Dual isolation technique for paediatric lung surgery.SH Pantvaidya, KK Golam, RV Pai, SG Saksena, SA Kaul
Dept of Anaesthesiology, LTMM College, Sion, Bombay.
This report describes a dual isolation technique adopted to isolate the lungs from one another at the time of right pneumonectomy in a child (age: 5 yrs, 10 kg weight) with evidence of infective lung disease associated with copious purulent secretion and compromised respiratory function. The isolation of right lung from left was achieved by placing Fogarty embolectomy catheter in right main bronchus and a plain polyvinylchloride endotracheal tube (which was aseptically preshaped to have a distal 45 degrees angulation towards left) in left main bronchus. No soiling of left lung occurred during surgery and patient remained hemodynamically stable. In the same child, post-thoracotomy pain was relieved for five days with buprenorphine, administered through a lumbar epidural catheter. The child had an uneventful post-operative course and cooperated for physiotherapy.
Keywords: Analgesics, Opioid, therapeutic use,Balloon Dilatation, Buprenorphine, therapeutic use,Case Report, Child, Preschool, Human, Intubation, Intratracheal, Male, Pain, Postoperative, drug therapy,Pneumonectomy, methods,
Pnenumonectomy and lobectomy are generally carried out with the patient in the lateral position, with the diseased lung being the uppermost. When an infected lung with copious secretions is removed in this fashion, the infected secretions are likely to flood the trachea and the dependent healthy lung, interfering with adequate ventilation. Under such circumstances, isolation of the lungs from one another becomes mandatory. For this purpose, specially designed double lumen tubes and bronchial blockers are available for adults. However in children, isolation of the lungs has been hampered by the non-availability of these special tubes and blockers in smaller sizes. We have been using the Fogarty embolectomy catheters as bronchial blockers in children. Similar use of these catheters are reported by others authors,.
These catheters when placed on the left side of right lower lobe bronchus are more stable than in the short right main bronchus. In the latter situation, there is a greater chance of migration of the catheter and hence failure to act as an effective blocker.
Recently, we had a child with an infected wet right lung, in whom during right pneumonectomy, we circumvented the above problem, by employing a dual isolation technique.
A 5-year-old boy, weighing 10 kg, was admitted, with history of cough associated with purulent, foul smelling, sputum and Grade III dyspnoea. Subsequent evaluation and chest X-ray showed collapse and consolidation of the right lung with gross mediastinal shift. On bronchoscopy, a foreign body and copious purulent secretions were removed from the bronchus. Bronchography confirmed the diagnosis. The patient had clinical evidence ofsevere compromise of respiratory function. Attempt to control the secretions and improve the respiratory status with high protein diet, antituberculous drugs, appropriate antibiotics and physiotherapy did riot succeed. Large quantities of purulent secretions were suctioned during bronchoscopy, done twice during this waiting period. After eleven weeks, the child showed no improvement and was posted for right pneumonectomy. Arterial blood sampled a week prior to the surgery showed features of respiratory acidosis (pH: 7.301. paCO2P : 50, paO2 : 86, HCO3 : 25 nmol/L O2 Sat : 95.3). Pre-operatively, there was clinical evidence of persistent wet infected lung on the right side and in the left base.
The patient was pre-medicated with oral diazepam 2 mg and intramusclar atropine 0.25 mg. He was preoxygenated and anaesthesia was induced with intravenous thiopentone sodium 2.5% (40 mg) and vecuronium bromide (1 mg). Bronchoscopy was performed and # 5 Fogarty embolectomy catheter was placed in the right main bronchus under vision. The balloon was inflated with 0.5 ml of sodium and megiumine diatrizoate (Urogralin 76%) and the bronchoscope was removed.
Following this, a plain polyvinylchloride endotracheal tube, # 4, suitably shaped with a stylet was placed in the left main bronchus. The distal 2 cm of the tube was given an angulation of 45?, the tip pointing towards the left. The remaining length of the tube was curved similar to an endotracheal tube in a plane perpendicular to that of the distal 2 cms [Figure - 1]. The aseptically preshaped tube was then kept at 4?C in a refrigerator to impart some firmness to it.
The position of the blocker and endobronchial tube was confirmed radiologically [Figure - 2]
It functioned effectively throughout the entire procedure, as there was no evidence of soiling of the left lung. This was confirmed by intermittent left endobronchial suction.
