Pediatric Anesthesiology

E   Narrative Review Article

An Update on One-Lung Ventilation in Children

T. Wesley Templeton, MD,* Federico Piccioni, MD,† and Debnath Chatterjee, MD, FAAP‡

One-lung ventilation in children continues to present technical and sometimes physiologic chal-
lenges to the clinician. The rarity of these cases at any single institution, however, has led to
very few prospective trials to guide best practices. As a result, most clinicians continue to be
guided by local tradition and preference. That said, the development of new bronchial blockers
such as the EZ-Blocker or blocking devices such as the Univent tube have continued to evolve
the practice of lung isolation in children. Further, the development of a variety of extraluminal
blocker techniques has led to innovations in practice through a relatively diverse landscape of
published case series offering different approaches to one-lung ventilation during the past 15
years. The Arndt bronchial blocker continues to represent the most well documented of these
devices. Additionally, recent advances have occurred in our understanding of the relevant ana-
tomic constraints of the lower pediatric airway. This review is intended to provide a comprehen-
sive and practical update to practicing pediatric anesthesiologists to further their understanding
of the modern practice of one-lung ventilation for thoracic surgery in children. (Anesth Analg
XXX;XXX:00–00)

GLOSSARY
BB = bronchial blocker; CPAP = continuous positive airway pressure; CT = computerized tomo-
graphic; DLT = double-lumen tube; ETT = endotracheal tube; FFB = flexible fiberoptic bronchoscope;
Fio2 = fraction of inspired oxygen; HPV = hypoxic pulmonary vasoconstriction; LPV = lung-protective
ventilation; OLV = one-lung ventilation; PEEP = positive end-expiratory pressure; Spo2 = oxygen
saturation; VATS = video-assisted thoracoscopic surgery; V/Q = ventilation/perfusion

O
ne-lung ventilation (OLV) in infants and
young children represents a niche practice
that has continued to evolve during the past
2 decades. One of the first comprehensive reviews of
this topic was published by Hammer.1 In many ways,
the basic approaches to OLV in young children, endo-
bronchial intubation, or placement of an extraluminal
bronchial blocker (BB) remain unchanged. Despite
the scarcity of these cases, the practice of OLV in
young children continues to evolve with improve-
ments in our knowledge of the anatomical constraints
of the lower pediatric airway, the development of
newer blocker devices, and innovative approaches to
extraluminal BB placement.
From the *Department of Anesthesiology, Wake Forest School of Medicine,
Winston-Salem, North Carolina; †Department of Critical and Supportive
Care, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico
(IRCCS) Instituto Nazionale dei Tumori, Milan, Italy; and ‡Department
of Anesthesiology, Children’s Hospital Colorado, University of Colorado
School of Medicine, Aurora, Colorado.
Accepted for publication June 19, 2020.
Funding: None.
The authors declare no conflicts of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s website (www.anesthesia-analgesia.org).
Reprints will not be available from the authors.
Address correspondence to T. Wesley Templeton, MD, Department of Anes-
thesiology, Wake Forest School of Medicine, Medical Center Blvd, Winston-
Salem, NC 27157. Address e-mail to ttemplet@wakehealth.edu.
Copyright © 2020 International Anesthesia Research Society
DOI: 10.1213/ANE.0000000000005077
INDICATIONS FOR OLV
The indications for OLV can be broadly categorized
as either to facilitate surgical exposure or to anatomi-
cally isolate one-lung from the other (Supplemental
Digital Content, Table 1, http://links.lww.com/AA/
D159).2–5 More recently, continued refinements in
minimally invasive surgical techniques have popular-
ized video-assisted thoracoscopic surgery (VATS) in
children which has led to an increased need for lung
isolation even in very young patients.6–11
Anatomical lung isolation in children may also be
necessary to avoid cross-contamination from one lung
to the other in cases of severe pulmonary hemorrhage
or empyema.12,13 Similarly, patients with pulmonary
alveolar proteinosis require lung isolation for sequen-
tial whole lung lavages to clear the accumulation of
lipoproteinaceous material within the alveoli.14,15
Another clinical scenario that warrants lung isolation
is ineffective ventilation of the ipsilateral healthy lung
secondary to a decrease in pressure or airflow on the
contralateral side from bronchial disruption or bron-
chopleural fistula.16
PHYSIOLOGICAL CONSIDERATIONS DURING OLV
IN CHILDREN
Key Points
1. 
Issues that inhibit ventilation/perfusion (V/Q)
matching and therefore predispose children to
hypoxemia during OLV include compression of the

