Effectiveness of Arndt endobronchial blockers in pediatric scoliosis surgery: a case series

Hypoxemia in School-age Children Undergoing One-lung Ventilation: A Retrospective Cohort Study from the Multicenter Perioperative Outcomes Group

BACKGROUND

Risk factors for hypoxemia in school-age children undergoing one-lung ventilation remain poorly understood. The hypothesis was that certain modifiable and nonmodifiable factors may be associated with increased risk of hypoxemia in school-age children undergoing one-lung ventilation and thoracic surgery.

METHODS

The Multicenter Perioperative Outcomes Group database was queried for children 4 to 17 yr of age undergoing one-lung ventilation. Patients undergoing vascular or cardiac procedures were excluded. The original cohort was divided into two cohorts: 4 to 9 and 10 to 17 yr of age inclusive. All records were reviewed electronically for the primary outcome of hypoxemia during one-lung ventilation, which was defined as an oxygen saturation measured by pulse oximetry (Spo2) less than 90% for 3 min or longer continuously, while severe hypoxemia was defined as Spo2 less than 90% for 5 min or longer. Potential modifiable and nonmodifiable risk factors associated with these outcomes were evaluated using separate multivariable least absolute shrinkage and selection operator regression analyses for each cohort. The covariates evaluated included age, extremes of weight, American Society of Anesthesiologists Physical Status of III or higher, duration of one-lung ventilation, preoperative Spo2 less than 98%, approach to one-lung ventilation, right operative side, video-assisted thoracoscopic surgery, lower tidal volume ventilation (defined as tidal volume of 6 ml/kg or less and positive end-expiratory pressure of 4 cm H2O or greater for more than 80% of the duration of one-lung ventilation), and procedure type.

RESULTS

The prevalence of hypoxemia in the 4- to 9-yr-old cohort and the 10- to 17-yr-old cohort was 24 of 228 (10.5% [95% CI, 6.5 to 14.5%]) and 76 of 1,012 (7.5% [95% CI, 5.9 to 9.1%]), respectively. The prevalence of severe hypoxemia in both cohorts was 14 of 228 (6.1% [95% CI, 3.0 to 9.3%]) and 47 of 1,012 (4.6% [95% CI, 3.3 to 5.8%]). Initial Spo2 less than 98% was associated with hypoxemia in the 4- to 9-yr-old cohort (odds ratio, 4.20 [95% CI, 1.61 to 6.29]). Initial Spo2 less than 98% (odds ratio, 2.76 [95% CI, 1.69 to 4.48]), extremes of weight (odds ratio, 2.18 [95% CI, 1.29 to 3.61]), and right-sided cases (odds ratio, 2.33 [95% CI, 1.41 to 3.92]) were associated with an increased risk of hypoxemia in the older cohort. Increasing age (1-yr increment; odds ratio, 0.88 [95% CI, 0.80 to 0.97]) was associated with a decreased risk of hypoxemia.

CONCLUSIONS

An initial room air oxygen saturation of less than 98% was associated with an increased risk of hypoxemia in all children 4 to 17 yr of age. Extremes of weight, right-sided cases, and decreasing age were associated with an increased risk of hypoxemia in children 10 to 17 yr of age.

EDITOR’S PERSPECTIVE

Rigid Bronchoscopic Placement of Fogarty Catheter as a Bronchial Blocker for One Lung Isolation and Ventilation in Infants and Children Undergoing Thoracic Surgery: A Single Institution Experience of 27 Cases

One-lung ventilation (OLV) is a challenging task in infants and children as few techniques are possible because of narrow anatomy. The aim of this study is to evaluate and experience lung isolation with Fogarty catheters as a bronchial blocker placed by rigid bronchoscope for OLV in infants and children with lung pathologies requiring surgical management in an industrial hospital. This study is a prospective study carried out in J.L.N. Hospital and Research Centre, Bhilai (CG), from January 2011 to December 2014. The study was designed to place Fogarty catheter for achieving OLV using rigid bronchoscope in children. The patient and anaesthesia characteristics, placement and positioning of Fogarty catheters, intraoperative course, complications and recovery of the patient were studied. The data were then compared with the relevant and available literature. Over the study period of 4 years, 27 cases were included, out of which 22 (81.48 %) cases had suppurative lung disease, three cases (11.11 %) had hydatid cyst of the lung, whereas one case (3.7 %) each of congenital lobar emphysema and congenital cystic adenomatoid malformation of the lung, respectively. In all cases general anaesthesia was provided using single lumen endotracheal tube and one lung ventilation achieved by parallel placement of Fogarty catheter as a bronchial blocker with rigid bronchoscope. The surgical management included thoracotomy with decortication in 21 cases, thoracotomy with excision of hydatid cyst in 3 cases, video-assisted thoracoscopic surgery, thoracotomy with left upper lobectomy and thoracotomy with left lower lobectomy in one case each, respectively. There were no major intraoperative and postoperative complications. There was no mortality in our study. We conclude that rigid bronchoscope can be safely and effectively used to place Fogarty catheter in main bronchus in infants and children for achieving OLV.

