PedsAnesthesiaNet - User contributions [en]

One Lung Ventilation

2023-09-19T01:01:46Z

Halcham1:

== 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 ==
{| class="wikitable"
|+
! colspan="2" |ABC"D" of Pediatric Lung Isolation
|-
|A
|Anatomy
|-
|B
|Bronchoscopy
|-
|C
|Chest imaging
|-
|D
|Diameter change with age
|}

== Important measurements ==
[[File:Measurements.png|thumb]]

- 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

{{Stub Notice}}

[[File:Pediatric lung isolation info sheet.jpg|thumb]]

* [https://pubmed.ncbi.nlm.nih.gov/33215885/ An Update on One-Lung Ventilation in Children]

[https://pubmed.ncbi.nlm.nih.gov/14717881/ Single-lung ventilation in infants and children]

[https://www.bjaed.org/article/S2058-5349(17)30028-8/fulltext Paediatric lung isolation]

[https://pubs.asahq.org/anesthesiology/article/135/5/842/117609/Hypoxemia-in-Young-Children-Undergoing-One-lung Hypoxemia in Young Children Undergoing One-lung Ventilation: A Retrospective Cohort Study]

[https://pubmed.ncbi.nlm.nih.gov/29484775/ Anesthesia of thoracic surgery in children]

[https://pubmed.ncbi.nlm.nih.gov/24988827/ 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]

[https://pubmed.ncbi.nlm.nih.gov/20716092/ Single lung ventilation with an endotracheal tube in a small child undergoing right thoracotomy]

[https://pubmed.ncbi.nlm.nih.gov/34767676/ Error traps in pediatric one-lung ventilation]

[https://pubs.asahq.org/anesthesiology/article/137/6/733/137059/Radiographic-Demonstration-of-Hypoxic-Pulmonary Radiographic Demonstration of Hypoxic Pulmonary Vasoconstriction during One-lung Ventilation]

[https://pubmed.ncbi.nlm.nih.gov/27600760/ Comment on: Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years]

[https://pubmed.ncbi.nlm.nih.gov/28800989/ A Prospective Comparison of Intraluminal and Extraluminal Placement of the 9-French Arndt Bronchial Blocker in Adult Thoracic Surgery Patients]

[https://pubmed.ncbi.nlm.nih.gov/30133914/ Inside out: Repurposing endobronchial intubation to facilitate extraluminal placement of a 5 Fr Arndt bronchial blocker in young infants]

[https://pubmed.ncbi.nlm.nih.gov/26956889/ Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years]

[https://pubmed.ncbi.nlm.nih.gov/35949780/ Selective Lobar Blockade With a Bronchial Blocker in Combination With a Double Lumen Tube to Manage Refractory Hypoxemia: A Case Report]

[https://pubmed.ncbi.nlm.nih.gov/32921610/ A Retrospective Evaluation of Airway Anatomy in Young Children and Implications for One-Lung Ventilation]

[https://pubmed.ncbi.nlm.nih.gov/29430803/ An initial experience with an Extraluminal EZ-Blocker® : A new alternative for 1-lung ventilation in pediatric patients]

[https://onlinelibrary.wiley.com/doi/10.1111/pan.12896 Cricoid and left bronchial diameter in the pediatric population]

[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]

One Lung Ventilation

2023-09-19T00:59:24Z

Halcham1:

== 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 ==
{| class="wikitable"
|+
! colspan="2" |ABC"D" of Pediatric Lung Isolation
|-
|A
|Anatomy
|-
|B
|Bronchoscopy
|-
|C
|Chest imaging
|-
|D
|Diameter change with age
|}

== Important measurements ==
[[File:Measurements.png|thumb]]

- 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 ==
{{Stub Notice}}

[[File:Pediatric lung isolation info sheet.jpg|thumb]]

* [https://pubmed.ncbi.nlm.nih.gov/33215885/ An Update on One-Lung Ventilation in Children]

[https://pubmed.ncbi.nlm.nih.gov/14717881/ Single-lung ventilation in infants and children]

[https://www.bjaed.org/article/S2058-5349(17)30028-8/fulltext Paediatric lung isolation]

[https://pubs.asahq.org/anesthesiology/article/135/5/842/117609/Hypoxemia-in-Young-Children-Undergoing-One-lung Hypoxemia in Young Children Undergoing One-lung Ventilation: A Retrospective Cohort Study]

