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Endobronchial Blockers in Babies and Children

支氣管封堵器用於小孩子的方法. Endobronchial Blockers in Babies and Children. 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. 双腔管支气管插管. 首选. Device of Choice. Double-lumen tube.

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Endobronchial Blockers in Babies and Children

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  1. 支氣管封堵器用於小孩子的方法 Endobronchial Blockersin Babies and Children 何名熙Anthony M.-H. Ho Department of Anaesthesia and Intensive Care The Chinese University of Hong Kong Prince of Wales Hospital

  2. 單肺麻醉通气气管One lung anesthesia 双腔管支气管插管 首选 Device of Choice Double-lumen tube

  3. http://funcage.com/blog/cute-baby-animals/funcage-cute-baby-animal-14/http://funcage.com/blog/cute-baby-animals/funcage-cute-baby-animal-14/

  4. 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

  5. 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

  6. Source: Christian Seefelder, MD

  7. 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:en-US:official&source=lnt&tbs=isz:l&tbm=isch&tbnid=RpKWa7GLnt_-rM:&imgrefurl=http://www.radpod.org/2008/06/16/congenital-lobar-emphysema-2/&imgurl=http://www.radpod.org/wp-content/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&ndsp=15&ved=1t:429,r:0,s:0&biw=1005&bih=576

  8. Source: Christian Seefelder, MD

  9. http://www.google.com.hk/imglanding?q=congenital+cystic+adenomatoid+malformation+of+the+lung&um=1&hl=zh-TW&client=firefox-a&sa=X&rls=org.mozilla:en-US:official&source=lnt&tbs=isz:l&tbm=isch&tbnid=Qpszx03iaIdVOM:&imgrefurl=http://www.radpod.org/2008/02/28/congenital-cystic-adenomatoid-malformation/&imgurl=http://www.radpod.org/wp-content/uploads/2008/02/ccam.jpg&w=1570&h=1034&ei=Ge-0TbGqKYvyvwPNvsWOBw&zoom=1&iact=hc&page=1&tbnh=131&tbnw=176&start=0&ndsp=15&ved=1t:429,r:0,s:0&biw=1005&bih=576http://www.google.com.hk/imglanding?q=congenital+cystic+adenomatoid+malformation+of+the+lung&um=1&hl=zh-TW&client=firefox-a&sa=X&rls=org.mozilla:en-US:official&source=lnt&tbs=isz:l&tbm=isch&tbnid=Qpszx03iaIdVOM:&imgrefurl=http://www.radpod.org/2008/02/28/congenital-cystic-adenomatoid-malformation/&imgurl=http://www.radpod.org/wp-content/uploads/2008/02/ccam.jpg&w=1570&h=1034&ei=Ge-0TbGqKYvyvwPNvsWOBw&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

  10. Calvert JK, et al. Arch Dis Child Fetal Neonatal Ed 2006;91:F26-F28

  11. 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

  12. 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 follow-ing right lateral thoracotomy for esophageal atresia. J Pediatr Surg 4:627–636

  13. ETT OD 4.9-5.6 5.6-6.2 6.2-7.5 6.6-8.2 ETT ID 3.5-4 4.0-4.5 4.5-5.5 5.0-6.0

  14. 单内腔管不适合用 于單肺麻醉 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 Use of a single-lumen ETT to effect 1-lung anesthesia

  15. Microcuff

  16. 适合用于<6-8岁的小孩子和婴儿

  17. 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).

  18. 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%)

  19. 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)

  20. 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

  21. Trachoesophageal Fistula

  22. 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)

  23. 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

  24. 切去/cut awayMurphy eye

  25. 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)

  26. Ho AMH, Karmakar MK. Ann Roy Coll Surg Engl 2007; 89:532-3 (Mini Step, InnerDyne, Salt Lake City, Utah, USA)

  27. (Mini Step, InnerDyne, Salt Lake City, Utah, USA) Ho AMH, Karmakar MK. Ann Roy Coll Surg Engl 2007; 89:532-3

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