Letters to the Editor: Letters & Announcements
To the Editor:
The use of bronchial blockade for single-lung ventilation in infants and children has grown in popularity. Placement of the blocker outside of the tracheal tube facilitates suctioning of the tracheal tube but makes repositioning of the blocker difficult. Placement of the blocker through the tracheal tube requires the presence of an airway adapter so that the blocker has egress from the breathing circuit. The commercially available adapter (Cook Critical Care, Bloomington, IN) has a dead space volume that is relatively large for infants and may not be available in some hospitals. A variety of “home-made” adapters have been described, but these may require the use of adhesives and may involve the risk of introducing foreign material into the airway.
Another impediment to placement of bronchial blockers via the tracheal tube in infants and small children is that the tracheal tube may be too small to accommodate the smallest available bronchoscope and blocker catheter as required for bronchoscopy-guided blocker placement (1). An alternative method is to selectively intubate the bronchus to be blocked with the tracheal tube, after which the blocker may be advanced into a distal bronchial segment through the tracheal tube. The tracheal tube may then be withdrawn into the trachea, and the blocker subsequently withdrawn into the proximal mainstem bronchus under fluoroscopic guidance (2).
The technique that we employ for single-lung ventilation in neonates and infants involves passage of a Fogarty catheter (2F in neonates and 3F in infants) through a T-connector that is commonly used as part of our IV tubing for children. For placement of a 2F Fogarty catheter, an 18-gauge IV catheter is placed through the injection port of the T-connector and the stylette removed; the Fogarty is then advanced through the IV catheter, T-connector, and elbow adapter of the anesthesia breathing circuit (Fig. 1). A 16-gauge IV catheter is used to facilitate placement of a 3F Fogarty catheter. The female end of the T-connector may be used for capnography. This assembly is then attached to the tracheal tube, which has been positioned in the mainstem bronchus to be blocked. The tracheal tube is withdrawn into the trachea, after which the Fogarty catheter is slowly pulled back so that its tip is located in the proximal mainstem bronchus under fluoroscopic guidance before inflation of the catheter balloon (Fig. 2).
Gregory B. Hammer, MD
Department of Anesthesia
Stanford University Medical Center
1. Hammer GB, Harrison K, Vricella LA, Black MD, Krane EJ. Single lung ventilation in children using a new paediatric bronchial blocker. Paediatr Anaesth 2002;12:69–72
© 2007 International Anesthesia Research Society
2. Hammer GB, Hall S, Davis PJ. Anesthesia for general, thoracic, and urologic surgery. In: Motoyama E, Davis PJ, eds. Smith's anesthesia for infants and children. 7th ed. Philadelphia: Mosby Elsevier, 2006:704