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Abstract
Background : Lung recruitment techniques are employed to help in improvement of pulmonary mechanics, facilitate early weaning, and shorten the duration of mechanical ventilation. We are reporting a novel lung recruitment technique employed in four children with left lung atelectasis, who underwent corrective surgery for congenital heart disease.
Materials and Methods : From January 2020 to March 2021, four pediatric cardiac patients having left lung atelectasis, undergoing corrective surgery were subjected to lung recruitment technique and had elective endobronchial intubation and suctioning with chest physiotherapy in the form of vibration and percussion. This was done along with intermittent ventilation with 100% oxygen.
Results : Successful recruitment of lung segments and clearance of atelectasis were confirmed by auscultation and chest X-ray in all four patients. All the cases were successfully weaned off the ventilator within 24–48 h. One patient had an opposite lung collapse after extubation, which was managed conservatively with chest physiotherapy. Another patient had bradycardia and desaturation during the procedure, which was improved after withdrawing the tube and instituting two lung ventilation with 100% oxygen.
Conclusions : This novel lung recruitment technique helps in recruitment of collapsed lung segments and thus helps in early weaning and shortens the duration of mechanical ventilation.
Keywords: Congenital heart disease, endotracheal tube, fiberoptic bronchoscope, recruitment technique
How to cite this article: Introduction 
Lung recruitment maneuver is a technique, in which temporary airway pressure is increased during mechanical ventilation, to open the collapsed alveoli and enhance alveolar units involving tidal ventilation to improve oxygenation.[1] Lung recruitment techniques include removal of mucus plugs, treatment of infection, sustained inflation followed by decremental positive end-expiratory pressure (PEEP), and prone positioning.[2]
Children with congenital heart diseases (CHD) suffer from respiratory complications caused by extrinsic or intrinsic obstruction of airways.
Materials and Methods From January 2020 to March 2021, we encountered four children with collapsed left lung, undergoing corrective cardiac surgery. They were subjected to lung recruitment maneuvers either preoperatively or postoperatively, resulting in favorable outcomes.
Technique
In children up to 3 years of age, both right and left mainstem bronchi diverge from the trachea at an angle of approximately 110° [Figure 1]. It makes endotracheal tube (ETT) negotiation easier in both left and right mainstem bronchi, whereas ETT or suction catheter enters the right main bronchus more commonly in infants and children, similar to adults.[3] We achieved endobronchial intubation by advancing the ETT in the lung with collapsed segments, by turning the head of the patient to the opposite side and rotating the ETT by 90° toward the side of the collapsed lung. The position of ETT was confirmed by auscultation. The lung was subjected to endobronchial suctioning through ETT, twice or thrice with intermittent manual ventilation with 100% oxygen. Percussion and vibration chest physiotherapy was done along with the application of PEEP to relieve atelectasis and collapse. Patients were subjected to the recruitment technique 2–3 times and average duration of the procedure was 10 min. Hemodynamic parameters and peak airway pressures were monitored continuously during the procedure. Peak Airway pressures were kept around 22–24 cm H2O and any increase beyond 25–26 cm H2O was avoided.
Figure 1: (a) Mainstem bronchi origin from trachea in a neonate. (b) ETT advanced into the left mainstem bronchus during recruitment maneuver. ETT: Endotracheal tubeCase 1
A 1-month-old male child, weighing 3 kg, presented with breathing difficulty. Transthoracic echocardiography (TTE) revealed ostium secundum atrial septal defect (ASD), large muscular ventricular septal defect (VSD) with left-to-right shunt, severe pulmonary artery hypertension (PAH), juxta ductal coarctation of the aorta, and patent ductus arteriosus (PDA). On auscultation of the chest, there was decreased air entry on the left side and serial chest X-ray showed left lung collapse [Figure 2]a. In view of urgency, the patient was posted for ASD, VSD closure, and arch repair. After completion of the surgery, the patient was shifted to the pediatric intensive care unit (PICU). The left endobronchial intubation was done by advancing 3 mm cuffed ETT into the left bronchus, and position of the tube was confirmed by auscultation of both lungs; there was no air entry on the right side and rhonchi on the left side. The patient was subjected to the lung recruitment technique described earlier. Left-sided air entry achieved on auscultation and postprocedure chest X-ray improved [Figure 2]b.