[https://pubmed.ncbi.nlm.nih.gov/29484775/ Anesthesia of thoracic surgery in children]

[https://pubmed.ncbi.nlm.nih.gov/24988827/ 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]

[https://pubmed.ncbi.nlm.nih.gov/20716092/ Single lung ventilation with an endotracheal tube in a small child undergoing right thoracotomy]

[https://pubmed.ncbi.nlm.nih.gov/34767676/ Error traps in pediatric one-lung ventilation]

[https://pubs.asahq.org/anesthesiology/article/137/6/733/137059/Radiographic-Demonstration-of-Hypoxic-Pulmonary Radiographic Demonstration of Hypoxic Pulmonary Vasoconstriction during One-lung Ventilation]

[https://pubmed.ncbi.nlm.nih.gov/27600760/ Comment on: Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years]

[https://pubmed.ncbi.nlm.nih.gov/28800989/ A Prospective Comparison of Intraluminal and Extraluminal Placement of the 9-French Arndt Bronchial Blocker in Adult Thoracic Surgery Patients]

[https://pubmed.ncbi.nlm.nih.gov/30133914/ Inside out: Repurposing endobronchial intubation to facilitate extraluminal placement of a 5 Fr Arndt bronchial blocker in young infants]

[https://pubmed.ncbi.nlm.nih.gov/26956889/ Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years]

[https://pubmed.ncbi.nlm.nih.gov/35949780/ Selective Lobar Blockade With a Bronchial Blocker in Combination With a Double Lumen Tube to Manage Refractory Hypoxemia: A Case Report]

[https://pubmed.ncbi.nlm.nih.gov/32921610/ A Retrospective Evaluation of Airway Anatomy in Young Children and Implications for One-Lung Ventilation]

[https://pubmed.ncbi.nlm.nih.gov/29430803/ An initial experience with an Extraluminal EZ-Blocker® : A new alternative for 1-lung ventilation in pediatric patients]

[https://onlinelibrary.wiley.com/doi/10.1111/pan.12896 Cricoid and left bronchial diameter in the pediatric population]

[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]

One Lung Ventilation

2023-09-19T00:53:06Z

Halcham1:

== 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 ==
{| class="wikitable"
|+
! colspan="2" |ABC"D" of Pediatric Lung Isolation
|-
|A
|Anatomy
|-
|B
|Bronchoscopy
|-
|C
|Chest imaging
|-
|D
|Diameter change with age
|}

== Important measurements ==
[[File:Measurements.png|thumb]]

- 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. Ballon 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 ==
{{Stub Notice}}

[[File:Pediatric lung isolation info sheet.jpg|thumb]]

* [https://pubmed.ncbi.nlm.nih.gov/33215885/ An Update on One-Lung Ventilation in Children]

[https://pubmed.ncbi.nlm.nih.gov/14717881/ Single-lung ventilation in infants and children]

[https://www.bjaed.org/article/S2058-5349(17)30028-8/fulltext Paediatric lung isolation]

[https://pubs.asahq.org/anesthesiology/article/135/5/842/117609/Hypoxemia-in-Young-Children-Undergoing-One-lung Hypoxemia in Young Children Undergoing One-lung Ventilation: A Retrospective Cohort Study]

[https://pubmed.ncbi.nlm.nih.gov/29484775/ Anesthesia of thoracic surgery in children]

[https://pubmed.ncbi.nlm.nih.gov/24988827/ 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]

[https://pubmed.ncbi.nlm.nih.gov/20716092/ Single lung ventilation with an endotracheal tube in a small child undergoing right thoracotomy]

[https://pubmed.ncbi.nlm.nih.gov/34767676/ Error traps in pediatric one-lung ventilation]

[https://pubs.asahq.org/anesthesiology/article/137/6/733/137059/Radiographic-Demonstration-of-Hypoxic-Pulmonary Radiographic Demonstration of Hypoxic Pulmonary Vasoconstriction during One-lung Ventilation]

[https://pubmed.ncbi.nlm.nih.gov/27600760/ Comment on: Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years]

[https://pubmed.ncbi.nlm.nih.gov/28800989/ A Prospective Comparison of Intraluminal and Extraluminal Placement of the 9-French Arndt Bronchial Blocker in Adult Thoracic Surgery Patients]

