PEDIATRIC ANESTHESIA: Case Report
Lung separation for one-lung ventilation can be accomplished by use of a double-lumen tube, a single-lumen tube (SLT) with intentional endobronchial intubation, a SLT with bronchial blocker or an arterial embolectomy catheter (Fogarty catheter), and a Univent tube. Because of the unavailability of appropriately sized double-lumen tubes and bronchial blockers, Fogarty catheters and Univent tubes are being used to achieve lung isolation in children (1–6). Placement of a Fogarty catheter can be accomplished outside or within a SLT blindly and with the help of rigid or fiberoptic bronchoscope (FOB) (4,7–9). Fogarty catheter placement inside the SLT using two FOB adapters connected in a series has been described for using a separate port for the FOB and the Fogarty catheter (10). Alternatively, a Fogarty catheter can be placed by passing through the hole made in a SLT and the FOB through a SLT adapter (11).
We describe successful placement of a Fogarty catheter for one-lung ventilation through a SLT using the single diaphragm of an adapter for both the FOB and the Fogarty catheter.
An 8-yr-old 18-kg girl was scheduled for left thoracotomy for excision of a bronchogenic cyst. After placement of routine monitors in the operating room, anesthesia was induced with thiopentone sodium, morphine sulfate, and vecuronium bromide. Anesthesia was maintained with oxygen, isoflurane, and vecuronium bromide. A 5F Fogarty catheter was inserted in the larynx under direct laryngoscopy. The trachea was then intubated with a 6.0-mm inner diameter (ID) cuffed SLT. A pediatric FOB (size, 3.5) was then introduced into the SLT through a FOB adapter to facilitate placement of the Fogarty catheter into the left bronchus, but the negotiation of the Fogarty catheter was not smooth by the side of the tube. It was not possible to insert the Fogarty catheter even with repeated attempts. The procedure was then abandoned, and a 6.0-mm ID uncuffed SLT was inserted into the trachea. Placement of a Fogarty catheter was attempted again, but it was not possible. It was then removed from the trachea and introduced through the same diaphragm of the adapter along with the FOB within the lumen of the SLT (Fig. 1). The movements of both the FOB and Fogarty catheter were smooth. There was no leak around the FOB and Fogarty catheter during ventilation while attempts at placement of the Fogarty catheter were made. The placement of the Fogarty catheter was accomplished with relative ease. The FOB was removed, and the Fogarty catheter was secured by plugging the diaphragm with an adhesive tape outside the adapter. The patient was positioned in the left-lateral decubitus position, and the position of the Fogarty catheter was again confirmed by auscultation of the chest and by FOB. No displacement and dislodgment of the Fogarty catheter occurred while repeated suctioning attempts were made. A similar technique for the placement of the Fogarty catheter within the SLT was successfully used in another 10-yr-old child who underwent left thoracotomy for the excision of a neurogenic tumor.
Bronchial blockers and arterial embolectomy catheters are often used in children undergoing thoracic surgeries. Placement of these devices may not be easy even in expert hands, especially in the left bronchus because of the greater takeoff angle and smaller diameter (1,2). Various techniques have been described for successful placement of bronchial blockers. Placement of a Fogarty catheter outside the tracheal tube can be achieved by direct visualization of the bronchus using a rigid bronchoscope, but the use of this technique may prolong laryngoscopy, bronchoscopy, and increase the risk of hypoxia and trauma to the upper airway (7–9). Fogarty catheter placement can be facilitated by inserting it into the trachea before intubation with a SLT or along the side of the SLT after intubation (4). Although it does not create additional potential for disconnection and leaks in the breathing circuit, it may increase the time for instrumentation of the larynx and the trachea. Alternatively, isolation of the lung can be achieved by placement of a bronchial blocker or a Fogarty catheter from outside the SLT with the help of a FOB (12). Hammer et al. (9) described bronchial blockade using an end hole, balloon wedge catheter. The bronchus on the operated side is initially intubated with a tracheal tube. A guidewire is then advanced blindly through the tracheal tube into the target bronchus. The tracheal tube is then removed, and the blocker is threaded over the guidewire into the target bronchus. The tracheal tube was again placed into the trachea by the side of the catheter.
Larson and Gasior (10) described Fogarty catheter placement inside the SLT using two FOB adapters, connected in series, to allow the FOB passage via one diaphragm while directing the Fogarty catheter from the other adapter. Although this technique may be effective albeit cumbersome, chances of disconnection and leak may persist because of the number of connectors present in the breathing circuit.
Asai et al. (11) described successful placement of a Fogarty catheter within a SLT by making a small hole to the side of the SLT with a 18-gauge needle and passing the Fogarty catheter through that hole with the help of the FOB inserted into the SLT via a self-sealing connector. This method may be effective but relies on accurate and leak proof drilling of the hole in a SLT. The diaphragm of a FOB adapter was used for placement of both the FOB and Fogarty catheter.
The placement of the FOB and the Fogarty catheter was achieved with relative ease in both of our cases. There was no appreciable leak around the FOB and the Fogarty catheter, and both were easily maneuverable within the SLT. In both cases, suction of the ventilated lung was performed by passing the suction catheter along the Fogarty catheter through the same diaphragm. Use of this technique has the advantage that it can minimize the attempts of instrumentation of the larynx and may shorten the time taken for accurate placement. This technique can be used safely in smaller children because a FOB as small as 1.7F is available, which can be used in 3 to 3.5-mm ID SLT with the appropriate size catheter. We found this technique safe, easy, and reliable for placement of a bronchial catheter and Fogarty catheter for isolation of the lung in children for one-lung ventilation.
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