Anaesthetic management of paediatric thoracotomy using endobronchial blocker: a case report

¹Narendra Kumar Prasadroa Salve Institute of Medical Science and Research Centre, Nagpur, India

^&Corresponding author
Ravikiran Damodhar Nikhade, Narendra Kumar Prasadroa Salve Institute of Medical Science and Research Centre, Nagpur, India

Introduction    

Paediatric thoracic surgery has advanced significantly in recent decades, driven by improvements in technology and minimally invasive techniques. Alongside these surgical innovations, paediatric airway management has evolved, enabling lung isolation in paediatric age group through devices such as paediatric bronchial blockers, univent tubes and modified double lumen tube (DLT). Lung-isolation provides a deflated ipsilateral lung, improving visualization and surgical access-particularly important in video-assisted thoracoscopic surgery (VATS). Despite its benefits, clinical practice varies; while some centers use lung isolation routinely, others reserve it for selected cases, often due to availability of sources, anatomical and technical limitations in young children [1]. Lung abscesses in children are uncommon, and most respond to medical management. Surgical drainage is rarely required, making this case clinically unusual. Achieving lung isolation in children under 6 years old is particularly difficult [2].

The 5F arndt endobronchial blocker is typically used intraluminally, but in this case, it was placed outside the ETT due to size constraints. This extraluminal technique is innovative and not commonly reported. Accurate placement of the blocker using a fibreoptic bronchoscope (FOB) through the ETT while the blocker was outside it demonstrates technical skill and a novel approach. This case provides important learning points for anaesthesiologists on managing lung isolation in small children, especially when conventional approaches aren't feasible [3]. The use of extraluminal bronchial blocker with FOB guidance showcases a practical and effective alternative technique in pediatric anesthesia. There is limited literature on OLV techniques in children under 5 years. This case adds valuable clinical insight and can guide others in similar challenging scenarios [4]. The case highlights how careful planning, equipment adaptation, and adherence to best practices can lead to successful outcomes in rare and complex paediatric cases. Understanding various paediatric lung isolation techniques is crucial for anaesthesiologists managing paediatric thoracic anaesthesia safely and effectively [5].

Patient and observation     

Patient information: a 4-year-old female weighing 10 kg presented with a history of a productive whitish cough for 20 days, worsening at night and early morning, and intermittent mild-to-moderate fever for 15 days associated with irritability. Initial management at a private hospital included antibiotics and a chest X-ray, which showed a large cavity with an air-fluid level in the right lower lung zone suggestive of a lung abscess (Figure 1).

Clinical findings: on admission, the patient was afebrile with pulse 115/min, BP 90/50 mmHg, and SpO2 100% on 2L oxygen. Air entry was decreased in the right infra-axillary and infra-mammary areas. No significant past medical history. She was born full term with normal development and complete immunisation.

Diagnostic assessment: a contrast-enhanced CT scan of the thorax revealed a thick-walled, multiseptated intraparenchymal cavity (7.1 x 4.7 x 7.6 cm, approx. volume 120 cc) with air-fluid levels involving the right upper lobe, lateral segment of right middle lobe, and anterior segment of right lower lobe. The wall measured 5 mm in thickness (Figure 2).

Therapeutic Intervention: due to lack of response to conservative management with IV piperacillin-tazobactam and vancomycin, the patient was planned for right thoracotomy and surgical drainage.

