documented

>>> It’s always a good idea to test the fit of the bronchoscope inside a TT before use in the patient

Pediatric Airway Diameters

- Average neonatal trachea has an AP diameter of about 4.3 mm for both males & females

- Trachea grows uniformly in males and females to about 14 mm at the age of 15 yrs old

- At this time, female trachea stops growing, but male trachea continues to grow to 16–18 mm by age of 19

- trachea is elliptical in shape, with the transverse diameter being larger than AP diameter Sizing of airway devices should be based on the smaller (anteroposterior) diameter.

Devices & Approaches

1- Single-Lumen Tracheal Tube

- Simplest option, can be used at any age but mostly used for the very young patients < 6 m.o.s

- Placing SLT in the right mainstem bronchus is easier than the left due to the less acute angle that it takes off from the trachea

- Pros: Simple/ Quick

- Cons: potential for inadequate collapse of operative lung / inability to suction the operative lung / inability to deliver (CPAP) to operative lung / Missing the RUL when doing right mainstem intubation

2- Bronchial Blockers

- Many types, include vascular balloon catheters, the Uniblocker (Fuji Systems), and Arndt endobronchial blocker, Cohen, EZ blocker

- Catheters may be placed either within (Coaxial) or external to the TT (Extra-axial)

- Use of Bronchoscope is imperative during placement of BB

- Deflation of the operative lung occurs by absorption atelectasis and requires a considerably longer period of time

Vascular Devices:

- Fogarty arterial embolectomy catheter, and Miller atrio-septostomy catheter

- No central channel for deflation or CPAP to the operative lung

- Both has angled tip which allows the user to direct the catheter to the desired bronchus.

- Balloon cuffs are high pressure, low volume and should be only inflated and positioned under FOB to avoid damaging bronchial mucosa

Arndt blockers:

- Has four-way adapter, and comes with swivel connector that allows ventilation during placement

- The blocker has a 2 ml cuff and lower inflation pressures.

- Has an inner lumen that contains a flexible nylon wire that extends along the length of the catheter and terminates as a flexible loop

- This loop slides over the bronchoscope and aids in positioning.

- Once the nylon guide is removed, it cannot be reattached, which may make repositioning attempts difficult should the blocker fall out of place.

- Once the nylon wire is removed, the central lumen may be used for suctioning and CPAP

Sizing of BB and FOB for SLTs

- Same sizing principles apply when using BB and FOB together as to when sizing FOB alone

- Typically in pediatrics, two sizes of bronchial blockers are used—5 and 7 Fr BB sized by Fr, divide by 3 to know the size in mm
- When using the coaxial technique, the Arndt bronchial blocker works well.

- However, when using the parallel technique, a bronchial blocker with a stiffer shaft and angled tip should be used.

- This can be accomplished with the 5 Fr Fuji Uniblocker, or a vascular device such as a 5 Fr Fogarty embolectomy catheter, or a 5 Fr Miller atrio-septostomy catheter

3- Univent Tubes

- TT that has a bronchial blocker within a separate lumen.

- If double-lung ventilation is required again, the bronchial blocker may be deflated and withdrawn into the tracheal lumen again

- Available Univent pediatric sizes: 3.5 and 4.5 mm ID

- Size of a Univent TT refers to the ID, where the OD will be much larger than the equivalent sized SLT

- Main disadvantage is that cross-sectional diameter of the ventilation lumen is smaller in order to accommodate the blocker lumen.

- This increases airway resistance and also limits the size of fiberoptic bronchoscope used to facilitate positioning

- Narrow age range where this method is the preferred: 6–8 yrs

4- Double Lumen Tubes

Considered Gold standard in ages > 8 yrs

The equation of Size =Age×1.5+14 can help to estimate the sizing needed

Smallest DLT size is a 26 Fr, which is generally suitable for children 8–10 yrs of age

Recommended method for each age group

A table listing the preferred method for lung isolation in each age group can be found in the Info sheet at the bottom of this page

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Relevant Article Depot:

An Update on One-Lung Ventilation in Children

Single-lung ventilation in infants and children

Paediatric lung isolation

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

Anesthesia of thoracic surgery in children

Approach to one lung ventilation during the surgical resection of an intrathoracic ganglioneuroblastoma in a three-year-old child: a case report and review of the literature

Single lung ventilation with an endotracheal tube in a small child undergoing right thoracotomy

