How to perform differential lung ventilation in pediatric cases?

Laryngeal mask combined with bronchial tube achieves one-lung ventilation for transthoracic oesophagectomy

Laryngeal mask combined with bronchial blocker provides an alternative for lung isolation but lacks adequate access to the non-dependent lung. Substituting the blocker with a bronchial tube may overcome this limitation. In this report, a #4.5 cuffed bronchial tube was introduced into the non-dependent lung through a second-generation laryngeal mask for transthoracic oesophagectomy. During the 2.5-hour thoracotomy, one-lung ventilation was achieved by isolating the left lung with the bronchial tube and ventilating the right lung via the laryngeal mask, using volume-control mode (7 mL/kg × 12/min) with P_IP21-23 cm H₂O, pH 7.36 and PaCO₂ 38.3. Prior to thoracotomy closure, suction and reinflation of the left lung were performed through the bronchial tube. Bronchoscopy via the laryngeal mask revealed no injury to the airway after removal of the bronchial tube. The case shows that laryngeal mask combined with bronchial intubation provides one-lung ventilation with access to the isolated lung.

Differential lung ventilation via tracheostomy using two endotracheal tubes in an infant: a case report

Background

This case report presents differential lung ventilation in an infant. The aim is to define an alternative technique for performing differential lung ventilation in children. To the best of our knowledge, this is the first report of this kind.

Case presentation

A 4.2-kg, 2.5-month-old Asian boy was referred to our facility with refractory hypoxemia and hypercarbia due to asymmetric lung disease with atelectasis of the left lung and hyperinflation of the right lung. He was unresponsive to conventional ventilator strategies; different ventilator settings were required. To perform differential lung ventilation, two separate single-lumen endotracheal tubes were inserted into the main bronchus of each lung by tracheotomy; the tracheal tubes were attached to discrete ventilators. The left lung was ventilated with a lung salvage strategy using high-frequency oscillatory ventilation, and the right lung was ventilated with a lung-protective strategy using pressure-regulated volume control mode. Differential lung ventilation was performed successfully with this technique without complications.

Conclusions

Differential lung ventilation may be a lifesaving procedure in select patients who have asymmetric lung disease. Inserting two single-lumen endotracheal tubes via tracheotomy for differential lung ventilation can be an effective and safe alternative method.

Lung isolation, one-lung ventilation and hypoxaemia during lung isolation

Lung isolation is being used more frequently in both adult and paediatric age groups due to increasing incidence of thoracoscopy and video-assisted thoracoscopic surgery in these patients. Various indications for lung isolation and one-lung ventilation include surgical and non-surgical reasons. Isolation can be achieved by double-lumen endotracheal tubes or bronchial blocker. Different issues arise in prone and semi-prone position. The management of hypoxia with lung isolation is a stepwise drill of adding inhaled oxygen, adding positive end-expiratory pressure to ventilated lung and continuous positive airway pressure to non-ventilated side.

Differential lung ventilation in an infant using LMA and a long tracheal tube

This is a case report of differential lung ventilation in an infant using a conventional laryngeal mask airway (LMATM) and a commercially available longer paediatric tracheal tube. This 2-month-old infant had her left-sided congenital diaphragmatic hernia repaired on the sixth day of her life, and had been mechanically ventilated. The right middle lobe became grossly emphysematous and herniated into the left side of the chest, and the right lower lobe became totally atelectatic. A right middle lobe lobectomy was planned. To avoid hyperinflating the right middle lobe, and to expand the right lower lobe without providing a high airway pressure on the left lung, the dependent lung (i.e. left lung) was ventilated with an LMA, and the right lower lobe was expanded with a long tracheal tube inserted through the LMA via the swivel connector. This combination of a conventional LMA and a commercially available longer paediatric tracheal tube could be another way of providing differential ventilation in infants.