Figure 2: (a) Left lung collapse. (b) CXR of the patient following recruitment maneuver. CXR: Chest X-rayCase 2
A 4-month-old female, weighing 3.5 kg, presented with difficulty in feeding and poor weight gain. TTE examination revealed large perimembranous VSD with bidirectional shunt and hyperkinetic PAH. Repeated chest X-ray of the patient showed collapse of the left lung despite aggressive physiotherapy and positioning maneuvers [Figure 3]a. Computed tomography (CT) thorax of the patient revealed moderate-to-severe osteoproximal compression of the left main bronchus with changes of aspiration pneumonitis in dependent segments of the left upper and lower lobes [Figure 3]c and [Figure 3]d. Surgical closure of VSD was planned. Postoperatively, the patient was shifted to PICU and was subjected to recruitment techniques in similar manner. Left-sided air entry was achieved on auscultation. Postprocedure chest X-ray improved [Figure 3]b.
Figure 3: (a) CXR showing left lung collapse. (b) CXR showing recruited left lung. (c and d) CT thorax of the patient showing moderate-to-severe osteoproximal compression of left main bronchus with changes of aspiration pneumonitis in dependent segments of the left upper and lower lobes. CXR: Chest X-ray, CT: Computed tomographyCase 3
A 7-month-old female, of 3.4 kg weight, was diagnosed with supracardiac total anomalous pulmonary venous connection (TAPVC) and was posted for rerouting of TAPVC. Chest x-ray and pulmonary CT angiography showed dilated right and left pulmonary arteries. Left main stem bronchus was severely compressed by dilated right pulmonary artery (RPA), with a complete collapse of left lung with the shift of mediastinum to ipsilateral side along with hyperinflation of the right lung [Figure 4]a, [Figure 4]c, [Figure 4]d, [Figure 4]e. On auscultation, there was minimal air entry on the left side. Because of repeated episodes of respiratory distress and compressed left main stem bronchus by dilated RPA, surgical repair was planned, after achieving hemodynamic stability and normal blood investigations. The patient was induced with injection of midazolam 0.1 mg/kg, injection of fentanyl 5 μg/kg, and injection of vecuronium 0.1 mg/kg. The patient was intubated with ETT No. 4 mm and bilateral air entry was checked. On auscultation following intubation, there was adequate air entry on the right side and left upper zone lung fields. Elective left endobronchial intubation was done inside the operating room and the patient was subjected to a recruitment maneuver in similar manner. ETT was then pulled out and fixed at 10 cm, following confirmation of bilateral breath sounds. Surgically, both mainstem bronchi were released and RPA was mobilized. The patient was shifted to PICU and postoperative chest X-ray showed normal left lung fields following the application of recruitment technique [Figure 4]b.
Figure 4: (a) CXR showing atelectasis left lung. (b) CXR showing recruited left lung. (c-e) CT angiography showing dilated right and left pulmonary arteries and severely com pressed left mainstem bronchus due to dilated RPA with complete collapse of the left lung with shift of the mediastinum to left side with hyperinflation of the right lung. CXR: Chest X-ray, CT: Computed tomography, RPA: Right pulmonary arteryCase 4
A 21-day-old female, having Taussig–Bing anomaly with large conoventricular VSD, severely hypoplastic transverse arch, and isthmus with juxta ductal coarctation and large PDA, was posted for arterial switch operation and VSD closure with arch repair. She was having a left-sided lung collapse on serial chest X-ray [Figure 5]a. The patient was intubated 3 days before surgery. Routine lung recruitment maneuvers including physiotherapy, nebulization, and positioning could not recruit the collapsed lung. Owing to the surgical urgency, the patient was posted for corrective surgery. After induction of anesthesia, the patient was subjected to the recruitment technique explained in methodology. On auscultation, air entry was achieved on the left side following the recruitment maneuver. On the table, a chest X-ray was done after the application of recruitment technique, which showed recruited left-sided lung [Figure 5]b. Complete surgical correction was performed.
