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Ann Thorac Surg 1995;60:930
© 1995 The Society of Thoracic Surgeons
DR JOHN P. CLARKE (Virginia Beach, VA): I enjoyed the paper, Drs McGahren and Rodgers. When you select two-lung ventilation, what ports do you generally use to maintain exposure? My colleagues and I find it hard, even in adults, to maintain exposure well with two-lung ventilation, and I am surprised that you can do that in children.
Second, in our experience with adult patients, we, plus a team of anesthesiologists and anesthetists, have used both double-lumen tubes and blocking tubes for one-lung ventilation. Technically, and maybe all of you already do this, I have found a pediatric bronchoscope useful for not only localizing and placing the blocker or confirming the position of the double-lumen tube but also confirming that the blocker or the double-lumen tube has not moved. Once the patient has been placed in the posterolateral position, it takes about 30 seconds to slip the pediatric bronchoscope in and check those positions. It is very helpful not to have to fiddle with the tube after the patient is on his or her side and prepared.
I am particularly interested, Dr McGahren, in how you maintain exposure with two-lung ventilation in the pediatric patient.
DR McGAHREN: Thank you, Dr Clarke. Addressing the second issue first, I can only reiterate that suggestion. In fact, the literature suggests that there is a tendency for a blocker or a double-lumen tube to move out of the desired position when the patient is moved. That is a very salient point.
As far as the first issue is concerned, we generally use three ports, perhaps four, for the needed exposure. We do have a fan type of retractor that we can use to move the lung out of the way. There is a bit of a struggle at times to accomplish this, but with that type of retractor and that number of ports, we find we can usually manipulate the lung one way or another according to the area in which we need to be.
DR LEWIS WETSTEIN (Freehold, NJ): I enjoyed your presentation. What delighted me more, however, is your use of talc for chemical pleurodesis. With the loss of tetracycline, I have been gaining experience with talc for chemical pleurodesis, and I have no doubts that it is the best material to use for that technique. I have been criticized for employing it in adolescents or young adults because of the concern that these patients may have to undergo an operation later in life for cancer, for example, and there could be a major technical difficulty in entering the chest. This seems a weak argument to me, ie, to modify my management of a present problem in light of the possibility of a problem years later.
As you are the experts and are using talc even in children, should that not be a viable concern?
DR McGAHREN: I think that is a reasonable concern. Basically you have to individualize the situation depending on the current condition of the child. If you thought a lung transplantation was going to be necessary for a particular child, then I think you would not want to use talc. On the other hand, we have found that in the children in whom we are going to end up doing thoracoscopy, there is somewhat of a risk/benefit analysis. Most children will not need lung transplantation later. In our experience, the children undergoing talc pleurodesis have tended to do well, and we have not had to see them again, even at a later time, for other procedures. This has also been reported in the last couple of years in the literature.
DR WETSTEIN: But barring the anticipation that you are going to do a lung transplantation, which is remote, you continue to employ it also?
DR McGAHREN: We do, yes. It has been very successful for us.
Related Article
Ann. Thorac. Surg. 1995 60: 927-930.
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