Abstract

AIR-8

A Novel Approach to One-Lung Ventilation in a Pediatric Patient with a Tracheostomy

Ellingboe M, Andras L
Children's Hospital of Los Angeles, Los Angeles, California, United states

Introduction: One-lung ventilation (OLV) poses complications to anesthesiologists caring for pediatric patients secondary to the size of available double lumen endotracheal tubes (DLTs) and bronchial blockers (BBs). Patients with tracheostomies requiring OLV present additional complications.
Case: A 4 year old female with complicated past medical history including subglottic stenosis status post tracheostomy with 3.5 cuffed Shiley tracheostomy tube presented for video-assisted thoracoscopic surgery (VATS) and lung biopsy with OLV. Inhalational induction was performed via tracheostomy. Direct laryngoscopy was performed and a 4 French Fogarty catheter was passed through the vocal cords under direct visualization. A 2.8 mm fiberoptic bronchoscope was advanced via the tracheostomy tube. The Fogarty catheter was advanced until visualized at the carina, followed by placement in the right mainstem bronchus and balloon was inflated under direct visualization. The patient was placed in the left lateral decubitus position and Fogarty position was verified. Lung separation was adequate for surgical exposure. At the conclusion of the procedure, the Fogarty balloon was deflated and the catheter removed. The right lung was reinflated under direct visualization with the thoracoscope. The patient was transferred to the PICU and the postoperative course was uneventful.
Discussion: Several methods of OLV have been described in the pediatric population, including DLTs, BBs, and endobronchial intubation. OLV via tracheostomy tube is less common, and even rarer in pediatrics. The smallest available DLT is 26 French and the smallest available BB requires a 4.5 mm ETT, ruling these methods out in the younger pediatric population.
Other previously described options for OLV in younger children include endobronchial intubation with a single lumen ETT and the use of a Fogarty catheter as a BB. A literature review failed to find reports of the use of a Fogarty catheter for OLV placed orally and passed external to a tracheostomy tube in a pediatric patient. Use of the Fogarty in this manner allows for maintenance of the entire lumen of the tracheostomy tube for ventilation. Interruptions in ventilation were minimized as the tracheostomy tube was left in place and a fiberoptic adapter was used while positioning the Fogarty, allowing ventilation of the patient to continue throughout manipulation of the airway. Another benefit is the ability to resume two-lung ventilation immediately by deflating the Fogarty balloon if the patient does not tolerate OLV. The maintenance of the full lumen of the tracheostomy tube for ventilation and minimization of interruptions in ventilation are incredibly useful tools in patients with lung disease and potential difficult lung separation requiring OLV.
References:
Fabila T. S., Menghraj S. J. “One lung ventilation strategies for infants and children undergoing video assisted thoracoscopic surgery.” Indian J Anaesth. 2013 Jul-Aug; 57(4): 339-344.
Fitzgerald J., Evans F. “Techniques for single lung ventilation in infants and children.” Anaesthesia Tutorial of the Week. World Federation of Societies of Anaesthesiologists. 23 Oct 2015.
Letal M., Thaem M. “Pediatric lung isolation.” BJA Education. 2017 Feb; 17(2): 57-62.