Anaesthetic plan and intraoperative management: general anaesthesia with endotracheal intubation and one lung ventilation was planned. Equipment prepared included a 5 Fr Arndt endobronchial blocker, 2.8 mm bronchoscope, age-appropriate ETTs, paediatric airway trolley, 20G epidural set, and emergency drugs. Premedication included IV glycopyrrolate 0.04 mg, midazolam 0.3 mg, fentanyl 20 mcg, and ketamine 10 mg. Anaesthesia was induced with IV propofol 20 mg and atracurium 5 mg. An extraluminal approach was used to insert the Arndt blocker before placing a 5.0 uncuffed ETT. The blocker was guided into the right main bronchus using a bronchoscope, and the position was confirmed by cuff inflation and auscultation. The patient was placed in the left lateral decubitus position. A 20g epidural catheter was inserted at the T9-T10 level. The endobronchial blocker (EBB) position was reconfirmed in the lateral position. Anaesthesia was maintained with sevoflurane and oxygen. Muscle relaxation was maintained with intermittent atracurium. An epidural bolus of 0.1% bupivacaine with 10 mcg fentanyl and IV paracetamol 150 mg were given for analgesia. Right thoracotomy and drainage with intercostal drain placement were performed. Surgery lasted 1.5 hours. Estimated blood loss was 30 ml, urine output was 60 ml, and 270 ml of ringer’s lactate was administered.

Postoperative management: post-procedure, lung recruitment was performed before deflating the EBB cuff. Neuromuscular blockade was reversed using IV neostigmine 0.5 mg and glycopyrrolate 0.08 mg. The patient was successfully extubated along with EBB after confirming adequate spontaneous breathing and stable vitals. In the paediatric intensive care unit (ICU), she remained stable on 4L oxygen with SpO2 of 100%. Epidural analgesia with 0.0625% bupivacaine was continued, and IV paracetamol QID for 3 days.

Follow-up and outcomes: the patient was monitored postoperatively in the paediatric ICU and continued to show clinical improvement. She was weaned off oxygen support over 48 hours and discharged home on the 7^th postoperative day. A follow-up visit after 2 weeks revealed complete resolution of respiratory symptoms and good wound healing. Chest X-ray confirmed resolution of the abscess cavity (Figure 3). Her activity and appetite had returned to normal.

Patient perspective: the patient’s guardians expressed their gratitude for the attentive and prompt care provided. They were relieved to see her recovering well and were highly satisfied with the overall outcome.

Informed consent: the patient’s guardians were informed about the clinical case, the surgical procedure, and the potential for publication of her anonymised medical data. They provided verbal and written consent to proceed with the case report and image use.

Patient’s consent: written informed consent was obtained from the patient's legal guardian for the publication of this case and any accompanying images.

Discussion     

One-lung ventilation (OLV) in pediatric patients is challenging due to small airway size and limited device options. Available methods include mainstem endobronchial intubation, which is simple but imprecise; double-lumen tubes, which are not suitable for children under 30-35 kg; and bronchial blockers (BBs), which are preferred for their flexibility and targeted lung isolation [6]. We selected a 5F Arndt bronchial blocker for our 4-year-old patient, placing it extraluminally due to the limited internal diameter (4.5 mm) of the endotracheal tube, which could not accommodate both the blocker and fibreoptic bronchoscope (FOB) intraluminally. Bronchial blockers can be inserted intraluminally or extraluminally, with FOB guidance being essential for accurate placement [7]. Cuff design also plays a role: spherical cuffs are suited for smaller, rounder bronchi, while elliptical cuffs provide a better seal in wider, elliptical airways. The Tappa blocker, a newer device specifically designed for pediatric use, offers soft, flexible construction with a preformed shape for easier placement and better airway conformity. In our case, the extraluminal Arndt blocker offered a safe, effective alternative for OLV, highlighting its value in small children where other options are limited.