[https://pubmed.ncbi.nlm.nih.gov/30133914/ Inside out: Repurposing endobronchial intubation to facilitate extraluminal placement of a 5 Fr Arndt bronchial blocker in young infants]

[https://pubmed.ncbi.nlm.nih.gov/26956889/ Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years]

[https://pubmed.ncbi.nlm.nih.gov/35949780/ Selective Lobar Blockade With a Bronchial Blocker in Combination With a Double Lumen Tube to Manage Refractory Hypoxemia: A Case Report]

[https://pubmed.ncbi.nlm.nih.gov/32921610/ A Retrospective Evaluation of Airway Anatomy in Young Children and Implications for One-Lung Ventilation]

[https://pubmed.ncbi.nlm.nih.gov/29430803/ An initial experience with an Extraluminal EZ-Blocker® : A new alternative for 1-lung ventilation in pediatric patients]

[https://onlinelibrary.wiley.com/doi/10.1111/pan.12896 Cricoid and left bronchial diameter in the pediatric population]

[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]

One Lung Ventilation

2023-09-19T00:51:22Z

Halcham1:

== 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 ==
{| class="wikitable"
|+
! colspan="2" |ABC"D" of Pediatric Lung Isolation
|-
|A
|Anatomy
|-
|B
|Bronchoscopy
|-
|C
|Chest imaging
|-
|D
|Diameter change with age
|}

== Important measurements ==
[[File:Measurements.png|thumb]]

- 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. Ballon 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 ==
{{Stub Notice}}

[[File:Pediatric lung isolation info sheet.jpg|thumb]]

* [https://pubmed.ncbi.nlm.nih.gov/33215885/ An Update on One-Lung Ventilation in Children]

[https://pubmed.ncbi.nlm.nih.gov/14717881/ Single-lung ventilation in infants and children]

[https://www.bjaed.org/article/S2058-5349(17)30028-8/fulltext Paediatric lung isolation]

[https://pubs.asahq.org/anesthesiology/article/135/5/842/117609/Hypoxemia-in-Young-Children-Undergoing-One-lung Hypoxemia in Young Children Undergoing One-lung Ventilation: A Retrospective Cohort Study]

[https://pubmed.ncbi.nlm.nih.gov/29484775/ Anesthesia of thoracic surgery in children]

[https://pubmed.ncbi.nlm.nih.gov/24988827/ 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]

[https://pubmed.ncbi.nlm.nih.gov/20716092/ Single lung ventilation with an endotracheal tube in a small child undergoing right thoracotomy]

[https://pubmed.ncbi.nlm.nih.gov/34767676/ Error traps in pediatric one-lung ventilation]

[https://pubs.asahq.org/anesthesiology/article/137/6/733/137059/Radiographic-Demonstration-of-Hypoxic-Pulmonary Radiographic Demonstration of Hypoxic Pulmonary Vasoconstriction during One-lung Ventilation]

[https://pubmed.ncbi.nlm.nih.gov/27600760/ Comment on: Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years]

[https://pubmed.ncbi.nlm.nih.gov/28800989/ A Prospective Comparison of Intraluminal and Extraluminal Placement of the 9-French Arndt Bronchial Blocker in Adult Thoracic Surgery Patients]

[https://pubmed.ncbi.nlm.nih.gov/30133914/ Inside out: Repurposing endobronchial intubation to facilitate extraluminal placement of a 5 Fr Arndt bronchial blocker in young infants]

[https://pubmed.ncbi.nlm.nih.gov/26956889/ Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years]

[https://pubmed.ncbi.nlm.nih.gov/35949780/ Selective Lobar Blockade With a Bronchial Blocker in Combination With a Double Lumen Tube to Manage Refractory Hypoxemia: A Case Report]

[https://pubmed.ncbi.nlm.nih.gov/32921610/ A Retrospective Evaluation of Airway Anatomy in Young Children and Implications for One-Lung Ventilation]

[https://pubmed.ncbi.nlm.nih.gov/29430803/ An initial experience with an Extraluminal EZ-Blocker® : A new alternative for 1-lung ventilation in pediatric patients]

[https://onlinelibrary.wiley.com/doi/10.1111/pan.12896 Cricoid and left bronchial diameter in the pediatric population]

[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]

One Lung Ventilation

2023-09-18T23:48:21Z

Halcham1:

