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  1. Infants with unilateral lung disease are best oxygenated with the healthy lung in the nondependent position given the soft, compressible nature of their ribcage, the relationship of FRC to residual volume, and less significant hydrostatic pressure gradient between the right and left lungs. This is contrary with what is usually seen in the adult population.

  2. The choice of induction technique (spontaneous breathing versus positive pressure ventilation) during airway foreign body retrieval should be dictated by the location of the foreign body and by the risk of advancing that object to a location in the respiratory tree that either obstructs ventilation or is not easily retrievable.

  3. The anesthetic management for a patient presenting with an anterior mediastinal mass is both complex and hazardous, particularly during induction of anesthesia. Maintenance of spontaneous ventilation is often preferred. The availability of a rigid bronchoscope, the ability to reposition the patient easily, and in some cases circulatory support (ECMO) assistance may be indicated for large and/or very symptomatic mediastinal masses.

A 2-month-old infant was diagnosed prenatally with a right-sided congenital cystic adenomatoid malformation. He is scheduled for a surgical resection via right thoracotomy. He just completed a 14-day course of antibiotics for pulmonary infection.

Vital signs Wt: 3.6 kg, BP 74/42, HR 135, RR 40, SpO2 96% on 0.2 L/min oxygen. CT scan reveals multiple 2 to 3 cm cystic lesions in the right upper lobe, some with air/fluid levels.

Thoracic surgery in the pediatric population presents additional challenges to the routine problems encountered in adult patients presenting with thoracic disease. This chapter will review the key knowledge necessary to care for these patients and will use one condition (congenital cystic adenomatous malformations) as an example of the general issues to consider for intrathoracic surgery in an infant. In addition, the chapter will provide a discussion of two other conditions that may result in a pediatric thoracic surgical procedure: foreign body in the airway and anterior mediastinal mass.

Conditions Necessitating Thoracic Surgery

Conditions that present in the first year of life may include lesions of the respiratory tree, lung, vasculature, and diaphragm.1 Examples include tracheal stenosis and malacia (both congenital and secondary to prolonged intubation), pulmonary sequestration, pulmonary hypoplasia (associated with a number of intrauterine problems), congenital diaphragmatic hernia, tracheoesophageal fistula, esophageal atresia, coarctation of the aorta and patent ductus arteriosus. Conditions that more commonly arise after the first year of life include primary or metastatic tumors (especially lymphoblastic lymphoma, Hodgkin lymphoma and neuroblastoma), severe infection (consolidated pneumonia, abscess and empyema), arteriovenous malformation, pectus excavatum and kyphoscoliosis. Finally, a common cause for an emergent thoracic procedure is a foreign body in the airway.

Anatomic Differences

There are several key differences between adult and pediatric airway anatomy.2 The first is the large head relative to the body, with a more prominent occiput in infants and ...

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