One lung ventilation & bronchial blocker guideline

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Objectives

This guideline is for paediatric anaesthetists and operating department staff and is to assist with planning for & institution of one lung ventilation for open thoracic or thoracoscopic procedures in anaesthetised children when deflation of a lung is necessary.

Scope

Children requiring one lung ventilation.

Audience

Paediatric anaesthetists and anaesthetic assistants.

Age ETT (ID)mm ETT (ID)mm Bronchial Blocker Fibreoptic scope Univent Bronchocath (French gauge)
  For selective endobronchial intubation consider microcuff in older child for tracheal intubation & use with bronchial blocker Arndt
RHSC stock - 5&7 French
External diameter Internal diameter





Check stock in advance; infrequent use items
<6 months 2.5-3 3.5 (- smallest ETT for FO bronch) 5 French extraluminal 2.2mm [Robertshaw no longer RHSC stock but GJNH have S/M/L R&L]


6-12 months 3-3.5 4-4.5 5 French extraluminal 2.2mm
1-2y 3.5-4 4.5 5 French extraluminal 2.2mm
1-2y 3.5-4 5 5 French intraluminal 2.2mm



2-4y 4-4.5 5-5.5 5 French intraluminal 2.2mm
4-6y 4.5-5 5.5-6 5 French intraluminal 2.2mm ? 3.5mm
6-8y 5-5.5 6.0 +/- cuffed 5 or 7 French intraluminal 2.8mm 3.5mm
8-10y 5.5-6 6.5 +/- cuffed 5 or 7 French intraluminal 2.8mm 3.5-?4.5mm 28 (not normal stock)
10-12y 6-7.0 6.5-7 cuffed 5 or 7 French intraluminal 2.8mm 4.5-6mm 28-32 (not normal stock)
12-14y 6-7.0 7 cuffed 5 or 7 French intraluminal 2.8mm 4.5-6mm 35
14-16y 6-7.0 8-8.5 cuffed 7 - 9 French intraluminal 2.8mm 7mm 35
16-18y 6-7.0 8-8.5 cuffed 7 - 9 French intraluminal 2.8mm 7mm 35-37
Adult equipment     GJNH may have size 7&9, and possibly Vivasight 9 &
EZblocker 7F
  GJNH may have size 8&9 GJNH stock sizes 35-41 (R&L)


Intraluminal (normal) assembly of endobronchial blocker connector;

    

 

Assemble these items before connection to the patient. Screw adaptor should be opened enough to allow easy movement of blocker.

LUBRICATE WELL - it's easy to damage the small scope

Advance the scope into the bronchus, then advance the blocker over the bronchoscope.
You may need the vicryl loop a bit tighter than shown on the above picture.

Withdraw the bronchoscope but keep the balloon on the blocker in view, inflate the balloon under direct vision until it just occludes the bronchus & note the volume required.

When the blocker is confirmed as in the correct position, tighten the screw adapter to keep it secure & remove the vicryl loop by unscrewing the red & white cap from the proximal end of the blocker.

Extraluminal use of endobronchial blocker for small ETTs

Lubricate tube v well, align blocker to blue line = posterior = large circumference side if ETT & pass through larynx under direct vision.
Blocker will advance easily but beware withdrawal is ‘sticky’ as vicryl loop will tend to catch.
Pass Bronchoscope into bronchus then advance blocker onto bronchoscope.
Position blocker in the same way as if it were intraluminal. 

 

Conical adapter in kit is to allow suction if required to help the lung deflate One way of applying CPAP – clear plastic adapter is in blocker kit
 

Opaque white connector with side port that fits green oxygen tubing = straight t-adapter (GE healthcare) 
In stores; top shelf above gas sampling lines

 

Alternative CPAP system allowing measurement of CPAP

Connect green tubing to O2 (0.5 -1 lpm usually sufficient). Level 3 way tap with chest = 0 on scale of the ruler
ALWAYS have 3 way tap open to all ports
,
 turn on O2 then fill open syringe barrel with saline to desired level of CPAP

 

 

 

References
  1. Wald SH, Mahajan A, Kaplan MB et al, Experience with the Arndt Paediatric Bronchial Blocker. British Journal of Anaesthesia 2005; 94 (1): 92-94
  2. Bastien JL, O’Brien JG, Frantz FW, Extraluminal use of the Arndt Pediatric Endobronchial blocker in an infact: a case report. Canadian Journal of Anesthesia 2006; 53(2): 159-161
  3. Golianu, B, Hammer GB, Pediatric Thoracic Anesthesia. Current Opinion in Anaesthesiology, 2005; 18: 5-11
  4. Cook Medical, Arndt Endobronchial Blocker SetCook Incorporated, 2008 ( this is the leaflet stuck onto the packet of the blocker)
  5. Cook Medical, Arndt endobronchial blockers - click on video button to view video demonstrating technique of insertion and placement. (Youtube version here)

 

Editorial Information

Last reviewed: 24 May 2016

Next review: 24 May 2019

Author(s): Graham Bell, Deborah Fordyce

Approved By: Clinical Effectiveness