== 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 ==
{| class="wikitable"
|+
! colspan="2" |ABC"D" of Pediatric Lung Isolation
|-
|A
|Anatomy
|-
|B
|Bronchoscopy
|-
|C
|Chest imaging
|-
|D
|Diameter change with age
|}

== Important measurements ==
[[File:Measurements.png|left|thumb]]

- 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. Ballon 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 ==
{{Stub Notice}}

[[File:Pediatric lung isolation info sheet.jpg|thumb]]

* [https://pubmed.ncbi.nlm.nih.gov/33215885/ An Update on One-Lung Ventilation in Children]

[https://pubmed.ncbi.nlm.nih.gov/14717881/ Single-lung ventilation in infants and children]

[https://www.bjaed.org/article/S2058-5349(17)30028-8/fulltext Paediatric lung isolation]

[https://pubs.asahq.org/anesthesiology/article/135/5/842/117609/Hypoxemia-in-Young-Children-Undergoing-One-lung Hypoxemia in Young Children Undergoing One-lung Ventilation: A Retrospective Cohort Study]

[https://pubmed.ncbi.nlm.nih.gov/29484775/ Anesthesia of thoracic surgery in children]

[https://pubmed.ncbi.nlm.nih.gov/24988827/ 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]

[https://pubmed.ncbi.nlm.nih.gov/20716092/ Single lung ventilation with an endotracheal tube in a small child undergoing right thoracotomy]

[https://pubmed.ncbi.nlm.nih.gov/34767676/ Error traps in pediatric one-lung ventilation]

[https://pubs.asahq.org/anesthesiology/article/137/6/733/137059/Radiographic-Demonstration-of-Hypoxic-Pulmonary Radiographic Demonstration of Hypoxic Pulmonary Vasoconstriction during One-lung Ventilation]

[https://pubmed.ncbi.nlm.nih.gov/27600760/ Comment on: Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years]

[https://pubmed.ncbi.nlm.nih.gov/28800989/ A Prospective Comparison of Intraluminal and Extraluminal Placement of the 9-French Arndt Bronchial Blocker in Adult Thoracic Surgery Patients]

[https://pubmed.ncbi.nlm.nih.gov/30133914/ Inside out: Repurposing endobronchial intubation to facilitate extraluminal placement of a 5 Fr Arndt bronchial blocker in young infants]

[https://pubmed.ncbi.nlm.nih.gov/26956889/ Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years]

[https://pubmed.ncbi.nlm.nih.gov/35949780/ Selective Lobar Blockade With a Bronchial Blocker in Combination With a Double Lumen Tube to Manage Refractory Hypoxemia: A Case Report]

[https://pubmed.ncbi.nlm.nih.gov/32921610/ A Retrospective Evaluation of Airway Anatomy in Young Children and Implications for One-Lung Ventilation]

[https://pubmed.ncbi.nlm.nih.gov/29430803/ An initial experience with an Extraluminal EZ-Blocker® : A new alternative for 1-lung ventilation in pediatric patients]

[https://onlinelibrary.wiley.com/doi/10.1111/pan.12896 Cricoid and left bronchial diameter in the pediatric population]

[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]

One Lung Ventilation

2023-09-18T23:42:49Z

Halcham1:

* 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

{| class="wikitable"
|+
! colspan="2" |ABC"D" of Pediatric Lung Isolation
|-
|A
|Anatomy
|-
|B
|Bronchoscopy
|-
|C
|Chest imaging
|-
|D
|Diameter change with age
|}

* Important measurements[[File:Measurements.png|left|thumb]]

* Pediatric Airway Diameters

- 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 DiametersAverage 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 & Approaches1- 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. Ballon 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
{{Stub Notice}}

[[File:Pediatric lung isolation info sheet.jpg|thumb]]

* [https://pubmed.ncbi.nlm.nih.gov/33215885/ An Update on One-Lung Ventilation in Children]

[https://pubmed.ncbi.nlm.nih.gov/14717881/ Single-lung ventilation in infants and children]

[https://www.bjaed.org/article/S2058-5349(17)30028-8/fulltext Paediatric lung isolation]

[https://pubs.asahq.org/anesthesiology/article/135/5/842/117609/Hypoxemia-in-Young-Children-Undergoing-One-lung Hypoxemia in Young Children Undergoing One-lung Ventilation: A Retrospective Cohort Study]

