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Ann Thorac Surg 1995;60:927-930
© 1995 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Anesthetic Techniques for Pediatric Thoracoscopy

Department of Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. Since 1981, we have performed 68 thoracoscopic procedures in 62 patients aged 7 months to 21 years.

Methods. We reviewed the anesthetic and ventilation strategy used for each procedure to determine which anesthetic strategies are safe and effective for particular children and conditions.

Results. Regional anesthesia with sedation was used for six procedures in 5 patients with a mean age of 16 years (range, 9 to 21 years). One patient required conversion to general anesthesia. General anesthesia with one-lung ventilation was attempted for 18 procedures in 17 patients with a mean age of 12 years (range, 7 months to 18 years). Two patients required conversion to two-lung anesthesia secondary to pulmonary intolerance. One of these patients and 2 others required thoracotomy. General anesthesia with two-lung ventilation was used for 44 procedures in 41 patients with a mean age of 9 years (range, 1 to 17 years). There were no anesthesia-related difficulties.

Conclusions. Regional anesthesia should be limited to the older, more cooperative patient. General anesthesia with one-lung ventilation is useful in adolescents, as they tolerate collapse of one lung well, and it is particularly desirable for procedures requiring exposure of the mediastinum and for talc pleurodesis. General anesthesia with two-lung ventilation can be used in any age group but is generally necessary for infants and small children, as they often will not tolerate the collapse of one lung, and in the larger child or adolescent with severe pulmonary compromise.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
see also page 930.

Since the first report [1] of thoracoscopy in children in 1976, experience with this surgical technique for a variety of indications in children has been reported [2–6]. Various anesthesia strategies for thoracoscopy in adults have been described [7–13]. However, little information is available about anesthetic strategies for thoracoscopy in children [14]. Therefore, we reviewed our series of thoracoscopic procedures performed on patients in the pediatric surgical service from 1981 through 1994 to determine which anesthesia strategies are safe and effective for particular children and conditions.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Charts of patients who had undergone thoracoscopic procedures in the pediatric surgical service were reviewed. Type of anesthesia, type of ventilation, patient age, diagnosis, side of chest of procedure, and anesthetic outcome were determined for each procedure. Procedures were then grouped according to whether regional or general anesthesia was used and, if general anesthesia was used, whether one-lung or two-lung ventilation was employed.

Patients undergoing regional anesthesia with sedation received a local or intercostal block with 0.25% bupivacaine hydrochloride with epinephrine combined with intravenous sedation. Choice of sedation was made by the anesthesiologist. Commonly used agents were ketamine hydrochloride, sodium pentobarbital, midazolam hydrochloride, and propofol. Supplemental oxygen was supplied.

The decision to attempt one-lung or two-lung ventilation under general anesthesia was made on the basis of a general assessment of the exposure required and the patient's size and pulmonary status. Usually, one-lung ventilation was desired for procedures involving the mediastinum. There were no strict criteria for size or pulmonary status, but clinical assessment was based on the patient's overall health and primary condition, tolerance of induction of anesthesia, and tolerance of initial one-lung ventilation.

Patients who received one-lung ventilation and who were large enough were intubated with a double-lumen endotracheal tube. Others received one-lung ventilation with a cuffed single-lumen endotracheal tube directed toward the lung to be ventilated. Positioning of this tube was facilitated with a flexible bronchoscope if the anesthesiologist was not satisfied that the endotracheal tube was in the desired position after blind passage.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
From 1981 through 1994, 68 thoracoscopic procedures were performed in 62 children aged 21 years and younger. Procedures included biopsy or excision of lung parenchyma, lung lesions, or mediastinal masses (40), drainage of empyema or effusion (15), pleurodesis (7), excision of a bronchogenic cyst (3), surveillance (2), and treatment of chylothorax (1).

Regional Anesthesia With Sedation
Regional anesthesia with sedation was used in six procedures performed on 5 patients (Table 1). The mean age of the patients was 16 years with a range of 9 to 21 years. The procedures were talc pleurodesis for recurrent pneumothorax (3), and biopsy of an anterior mediastinal mass (3). One patient undergoing pleurodesis required conversion to general anesthesia and two-lung ventilation because of difficulty in managing pain.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Rodgers and Talbert [1] first described thoracoscopy for use in the biopsy of lung and pleural lesions in children in 1976. Currently, there are multiple indications for thoracoscopy in children [2, 4–615]. In addition, three main anesthetic approaches for these procedures have evolved: local or regional anesthesia supplemented with sedation, general anesthesia with one-lung ventilation, and general anesthesia with two-lung ventilation [7–14].

Local or regional anesthesia with sedation requires an informed, cooperative patient. Anesthesia can be accomplished with local, intercostal, pleural, or epidural blocks or a combination thereof [7]. One must be confident of one's ability to reverse the sedation while assuring a patent airway or intubate a patient should anesthesia-related complications or the need for a thoracotomy arise. Nonetheless, this technique can be especially useful in cooperative adolescents. We have also found it particularly beneficial when obtaining tissue from a large mass of the anterior mediastinum that may compress the trachea and cause airway obstruction with induction of general anesthesia.

