One-lung Ventilation in Pediatric Patients: Lung Isolation Techniques and Clinical Management

Summary

This review evaluates pediatric lung isolation techniques, emphasizing age-specific strategies: double-lumen tubes for children >8 years, intraluminal blockers for ages 2–8 years (ETT ID ≥4.5 mm), and extraluminal blockers or mainstem intubation for infants <2 years. It highlights how 3D printing and protective ventilation optimize safety.

Abstract

Implementing one-lung ventilation (OLV) in pediatric patients presents unique clinical challenges due to age-dependent physiological and anatomical constraints. As minimally invasive thoracic surgery expands in pediatrics, the demand for precise lung isolation has increased. This narrative review evaluates current techniques—single-lumen tubes (SLT), double-lumen tubes (DLT), and bronchial blockers (BB)—with a focus on their safety profiles and clinical indications. Findings indicate that DLTs remain the benchmark for older children but are anatomically prohibitive for those under 8–10 years or shorter than 130 cm. BBs are the primary alternative for children aged 2–8 years (ETT ID ≥4.5 mm), although traditional devices such as the Arndt-Fogarty blockers have design limitations. For infants under 2 years, the primary strategies remain SLT mainstem intubation or extraluminal blocker placement, both of which carry a risk of right upper lobe (RUL) obstruction. Emerging innovations, particularly 3D-printed anatomically customized blockers, are highlighted as potential solutions to resolve device “fit” challenges in infants. Perioperative management remains non-standardized; however, evidence-based recommendations emphasize lung-protective ventilation to reduce pulmonary complications. Hypoxemia occurs in approximately 26% of pediatric OLV cases and requires a prioritized management framework that includes fiberoptic verification, secretion clearance, and optimized PEEP/CPAP application. By synthesizing current evidence, this review provides a decision-making algorithm to guide optimal device selection and improve safety outcomes in this vulnerable pediatric population.

Introduction

For anesthesiologists, managing one-lung ventilation (OLV) in children poses significantly greater challenges than in adults. As minimally invasive thoracoscopic and robotic surgical techniques continue to evolve and expand, the demand for OLV in pediatric thoracic surgery is increasing. In parallel, advances in the understanding of pediatric physiology and lower respiratory tract anatomy, along with the development of bronchial blocking devices and related technologies, have contributed to progress in pediatric lung isolation.

Under physiological conditions, the human body maintains a homeostatic balance between ventilation and perfusion (....

Protocol

Pediatric lung isolation techniques
Although double-lumen tubes (DLTs) serve as the definitive benchmark for one-lung ventilation (OLV) in adult thoracic surgery, pediatric lung isolation lacks a universally accepted gold standard⁹. Current practice relies on a tailored selection of single-lumen endotracheal tubes (SLTs), DLTs, or bronchial blockers (BBs), depending on the patient’s age and anatomy¹⁰ (Table 1).

Device Category

Devi....

Results

The management of one-lung ventilation (OLV) in pediatric patients remains one of the most demanding tasks in modern anesthesiology and is fundamentally distinct from adult practice due to unique physiological and anatomical constraints. This review highlights that, despite increasing demand for pediatric thoracic surgery, a unified “gold standard” for lung isolation remains elusive. Device selection is dictated by age and airway dimensions: while double-lumen tubes (DLTs) provide optimal isolation in older c.......