One lung ventilation for children?

[Geoffrey Parkins]

I rencently had the challenging task of giving a single lung ventilation to a 5 year-old 25kg child who had been in a traffic accident and had a large hemothorax. The surgeons wanted to explore and repair on one lung if possible. The case was urgent enough for there to be no time to transfer to a dedicated pediatric hospital.

I managed to put a standard 5.5 ETT into the right main bronchus, with a big enough leak to allow the left lung to deflate. The surgeons were happy with their access and the bleeder was repaired.

My problems started when the surgeons requested repeated inflations and deflations of the left lung to identify persisting air leaks. I managed to pull the tube back and pass it down again several times, each time hoping it would go back into the right main bronchus. This worked well but was a very cumbersome technique.

I thought about putting in a Fogarty catheter as a bronchial blocker, but could not fit the catheter and bronchoscope together down the lumen. My smallest double lumen tube was a 32F - too big for this child.

Any other ways of tackling this situation?

[John Farnsworth]

There are pediatric-size Univent tubes that allow the passage of a pediatric size bronchoscope for placement. The alternative is blind placement of the Univent bronchial blocker or a Fogarty catheter, test ventilate and check which side it has gone to. If the wrong side, the pull back, twist 180^o and re-insert. A bit fiddly, but only has to be done once. Then blowing up the balloon and deflations do not require any further manipulations.

[Emma Davey M.D.]

We have the Cook Arndt Bronchial blocker which is a three-way accessory that attaches to any ETT. It allows the passage of a pediatric bronchoscope.
I have uploaded some pics below which should makes its use self-explanatory.

[Hossam]

very nice and demonestrative images .........thanx Emma :)

[jeflet]

I find the Cook cather system excellent.  The big advantage is all in the connector at the top - which allows the  bronchoscope and the catheter to seal thus allowing ventilation to continue.

The only disadvantage is that the lumen of the catheter is small and does not allow good deflation of the lung, especially  if secretions get caught in it.  I get around this problem as best I can by deflating the catheter balloon, disconnecting the circuit (to allow the lungs to collapse to FRC), inflating the blocker balloon to isolate the 'bad' lung, then resuming ventilation of the 'good' lung.  This gives the deflated lung a good head-start on collapsing and the surgeon can usually displace the remaining air from their operative field - if only to another part of the deflated lung, while absorption of the alveolar gas occurs.

[lovebailey2000]

Hey Emma
Cudn't c the pics! Pls upload again.