One lung ventilation strategies for infants and children undergoing video assisted thoracoscopic surgery

The advantages of video assisted thoracoscopic surgery (VATS) in children have led to its increased usage over the years. VATS, however, requires an efficient technique for one lung ventilation. Today, there is an increasing interest in developing the technique for lung isolation to meet the anatomic and physiologic variations in infants and children. This article aims to provide an updated and comprehensive review on one-lung ventilation strategies for infants and children undergoing VATS. Search of terms such as ‘One lung ventilation for infants and children’, ‘Video assisted thoracoscopic surgery for infants and children’, and ‘Physiologic changes during one lung ventilation for infants and children’ were used. The search mechanics and engines for this review included the following: Kandang Kerbau Hospital (KKH) eLibrary, PubMed, Ovid Medline, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews. During the search the author focused on significant current and pilot randomized control trials, case reports, review articles, and editorials. Critical decision making on what device to use based on the age, weight, and pathology of the patient; and how to use it for lung isolation are discussed in this article. Furthermore, additional information regarding the advantages, limitations, techniques of insertion and maintenance of each device for one lung ventilation in infants and children were the highlights in this article.

One lung ventilation in a patient with an upper and lower airway abnormality

One-lung ventilation for a thoracotomy procedure was achieved with the help of a endobronchial blocker in a young girl with limited mouth opening, minimal neck extension, and a distorted tracheo-bronchial anatomy. As the patient would not cooperate for an awake nasotracheal intubation despite adequate preperation, an inhalational anesthetic was used to make the patient unconscious, taking care that spontaneous breathing was maintained. Nasotracheal intubation was done with the help of a fiberoptic bronchoscope. A wire-guided Arndt endobronchial blocker was placed coaxially through the endotracheal tube using a fiberoptic bronchoscope. This case report highlights that in a scenario of both upper and lower airway distortion, a bronchial blocker positioned through a nasotracheal tube under fiberoptic guidance might be the best option when one-lung ventilation is required.

Fusionless instrumentation systems for congenital scoliosis: expandable spinal rods and vertical expandable prosthetic titanium rib in the management of congenital spine deformities in the growing child

STUDY DESIGN

Review of relevant literature including personal opinions.

OBJECTIVE

To review the current researches investigating the efficacy of growing rod and thoracic expansion techniques in the treatment of congenital spine deformity of young children, and to highlight the contrasting advantages and limitations in the fusionless treatment of progressive congenital scoliosis.

SUMMARY OF BACKGROUND DATA

Congenital scoliosis has the potential for severe spinal deformity and thoracic insufficiency syndrome (TIS). Conventional fusion treatments in children tend to shorten the spine further exacerbating trunk shortening and TIS. In the surgical treatment of congenital spinal deformities in young children, while reconstructing the spinal deformity, one should simultaneously pursue preserving the growth potential of the vertebrae, improving the volume, symmetry, and functions of the thorax, and protecting this improvement during the growth. Today, employed in the treatment of spinal deformities of young children, there are 2 deformity reconstruction methods serving these targets: Growing rod technique and vertical expandable prosthetic titanium rib (VEPTR) with or without expansion thoracostomy.

METHODS

Peer-reviewed research articles and major international meeting presentations were reviewed. Methods were compared in terms of advantages and limitations.

RESULTS

The growing rod technique is a safe and reliable method in the treatment of congenital spine deformity of young children who present some flexibility in the anomalous segment, or when the congenital anomaly involves a vertebral segment too long for resection, or with compensating curve with structural pattern concomitant to the congenital deformity. Expansion thoracostomy and VEPTR are the appropriate choice for severe congenital spine deformity when a large amount of growth remains. Although ventilator dependence is significantly decreasing, thoracic volume and space available for the lung are increased after expansion thoracostomy and VEPTR.

CONCLUSION

Growing rod technique should be used in patients where the primary problem is at the vertebral column. If the patient has rib fusions and/or TIS has developed, in other words, if the primary problem involves the thoracic cage, expansion thoracostomy and VEPTR should be an appropriate option.