Error traps in pediatric one-lung ventilation

Radiographic Demonstration of Hypoxic Pulmonary Vasoconstriction during One-lung Ventilation

Comment on: Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years

A Prospective Comparison of Intraluminal and Extraluminal Placement of the 9-French Arndt Bronchial Blocker in Adult Thoracic Surgery Patients

Inside out: Repurposing endobronchial intubation to facilitate extraluminal placement of a 5 Fr Arndt bronchial blocker in young infants

Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years

Selective Lobar Blockade With a Bronchial Blocker in Combination With a Double Lumen Tube to Manage Refractory Hypoxemia: A Case Report

A Retrospective Evaluation of Airway Anatomy in Young Children and Implications for One-Lung Ventilation

An initial experience with an Extraluminal EZ-Blocker® : A new alternative for 1-lung ventilation in pediatric patients

Cricoid and left bronchial diameter in the pediatric population

Inflation volume-balloon diameter and inflation pressure-balloon diameter characteristics of commonly used bronchial blocker balloons for single-lung ventilation in children

Hypoxaemia during one lung ventilation

Double-lumen tubes and bronchial blockers

Individualized positive end-expiratory pressure (PEEP) during one-lung ventilation for prevention of postoperative pulmonary complications in patients undergoing thoracic surgery: A meta-analysis

Manual angulation of the Arndt endobronchial blocker to improve the ease of lung isolation

A novel maneuver to correct the position of an EZ-Blocker® endobronchial blocker

Effects of Dexmedetomidine in Improving Oxygenation and Reducing Pulmonary Shunt in High-Risk Pediatric Patients Undergoing One-Lung Ventilation for Thoracic Surgery: A Double-Blind Randomized Controlled Trial

Point-of-Care Lung Ultrasound to Evaluate Lung Isolation During One-Lung Ventilation in Children: A Blinded Observational Feasibility Study

