Review: One lung ventilation in children

Myron Yaster

T Wesley Templeton, Federico Piccioni, Debnath Chatterjee.  An Update on One-Lung Ventilation in Children. Anesth Analg.  2021; May 1;132(5):1389-1399. PMID: 33215885

The original and still champion: 

Hammer GB. Single-lung ventilation in infants and children. Paediatr Anaesth. 2004; 14:98–102.  PMID: 14717881

When starting the PAAD, Ron Litman thought that having one “classic” article a week would let the readers know how our practice evolved and how we got to where we are today.  So, this review article by Templeton et al. on one lung ventilation is a perfect segue to Greg Hammer’s classic original article on this subject (and if you look carefully, you’ll see that Greg’s is a single authored paper.  And how often do you EVER see a single authored paper?, almost never!).  Additionally, on a personal level, 2 of the authors, Greg Hammer and Dabe Chatterjee, are really good friends so highlighting their work is a “twofer” for me.

I think all of you have some experience with one lung ventilation (OLV) and the current review really doesn’t offer many changes to Greg’s original paper other than some terrific illustrations (figures).  So, if you need a “refresher” or are teaching these techniques to residents and fellows, this is a great paper.  I’m going to highlight some of the key points that are sometimes confusing.

The indications for OLV “can be broadly categorized as either to facilitate surgical exposure or to anatomically isolate one-lung from the other. One of the more common current reasons, particularly in very young patients, is for video-assisted thoracoscopic surgery (VATS)”.  There are multiple ways to do OLV using endobronchial intubation, bronchial blockers (either intra or extra-luminal) or double lumen tubes. All of which are extensively reviewed in this  paper. However, regardless of the technique, in my experience, one of the trickiest recall issues is what size tube, bronchial blocker, fiber optic scope, etc. can one use?  These decisions are often based on the patient’s age, size and weight.  I am attaching table 1 from the Templeton paper as a memory aid (it’s really a bitch getting old!).  (And for those of you who make memory cards for distribution within your institutions, these tables may be very helpful additions).

I’ve always thought that the best way to accomplish OLV is by using a double lumen tube but could never remember how to size them.  Templeton et al. point out that “the smallest double-lumen tube (DLT) available is 26F with an external diameter between 8.7 and 9.3 mm, which corresponds to a 6.5 ETT and therefore should not be used in children <8 years of age”.  For smaller and younger children either intra or extraluminal bronchial blockers (BB) with fiberoptic guidance are the way to go and using the table will help a great deal in picking the right sized equipment.  Some key BB points from the paper:

1.     Extraluminal placement of a BB device remains the only viable option to perform lung isolation with a BB in children <2 years of age.

2.     BBs are more likely to be displaced when compared to endobronchial intubation.

3.     Extraluminal placement of a BB on the right side is frequently easier than placing it on the left.

4.     No single approach to extraluminal BB placement appears to be superior to another.

5.     Fluoroscopy can be used to guide BB placement when visualization with a flexible fiberoptic scope is hindered by secretions or a lack of physiologic reserve.

6.     Ideally, BB balloon inflation should be performed under direct visualization to reduce over inflation of the cuff and the possibility of airway injury.

How to deflate the non-ventilated lung has always been an issue to me.  In my experience, applying suction thru the tiny lumen of the BB does not work very well (and obviously is not even an option if using a Forgarty balloon catheter).  Pre-suctioning the main stem bronchus of the lung to be blocked with the fiberoptic scope’s larger channel, prior to inflating the balloon, has worked best for me (as well as using 100% FiO2 to promote absorption atelectasis during the process).  

Finally, the authors provide this handy-dandy summary table.

I’ve spoken to John Fiadjoe and we should be back to at least a 3/week schedule very shortly.

Myron Yaster MD