Successful One-Lung Ventilation with Fogarty Balloon for Thoracotomy Lobectomy in A 5-Year-Old Girl

Introduction: Pediatric thoracic surgery, particularly lung resection, has special difficulties due to anatomical and physiological differences compared to adults. One-lung ventilation (OLV) is often necessary to optimize surgical exposure while minimizing lung injury. Traditional methods, like double-lumen endotracheal tubes, can be difficult to use in children due to their smaller airways and the risk of trauma. Thus, alternative approaches, such as bronchial blockers like Fogarty occlusion catheters, have gained prominence.

Objective: This case report aims to highlight the use of the Fogarty balloon in a pediatric patient undergoing lobectomy for organized pleural effusion linked to pneumonia.

Case Report: A 5-year-old girl with recurrent pneumonia presented with persistent cough, intermittent fever, and respiratory distress. Physical examination revealed decreased breath sounds and mild cyanosis. Imaging confirmed a large organized pleural effusion, suspected to be empyema. The surgical team chose a right thoracotomy lobectomy to remove the affected lung tissue. Preoperative consultations included pediatric surgery, anesthesiology, and respiratory therapy to ensure comprehensive care. A multi-modal pain management strategy, emphasizing regional anesthesia through epidural blocks, was implemented. For OLV, the anesthetic team selected a Fogarty balloon catheter to minimize airway trauma. After intubating with a single-lumen endotracheal tube, the balloon was inserted into the right main bronchus and inflated to occlude it, allowing ventilation of the left lung.

Discussion: The Fogarty balloon effectively provided lung isolation while preserving airway integrity, facilitating optimal surgical exposure and stable oxygenation. Continuous monitoring of oxygenation during OLV was crucial for patient safety.

Conclusion: The use of a Fogarty balloon for bronchial blockade and epidural anesthesia was successful in this pediatric lobectomy case. These techniques enhanced surgical safety, efficacy, and postoperative recovery, suggesting that there must be ongoing research to establish standardized protocols for pediatric thoracic procedures.

INTRODUCTION

Pediatric thoracic surgery, particularly procedures involving lung resection, poses special difficulties due to anatomical and physiological differences compared to adult patients. One-lung ventilation (OLV) is commonly necessary during these procedures to optimize surgical exposure and minimize lung injury (¹). Traditional techniques, including the use of double-lumen endotracheal tubes, can be difficult to implement in children due to their smaller airways and the potential for airway trauma (²). Consequently, alternative methods, such as the use of bronchial blockers, including Fogarty occlusion catheters, have gained attention (¹-³). This report examines the successful utilization of a Fogarty balloon as a bronchial blocker in a 5-year-old girl undergoing lobectomy due to organized pleural effusion associated with pneumonia.

CASE REPORT

A five-year-old girl was referred to our facility with a history of repeated episodes of pneumonia. Her symptoms included persistent cough, intermittent fever, and noticeable respiratory distress. Mild cyanosis, tachypnea, and diminished right-sided breath sounds were detected by auscultation. Initial imaging studies, including a chest X-ray, revealed a significant accumulation of fluid in the right-sided pleural cavity. Subsequent chest ultrasound and CT imaging confirmed the presence of an organized pleural effusion, with suspicion of empyema and a localized lesion in the right lower lobe.

The patient's medical history included a previous hospitalization for pneumonia six months prior, during which she was treated with antibiotics. She was fully immunized for her age and had no known drug allergies. Laboratory tests revealed moderate anemia, likely secondary to chronic disease or recurrent infections, but the patient maintained a satisfactory nutritional status and was otherwise healthy.

Preoperative Evaluation

Preoperative assessments included a thorough evaluation of the patient's respiratory status and nutritional condition. Pulmonary function tests were performed to evaluate her baseline lung capacity, although their interpretation was limited by her age. The patient was also seen by a pediatric nutritionist to ensure optimal nutritional support leading up to the surgery.

Informed consent was obtained from the guardians after thoroughly discussing the surgical procedure, potential complications, and the anesthetic plan. The anesthetic approach focused on minimizing perioperative stress and pain, particularly given the patient's age and underlying respiratory condition.

Anesthetic Management

The anesthetic team planned a multi-modal approach for pain management, emphasizing the importance of regional anesthesia. The choice of epidural anesthesia was made to provide effective analgesia throughout the surgical procedure and postoperative recovery.

One-Lung Ventilation Strategy

For OLV, a Fogarty balloon catheter was selected as the bronchial blocker. This decision was based on the catheter's ability to provide effective lung isolation while minimizing the risk of airway trauma, particularly in small pediatric patients. The Fogarty balloon, TufTex® Embolectomy Catheter size 4Fr, was prepared forsertion, ensuring that it was compatible with the size of the patient's airway.

The approach involved introducing the Fogarty balloon into the right main bronchus following the insertion of a single-lumen endotracheal tube. First, a 4.5-cuffed endotracheal tube was inserted and auscultation was performed to ensure and measure the depth when both lungs were symmetrically ventilated. After the initial insertion of the endotracheal tube, it was advanced further to confirm that ventilation was more effective in the right lung than in the left.

Figure 1.(A) Fogarty balloon TufTex® Embolectomy Catheter size 4Fr, length 80 cm, balloon volume 0.75 ml, Inflated Balloon Diameter 10.5 mm, Deflated Balloon Diameter 1.32 mm; (B) Endotracheal tube Forsch Medical size 4.5 cuffed, diameter 6.0 mm

Figure 2.Bronchial block procedure in a patient. (A) Intubation using Endotracheal tube; (B) Forgaty catheter placement using three-way stopcock; (C) Forgaty catheter placement using mountpiece

This step was vital for establishing proper one-lung ventilation by ensuring that the Fogarty balloon catheter was established in the main right bronchus to facilitate lung isolation. The endotracheal tube was then retracted to its initial measured depth while ensuring that the position of the Fogarty balloon catheter remained stable. To verify successful isolation of the right lung, auscultation was performed both before and after inflating the Fogarty balloon.

Epidural Anesthesia Technique

An epidural puncture was performed at the L2-L3 interspace using a sterile technique. The anesthesiologist carefully advanced the epidural catheter until T9-T10. 0.25% bupivacaine with a total volume of 12 mL was given, with careful monitoring for any signs of intravascular or intrathecal placement. After confirming the efficacy of the epidural, a continuous infusion of 0.1% bupivacaine was planned postoperatively at a rate of 12 mL every 12 hours.

Surgical Procedure

The patient was transported to the operating room and carefully monitored. Standard monitoring devices, including electrocardiogram (ECG), pulse oximetry, and non-invasive blood pressure monitoring, were established.

Once the patient was adequately anesthetized, the single-lumen endotracheal tube was placed. After intubation, the Fogarty balloon was gently inserted into the right main bronchus using direct visualization with a flexible bronchoscope. The balloon was inflated to achieve lung isolation.

The right lateral thoracotomy was then initiated. The surgical team carefully assessed the thoracic cavity, taking care to minimize trauma to surrounding structures. The procedure involved resection of the affected lung tissue and drainage of the pleural effusion, which was found to be purulent. The operation lasted approximately 90 minutes, during which the patient’s vital signs remained stable, and oxygen saturation levels consistently exceeded 95%.

Figure 3.Positioning for the procedure patient. (A) Left Lateral Decubitus (B) One lung ventilation with the collapsed right lung (C) Successful lobectomy

Once the lobectomy was completed, the Fogarty balloon was deflated and withdrawn.

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