One Lung Ventilation Using Bronchial Blocker Through

Endotracheal Tube in a Child

Case Report

CASE REPORT

An 6-yr-old 18-kg boy, diagnosed case of neuro-blastoma in posterior mediastinum, presented to us.

He was scheduled for right thoracotomy for excision ofa neuroblastoma. He had received 6 cycles of chemo-therapy. Medical history was unremarkable. Hisinvestigations CBC, RFT, PFT, chest X-ray were normal.

He was kept nil per oral for 6 hours. Written informedconsent was taken.

Plan was general anesthesia with one lung ventilationusing bronchial blocker through single lumen tube.

In OR after placement of routine monitors , anesthesiawas induced with intravenous inj propofol 40 mg, injfentanyl 40 mcg. After checking for mask ventilation, injatracurium 10 mg was given.

Direct laryngoscopy was done, and trachea wasintubated with a 6.0-mm inner diameter (ID) cuffed Singlelumen tube (SLT ).

It was passed into right bronchus . One lung ventilationwas confirmed by auscultation.Then bronchial blockerwas passed through the endotracheal tube into rightbronchus.

Single lumen tube was then withdrawn upto carina . Apediatric Fibreoptic bronchoscope (size 3.5) was thenintroduced into single lumen tube and bronchial blocker

ONE LUNG VENTILATION USING BRONCHIAL BLOCKER THROUGHENDOTRACHEAL TUBE IN A CHILD

V Muralidhar* and Neha Malik***Senior Consultant, **Junior Registrar, Department of Anaesthesia,

Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India.Correspondence to: Dr V Muralidhar, Senior Consultant, Department of Anaesthesia, Indraprastha Apollo Hospitals,

D-101, Royal Residency, Plot D-11, Sector 44, Noida 201 301, India.E-mail: murali2u@gmail.com

One lung ventilation is being commonly used in children. Lung separation for one-lung ventilation can beaccomplished by use of a double-lumen tube, a single-lumen tube (SLT) with intentional endobronchialintubation, a SLT with bronchial blocker or an arterial embolectomy catheter (Fogarty catheter), and a Univenttube. Placement of a bronchial blocker can be accomplished outside or within a SLT blindly and with the helpof rigid or fiberoptic bronchoscope (FOB). We describe here successful placement of a bronchial blocker forone-lung ventilation through a SLT.

Key word: One lung ventilation bronchial blocker through endotracheal tube.

was then withdrawn till the cuff was visible. Tube wasthen secured.

Anesthesia was maintained with oxygen, isoflurane,and atracurium. The patient was positioned in the left-lateral decubitus position, and the position of thebronchial blocker was again confirmed by auscultation ofthe chest and by fibreoptic bronchoscopy.

At the end of surgery chest drain was put. Bronchialblocker was removed. Lungs were fully expanded bymanual ventilation. Anesthesia was reversed with injNeostigmine 1 mg and inj Glycopyrollate 0.4 mg. Tracheawas extubated. It was uneventful.

DISCUSSION

Bronchial blockers and arterial embolectomycatheters are often used in children undergoing thoracicsurgeries. Placement of these devices may not be easyeven in expert hands.

Various techniques have been described for successfulplacement of bronchial blockers. Placement of bronchialblocker outside the tracheal tube can be achieved by directvisualization of the bronchus using a rigid bronchoscope,but the use of this technique may prolong laryngoscopy,bronchoscopy, and increase the risk of hypoxia andtrauma to the upper airway.

Bronchial blocker placement can be facilitated byinserting it into the trachea through SLT or along the sideof SLT with the help of FOB.

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Case Report

• S.H Wald, et al [1] described the use of Arndt 5French (Fr) paediatric endobronchial blocker, forsingle lung ventilation. The blocker and thefibreoptic scope were placed through their respectiveports in the multi-port airway adapter provided. Theinner filament at the end of the blocker was thenlooped over the fibreoptic scope and the adapter wasconnected to the tracheal tube and breathing circuit.The fibreoptic scope was advanced undervideoscopic guidance into the desired mainstembronchus and then the blocker was advanced past thefibreoptic scope. The balloon was then inflated underfibreoptic visualization, the scope removed, and thebronchial port was tightened.

