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One-lung Ventilation in Pediatric Patients: Lung Isolation Techniques and Clinical Management
Zixu Hao1, Fangliang Xing2, Xin Zhao3
1Department of Anesthesiology, Beijing Children's Hospital, Capital Medical University.
Insights
Pediatric one-lung ventilation (OLV) requires careful device selection. Double-lumen tubes suit older children, while bronchial blockers are alternatives for younger ones, with innovations improving infant care.
Area of Science:
- Pediatric Anesthesiology
- Thoracic Surgery
- Respiratory Physiology
Background:
- Pediatric minimally invasive thoracic surgery is expanding, increasing the need for effective lung isolation techniques.
- Age-dependent physiological and anatomical differences in children present unique challenges for one-lung ventilation (OLV).
Purpose of the Study:
- To review and evaluate current lung isolation techniques for pediatric OLV, including single-lumen tubes (SLT), double-lumen tubes (DLT), and bronchial blockers (BB).
- To assess the safety profiles and clinical indications of different OLV devices in pediatric patients.
- To provide a decision-making algorithm for optimal device selection and improved safety outcomes.
Main Methods:
- Narrative review of current literature on pediatric OLV techniques.
- Evaluation of safety profiles, anatomical constraints, and clinical indications for SLT, DLT, and BB.
- Synthesis of evidence to develop an evidence-based management framework and decision-making algorithm.
Main Results:
- Double-lumen tubes are suitable for older children (>8-10 years or >130 cm), but not for younger or smaller patients.
- Bronchial blockers are the primary alternative for children aged 2-8 years (ETT ID ≥4.5 mm), though traditional designs have limitations.
- For infants (<2 years), strategies include SLT mainstem intubation or extraluminal blockers, with emerging 3D-printed blockers offering potential solutions.
- Hypoxemia affects ~26% of pediatric OLV cases, necessitating standardized management including fiberoptic verification and optimized ventilation.
Conclusions:
- Optimal device selection for pediatric OLV depends on patient age and anatomy, with DLTs for older children and BBs or specialized techniques for younger ones.
- Emerging innovations like 3D-printed blockers show promise for addressing device fit issues in infants.
- Standardized perioperative management and lung-protective ventilation are crucial for reducing pulmonary complications in pediatric OLV.
Abstract:
Implementing one-lung ventilation (OLV) in pediatric patients presents unique clinical challenges due to age-dependent physiological and anatomical constraints. As minimally invasive thoracic surgery expands in pediatrics, the demand for precise lung isolation has increased. This narrative review evaluates current techniques-single-lumen tubes (SLT), double-lumen tubes (DLT), and bronchial blockers (BB)-with a focus on their safety profiles and clinical indications. Findings indicate that DLTs remain the benchmark for older children but are anatomically prohibitive for those under 8-10 years or shorter than 130 cm. BBs are the primary alternative for children aged 2-8 years (ETT ID ≥4.5 mm), although traditional devices such as the Arndt-Fogarty blockers have design limitations. For infants under 2 years, the primary strategies remain SLT mainstem intubation or extraluminal blocker placement, both of which carry a risk of right upper lobe (RUL) obstruction. Emerging innovations, particularly 3D-printed anatomically customized blockers, are highlighted as potential solutions to resolve device "fit" challenges in infants. Perioperative management remains non-standardized; however, evidence-based recommendations emphasize lung-protective ventilation to reduce pulmonary complications. Hypoxemia occurs in approximately 26% of pediatric OLV cases and requires a prioritized management framework that includes fiberoptic verification, secretion clearance, and optimized PEEP/CPAP application. By synthesizing current evidence, this review provides a decision-making algorithm to guide optimal device selection and improve safety outcomes in this vulnerable pediatric population.
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