[https://pubmed.ncbi.nlm.nih.gov/29484775/ Anesthesia of thoracic surgery in children]

[https://pubmed.ncbi.nlm.nih.gov/24988827/ 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]

[https://pubmed.ncbi.nlm.nih.gov/20716092/ Single lung ventilation with an endotracheal tube in a small child undergoing right thoracotomy]

[https://pubmed.ncbi.nlm.nih.gov/34767676/ Error traps in pediatric one-lung ventilation]

[https://pubs.asahq.org/anesthesiology/article/137/6/733/137059/Radiographic-Demonstration-of-Hypoxic-Pulmonary Radiographic Demonstration of Hypoxic Pulmonary Vasoconstriction during One-lung Ventilation]

[https://pubmed.ncbi.nlm.nih.gov/27600760/ Comment on: Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years]

[https://pubmed.ncbi.nlm.nih.gov/28800989/ A Prospective Comparison of Intraluminal and Extraluminal Placement of the 9-French Arndt Bronchial Blocker in Adult Thoracic Surgery Patients]

[https://pubmed.ncbi.nlm.nih.gov/30133914/ Inside out: Repurposing endobronchial intubation to facilitate extraluminal placement of a 5 Fr Arndt bronchial blocker in young infants]

[https://pubmed.ncbi.nlm.nih.gov/26956889/ Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years]

[https://pubmed.ncbi.nlm.nih.gov/35949780/ Selective Lobar Blockade With a Bronchial Blocker in Combination With a Double Lumen Tube to Manage Refractory Hypoxemia: A Case Report]

[https://pubmed.ncbi.nlm.nih.gov/32921610/ A Retrospective Evaluation of Airway Anatomy in Young Children and Implications for One-Lung Ventilation]

[https://pubmed.ncbi.nlm.nih.gov/29430803/ An initial experience with an Extraluminal EZ-Blocker® : A new alternative for 1-lung ventilation in pediatric patients]

[https://onlinelibrary.wiley.com/doi/10.1111/pan.12896 Cricoid and left bronchial diameter in the pediatric population]

[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]

One Lung Ventilation

2023-09-18T23:41:40Z

Halcham1:

One Lung Ventilation

2023-09-18T23:39:22Z

Halcham1: Detailed description of Lung Isolation techniques

* 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

{| class="wikitable"
|+
! colspan="2" |ABC"D" of Pediatric Lung Isolation
|-
|A
|Anatomy
|-
|B
|Bronchoscopy
|-
|C
|Chest imaging
|-
|D
|Diameter change with age
|}

* Important measurements[[File:Measurements.png|left|thumb]]

* Pediatric Airway Diameters

- 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 DiametersAverage 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 & Approaches1- 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. Ballon 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
{{Stub Notice}}

[[File:Pediatric lung isolation info sheet.jpg|thumb]]

* [https://pubmed.ncbi.nlm.nih.gov/33215885/ An Update on One-Lung Ventilation in Children]

[https://pubmed.ncbi.nlm.nih.gov/14717881/ Single-lung ventilation in infants and children]

[https://www.bjaed.org/article/S2058-5349(17)30028-8/fulltext Paediatric lung isolation]

[https://pubs.asahq.org/anesthesiology/article/135/5/842/117609/Hypoxemia-in-Young-Children-Undergoing-One-lung Hypoxemia in Young Children Undergoing One-lung Ventilation: A Retrospective Cohort Study]

[https://pubmed.ncbi.nlm.nih.gov/29484775/ Anesthesia of thoracic surgery in children]

[https://pubmed.ncbi.nlm.nih.gov/24988827/ 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]

[https://pubmed.ncbi.nlm.nih.gov/20716092/ Single lung ventilation with an endotracheal tube in a small child undergoing right thoracotomy]

[https://pubmed.ncbi.nlm.nih.gov/34767676/ Error traps in pediatric one-lung ventilation]

[https://pubs.asahq.org/anesthesiology/article/137/6/733/137059/Radiographic-Demonstration-of-Hypoxic-Pulmonary Radiographic Demonstration of Hypoxic Pulmonary Vasoconstriction during One-lung Ventilation]

[https://pubmed.ncbi.nlm.nih.gov/27600760/ Comment on: Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years]