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 One-Lung Ventilation
dependent lung as a result of a less rigid cartilagi-
nous rib cage and abdominal pressure transmitted
through the diaphragm, reducing compliance and
ventilation in the dependent lung.
2. A reduction in the hydrostatic gradient from the
nondependent to the dependent lung due to a
child’s reduced size leads to less effective shunting
of blood away from the nondependent lung to the
dependent lung leading to worsening V/Q match-
ing during OLV.
In an awake patient in the upright position, venti-
lation and perfusion of the lungs are well matched
with the dependent portions of the lungs receiv-
ing greater blood flow as a result of the increasing
hydrostatic gradient from top to bottom paired with
the relatively favorable location of the lung bases on
their respective compliance curves. These normal
homeostatic mechanisms and favorable V/Q match-
ing patterns, however, can be significantly altered
during anesthesia, OLV, and lateral decubitus posi-
tioning (Figure 1).
With the initiation of OLV in the lateral decubitus
position, the nondependent lung collapses, leading
to atelectasis and decreased compliance, thus shift-
ing ventilation back to the dependent lung. Further,
alveolar hypoxia in the nondependent lung activates
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hypoxic pulmonary vasoconstriction (HPV) within
seconds, directing blood away from poorly ventilated
areas to better-ventilated areas. HPV in these seg-
ments will peak at 15–20 minutes followed by a sec-
ond delayed response, which will peak at 2 hours.17
Based on animal studies, HPV decreases blood flow
to the nondependent lung by 50%.18 In practice, these
compensatory mechanisms facilitate adequate oxy-
genation during thoracic surgery and OLV in adult
patients with the well-perfused and ventilated lung
in the dependent position.19
In infants and young children, these physiologic
mechanisms may be significantly altered with sig-
nificant reductions in optimal V/Q matching.20 The
reasons for this difference are multifactorial. The
mostly cartilaginous rib cage of infants cannot fully
support the underlying lung. Functional residual
capacity in infants is maintained closer to the resid-
ual volume, making airway closure likely to occur
in the dependent lung even during tidal breathing.21
The mechanical advantage offered by the dependent
diaphragm in adults is less pronounced in infants.
Finally, the decreased hydrostatic pressure gradient
between the nondependent and dependent lungs
reduces the degree of redistribution of pulmonary
blood flow to the dependent lung in infants and
young children. These factors along with a higher
Figure 1. Effects of lateral positioning on the
redistribution of pulmonary blood flow and V/Q
mismatch in an anesthetized patient. In the lat-
eral position (A), there is a decrease in com-
pliance and functional residual capacity in the
dependent lung from external compression by
the mediastinum, an increase in intraabdomi-
nal pressure transmitted to the chest via the
diaphragm, and a decrease in chest wall com-
pliance. Lateral positioning also leads to an
increase in perfusion to the dependent lung,
which receives 60% of the pulmonary blood
flow and the nondependent lung receives 40%
of the pulmonary blood flow. With OLV (B), col-
lapse and atelectasis in the nondependent lung
activate hypoxic pulmonary vasoconstriction,
directing blood toward the better-ventilated
lung, thereby improving V/Q matching. HPV indi-
cates hypoxic pulmonary vasoconstriction; OLV,
one-lung ventilation; PBF, pulmonary blood flow;
V/Q, ventilation/perfusion.
ANESTHESIA & ANALGESIA
 EE Narrative Review Article

metabolic rate in infants can result in hypoxemia

Summary of bronchial diameters and recommended lung isolation device or ETT size for lung isolation. ETT outer diameters can vary significantly by manufacturer, so care must be taken to evaluate the outer diameter

Abbreviations: BB, bronchial blocker; C, cuffed; CT, computerized tomography; DLT, double-lumen tube; E, extraluminal; ETT, endotracheal tube; Fuji, Fuji Uniblocker; I, intraluminal; L, left; OD, outer diameter; OLV, one-lung
26F
DLT
−
−

−
+
-

-
during OLV.