@@ Line 1: / Line 1: @@
-* <u>Introduction</u>   - Pediatric thoracic anesthesia is more challenging than Adults
+== <u>Introduction</u>  ==
+- Pediatric thoracic anesthesia is more challenging than Adults
 - DLT is gold standard for children > 8 Yrs
@@ Line 6: / Line 7: @@
 - Caution with BB due to high pressure balloon cuffs  - Many surgical procedures in the chest need OLV, but some can be done without it
-* <u>ABC”D” OF Pediatric Lung isolation</u>
+== <u>ABC”D” OF Pediatric Lung isolation</u> ==
 {| class="wikitable"
 |+
@@ Line 25: / Line 26: @@
 |}
-* <u>Important measurements</u>[[File:Measurements.png|left|thumb]]
+== <u>Important measurements</u> ==
+[[File:Measurements.png|thumb]]
-* <u>Pediatric Airway Diameters</u>
+-   How to know if FOB fits in the Tube?
--   How to know if FOB fits in the Tube?
              ODB/IDTT < 0.9
@@ Line 46: / Line 46: @@
 >>>  It’s always a good idea to test the fit of the bronchoscope inside a TT before use in the patient
-* <u>Pediatric Airway Diameters</u>Average neonatal trachea has an AP diameter of about 4.3 mm for both males & females Trachea grows uniformly in males and females to about 14 mm at the age of 15 yrs old  At this time, female trachea stops growing, but male trachea continues to grow to 16–18 mm by age of 19.  trachea is elliptical in shape, with the transverse diameter being larger than AP diameter  Sizing of airway devices should be based on the smaller (anteroposterior) diameter.
+== <u>Pediatric Airway Diameters</u> ==
-* <u>Devices & Approaches</u>1- Single-Lumen Tracheal Tube Simplest option, can be used at any age but mostly used for the very young patients < 6 m.o.s  Placing SLT in the right mainstem bronchus is easier than the left due to the less acute angle that it takes off from the trachea  '''Pros:''' Simple/ Quick  '''Cons:''' potential for inadequate collapse of operative lung / inability to suction the operative lung / inability to deliver (CPAP) to operative lung / Missing the RUL when doing right mainstem intubation  <br />2- Bronchial Blockers  Many types, include vascular balloon catheters, the Uniblocker (Fuji Systems), and Arndt endobronchial blocker, Cohen, EZ blocker  Catheters may be placed either within (Coaxial) or external to the TT (Extra-axial)  Use of Bronchoscope is imperative during placement of BB  Deflation of the operative lung occurs by absorption atelectasis and requires a considerably longer period of time  <br />Vascular Devices:   Fogarty arterial embolectomy catheter, and Miller atrio-septostomy catheter  No central channel for deflation or CPAP to the operative lung  Both has angled tip which allows the user to direct the catheter to the desired bronchus.  Ballon cuffs are high pressure, low volume and should be only inflated and positioned under FOB to avoid damaging bronchial mucosa  <br />Arndt blockers:  Has four-way adapter, and comes with swivel connector that allows ventilation during placement  The blocker has a 2 ml cuff and lower inflation pressures.  Has an inner lumen that contains a flexible nylon wire that extends along the length of the catheter and terminates as a flexible loop  This loop slides over the bronchoscope and aids in positioning.   Once the nylon guide is removed, it cannot be reattached, which may make repositioning attempts difficult should the blocker fall out of place.  Once the nylon wire is removed, the central lumen may be used for suctioning and CPAP  <br />Sizing of BB and FOB for SLTs  Same sizing principles apply when using BB and FOB together as to when sizing FOB alone  Typically in pediatrics, two sizes of bronchial blockers are used—5 and 7 Fr  BB sized by Fr, divide by 3 to know the size in mm  <br />When using the coaxial technique, the Arndt bronchial blocker works well.  However, when using the parallel technique, a bronchial blocker with a stiffer shaft and angled tip should be used.   This can be accomplished with the 5 Fr Fuji Uniblocker, or a vascular device such as a 5 Fr Fogarty embolectomy catheter, or a 5 Fr Miller atrio-septostomy catheter   <br />3- Univent Tubes  TT that has a bronchial blocker within a separate lumen.  If double-lung ventilation is required again, the bronchial blocker may be deflated and withdrawn into the tracheal lumen again  Available Univent pediatric sizes: 3.5 and 4.5 mm ID  Size of a Univent TT refers to the ID, where the OD will be much larger than the equivalent sized SLT  Main disadvantage is that cross-sectional diameter of the ventilation lumen is smaller in order to accommodate the blocker lumen.  This increases airway resistance and also limits the size of fiberoptic bronchoscope used to facilitate positioning  Narrow age range where this method is the preferred: 6–8 yrs  <br />4- Double Lumen Tubes  Considered Gold standard in ages > 8 yrs  The equation of Size =Age×1.5+14  can help to estimate the sizing needed  Smallest DLT size is a 26 Fr, which is generally suitable for children 8–10 yrs of age
+===== - Average neonatal trachea has an AP diameter of about 4.3 mm for both males & females =====
+- Trachea grows uniformly in males and females to about 14 mm at the age of 15 yrs old
+- At this time, female trachea stops growing, but male trachea continues to grow to 16–18 mm by age of 19
+- trachea is elliptical in shape, with the transverse diameter being larger than AP diameter  Sizing of airway devices should be based on the smaller (anteroposterior)   diameter.
+== <u>Devices & Approaches</u> ==
+=== 1- Single-Lumen Tracheal Tube ===
