Endobronchial Blockers
in Babies and Children
支氣管封堵器用於小孩子的方法
何名熙 Anthony M.-H. Ho
Department of Anaesthesia and Intensive Care
The Chinese University of Hong Kong
Prince of Wales Hospital
單肺麻醉通气气管 One lung anesthesia
首
选
Device
of
Choice
双腔管
支气管
插管
Double-lumen tube
http://funcage.com/blog/cute-baby-animals/funcage-cute-baby-animal-14/
不适合用于 <6-8岁
的小孩子和婴儿
DLTs and Univent are
not suitable for children
<6-8 years of age
Situations in which 1-lung is required in
children include:
•
•
•
•
•
•
•
Lung abscess/empyema
Bronchopulmonary fistula
TEF/TOF
Mediastinal and paraspinal tumours
Lung tumours
Congenital cystic adenomatoid malformation
Congenital lobar emphysema
Source: Christian Seefelder, MD
Congenital
lobar
emphysema
http://www.google.com.hk/imglanding?q=congital+lobar+emphysema&um=1&hl=zh-TW&client=firefox-a&sa=X&rls=org.mozilla:enUS:official&source=lnt&tbs=isz:l&tbm=isch&tbnid=RpKWa7GLnt_-rM:&imgrefurl=http://www.radpod.org/2008/06/16/congenital-lobar-emphysema2/&imgurl=http://www.radpod.org/wpcontent/uploads/2008/06/congenital_lobar_emphysema_2.jpg&w=1204&h=1130&ei=oe20TYzvHZDCvgOlga2FBw&zoom=1&iact=hc&page=1&tbnh=136&tbnw=161&start=0&nd
sp=15&ved=1t:429,r:0,s:0&biw=1005&bih=576
Source: Christian Seefelder, MD
http://www.google.com.hk/imglanding?q=congenital+cystic+adenomatoid+malformation+of+the+lung&um=1&hl=zh-TW&client=firefoxa&sa=X&rls=org.mozilla:enUS:official&source=lnt&tbs=isz:l&tbm=isch&tbnid=Qpszx03iaIdVOM:&imgrefurl=http://www.radpod.org/2008/02/28/congenital-cystic-adenomatoidmalformation/&imgurl=http://www.radpod.org/wp-content/uploads/2008/02/ccam.jpg&w=1570&h=1034&ei=Ge0TbGqKYvyvwPNvsWOBw&zoom=1&iact=hc&page=1&tbnh=131&tbnw=176&start=0&ndsp=15&ved=1t:429,r:0,s:0&biw=1005&bih=576
Calvert JK, et al. Arch Dis Child Fetal
Neonatal Ed 2006;91:F26-F28
Collapsing a lung in a small patient
• 1-lung anaesthesia
– Deliberate endobronchial intubation
– Endobronchial blocker with endotracheal tube
– Endobronchial blocker with LMA
• Insufflation of pneumothorax by surgeon
• Open thoracotomy+retraction
• Some combination of the above
MSK sequelae of open thoracotomy
in children并发及后遗症
•
•
•
•
•
•
•
•
Big scar 大的伤疤 (100%)
Severe postoperative pain 手术后极度疼痛 (100%)
Asymmetry of the thoracic wall 胸膛不对称 (20%)
“Winged” scapula (24%)
Scoliosis 脊椎骨畸形发展 (8%)
Fusion of the ribs 肋骨连接起来 (10%)
Breast maldevelopment 胸部畸形发展 (3.3%)
Shoulder deformity 肩畸形发展 (reported)
Jaureguizar E, et al. (1985) Morbid musculoskeletal sequelae of thoracotomy for
tracheoesophageal fistula. J Pediatr Surg 20:511–514 6.
Freeman NV, Walkden J (1969) Previously unreported shoulder deformity following right lateral thoracotomy for esophageal atresia. J Pediatr Surg 4:627–636
ETT
ETT
ID
OD
3.5-4
4.9-5.6
4.0-4.5
5.6-6.2
4.5-5.5
6.2-7.5
5.0-6.0
6.6-8.2
单内腔管不 适合用
于單肺麻醉
Use of a singlelumen ETT to effect
1-lung anesthesia
From: Hammer G,
Hall S, Davis PJ.
Anesthesia for
general abdominal,
thoracic, urologic,
and bariatric surgery.
In: Smith’s
Anesthesia for
Infants and Children,
7th ed. Ed.
Motoyama EK,
Davis PJ, Mosby
2006, Philadelphia.
685-722
Microcuff
适合用于
<6-8岁的
小孩子和
婴儿
Endotracheal
tube
<6-8岁的小孩子和婴儿的單肺麻醉方法
Conventional technique for lung isolation in small
children (<6-8 years of age).
经常出现的一个问题
Retrograde dislodgement of endobronchial blocker causing loss of
lung isolation and airway obstruction.
3 of 23 cases
(13%)
Retrograde Dislodgement of
Endobronchial Blocker
• Problem – not an uncommon problem with low
pressure high volume Fogarty embolectomy
catheters; even with the new 5 Fr Arndt
endobronchial blocker with high volume low
pressure balloon, retrograde migration of
blocker occurred in 3 out of 23 cases (Wald SH, et
al. Experience with the Arndt paediatric bronchial blocker. Br J
Anaesth 2005; 94:92-4)
Loss of OLA
• Inconvenient
• Repositioning very difficult, especially in
tiny patients (stooping down and crawling
under the drapes and interfering with
surgery)
• Highly exhausting
• Desperate surgeons trying to stem a major
bleed leading to blocker dislodgement
Trachoesophageal Fistula
Airway Management
-Anatomy
• Bronchoscopic findings (113 patients)
Paediatr Anaesth 1992;2:297-303
– 11% at or below carina
– 22% within 1 cm above
– 67% above
• Ventilation difficulties, gastric distention
(16%, N=61)
Paediatr Anaesth 1998;8:313-319
– Large fistula (>3mm)
Fistula quite a bit above carina
• Pass the ETT distally enough to block the
fistula
• May be even achieving endobronchial
intubation using the same ETT
切去/cut
away
Murphy
eye
Step 1: Suctioning of oesophageal stump
Step 2: Induction of anaesthesia, lignocaine spray
Step 3: Fibrescopic bronchoscopy (left panel)
Step 4: Pass blocker with tip bent toward posterior
Step 5: Intubate with tracheal tube (ET)
Step 6: Fibrescopy via ET lumen (middle panel)
Step 7: Remove ET
Step 8: Pass 2nd blocker with tip bent toward right
Step 9: Intubate followed by bronchoscopy (right panel)
Ho AMH, Karmakar MK. Ann Roy Coll Surg Engl 2007; 89:532-3
(Mini Step,
InnerDyne, Salt Lake
City, Utah, USA)
(Mini Step, InnerDyne, Salt
Lake City, Utah, USA)
Ho AMH, Karmakar MK. Ann
Roy Coll Surg Engl 2007;
89:532-3