ANATOMICAL IMPLICATIONS FOR OLV

Univent
4.5

−
−
−
−
−
−
−
+
Key Points
1. The left mainstem bronchus is consistently smaller
than the right mainstem bronchus and requires an

Univent
3.5

−
−
−
−
−
−
+
+
endotracheal tube (ETT) ½ size smaller for endo-
bronchial intubation.
2. The distance from the carina to the take-off of the

Blocker
EZ-

E/I
−
−
−
−
−
−
left upper lobe bronchus is typically 3 times the

E
distance from the carina to the take-off of the right
upper lobe, allowing a larger margin of error when

Fuji

E/I
9F

−
−
−
−
−
−
−
adjusting the depth of a BB or performing an endo-

Median bronchial diameter measured by high resolution CT (Downard MG, Johnson AL, Heald CJ, Anthony EY, Singh J, Templeton TW, unpublished data, April 2019).
bronchial intubation on the left side.

Fuji

E/I
E/I
E/I
5F

−
E
E
E
E
3. The take-off of the right upper lobe remains very
close to the carina (≤1 cm) in patients up to 8 years

Fogarty
of age, making lung isolation frequently more tech-

E/I
E/I
4F

−
−
E
E
E
E
nically challenging with a much smaller range for
optimal device placement.

Fogarty
Our understanding of the lower tracheobron-

E/I
E/I
3F

−
−
E
E
E
E
chial anatomy has increased substantially during
the past several years. One of the first attempts to

9F Arndt
further delineate this anatomy was by Hammer

E/I
BB
−
−
−
−
−
−
−
et al,22 where he provided estimates of ETT sizes for
endobronchial intubation based on an analysis of
autopsy specimens and computerized tomographic
7F Arndt

(CT) examinations.22–25 More recently, several stud-

E/I
E/I
BB
Table 1.  Age and Device Selection for OLV in Infants and Young Children

−
−
−
−
E
E
ies have used high-resolution CT to better character-
ize the anatomy of the lower airway from the glottis
down to the left and right mainstem bronchi.26–30
5F Arndt

Anatomic considerations relevant for the execution

E/I
E/I
E/I
BB

−
E
E
E
E

of OLV in children include, first, the left mainstem

bronchus is smaller than the right mainstem bron-
chus in children, so an ETT that is appropriate for
3.0 (4.3)
3.5 (4.9)
3.5 (4.9)
4.0 (5.6)
5.0 (6.9)
5.0 (6.9)
Intubation (OD mm)b
Standard C ETT Size
for Endobronchial

the right mainstem bronchus may ultimately be too

−
−
L

of a given ETT when planning to use it for endobronchial intubation and OLV.

large to enter the left mainstem bronchus. Further,

the size of the left mainstem bronchus in children
3.0 (4.3)
3.0 (4.3)
3.5 (4.9)
4.0 (5.6)
4.5 (6.2)
4.5 (6.2)
5.5 (7.5)
6.0 (8.2)

Measurement of outer diameter is for Shiley endotracheal tubes.

0–3 months old may even be too small to accommo-

R

Median bronchial diameter measured by high resolution CT.32

date a 3.0 uncuffed ETT. Second, the distance from

the carina to the take-off of the right upper lobe
in most children is <1 cm, even in children up to
2.5 (3.6)
2.5 (3.6)
3.0 (4.2)
3.5 (4.9)
3.5 (4.9)
4.0 (5.5)
5.0 (6.9)
Intubation (OD mm)b

8 years of age. This is significant because it makes

−
Endobronchial

L
Standard UC
ETT Size for

it very easy to pass an ETT beyond the take-off of

the right upper lobe, thereby ventilating only the
3.0 (4.2)
3.0 (4.2)
3.5 (4.9)
4.0 (5.5)
4.5 (6.2)
4.5 (6.2)
5.5 (7.5)

right middle and lower lobes and potentially exac-

R

erbating hypoxemia and hypercarbia in very young

ventilation; R, right; UC, uncuffed.

patients.1,31 Fortunately, the distance from the carina

to the take-off of the left upper lobe is on average 3
3.6a
3.9a
4.2a
5.6c
6.6c
7.3c
7.8c
8.8c
Mainstem
Bronchus

L
Diameter

times greater, giving the clinician a much larger mar-

(mm)a

gin of error when placing an ETT or BB into the left

0–3 mo 4.4a
3–6 mo 4.7a
6–12 mo 5.4a
5.4c
7.5c
8.3c
8.9c
9.9c
R

mainstem bronchus. Table 1 summarizes the recom-

mended ETT and BB sizes for patients <9 years of
8–10 y

age, based on CT measurements of the left and right

1–2 y
2–4 y
4–6 y
6–8 y
Age

mainstem bronchi from several authors.