• Hammer, et al. [2,3] described bronchial blockadeusing an end hole, balloon wedge catheter. Thebronchus on the operated side is initially intubatedwith a tracheal tube. A guidewire is then advancedblindly through the tracheal tube into the targetbronchus. The tracheal tube is then removed, and theblocker is threaded over the guidewire into the targetbronchus. The tracheal tube was again placed intothe trachea by the side of the catheter.

• Joseph D Tobias [4] described previously the use ofthe adult 9 Fr Arndt bronchial blocker in two childrenaged 9 and 10 yr.

• Yun, et al [5] reported successful single lungventilation in a 14-yr-old using the paediatric 5 Frbronchial blocker and Hammer and colleaguespublished a case report involving a 4-yr-old and a 17-month old patient .

• Harvey, et al [6] described the use of bronchialblocker placed outside a single lumen tube in 43years old female patient presented for thoracoscopicleft lung biopsy for suspected carcinoma withrestricted mouth opening.

• Nino, et al [7] described the use of 8/22f bronchialblocker to rescue an illfitting double lumen tube in71 years old patient with left upper lobeadenocarcinorna posted for left preumonectomy.

Bronchoscopy revealed that right upper lobe bronchusarose from night main stem bronchus 3mn below thecarina. Placement of right double lumen tube failed toprovide enough seal as the bronchial cuff was observed tobe partially above the carina bronchial blocker was passedthrough lumen of double lumen tube level of carina. Itdecreased the air leak and allowed complete deflation ofleft lung [8].

Existing methods for single lung ventilation are eitherimpossible to use in small children (double lumenendobronchial tubes) or inconsistently successful(Fogarty catheter, endobronchial intubation).

The narrow airways of children under 8 yr old or lessthan 30 kg in weight preclude placement of a doublelumen endobronchial tube as the smallest size available isa 26 Fr. The smallest Univent tube has a large outerdiameter (8 mm OD) and narrow inner diameter (3.5 mmID) limiting its use to an older age group. Endobronchialintubation may only inconsistently provide lung isolation,may only provide partial lung isolation, or may require re-adjustment to the trachea, risking extubation.

A Fogarty catheter is not designed for use in theairway, as it is equipped with a high-pressure, low-volumeballoon; it may be difûcult to secure and does not have alumen for application of continuous positive airwaypressure.

Our experience suggests that the paediatric bronchialblocker can be used as a consistent, safe method of singlelung ventilation in most young children.

REFERENCES

1. SH Wald, A Mahajan, MB Kalpana, JB Atkinson.Experience with the Arndt Paediatric Bronchial Blocker.British Journal of Anaesthesia. 2005; 94(1): 92-94.

2. Hammer GB, Harrison TK, Vricella LA, et al. Single lungventilation in children using a new paediatric bronchialblocker. Paediat Anaesth 2002; 12: 69-72.

3. Hammer GB, Manos SJ, Smith BM, et al. Single lungventilation in pediatric patients. Anaesthesiology 1996;84: 1503-1506.

4. Tobias JD. Variations on one-lung ventilation. J ClinAnesth 2001; 13: 35-39.

5. Yun ES, Saulys A, Popic PM, et al. Single-lung ventilationin a pediatric patient using a pediatric fiberoptically-directed wireguided endobronchial blocker. Can J Anesth2002; 49: 256-261.

6. Harvey SC, Alpert CC, Fishman RL. Independentplacement of bronchial blocker for single lung ventilation:an alternative method for the difficult airway. AnesthAnalg 1996; 83: 1330-1331.

7. Nino M, Body SC, Hartigan PM. The use of a bronchialblocker to rescue an ill-fitting double-lumen endotrachealtube. Anesth Analg 2000; 91: 1370-1371.

8. Benumof JL. Separation of the two lungs (double-lumentubes, bronchial blockers and endobronchial singlelumen tubes). In Benumof JL, ed. Airway management:principle and practice. St Louis, MO; Mosby-year book,1996:412.

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