[https://pubmed.ncbi.nlm.nih.gov/28800989/ A Prospective Comparison of Intraluminal and Extraluminal Placement of the 9-French Arndt Bronchial Blocker in Adult Thoracic Surgery Patients]

[https://pubmed.ncbi.nlm.nih.gov/30133914/ Inside out: Repurposing endobronchial intubation to facilitate extraluminal placement of a 5 Fr Arndt bronchial blocker in young infants]

[https://pubmed.ncbi.nlm.nih.gov/26956889/ Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years]

[https://pubmed.ncbi.nlm.nih.gov/35949780/ Selective Lobar Blockade With a Bronchial Blocker in Combination With a Double Lumen Tube to Manage Refractory Hypoxemia: A Case Report]

[https://pubmed.ncbi.nlm.nih.gov/32921610/ A Retrospective Evaluation of Airway Anatomy in Young Children and Implications for One-Lung Ventilation]

[https://pubmed.ncbi.nlm.nih.gov/29430803/ An initial experience with an Extraluminal EZ-Blocker® : A new alternative for 1-lung ventilation in pediatric patients]

[https://onlinelibrary.wiley.com/doi/10.1111/pan.12896 Cricoid and left bronchial diameter in the pediatric population]

[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]

One Lung Ventilation

2023-09-04T01:32:58Z

Halcham1:

[[File:Pediatric lung isolation info sheet.jpg|thumb]]
{{Stub Notice}}

[https://pubmed.ncbi.nlm.nih.gov/33215885/ An Update on One-Lung Ventilation in Children]

[https://pubmed.ncbi.nlm.nih.gov/14717881/ Single-lung ventilation in infants and children]

[https://www.bjaed.org/article/S2058-5349(17)30028-8/fulltext Paediatric lung isolation]

[https://pubs.asahq.org/anesthesiology/article/135/5/842/117609/Hypoxemia-in-Young-Children-Undergoing-One-lung Hypoxemia in Young Children Undergoing One-lung Ventilation: A Retrospective Cohort Study]

[https://pubmed.ncbi.nlm.nih.gov/29484775/ Anesthesia of thoracic surgery in children]

[https://pubmed.ncbi.nlm.nih.gov/24988827/ 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]

[https://pubmed.ncbi.nlm.nih.gov/20716092/ Single lung ventilation with an endotracheal tube in a small child undergoing right thoracotomy]

[https://pubmed.ncbi.nlm.nih.gov/34767676/ Error traps in pediatric one-lung ventilation]

[https://pubs.asahq.org/anesthesiology/article/137/6/733/137059/Radiographic-Demonstration-of-Hypoxic-Pulmonary Radiographic Demonstration of Hypoxic Pulmonary Vasoconstriction during One-lung Ventilation]

[https://pubmed.ncbi.nlm.nih.gov/27600760/ Comment on: Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years]

[https://pubmed.ncbi.nlm.nih.gov/28800989/ A Prospective Comparison of Intraluminal and Extraluminal Placement of the 9-French Arndt Bronchial Blocker in Adult Thoracic Surgery Patients]

[https://pubmed.ncbi.nlm.nih.gov/30133914/ Inside out: Repurposing endobronchial intubation to facilitate extraluminal placement of a 5 Fr Arndt bronchial blocker in young infants]

[https://pubmed.ncbi.nlm.nih.gov/26956889/ Bending the rules: a novel approach to placement and retrospective experience with the 5 French Arndt endobronchial blocker in children <2 years]

[https://pubmed.ncbi.nlm.nih.gov/35949780/ Selective Lobar Blockade With a Bronchial Blocker in Combination With a Double Lumen Tube to Manage Refractory Hypoxemia: A Case Report]

[https://pubmed.ncbi.nlm.nih.gov/32921610/ A Retrospective Evaluation of Airway Anatomy in Young Children and Implications for One-Lung Ventilation]

[https://pubmed.ncbi.nlm.nih.gov/29430803/ An initial experience with an Extraluminal EZ-Blocker® : A new alternative for 1-lung ventilation in pediatric patients]

[https://onlinelibrary.wiley.com/doi/10.1111/pan.12896 Cricoid and left bronchial diameter in the pediatric population]

[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]

File:Pediatric lung isolation info sheet.jpg

2023-09-04T01:32:37Z

Halcham1:

principles of peds lung isolation

File:Measurements.png

2023-09-04T01:28:55Z

Halcham1:

tracheal tubes sizing