a

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 One-Lung Ventilation
TECHNIQUES FOR OLV IN CHILDREN
Endobronchial Intubation
Key Points
1. In children <8 years of age, the clinician should
consider reducing the ETT size by 0.5 mm internal
diameter for left-sided endobronchial intubation.
2. Endobronchial intubation in young children can be
complicated by partial or almost complete occlu-
sion of the ETT by blood or other airway secretions
during thoracic procedures leading to difficulties
with ventilation and oxygenation.
Endobronchial intubation remains the simplest means
of achieving OLV, especially in children <2 years of age.32
Right-sided endobronchial intubation can be accom-
plished simply by advancing the ETT until the breath
sounds on the left disappear. In most cases, the ETT will
naturally enter into the right mainstem bronchus. The
clinician must take care to avoid advancing the ETT
too distally to prevent occlusion of the take-off of the
right upper lobe bronchus. It is important to note that
uncuffed ETTs have a Murphy eye, which may help ven-
tilating the right upper lobe when used for right-sided
endobronchial intubation. For left-sided endobronchial
intubation, the bevel of the ETT is rotated 180°, and the
patient’s head is turned to the right.31 Endobronchial
intubation can also be achieved with the aid of a flexible
fiberoptic bronchoscope (FFB) and railroading the ETT
into the desired mainstem bronchus.33 Alternatively,
some clinicians will advance the ETT into the desired
mainstem bronchus using fluoroscopic guidance.
While endobronchial intubation is technically easy
to execute, there are several disadvantages, including
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the potential for an improper seal and inadequate col-
lapse of the operative lung, inability to suction the
operative lung, inability to deliver continuous posi-
tive airway pressure (CPAP) to the operative lung,
and the potential for the ETT to become occluded
with secretions and sanguineous debris.1,34,35
Bronchial Blocker
Key Points
1. Extraluminal placement of a BB device remains the
only viable option to perform lung isolation with a
BB in children <2 years of age.
2. BBs are more likely to be displaced when com-
pared to endobronchial intubation.
3. There are multiple approaches available to facili-
tate the successful placement of an extraluminal BB
in young children.
Catheter-based balloon blockers represent the only
other alternative technique for performing OLV in
young children. In general, they can be placed either
intraluminally or extraluminally (Figure 2). Fogarty
embolization catheters (Edwards Life Sciences, Irvine,
CA) and Arndt BB (Cook Medical, Bloomington, IN)
represent 2 older alternative BBs for OLV in children.
More recently though, 3 newer blocker devices have
been introduced, including the 5F Fuji Uniblocker
(Ambu, Columbia, MD), Univent tube (Fuji Systems
Corporation, Tokyo, Japan), and EZ-Blocker (Teleflex,
Wayne, PA).
Historically, the Fogarty embolectomy catheters
were the first available catheter-based balloon blockers
Figure 2. Intraluminal versus extraluminal
approach to bronchial blocker placement. A,
Intraluminal approach with fiberoptic scope and
bronchial blocker inserted through the multiport
adapter with both devices present within the
endotracheal tube. B, Extraluminal bronchial
blocker with blocker present outside of the endo-
tracheal tube within the airway and the fiberoptic
scope inserted through the multiport adapter and
endotracheal tube to facilitate placement.
ANESTHESIA & ANALGESIA
 EE Narrative Review Article
for OLV in children, with the earliest description in
1969.36–38 Unlike most of the more modern blockers,
they have a low-volume, high-pressure balloon, and
therefore, the balloon must be inflated under direct
vision with a FFB and inflated to the smallest volume
that seals the bronchus.35 Bronchial injury from over
distension of the cuff of a Fogarty embolectomy cath-
eter during OLV has been described.39 Another disad-
vantage of the Fogarty embolectomy catheter is the
absence of a center channel to deflate the operative
lung.
The Arndt BB remains the most well documented
of all BBs in young children.40–43 This blocker has sev-
eral unique features, including a high-volume, low-
pressure cuff, and a removable internal wire loop that
extends through the whole blocker and terminates as
a loop that slides over the fiberoptic bronchoscope
while positioning.
The 5F Uniblocker is less well documented in chil-
