Pediatric Anesthesia: Society for Pediatric Anesthesia: Brief Communication
SECTION EDITOR: WILLIAM J. GREELEY.
Video-assisted thoracoscopic surgery (VATS) was first introduced as a surgical technique in 1991 [1-3]. One-lung ventilation (OLV) has been suggested as an approach to ventilation for this kind of procedure [4-7]. OLV may be difficult in infants and small children, because endobronchial intubation with a single lumen to achieve OLV often blocks the right upper lobe of the intubated lung because of the close proximity of the right upper lobe bronchus to the carina. We designed a modified endotracheal tube (ETT) to facilitate OLV for infants and small children undergoing VATS.
We modified an ETT by cutting a U-shaped notch over an uncuffed Murphy endotracheal tube (Mallinckrodt Medical, Althelone, Ireland) near its proximal bevel edge. This notch was directly opposite the Murphy's orifice (Figure 1). The selection of the appropriate size to which the notch was cut varied according to the size of the ETT used. The cut edges of the notch were polished using sandpaper, and the tube was resterilized.
We used our modified ETT in 30 infants and children aged 1-22 mo (mean 9 +/- 7.1 mo) weighing 2.9-9.8 kg (mean 6.36 +/- 2.14 kg) diagnosed with isolated patent ductus arteriosus (PDA) undergoing closure of the ductus by VATS. Anesthesia was induced without premedication. Standard monitoring was used. A right radial arterial cannula was placed after anesthesia induction. Anesthesia was induced with IV midazolam 0.1 mg/kg and fentanyl 5 [micro sign]g/kg. Ventilation was controlled with 100% oxygen via the Bain circuit. After the administration of IV vecuronium 0.1 mg/kg to facilitate endotracheal intubation, the modified ETT with malleable stylet was inserted into the right mainstem bronchus using the left face-level blind method . The tube was then rotated approximately 120[degree sign] clockwise. The precise position of the tube was confirmed by bilateral chest auscultation and fiberoptic bronchoscopy while the scope was passed through a self-sealing diaphragm of the elbow connector into the bronchial lumen. Anesthesia was maintained with isoflurane in oxygen, with additional fentanyl and vecuronium as needed. After the patient was turned to the right recumbent position, the placement of modified ETT was rechecked using auscultation and bronchoscopy. Endobronchial intubation was secured, and VATS was performed to close the PDA. After the PDA was ligated, the modified ETT was withdrawn 2-3 cm into the trachea. After the left collapsed lung was expanded and viewed on the video monitor, normal ventilation was resumed. After surgery and before tracheal extubation, a bronchoscopy was performed to examine the carina, right main bronchus, truncus intermedius, and orifice of the right middle lobe bronchus. No tracheal or bronchial mucosa laceration, abrasion, or hemorrhage was evident in any patient.
We also measured arterial blood gases five times during the anesthesia: 1) with the patient in the supine position during two-lung ventilation with chest closed; 2) with the patient in the supine position 3 min after starting OLV with chest closed; 3) with the patient in the right recumbent position during OLV with the chest closed; 4) with the patient in the right recumbent position during OLV with the chest open, and 5) with the patient in the right recumbent position during two-lung ventilation with chest closed. No hypoxemia, and only mild hypercapnia (PaCO (2) <46 mm Hg), occurred during OLV. The remaining course and outcome of surgery and anesthesia were uneventful.
In 1991, VATS was introduced and advocated by Lewis and colleagues . OLV has been suggested as an approach to ventilation for this kind of operation [4-7]. To achieve OLV for infants and small children, endobronchial intubation with a single-lumen tube has been suggested . This approach is often complicated by right upper lobe collapse. We designed a modified ETT to facilitate endobronchial intubation for infants and small children undergoing VATS in which right upper lobe ventilation is preserved. We report a series of 30 cases of PDA ligation with VATS in which our modified ETT was safe and effective.
In conclusion, surgical conditions for VATS are improved by OLV, which provides for safe intrathoracic videoscopic instrumentation and a quiet surgical field. To achieve OLV for infants and small children, our modified ETT provided reliable endobronchial intubation without blocking the upper bronchial orifice and without intraoperative hypoxemia or impairment of gas exchange. Furthermore, no tracheal or bronchial mucosa injury was seen on fiberoptic bronchoscopy after the use of the modified ETT.
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