FOR pediatric video-assisted thoracic surgery, surgical access has been conventionally accomplished by the total collapse of the ipsilateral lung via blocking 1,2or intubation 3,4of the selected main bronchus. However, single-lung ventilation includes possible detrimental effects on the physiologic conditions in small children. 5More selected exposure of the targeted intrathoracic space may decrease these risks.
Recently, we reported a newly devised double-access-port endotracheal tube (DAPT) for pediatric one-lung anesthesia. 6The tube provides independent access for ventilation and bronchial blocking using a balloon-tipped catheter so that fiberoptic adjustment of the balloon position is possible during sufficient ventilation. The current report describes the successful use of this device for selective lobar–bronchial blocking.
A 5-yr 9-month-old boy (105 cm, 15.3 kg) was scheduled to undergo video-assisted correction of pectus excavatum. In this procedure, a large steel correcting bar is passed through the right middle intercostal space and advanced substernally across the anterior mediastinum to the same intercostal space on the left side. 7To avoid complications, good exposure of the deformed substernal area that makes contact with the pericardium in the right intrathoracic cavity is necessary.
Anesthesia was induced using sodium thiopental, fentanyl, and vecuronium and maintained with oxygen, air, sevoflurane, fentanyl, and vecuronium. The patient’s trachea was intubated with a 5.5-mm ID uncuffed DAPT, and ventilation was controlled via the main port of the DAPT. Subsequently, a 4-French Fogarty catheter (Fogarty Occlusion Catheter; Baxter Healthcare Co., Irvine, CA) was introduced through a Y connector (Bodai Swivel Y; Sontek Medical Inc., Hingham, MA) on the ventilating port of the DAPT under the vision of a 2.2-mm OD fiberscope (Olympus LF-P; Olympus Optical Co. Ltd., Tokyo, Japan) that was passed through the side port (fig. 1). To ensure airtightness, we used 8-French catheter sheathes (Radifocus, 2.5-mm ID; Terumo Co. Ltd., Tokyo, Japan) with slitted rubber caps on both access ports. The balloon of the Fogarty catheter was advanced and placed at the right bronchus intermedius (between the orifice of the upper and middle lobar bronchi, fig. 2). The inflation of the balloon with 1.3 ml air provided good surgical access to the substernal area with the deflation of the right middle and lower lobes. The duration of the lobar blocking was 34 min. No detrimental changes in hemodynamics or blood gases were observed during the period of lobar collapse. Before completion of the operation, the Fogarty catheter was removed and appropriate reinflation of the lobes was confirmed via thoracoscopic inspection. The bronchial wall where the balloon was placed was also confirmed to be intact before extubation. The repair was completed in 72 min without complications. The patient was discharged from the hospital 10 days after the procedure; cosmetic result was satisfactory.
A 5-yr 6-month-old girl (113 cm, 18.6 kg) was scheduled to undergo thoracoscopic resection of a neurofibroma in the right lower posterior mediastinum. Anesthesia was induced using nitrous oxide and sevoflurane in oxygen and maintained with oxygen, air, sevoflurane, fentanyl, and vecuronium. Ventilation was controlled via a 5.0-mm ID cuffed DAPT. The patient’s right middle and lower bronchi were blocked with the balloon of a 4-French Fogarty catheter using the same technique as in case 1. The exposure of the surgical area was excellent, and inflation of the right upper lobe did not disturb the surgical procedures. The duration of the selective lobar–bronchial block was 110 min. Ventilation of the left lung and the right upper lobe stabilized hemodynamics and oxygenation during the procedure. The operation was completed in 138 min. No lung-associated or other complications developed after the operation, and the patient was discharged 1 week after the procedure.
Because of recent improvements in surgical and optical instruments, a more limited exposure rather than the total collapse of the ipsilateral lung may be sufficient for VATS in children. The current report showed two cases. We applied the described technique for blocking targeted lobes in three other VATS cases, including a partial resection of the left lower lobe for a metastatic tumor (9 yr) and two patients (5 and 6 yr) with pectus excavatum. The exposure of the targeted thoracic cavity was excellent and sufficient for surgical access in each patient. There was no case in which the selective lobar collapse was aborted because of a critical depression in either hemodynamics or oxygenation. No serious lung-related complications were observed in the patients.
We used Fogarty catheters for blocking the selected bronchi. Advantages of using this catheter as a blocker include the variation of balloon sizes available and good controllability of the catheter tip with use of a guidewire. However, the lack of a suction port in the Fogarty catheter impedes two important tasks during the selective bronchial blockade. First, rapid deflation of lobes is difficult when needed. We inflated the balloon in the end-expiratory phase, but often a certain period of time passed until complete collapse occurred by absorption atelectasis. Second, continuous positive airway pressure cannot be administered to the deflated lobes. This may increase the risk of hypoxemia and residual atelectasis; however, neither was observed in these patients.
The successful blocking of the desired lobes depends on the precise introduction and alignment of the blocker balloon. Using a DAPT fabricated by combining two conventional endotracheal tubes, 6we achieved the fiberscope-aided introduction of a Fogarty catheter into a targeted bronchus without difficulty while maintaining sufficient ventilation. Manual preforming of the guidewire in the Fogarty catheter also facilitates control of the placement of the catheter tip. The simultaneous use of ventilation could reduce the risk of hypoxemia during block positioning and could allow for realignment of the balloon in the event of intraoperative dislocation.
In small children, the risk of bronchial injury as a result of balloon blocking should be considered. Therefore, the choice of an appropriate balloon size and inflation of the balloon using a minimal volume of air also are important. In our experience, a 4-French Fogarty balloon (maximum OD, 9 mm with 1.7 ml air) was suitable for blocking a selected bronchus in the 5- to 6-yr-old patients. In the 9-yr-old patient, however, because this size did not block the left lower bronchus sufficiently, we switched to a 6-French catheter (maximum balloon OD, 13 mm) during the operation. For younger patients, a size smaller than 4-French may be necessary.
Minimal access thoracic and chest wall surgery has been performed in children and has provided great benefits, such as smaller incisions, improved cosmesis, decreased procedural pain, and shorter hospital stay duration. 8Video-assisted techniques have facilitated the use of these minimally invasive procedures. However, conventional one-lung anesthesia for these procedures is not ideal. The selective lobar–bronchial blocking described herein can reduce further the invasiveness of such procedures.