Hypoxemia in Young Children Undergoing One-lung Ventilation: A Retrospective Cohort Study.
One lung ventilation in children remains a specialised practice in children performed by either endobronchial intubation or use of a bronchial blocker. With low case numbers, assessment of best practice is difficult. This retrospective cohort study interrogated data from a large multicentre cohort of children (aged 2 months to 3 years) undergoing one-lung ventilation for non-cardiac procedures. Investigators analysed 306 cases across 15 sites looking at factors that influenced likelihood of hypoxaemia during one-lung ventilation, primarily the relationship between lung isolation technique and incidence of hypoxaemia.
Investigators noted hypoxemia was common, with 26% of children saturating at less than 90% for 3 min or more and 18% of children saturating at less than 90% for 5 min or more (continuous). Bronchial blocker use was found to be associated with a lower risk of hypoxemia during one-lung ventilation. Investigators also noted left-sided surgery had reduced incidence of hypoxemia, however this finding did not reach statistical significance when controlled for other factors. Hypoxemia risk had no relationship with lower tidal volume ventilation, younger age, lower preoperative saturations, or increased duration of one-lung ventilation after controlling for other factors.
This study adds to the limited multicentre data available on one-lung ventilation in children. Most data to date derives from individual experience and single centre case series. Notably, multicentre studies have not previously looked at factors such as age, surgical side, or lower tidal volume ventilation with respect to risk stratification for the outcome of intraoperative hypoxemia during one-lung ventilation. However, limitations of this study include relatively small sample size and retrospective method. While it is of interest to paediatric anaesthetists that bronchial blocker use was associated with less hypoxemia in children undergoing one-lung ventilation in this cohort, study limitations mean this finding cannot be taken as evidence of causation.
Take Home Message
This study provides impetus for us to reconsider our choice of practice between endobronchial intubation and bronchial blocker use due to the potential benefit of less hypoxemia during one-lung ventilation with bronchial blocker use in children undergoing non-cardiac thoracic procedures. A definitive change of practice recommendation regarding choice of lung isolation technique for such patients is not recommended based on this study due to limitations outlined. Individualised risk benefit including factoring in technical expertise of the proceduralist is always the safest approach.
Reviewed by Chloe Heath