The radial artery was cannulated with a Teflon 22F gauge cannula. This was for the dual purpose of serial blood gas analysis and continuous arterial pressure monitoring. Unfortunately, the blood gas estimates were not available because of failure of equipment. However, continuous, non-invasive monitoring of arterial oxygen saturation and expired carbon dioxide levels were done using a pulse oximeter (Biox Ohmeda 3200 e) and capnometer (Ohmeda 5200) respectively. Arterial oxygen saturations were throughout maintained above 90% and at no time the expired carbon dioxide levels went above 35 mm Hg. It is to be noted that carbon dioxide levels in expired gases do not necessarily, faithfully reflect the arterial carbon dioxide levels during various manipulations of lung surgery.
The patient was haemodynamically stable during the entire procedure. At the time of right clamping during pnuemonectomy, the Fogarty balloon was deflated and completely withdrawn from the trachea.
On completion of the surgical procedure, before reversing the anaesthesia an epidural catheter (# 18), with a bacterial filter was inserted through L3-4 interspace in a cephalad direction keeping 2 cm of the catheter in the epidural space., the catheter tip presumably, being at the L1, L2 level. No radiological confirmation of the tip of epidural catheter was carried out, as this is not our practice. Buprenorphine (40 ?g) diluted in 5 ml saline was injected through the catheter. The child was extubated and shifted to the recovery area.
The post-thoracotomy pain was relieved with a single daily injection of Buprenorphine (20 ?g in 5ml saline) for the next five days. Analgesia was satisfactory and the pre-operatively, irritable child co-operated well for physiotherapy and had an uneventful post-operative course.
Failure to control secretions in patients with infective lung diseases, undergoing lobectomy or pneumonectomy, appreciably increases morbidity and mortality. In our patient, not only were the secretions from the right side not clearing but, were also progressively infecting the left lung. To protect the remaining part of the left lung from further damage, it was decided to undertake pneumonectomy in spite of the highly compromised respiratory status. Therefore, it became mandatory to employ a secure technique of isolation of the lungs during surgery. For this purpose, endobronchial intubation with a regular paediatric endotracheal tube for one lung anaesthesia or bronchial blocking with Fogarty embolectomy catheters' have been practiced in paediatric cases. However, in our case, one lung anaesthesia along with endobronchial intubation on the left side was not considered adequate as the secretions from the infected right lung could still flood the trachea and seep by the side of the non cuffed tube in the left bronchus. Similarly, only a Fogarly balloon blocker may not be effective as the right main bronchus is short and the balloon might be displaced. Hence it was decided to combine both those methods.
Preshaping facilitated the more difficult technique of left sided endobronchial placement without turning the head to the opposite side, which in this case, might have dislodged the already placed blocker. In one of the two reports of dual technique employed, the endobronchial placement of the tube was on the right side, which is easier than the left. In the other report, the bronchial blocker was placed in the more stable postion of the right lower lobe bronchus for the lobectomy.
To prevent any post-operative complications such as atelectasis and infection in the remaining lung, effective physiotherapy was essential. Hence continuous pain relief with epidural narcotic was chosen with all its benefits, which include good pain relief decreased total requirements of narcotics, improved pulmonary function and early ambulation. Effective pain relief, through lumbar catheter in children as young as 2 days, have been reported,,. Meignier and Souronll used lumbar epidural bupivacaine for postoperative analgesia in 7 children with respiratory disability or insufficiency with satisfactory results.
In our past study of 88 children undergoing infraumbilical surgical procedures, 30 patients received epidural buprenorphine in the dosage of 4 ?g/kg caudally. It produced very effective analgesia without any respiratory depression (under publication). In adults, studies using buprenorphine upto 6 ?g/kg epidurally have shown good pain relief without any respiratory depression,,,,.
We have had no direct reference from the literature regarding use of this specific combination of diazepam and buprenorphine. Oral diazepam was used because the earlier experiences of using trimeperazine orally in the same child prior to bronchography and bronchoscopy were not satisfactory and the child continued to be very irritable.
The child was premedicated with oral diazepam at 7.30 hrs and epidural buprenorphine was given at 16.30 hrs. Dizaepam by itself does not cause much respiratory depression. Its second peak effect due to recirculation is seen 6-8 hours after administration. The onset of respiratory depressant effect of buprenorphine due to cephalad spread is seen after 6-8 hrs. Due to the gap of nine hours between premedication and epidural injection, there was no likely overlap of respiratory depressant effects, it any, of both the drugs.
The patient was monitored and nursed in semi-sitting position for the next five days in the intensive care area, one of the reasons being the possibility of respiratory depression with use of epidural buprenorphine.
In conclusion, we found this approach, of dual isolation technique and post-operative respiratory care, aided by post-operative pain relief, forming an effective peri-operative method of managing children with infective wet lung disease, undergoing pulmonary surgery.
[Figure - 1], [Figure - 2]