dren. The Uniblocker is manufactured with a bend at
the distal tip of the device, just proximal to the bal-
loon tip and a shaft that is slightly more rigid than the
Arndt BB. It can be directed into the desired mainstem
bronchus by twisting the shaft at the point of insertion
into the multiport adapter if used via an intralumi-
nal approach or at the lips if used via an extraluminal
approach. The balloon cuff, like the Arndt, is a high-
volume low-pressure cuff, and similar to the Fogarty
embolectomy catheter, there is no central lumen for
CPAP or suctioning.35
Two devices that depart in some ways from the
blockers described above are the EZ-Blocker and
the Univent tube. The EZ-Blocker is a newer BB
with a unique “Y”-shaped design at the distal end
(Supplemental Digital Content, Figure 1, http://
links.lww.com/AA/D159).44 It should be noted that
the EZ-Blocker is approved by the Food and Drug
Administration for OLV in adults but not in children.
The Univent tube, on the other hand, is an ETT, in
which the blocker is attached via a connected channel
to the ventilating lumen, creating an in situ extralu-
minal blocker.45
INTRALUMINAL BB PLACEMENT
In children, safe intraluminal use is limited to pediat-
ric patients >3 or 4 years of age because a 5F blocker
and 2.2 mm FFB require at least a 4.5 mm internal
diameter ETT to accommodate both the blocker and
the FFB. That said, there is a case series describing
the use of 5F intraluminal blockers placed blindly in
children as young as 1 month of age through a 4.0
uncuffed ETT.46 This, however, does not represent the
current standard of care for OLV in young children.
The intraluminal approach to BB placement in older
children is well documented elsewhere.47,48 Finally,
there are reports of intraluminal use of the EZ blocker
XXX XXX • Volume XXX • Number XXX
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in children down to 10 years of age, although this
remains off label.49
EXTRALUMINAL APPROACHES TO BB PLACEMENT
IN CHILDREN
Key Points
1. Extraluminal placement of a BB on the right side
is frequently easier than placing it on the left,
although more precision is necessary when adjust-
ing the final depth of the device.
2. No single approach to extraluminal BB placement
appears to be superior to another.
3. Fluoroscopy can be used to guide BB placement
when visualization with a flexible fiberoptic scope
is hindered by secretions or a lack of physiologic
reserve.
The Loop Approach. One of the earliest approaches to
extraluminal placement using the Arndt BB was to use
the distal wire loop to lasso the ETT before placement
in the patient. Following direct laryngoscopy, the
ETT and blocker are inserted simultaneously into the
patient. The ETT is secured, and a FFB is then advanced
into the desired mainstem bronchus. The Arndt BB is
then advanced off of the ETT onto the FFB using the
wire loop until it passes over the scope now in place
in the desired mainstem bronchus. Variations on this
approach include driving the FFB through the ETT
and then through the wire loop of an already extant
extraluminal Arndt blocker placed before the ETT.
The scope is then driven into the desired mainstem
bronchus, and the blocker is threaded over the FFB
into the desired mainstem bronchus.42
Bending the Blocker. More recently, some groups have
described placing a bend approximately 1–1.5 cm
proximal to the distal balloon to create a steerable end
to the Arndt blocker, which can be manipulated under
direct vision or fluoroscopy (Figure 3).43,50 In this
technique, a 30°–45° bend is placed 1–1.5 cm proximal
to the distal balloon before induction or placement of
the device. Following direct or video laryngoscopy, the
blocker is first advanced through the glottic opening
for 3–5 cm or until resistance is met. Subsequently,
an ETT is inserted adjacent to the blocker. While not
required, anterior positioning of the ETT relative to
the blocker tends to lead to better overall mechanics,
as force applied to the proximal end of the blocker
to advance the device more distally tends to be more
directly transmitted depending on the tightness of fit
of the ETT and blocker at the level of the glottis. Ideally,
the fit between the blocker and the ETT at the level
of the glottis should allow for adequate ventilation
as well as vertical translocation of the BB. This will
typically occur around a leak pressure of 18–24 cm
H2O.51 Additionally, the ETT should be placed slightly
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 One-Lung Ventilation

