One-Lung Ventilation: A Pediatric Simulation Case for Anesthesiology Residents

Samuel Bartmess; Martin D'Ambrosio; Clark Obr

doi:10.15766/mep_2374-8265.10461

This activity is designed for midlevel and senior anesthesia trainees to experience the complexities of one-lung ventilation in pediatrics in a high-fidelity simulated environment. With the use of video-assisted thoracoscopic surgery (VATS) becoming increasingly common in pediatrics, we identified this area as an opportunity for the development of a dedicated educational simulation activity. Our simulated patient is a 3-year-old girl with empyema presenting for decortication via VATS who subsequently develops hypoxemia. The main challenges for the trainee include airway selection and insertion, lung isolation with fiber optic confirmation, and management of hypoxemia in the setting of one-lung ventilation. A pediatric medical simulator suitable for practicing resuscitation is required, and a tracheobronchial tree model is highly desirable. Basic knowledge of thoracic and pediatric anesthesia is required, but specific experience with pediatric lung isolation is not. Learners who experienced the content of this simulation expressed a strong sentiment of value. All pilot trainees were surveyed and indicated they either agree or strongly agree (4 or 5, respectively, on a 5-point Likert scale) that "This simulation enhanced my understanding of how to select lung isolation devices for pediatric patients" and "This simulation enhanced my understanding of how to manage hypoxia in context in one-lung ventilation." Comments were overall positive, including "I am better prepared to manage pediatric one lung ventilation cases." At the University of Iowa, this activity is part of a core curriculum of simulation training that resident physicians in anesthesiology experience during their training. It functions as a tool for education, evaluation, and self-identification of weaknesses in the learner's knowledge base as it relates to the perioperative management of pediatric one-lung ventilation, as well as for reinforcing material learned in the classroom and operating room. Numerous anesthesiology residents and faculty have pilot-tested this simulation, and necessary modifications have been made based on their feedback. *********************************** Educational Objectives By the end of this simulation, the learner will be able to: 1. Interpret/summarize general history, physical exam, imaging, and labs of a pediatric patient in the context of planned procedure (American Board of Anesthesiology milestone [ABA] Patient Care [PC] 1, Medical Knowledge [MK] 1). 2. Compare/critique the various lung isolation devices, including single lumen endotracheal tube (ETT), balloon-tipped bronchial blockers (BBs) such as Arndt endobronchial blocker, double lumen endobronchial tubes, and Univent tubes such as Fuji BBs (ABA PC1). 3. Plan for general anesthesia with lung isolation (ABA PC2). 4. Select an appropriate airway isolation device (i.e., BB available with appropriately matched single lumen ETT), understanding the unavailability of double lumen endobronchial tubes for this patient population (ABA PC2). 5. Plan for anticipated and potential intraoperative needs by having a selection of BBs available with appropriately matched single lumen ETT, backup airway adjuncts, arterial line ready, bronchoscopy tower with small-sized bronchoscope prepared and calibrated, continuous positive airway pressure (ABA PC2). 6. Discuss overall operative plan with surgeon, including need for bronchoscopy and likelihood of ICU postoperatively (ABA PC2, Interpersonal Skills and Communication [ICS] 2). 7. Develop postoperative analgesic and care plan (ABA PC3). 8. Perform mask ventilation (ABA PC8). 9. Optimize patient positioning for intubation and perform basic airway placement (ABA PC8). 10. Successfully place lung isolation device (ABA PC8). 11. Perform fiber optic bronchoscopy and lung isolation device placement (if tracheobronchial tree model available) (ABA PC2, PC8). 12. Identify tracheal and bronchial landmarks using online bronchoscopy simulator, thus inferring correct versus incorrect BB placement (if tracheobronchial tree model not available) (ABA PC2, PC8). 13. Recognize the need for arterial line and baseline blood gas (ABA PC2, PC9). 14. Recognize hypoxemia as one important potential complication and explain risk factors for hypoxemia (ABA PC4). 15. Implement lung recruitment maneuvers before one-lung ventilation to decrease the risk of hypoxemia (ABA PC4). 16. Identify the development of hypoxemia (ABA PC4, PC9). 17. Implement continuous positive airway pressure and/or positive end-expiratory pressure to treat hypoxemia (ABA PC4). 18. Recognize the need to call for help when severe hypoxemia or cardiac arrest occurs (ABA PC5). 19. Manage cardiac arrest following Advanced Cardiovascular Life Support and delegate duties accordingly (ABA PC5, MK1, ICS3). 20. Evaluate/critique areas of strength and areas for improvement discovered during the simulation (ABA Professionalism 4).

One-Lung Ventilation: A Pediatric Simulation Case for Anesthesiology Residents

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