Summary of clinical experience in using bronchial occluders

Bronchial occluders are now playing an increasingly important role in clinical practice. Conventional bronchial occluders are indicated for the following:

1. Patients with difficult airway who need thoracotomy: patients with a history of surgery or radiotherapy in the oral cavity, throat, or neck, or with glottic or airway stenosis; morbidly obese; patients who can be awake and have a single-lumen endotracheal tube + occluder inserted;

2. Selective lobar isolation: history of contralateral lung surgery, and it is expected that the patient cannot tolerate single-lung ventilation;

3. During thoracotomy in children, the bronchial occluder can be placed in a thinner single-lumen endotracheal tube;

4. Minimally invasive surgery of the esophagus, mediastinum, and heart to avoid needing to go to the ICU for tube replacement after surgery;

5. The patient has been intubated and temporary lung isolation is required due to changes in the patient's condition during the operation.

Contraindications:

1. Wet lung, potential contamination risk of the contralateral lung;

2. Central lung cancer, complete lung resection;

3. Surgery close to the occluded air sac: upper lobe sleeve lobectomy;

4. Right lung surgery, but the opening of the right upper lobe bronchus is higher, at the same level as the carina or above the carina.

The following are the cases treated in our hospital:

Case 1

The patient, a 9-year-old male, was scheduled to undergo left-sided thoracoscopic mediastinal tumor resection under general anesthesia and single-lung ventilation. The patient was 125 cm tall and weighed 21 kg. The anesthesia method selected was: first inserting the Innsides 5F bronchial occluder, then inserting a common single-lumen endotracheal tube, model 5.5#, and occluding the left lung through the endotracheal fiberoptic bronchoscope. During the operation, the single-lung ventilation was good, the airway pressure was maintained below 20 mbar, and the blood gas analysis showed that the intraoperative PCO2 was less than 45 mmHg. The operation was successfully completed.

Case 2

The patient, a 5-year-old male, was scheduled to undergo right pleural decortication under general anesthesia and single-lung ventilation. The patient was 115 cm tall and weighed 20 kg. Anesthesia method selection: After induction, an occluder was inserted (Zhuhai Fornia DS-60 as shown in Figure 1, the occluder has an outer diameter of 3.0 mm and a length of 600 mm). Before intubation, the four-way rotatable joint was removed (Figure 2), and then a common single-lumen endotracheal tube, model 4.5#, was inserted.

During the operation, single-lung ventilation was good, airway pressure was controlled below 21mbar, PETCO2 was below 38mmHg, and blood gas analysis showed PCO2 was less than 35mmHg. The operation was successfully completed, and the child was extubated after the operation without obvious airway complications.

Lessons learned:

Bronchial occluders are safe, effective, easy to operate, and have a low incidence of postoperative complications. They have been widely used in single-lung ventilation surgery in thoracic surgery. However, tracheal tubes suitable for children have a small inner diameter and are difficult to place in the lumen. The occluder itself will reduce the airway ventilation area, thus limiting its use. Some hospitals place bronchial occluders outside the tracheal tube, which is not affected by the inner diameter of the tracheal tube. The position of the occluder can be adjusted at any time during the operation, which increases the accuracy of the surgical operation and reduces the incidence of adverse prognosis. In general, 5F and 7F occluders are more commonly used in children, and 9F occluders are rare in children.

Figures 5 and 6 show the specifications of a certain manufacturer's occluder. The outer diameter of a 9F occluder is approximately 3.00 mm, and the outer diameter of a 5F occluder is approximately 1.7 mm.

Figure 5

Figure 6

The following table shows the specifications of commonly used occluders and the population they are suitable for. The outer diameter of Zhuhai Funia DS-60 is 3.00mm and it is suitable for adults.

Because our department did not have regular spare pediatric occluders before, we temporarily used adult occluders for pediatric patients. In our case 2, the 5-year-old child successfully completed the operation using this type of occluder. The intraoperative occlusion effect was good, the perioperative airway pressure was at a normal level, and the intraoperative blood gas analysis showed that PCO2 was at a normal level. The child had no obvious complications and adverse reactions after the operation, which can provide help for pediatric patients undergoing single-lung ventilation surgery in the future.

Searching domestic and foreign literature, it is rare to see 9F occluders used in pediatric patients.

Zhang Xiaodong, Department of Anesthesiology, Shenzhen Third People's Hospital

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