+- Simplest option, can be used at any age but mostly used for the very young patients < 6 m.o.s
+- Placing SLT in the right mainstem bronchus is easier than the left due to the less acute angle that it takes off from the trachea
+====== '''- Pros:''' Simple/ Quick  ======
+===== '''- Cons:''' potential for inadequate collapse of operative lung / inability to suction the operative lung / inability to deliver (CPAP) to operative lung / Missing the RUL when doing right mainstem intubation =====
+=== 2- Bronchial Blockers  ===
+- Many types, include vascular balloon catheters, the Uniblocker (Fuji Systems), and Arndt endobronchial blocker, Cohen, EZ blocker
+- Catheters may be placed either within (Coaxial) or external to the TT (Extra-axial)
+- Use of Bronchoscope is imperative during placement of BB
+-  Deflation of the operative lung occurs by absorption atelectasis and requires a considerably longer period of time
+===== Vascular Devices:   =====
+- Fogarty arterial embolectomy catheter, and Miller atrio-septostomy catheter
+- No central channel for deflation or CPAP to the operative lung
+- Both has angled tip which allows the user to direct the catheter to the desired bronchus.
+-  Balloon cuffs are high pressure, low volume and should be only inflated and positioned under FOB to avoid damaging bronchial mucosa
+===== Arndt blockers:  =====
+- Has four-way adapter, and comes with swivel connector that allows ventilation during placement
+- The blocker has a 2 ml cuff and lower inflation pressures.
+- Has an inner lumen that contains a flexible nylon wire that extends along the length of the catheter and terminates as a flexible loop
+- This loop slides over the bronchoscope and aids in positioning.
+- Once the nylon guide is removed, it cannot be reattached, which may make repositioning attempts difficult should the blocker fall out of place.
+- Once the nylon wire is removed, the central lumen may be used for suctioning and CPAP
+===== Sizing of BB and FOB for SLTs  =====
+- Same sizing principles apply when using BB and FOB together as to when sizing FOB alone
+- Typically in pediatrics, two sizes of bronchial blockers are used—5 and 7 Fr  BB sized by Fr, divide by 3 to know the size in mm  <br />- When using the coaxial technique, the Arndt bronchial blocker works well.
+- However, when using the parallel technique, a bronchial blocker with a stiffer shaft and angled tip should be used.
+- This can be accomplished with the 5 Fr Fuji Uniblocker, or a vascular device such as a 5 Fr Fogarty embolectomy catheter, or a 5 Fr Miller atrio-septostomy catheter
+=== 3- Univent Tubes  ===
+- TT that has a bronchial blocker within a separate lumen.
+-  If double-lung ventilation is required again, the bronchial blocker may be deflated and withdrawn into the tracheal lumen again
+- Available Univent pediatric sizes: 3.5 and 4.5 mm ID
+- Size of a Univent TT refers to the ID, where the OD will be much larger than the equivalent sized SLT
+-  Main disadvantage is that cross-sectional diameter of the ventilation lumen is smaller in order to accommodate the blocker lumen.
+- This increases airway resistance and also limits the size of fiberoptic bronchoscope used to facilitate positioning
+-  Narrow age range where this method is the preferred: 6–8 yrs
+=== 4- Double Lumen Tubes ===
+Considered Gold standard in ages > 8 yrs
+The equation of Size =Age×1.5+14  can help to estimate the sizing needed
+Smallest DLT size is a 26 Fr, which is generally suitable for children 8–10 yrs of age
+== <u>Recommended method for each age group</u> ==
+A table listing the preferred method for lung isolation in each age group can be found in the Info sheet at the bottom of this page
-* <u>Recommended method for each age group</u>
 {{Stub Notice}}
@@ Line 89: / Line 171: @@
 [https://pubmed.ncbi.nlm.nih.gov/33406307/ Inflation volume-balloon diameter and inflation pressure-balloon diameter characteristics of commonly used bronchial blocker balloons for single-lung ventilation in children]
+[https://www.bjaed.org/article/S2058-5349(23)00079-3/fulltext Hypoxaemia during one lung ventilation]
+[https://www.bjaed.org/article/S2058-5349(23)00106-3/fulltext Double-lumen tubes and bronchial blockers]
+[https://pubmed.ncbi.nlm.nih.gov/34260559/ Individualized positive end-expiratory pressure (PEEP) during one-lung ventilation for prevention of postoperative pulmonary complications in patients undergoing thoracic surgery: A meta-analysis]
+[https://link.springer.com/article/10.1007/s12630-024-02709-1 Manual angulation of the Arndt endobronchial blocker to improve the ease of lung isolation]
+[https://link.springer.com/article/10.1007/s12630-024-02767-5 A novel maneuver to correct the position of an EZ-Blocker® endobronchial blocker]
+[https://www.cureus.com/articles/293539-effects-of-dexmedetomidine-in-improving-oxygenation-and-reducing-pulmonary-shunt-in-high-risk-pediatric-patients-undergoing-one-lung-ventilation-for-thoracic-surgery-a-double-blind-randomized-controlled-trial Effects of Dexmedetomidine in Improving Oxygenation and Reducing Pulmonary Shunt in High-Risk Pediatric Patients Undergoing One-Lung Ventilation for Thoracic Surgery: A Double-Blind Randomized Controlled Trial]
+[https://journals.lww.com/anesthesia-analgesia/fulltext/2024/12000/point_of_care_lung_ultrasound_to_evaluate_lung.24.aspx Point-of-Care Lung Ultrasound to Evaluate Lung Isolation During One-Lung Ventilation in Children: A Blinded Observational Feasibility Study]