Remembering the classics: Single Lung Ventilation in Children
Greg Hammer MD
One lung ventilation to facilitate surgical exposure or to anatomically isolate a lung is a technical tour de force in pediatrics. In adults, placing a double lumen is pretty straight forward and a technique I’m pretty sure all of you learned in training and are reasonably comfortable with. Not so in children primarily because double lumen tubes are simply too big to be used in children < 8-10 years of age. Dr. Greg Hammer was an early pioneer in trying to figure out how to do one lung anesthesia in children and I asked him to revisit his original articles first published in the 1990s.
In addition, for those of you who want a deeper dive (and video) please take a look at the following links in OpenAnesthesia
https://www.openanesthesia.org/keywords/one-lung-ventilation-in-children/?search_term=one%20lun
and this podcast (with video)
https://www.openanesthesia.org/vodcasts/pediatric-one-lung-ventilation/?search_term=one%20lung
Myron Yaster MD
Original Article
Hammer GB, Manos SJ, Smith BM, Skarsgard ED, Brodsky JB. Single-lung ventilation in pediatric patients. Anesthesiology. 1996 Jun;84(6):1503-6. doi: 10.1097/00000542-199606000-00028. PMID: 8669693.
Common techniques in one lung anesthesia include endobronchial intubation, bronchial blockers and double lumen tubes in older (> 8-10) children. Double lumen tubes were simply too large to be used in children and endobronchial intubation precluded suctioning and/or oxygenating the surgical lung. An alternative was needed.
I became interested in bronchial blockers in the 1990s. The use of bronchial blockers in infants and children for single lung ventilation (SLV) was first described over 50 years ago.[1] Publications over the next two and a half decades primarily referenced the use of the Fogarty (closed tip) catheter for bronchial blockade in pediatric patients undergoing thoracic surgery. In the 1990s, video-assisted thoracoscopic surgery (VATS) for chest surgery in children became increasingly common. Indeed, procedures to facilitate surgical repair really took off and included lung biopsy, resection of lung masses, pleural surgery, vascular surgery, anterior thoracic spinal fusion, and mediastinal esophageal surgery. As this technology evolved, smaller VATS instruments facilitated the use of this method in infants and even neonates. VATS procedures call for the collapse of the surgical lung. Initially, CO2 insufflation of the operative lung was commonly used to compress the lung, thereby allowing for improved visualization. Bronchial blockade gradually became more widely utilized as an alternative to insufflation for compressing the operative lung, thereby avoiding the need for creating an additional port for retractor placement and potentially reducing trauma to the retracted lung.[2-6]
My first article on how to do this was published in 1996 and described the use of an end-hole catheter for SLV in pediatric patients. The importance of this paper lies in its revelation of the utility of using the bronchial blocker (BB) catheter lumen (1) to facilitate BB placement over a guidewire and (2) to insufflate oxygen, thereby creating continuous positive airway pressure (CPAP) in cases of hypoxemia during VATS. The article described a technique for placing the BB by first intubating the mainstem bronchus to be occluded with a standard ETT, then placing a J-tipped guidewire through the ETT lumen into the bronchus before removing the ETT while leaving the guidewire in place. The BB was then passed over the guidewire into the bronchus, and the trachea was then reintubated with an ETT, leaving the BB outside the ETT to allow for unimpeded suctioning of the ETT. Final positioning of the BB was performed under fiberoptic visualization. In one of the patients described in the article, oxygen desaturation during VATS was successfully treated by insufflating oxygen via the BB lumen, creating CPAP, and rapidly restoring oxygen saturation to 99%. Hypoxemia wasn’t and shouldn’t be surprising. In the lateral position the dependent lung is poorly ventilated and will be better perfused thereby increasing V/Q mismatch. The non-dependent lung will be deliberately collapsed also contributing to V/Q mismatch with resultant hypoxemia.
The primary author of this article subsequently worked with engineers at Cook, Inc., to design a 5Fr BB with an easily visualized blue catheter balloon of appropriate dimensions (the Arndt bronchial blocker). A plethora of articles was thereafter published, describing various techniques for BB placement, both inside and outside the ETT, most commonly using the 5 Fr Cook BB.[7] The Arndt bronchial blockers are available in 5, 7 and 9 Fr sizes. An excellent video demonstrating this technique was referenced by Myron in his opening statement.
I was lucky to be working at a golden time when working with industry to solve clinical problems was encouraged and perceived to be a beneficial partnership and not something to be avoided or to taint me as an investigator. This partnership led to the development of the current bronchial blockers we use in our practice. I wonder if it is it still possible.
Send your thoughts and comments to Myron (myasterster@gmail.com) who will post them in a Friday reader response.
References
1. Watson CB, Bowe EA, Burk W: One-lung anesthesia for pediatric thoracic surgery: a new use for the fiberoptic bronchoscope. Anesthesiology 1982, 56(4):314–315.
2. Hammer GB, Fitzmaurice BG, Brodsky JB: Methods for single-lung ventilation in pediatric patients. AnesthAnalg 1999, 89(6):1426–1429.
3. Hammer GB: Pediatric thoracic anesthesia. AnesthAnalg 2001, 92(6):1449–1464.
4. Hammer GB: Selective bronchial blockade in small infants. AnesthAnalg 2001, 93(6):1624–1625.
5. Hammer GB, Harrison TK, Vricella LA, Black MD, Krane EJ: Single lung ventilation in children using a new paediatric bronchial blocker. PaediatrAnaesth 2002, 12(1):69–72.
6. Hammer GB: Single-lung ventilation in infants and children. PaediatrAnaesth 2004, 14(1):98–102.
7. Templeton TW, Piccioni F, Chatterjee D: An Update on One-Lung Ventilation in Children. Anesthesia and analgesia 2021, 132(5):1389–1399.