Figure 3. Summary of “Bending the Rules”

approach for extraluminal placement for
bronchial blocker placement. A, Arndt bron-
chial blocker prepared with 30°–45° bend. B,
Extraluminal 5F Arndt bronchial blocker in glot-
tis before placement of endotracheal tube. C,
Bronchial blocker is manipulated using a twisting
motion at the oral aperture to direct the distal tip.
D, Sealing pressure at cricoid should be between
17 and 24 cm H2O to allow for cephalad/cau-
dad translocation of the bronchial blocker. E,
Endotracheal tube with fiberoptic scope inside.
F, Note the increased distance from end of endo-
tracheal tube to carina to facilitate visualization
and manipulation of blocker within the airway. G,
Bronchial blocker is advanced into the desired
mainstem bronchus distal to the carina. H,
Bronchial blocker occlusive balloon is inflated
under direct vision once patient is in the final
position.

Figure 4. Schematic summary of intra- to extraluminal approach to bronchial blocker placement. A, 1: Fiberoptic scope passed through endo-
tracheal tube into the left mainstem bronchus. B, 1: Endotracheal tube railroaded over flexible fiberoptic into the desired mainstem bronchus.
C, 1: Bronchial blocker threaded into endotracheal tube. 2: Endotracheal tube removed leaving bronchial blocker in place. D, 1: Repeat direct
laryngoscopy and second endotracheal tube placed adjacent to bronchial blocker in glottis. 2: Fiberoptic scope inserted into endotracheal
tube. 3: Bronchial blocker depth adjusted. 4: Occlusive balloon is inflated under direct vision in left mainstem bronchus.

higher than normal in the trachea to allow for better
visualization of the anatomy at the level of the carina.43
Once the ETT and blocker are in place, and the clini-
cian is satisfied with the fit of these devices in the glot-
tis, the ETT should be secured. Next, an appropriately
sized FFB is introduced into the ETT to assist with the
final positioning of the blocker. In the majority of cases,
the blocker will naturally pass into the right mainstem
bronchus. If this is the operative side, the blocker
depth should be left slightly deep as small movements
of the head relative to the thorax during position-
ing can lead to proximal migration of the blocker. If
the blocker is in the incorrect mainstem, the blocker
should be withdrawn proximally and then reinserted
using a twisting motion at the point of entry of the
blocker into the mouth, to steer the blocker into the
correct mainstem bronchus (Figure 4). Unfortunately,
this frequently must be done during periods of apnea
in young children as the FFB will frequently almost
completely occlude the lumen of the ETT, preventing
any meaningful gas exchange. In situations where this
becomes limiting because of the presence of coincident
lung pathology or poor visualization of the airway, the
clinician can use fluoroscopy to direct or steer the BB
into the correct mainstem bronchus.41
Intraluminal to Extraluminal BB Placement. Another
alternative approach to BB placement is to use the ETT