Figure 5: (a) CXR showing atelectasis left lung. (b) CXR showing recruited left lung. CXR: Chest X-rayWe got favorable outcomes following application of the recruitment technique in all four patients, resulting in recruitment of collapsed left lung, which was confirmed by auscultation and chest X-ray. Case 1 was extubated after 36 h following surgical repair. Case 2 was extubated after 8 h, postoperatively. Extubation of case 3 was performed 20 h after surgical completion. However, on the 3rd postoperative day, the patient developed right lung collapse, which required chest physiotherapy and intermittent nasal continuous positive airway pressure for 24 h. Case 4 had bradycardia (108/min) and desaturation (SpO2 – 66%) during the application of recruitment technique, which was improved after withdrawing the tube and instituting two lung ventilation with 100% oxygen. The patient was extubated after 30 h, postoperatively.
Discussion Incomplete expansion or collapse of part of the lung, called atelectasis, may involve a lung subsegment or entire lung and occurs preferentially in younger children.[4] An HS, et al.,[5] found that extrinsic compression in children with CHD was the most common lower airway abnormality with a predilection for the left main bronchus, whereas intrinsic airway obstruction in children can be due to bronchiolitis, aspiration, or increased airway secretions. Adriani and Griggs[6] reported that both right and left mainstem bronchi diverge from the trachea at an angle of approximately 110° in children up to 3 years of age, making ETT and suction catheters enter right and left main bronchi with comparable frequency. In cases of severe atelectasis, bronchoscopic removal of secretions and mucus plug would help.[3],[7] Pediatric patients with VSD, TAPVC, or truncus arteriosus with severe PAH and having dilated pulmonary artery often leads to compression of trachea and bronchi. In such cases, correction of the anomaly itself relieves pressure and compression of airways. Therefore, in case 2, only VSD repair was done. In patients with severe tracheobronchomalacia, various surgical modalities can be used such as aortopexy, tracheobronchopexy, and tracheobronchoplasty. Aortopexy involves lifting the aorta anteriorly and suturing it to the posterior surface of the sternum.[8] Tracheostomy in small infants requires changes in the size and length of the tracheostomy tube as the child grows and is associated with the risk of tracheal injury.[9]
This technique was helpful in relieving chronic atelectasis of the lung in these patients, which resulted in a shorter duration of mechanical ventilation and ICU stay and can be performed with ease in both operating room and PICU. Moreover, in small size and premature neonates, who require ETT <3.5 mm, it becomes difficult to negotiate the smallest size fiber optic bronchoscope (FOB) (2.8 mm). It is also helpful in cases where there are relative contraindications to FOB such as patients with PAH and uncorrected bleeding diathesis.
Limitations
This technique requires endobronchial intubation. Routine chest physiotherapy is advised in extubated patients with lung collapse, who do not fit into the criteria for mechanical ventilation.
Continuous hemodynamic and airway pressure monitoring are required during this maneuver. Hemodynamic compromise can occur as seen in case 4, who had bradycardia and desaturation during the recruitment maneuver and can result in pulmonary barotrauma due to excessive increment in airway pressures.
Conclusions This article describes a novel approach to treat atelectasis and recruit lung parenchyma by endobronchial intubation. Results were effective in four patients and a larger study involving more patients is warranted to gather more evidence.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Acknowledgment
We would like to thank Dr. Trushar Gajjar, pediatric cardiac surgeon, for his valuable guidance in manuscript preparation. We are also thankful to operating pediatric cardiac surgeon Dr. Amit Mishra in above-mentioned cases.
Financial support and sponsorship
This study was supported by U.N. Mehta Institute of Cardiology and Research Centre.
Conflicts of interest
There are no conflicts of interest.
References 
Correspondence Address:
Dr. Jigisha Chandrakant Pujara
Department of Cardiac Anesthesia, U. N. Mehta Institute of Cardiology and Research Centre, Affiliated to B. J. Medical College, Ahmedabad, Gujarat
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/apc.apc_76_22
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