for Thoracic Surgery in Children

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© Springer Nature Switzerland AG 2020
Craig Sims, Dana Weber and Chris Johnson (eds.) A Guide to Pediatric Anesthesiadoi.org/10.1007/978-3-030-19246-4_21



21. Anesthesia for Thoracic Surgery in Children



Neil Chambers1   and Siva Subramaniam1  


(1)
Department of Anaesthesia and Pain Management, Perth Children’s Hospital, Nedlands, WA, Australia

 



 

Neil Chambers



 

Siva Subramaniam (Corresponding author)



Keywords

One lung ventilationDouble lumen endotracheal tubesBronchial blockersArndt endobronchial blockerCongenital pulmonary airway malformations


This chapter outlines the differences between children and adults undergoing thoracic surgery and discusses some aspects of applied physiology and clinical practice. Anesthetic management of these cases requires an understanding of the relevance of age and pathophysiology, and knowledge of the risks of surgery and anesthesia. These risks include equipment problems, perioperative loss of airway and ventilation problems, bleeding, pneumothorax, and lung soiling.


21.1 Background


Pathologies in children requiring thoracic surgery involve congenital, neoplastic, infective, traumatic and cystic lesions (Table 21.1). Congenital lung malformations are a collection of uncommon conditions that primarily present in childhood and are not commonly seen in adult practice (Table 21.2).


Table 21.1

Indications for thoracic surgery in children of different age groups




















Age group


Indication


Neonate and infant


PDA and coarctation of the aorta Congenital lung malformations


Tracheo-esophageal fistula


Child


Tumor


Adolescent


Tumor


Scoliosis anterior repair


Correction chest wall deformity




Table 21.2

Congenital lung malformations likely to require surgery


























Condition


Abnormalities


Congenital pulmonary airway malformations (CPMA; formerly called CCAM)


Cystic or solid mass connected to a bronchus, usually within one lobe of the lung. Commonest congenital lung malformation.


Bronchial mucocele (bronchial atresia)


Focal narrowing or obliteration of distal segment of bronchus causing a mucous-filled cyst.


Bronchogenic cyst


Embryologic duplication cyst filled with mucous and not communicating with a bronchus. Can compress adjacent structures.


Congenital lobar emphysema


Hyperinflation of one or more lobes. Symptoms if large; may cause pneumothorax.


Pulmonary sequestration


Non-functioning lung tissue supplied by anomalous systemic artery and not communicating with a bronchus


Thoracic surgery is carried out by thoracotomy or thoracoscopy (Video Assisted Thoracoscopic Surgery, VATS). Thoracic surgery in adults almost always requires lung isolation and one-lung ventilation (OLV), usually with a double lumen tube. Children’s lungs are usually healthy and respond differently to surgical intervention compared to chronically diseased adult lungs, and one-lung ventilation is not always needed. Thoracoscopy with a low intrapleural pressure (below 8–10 mmHg) is well tolerated by children, who do not usually get significant mediastinal shift or cardiovascular changes. Although two-lung ventilation has been used for many years in children, and can be used during some procedures such as thoracoscopic sympathectomy, surgical access is often better if one-lung ventilation is performed. Some of the equipment issues for one-lung ventilation in children have been addressed, and one-lung ventilation is being increasingly used in children.


21.2 One-Lung Ventilation in Children


The indications for one-lung ventilation in children are similar to those for adults, although no indication can be regarded as absolute in children (Table 21.3). One-lung ventilation can be technically difficult in small children and has potential risks such as airway trauma or obstruction. These risks need to be balanced against the potential gain in surgical access. It is generally well tolerated in children, although reinflation of the lung is associated with a mild acute lung injury. Distribution of ventilation in the lateral position during IPPV is similar in children and adults. During spontaneous ventilation however, the compressible thoracic cage and reduced effect of gravity on lung perfusion has the potential to worsen ventilation-perfusion mismatch in the dependent infant lung. There are three different techniques for one-lung ventilation in children, each having their own advantages and disadvantages.
Nov 27, 2021 | Posted by in ANESTHESIA | Comments Off on for Thoracic Surgery in Children
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