Lung isolation in paediatric anaesthesia is a crucial yet complex procedure necessary for managing thoracic pathologies, such as lung abscesses, congenital anomalies, and thoracic surgeries requiring one-lung ventilation (OLV). Due to the significantly smaller airway size in paediatric patients, conventional double lumen tubes (DLTs), which are chosen for lung isolation in adults, are often not viable. The smallest available DLT (26Fr) can only be used in children aged eight years and older, making it unsuitable for younger patients [8]. Instead, bronchial blockers (BBs) have become the preferred choice and are absolutely indicated in lung abscess, offering greater flexibility and adaptability for paediatric cases. In our case, a 4-year-old patient with a right lung abscess, we have used ETT no 5 (uncuffed) with 5Fr Arndt endobronchial blocker (extraluminally) under the guidance of a 2.8mm bronchoscope. As the 2Fr and 3Fr Arndt blockers are the smallest, and the 1.2mm bronchoscope is also not available in India. Other blockers. Among the various bronchial blockers available, the Arndt endobronchial blocker is particularly beneficial for paediatric patients. It features a wire-guided loop system that allows precise placement under fibreoptic bronchoscopy guidance [9]. The Arndt blocker has a lower inflation pressure (approximately 340 cm H₂O) compared to other vascular devices like the Fogarty catheter (690-710 cm H₂O), reducing the risk of bronchial mucosal injury. This is especially important in paediatric airways, where excessive pressure can lead to trauma and long-term complications. Other options available are the Tappa Blocker (smallest 7Fr) and Cohen Blocker (smallest 9Fr), which are not suitable for ETT no 5.

The installation of a bronchial blocker can be performed using either an intraluminal or extraluminal approach. In the intraluminal approach, the blocker is passed through the lumen of a single-lumen endotracheal tube (ETT) and positioned into the desired bronchus using fibreoptic bronchoscopy. However, this method may be challenging in smaller children due to size constraints. Alternatively, the extraluminal approach, where the blocker is placed alongside the ETT externally, offers advantages such as faster placement, less resistance to gas flow, and better visualization of the blocker position. Also, in the extraluminal approach, ventilation is not hampered. Despite their advantages, bronchial blockers have certain limitations. They may migrate proximally into the trachea, potentially impeding ventilation to both lungs and leading to acute hypoxemia. Additionally, achieving a proper seal of the bronchus can be difficult, especially when using uncuffed ETTs, which are common in paediatric patients. Some blockers have closed tips, preventing suctioning or the application of continuous positive airway pressure (CPAP) to the operative lung. Once the guide wire is removed, repositioning the blocker can become difficult, requiring reinsertion under bronchoscopy guidance. The successful use of bronchial blockers in paediatric anaesthesia requires careful planning, proper device selection, and expertise in fibreoptic bronchoscopy. The use of low-pressure bronchial blockers minimizes the risk of airway trauma, while fibreoptic guidance ensures accurate placement, leading to safer and more effective lung isolation. Postoperative monitoring is essential to identify complications such as pneumothorax, lung collapse, or airway obstruction. By employing a tailored approach and adhering to best practices, anaesthesiologists can enhance surgical outcomes and improve the safety of pediatric patients undergoing thoracic procedures.

Conclusion     

An extraluminal 5F Arndt endobronchial blocker administered under fiberoptic guidance can safely accomplish one-lung breathing, as demonstrated by the effective anesthetic care of this 4-year-old kid with a right lung abscess. Small pediatric airways and constrained device sizes are overcome by this method. To guarantee efficient lung isolation and ideal surgical conditions, careful planning, the right device selection, and expert fiberoptic deployment are crucial. For anesthesiologists handling complicated thoracic cases in young children, this case provides important insight into the significance of modifying procedures to pediatric anatomy.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All the authors have read and agreed to the final version of this manuscript.

Figures     

Figure 1: a large cavity and air fluid is seen at right lower zone

Figure 2: contrast-enhanced computed tomography; thorax- a large thick walled multiseptated intraparenchymal cavity measuring 7.1x4.7x7.6cm (approx. vol 120cc) involving the right upper lobe, lateral segment of right middle lobe and anterior segment of right lower lobe with wall thickness measuring 5mm showing air fluid levels within; adjacent consolidatory changes s/o infective etiology: right lung abscess

Figure 3: post operative chest X-ray: inflated right lung field with implantable cardioverter-defibrillator (ICD) in situ

References