Single-lung Ventilation for Pulmonary Lobe Resection in a Newborn Tariq Alzahrani Demonstrator College of Medicine King Saud University

Introduction For lung isolation - double-lumen tubes - univent tube - single-lumen endobronchial tubes - endobronchial blockers Lung isolation is generally limited to children older than 1yr.

History 34 wk gestation. 3 kg. Congenital emphysema of the left upper lobe. Infective pulmonary complication. Intermittent ventilatory support with 3.5mm(ID) nasotracheal tube

Increasing volume of the left upper pulmonary lobe caused progressive mediastinal shift & the need for urgent surgery. At the time of surgery, the infant was spontaneously breathing with a natural airway & was 40 days old.

Intra Operative G.A (thiopental, sufentanil,rocuronium, & sevoflurane ) Monitored (pulse oximetry, ECG, temperature probe, capnography & Lt radial artery invasive B.P) A 22G central venous catheter was placed via the Rt internal jugular vein.

Intubated nasally with an uncuffed 4mm ID. FWEB (fiberoptically directed,wire- guided 5f endobronchial blocker) was coaxially guided into the left main stem bronchus using a 2 mm pediatric fiberscope.

The left lung collapsed by continuously suctioning the 0.7 mm lumen of the FWEB after removal of the guidewire. Right-sided decubitus position & positioning of FWEB was verified fiberoptically. 2.5 h, R.R 30-40/min, PAWP was limited to 25cm H 2 o resulting in a minute volume of L, fio 2 1, pao 2 350mmhg. Paco 2 increased during mechanical ventilation to maximum of 84 mmhg corresponding to a pH of 7.06.

Manually ventilated. After resection of the left upper pulmonary lobe, the left lung was cautiously expanded under visual control & the FWEB removed. PICU with 4mm ET still in place. 1 day postoperative, the infant was nasally extubated & after uneventful recovery discharged to the word.

Discussion Youngest child for SLV. A regular cuffed ET that is mm ID smaller than indicated for endotracheal intubation can be used to allow the cuff to fit the main stem bronchus. 3 mm cuffed tubes have been applied in infants < 12 months old, this technique has certain limitations :

1.The mainstem bronchi are out of reach for conventional ET S if the nasotracheal route is preferred to minimize the risk of dislocation. 2.Significant airway trauma may result from advancing an ET blindly, especially if a stylet is used to enter the left mainstem bronchus. 3.Hypoxemia may result from obstruction of the upper lobe bronchus by the cuff of the ET, typically when the short right mainstem bronchus is intubated.

4.Suction cannot be applied to the operative side to promote lung collapse. 5.O 2 & continuous positive airway pressure cannot be administered to the operative lung if the patient experiences O 2 desaturation. The component of the system (multiport adaptor, moisture exchange filter ) significantly add to dead space ventilation leading to the limits of acceptable respiratory acidosis in this case.

Others have used continues caudal epidural anesthesia in congenital lobar emphysema in an attempt to avoid positive pressure ventilation.

Conclusion They have demonstrated the feasibility of SLV in a newborn using a coaxially placed fiberoptically directed endobronchial blocker.