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

Email: Neil.Chambers@health.wa.gov.au

Siva Subramaniam (Corresponding author)

Email: Sivanesan.Subramaniam@health.wa.gov.au

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

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.

Table 21.3

Indications and contraindications for one-lung ventilation

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