General anesthesia with one-lung ventilation can be used in any patient who can tolerate it from a pulmonary standpoint. We select such patients on the basis of the need for lung collapse for exposure. We have found one-lung ventilation to be particularly useful for talc pleurodesis and for the biopsy or excision of mediastinal or hilar masses. If the patient is large enough (usually larger than 30 kg), a double-lumen endotracheal tube can be used. A bronchoscope can be employed to guide the tube into proper placement. A 3.5-mm bronchoscope will pass through a lumen of a 35F double-lumen tube, though currently available ultrathin bronchoscopes can facilitate the use of smaller double-lumen endotracheal tubes if necessary. These bronchoscopes are as small as 1.8 mm. If a double-lumen tube is used, it is desirable to pass the longer end into the main bronchus of the lung that is to be deflated so as not to interfere with the ventilation of the opposite upper lobe. Care must be taken in the positioning of the tube and in the maintenance of that position. Some authors [7] advocate the use of bronchoscopy to check positioning in every case. We have not considered this necessary if assessment of breath sounds and chest movement convincingly demonstrates appropriate position.

If the patient is too small for a double-lumen endotracheal tube, a cuffed single-lumen tube can be placed selectively into the main bronchus of the lung to be ventilated. This can be performed with the aid of a 3.5-mm flexible bronchoscope if the tube is 5.0 mm or larger. A 1.8-mm ultrathin bronchoscope can be passed through a 2.5-mm endotracheal tube. We have found this successful in both small and large patients. Thus, only 3 patients, aged 14, 15, and 17 years, underwent one-lung ventilation with a double-lumen endotracheal tube in this series.

An endotracheal tube can be supplemented with a ``bronchial blocker'' placed in the main bronchus of the lung to be deflated to achieve one-lung ventilation. Usually, a Fogarty catheter is used and is placed under bronchoscopic guidance [7, 15]. A Swan-Ganz catheter is an alternative choice in that it allows the delivery of oxygen through the distal port to the deflated lung [16]. One must be vigilant that a bronchial blocker does not become dislodged into the trachea, especially if the blocker is placed in the right main bronchus, as that bronchus is short [7]. We have not found it necessary to employ this technique in our series, as we have been able to achieve one-lung ventilation with the techniques already described.

General anesthesia with two-lung ventilation is employed for patients who cannot tolerate the collapse of one lung from a pulmonary standpoint, for small infants, and for procedures not requiring lung collapse for the desired exposure. This approach has sufficed for the majority of our patients, particularly infants and small children, as they often do not tolerate the collapse of one lung. If general anesthesia with two-lung ventilation is chosen, it is preferable for the patient to breathe spontaneously because pulmonary expansion with positive-pressure ventilation may not allow adequate exposure.

This series demonstrates the safety of a variety of anesthetic approaches for thoracoscopy in children, as well as the safety with which one method of anesthesia can be changed to another or a thoracoscopic procedure can be converted to open thoracotomy. The choice of anesthetic technique for pediatric thoracoscopy must be individualized on the basis of patient size, pulmonary status, and exposure required.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Forty-first Annual Meeting of the Southern Thoracic Surgical Association, Marco Island, FL, Nov 10--12, 1994.

Address reprint requests to Dr McGahren, Department of Surgery, University of Virginia Health Sciences Center, Box 181, Charlottesville, VA 22908.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Rodgers B, Talbert J. Thoracoscopy for diagnosis of intrathoracic lesions in children. J Pediatr Surg 1976;11:703–8.[Medline]
2. Rogers D, Philippe P, Lobe T, et al. Thoracoscopy in children: an initial experience with an evolving technique. J Laparosc Surg 1992;2:7–14.
3. Ryckman F, Rodgers B. Thoracoscopy for intrathoracic neoplasia in children. J Pediatr Surg 1982;17:521–4.[Medline]
4. Lobe T. Pediatric thoracoscopy. Semin Thorac Cardiovasc Surg 1993;5:298–302.[Medline]
5. Rodgers B. Thoracoscopic procedures in children. Semin Pediatr Surg 1993;2:182–9.[Medline]
6. Kern J, Rodgers B. Thoracoscopy in the management of empyema in children. J Pediatr Surg 1993;28:1128–32.[Medline]
7. Kraenzler E, Hearn C. Anesthetic considerations for video-assisted thoracic surgery. Semin Thorac Cardiovasc Surg 1993;5:321–6.[Medline]
8. Schwartz A, Hensley F. Anesthetic considerations for thoracoscopic procedures. J Cardiothorac Vasc Anesth 1992;6:624–7.[Medline]
9. Mulder DS. Pain management principles and anesthesia techniques for thoracoscopy. Ann Thorac Surg 1993;56:630–2.[Abstract]
10. Horswell JL. Anesthetic techniques for thoracoscopy. Ann Thorac Surg 1993;56:624–9.[Abstract]
11. Lamb J. Anesthesia for thoracoscopic pulmonary lobectomy. Can J Anaesth 1993;40:1073–5.[Abstract/Free Full Text]
12. Barker S, Clarke C, Trivedi N, et al. Anesthesia for thoracoscopic laser ablation of bullous emphysema. Anesthesiology 1993;78:44–50.[Medline]
13. Millar F, Hutchison G, Wood R. Anesthesia for thoracoscopic pleurectomy and ligation of bullae. Anesthesiology 1992;47:1060–2.
14. Tobias J. Anesthetic considerations for endoscopic procedures in children. Semin Pediatr Surg 1993;2:190–4.[Medline]
15. Rao C, Krishna G, Grosfeld J, et al. One-lung pediatric anesthesia. Anesth Analg 1981;60:450–2.[Free Full Text]
16. Dalens B, Labbe A, Haberer J. Selective endobronchial blocking versus selective intubation [Letter]. Anesthesiology 1982;57:555.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): John A. Kern Bradley M. Rodgers Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by McGahren, E. D. Articles by Rodgers, B. M. Search for Related Content PubMed PubMed Citation Articles by McGahren, E. D. Articles by Rodgers, B. M. Related Collections Related Article