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 EE Narrative Review Article
as a conduit for the placement of a BB (Figure 4).33,42
In this technique, following direct laryngoscopy,
an appropriately sized ETT is advanced into the
desired mainstem bronchus, either blindly or using
a FFB. Once the ETT is in the desired endobronchial
location, the FFB is removed and is replaced by a BB.
In some cases, a modest amount of lubrication may
be necessary to insert the balloon of a 5F Arndt BB
through a 3.0 ETT. Once the blocker is in place, the
ETT is then slid out of the airway over the BB now
in place. A second ETT is then placed adjacent to BB
within the glottis. If the patient desaturates during
this process, the clinician should ventilate the child
with the BB in place. Once the second ETT is in place
adjacent to the BB, it is secured, and the blocker depth
is adjusted under direct vision to be slightly deep
to begin with, to avoid dislodgement during lateral
positioning. Once in the final lateral position, the
blocker depth should be adjusted to be slightly below
the carina, and the balloon is inflated under direct
vision.42 The advantages of this approach include a
typically shorter duration of laryngoscopy because
the clinician is not trying to place a blocker and an ETT
at the same time. The second advantage appears to be
significantly less blocker manipulation when trying
to insert the blocker into the left mainstem bronchus.
Finally, this technique can be executed with a number
of different BBs. The primary disadvantage remains
periods of apnea during flexible bronchoscopy.42
Extraluminal EZ-Blocker Placement
Key Points
1. An extraluminal EZ-Blocker should not be used in
children <6 years of age.
2. The EZ-Blocker may be more positionally stable
than other BBs as a result of its unique “Y” design.
As stated earlier, the EZ-Blocker is a relatively new
“Y”-shaped BB with two 4-cm distal ends with bal-
loon cuffs attached to the 7F shaft designed to rest
on the carina (Supplemental Digital Content, Figure
1, http://links.lww.com/AA/D159).44 Because of its
native “Y” conformation, it is not possible to insert the
device extraluminally by itself. Instead, the blocker
must be inserted using a 5.5 uncuffed ETT as a remov-
able introducer.52 This is done by cutting a 5.5 internal
diameter uncuffed ETT lengthwise and then insert-
ing the blocker into it. Following direct laryngoscopy,
the combined blocker-ETT apparatus is advanced
through the glottic opening. The ETT is then peeled
away. Subsequently, laryngoscopy is repeated, and
another ETT is placed adjacent to the blocker tube
within the glottis. Final positioning is then performed
under direct vision using a FFB.
Potential advantages of the EZ-Blocker likely
include increased positional stability during surgery,
XXX XXX • Volume XXX • Number XXX
Copyright © 2020 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
as well as the potential to perform sequential lung iso-
lation without having to reposition the device. At this
time, it is only manufactured in a 7F size and is lim-
ited to children 6 years of age and older.53
Univent Tube
Key Points
1. The size designations for the Univent tube repre-
sent the internal diameter of the ventilating lumen.
2. The 3.5 size Univent tube should not be used in
children <8 years of age because its external diam-
eter is 8 mm.
The Univent tube is essentially an ETT combined with
an extraluminal BB.45 Following direct laryngoscopy,
the Univent tube is advanced through the glottic open-
ing, and the blocker is then driven into the desired
mainstem bronchus under direct vision using a FFB by
rotating the ETT clockwise or counterclockwise. The
Univent tube comes in 3 sizes, 3.5, 4.5, and 5.5. The
sizing number denotes the internal diameter of the
ventilating lumen on the device. It is important to note
that the Univent tube has a low-volume, high-pres-
sure cuff, and the internal diameter of the ventilating
lumen is quite small relative to the size of the patient
for which it is intended to be used. This smaller lumen
can lead to increased ventilatory resistance as well as
the increased potential for device occlusion with blood
or secretions. The primary limitation of Univent tubes
in children, however, remains its external diameter.
The 3.5 Univent tube has an external diameter of 8.0
mm, which is roughly equivalent to a 6.0 ETT, limit-
ing its use to children 8 years of age and older. The 4.5
and 5.5 Univent tubes have an additional channel that
allows CPAP and suctioning of the operative lung. At
this time, there are only a few case reports describing
the use of the Univent tube in children.45,54,55
BB Balloon Inflation
Key Point
1. Ideally, BB balloon inflation should be performed
under direct visualization to reduce over inflation
of the cuff and the possibility of airway injury.
Most modern BBs are reported to have high-volume,
low-pressure cuffs in contrast to Fogarty catheters or the
blocker associated with the Univent tube which have
low-volume, high-pressure cuffs. In clinical practice,
however, the inflation pressure necessary to facilitate
balloon distention and by extension occlusion of the
desired bronchus likely exceeds 50 cm H2O and may
further exceed 100 cm H2O.42,43 These pressures exceed
mucosal perfusion pressures in most cases, but fortu-
nately do not seem to lead to significant morbidity. Each
individual blocker manufacturer has specific recom-
mendations for inflation volume. Typical volumes for
www.anesthesia-analgesia.org 7
 One-Lung Ventilation
the smaller Fogarty, 5F Arndt, and 5F Fuji are between
1.5 and 3 mL (Supplemental Digital Content, Figure 2,
http://links.lww.com/AA/D159). Larger blockers may
take up to 10 mL. In general, it is good clinical practice to
inflate the balloon under direct vision to reduce the pos-
sibility of over inflation and potential bronchial injury.39
Double Lumen Tubes
Key Point
1. The smallest double-lumen tube (DLT) available is
26F with an external diameter between 8.7 and 9.3
mm, which corresponds to a 6.5 ETT and therefore
should not be used in children <8 years of age.
DLTs are often considered the gold standard for OLV in
adults. DLTs have 2 lumens with 1 lumen that is angled
and longer which is meant to be positioned in the main-
stem bronchus and a shorter lumen meant to be posi-
tioned in the trachea. DLTs are available as left-sided or
right-sided tubes. Left-sided DLTs are more commonly
used to prevent occlusion of the take-off of the right upper
lobe bronchus. Following direct laryngoscopy, the DLT is
advanced past the glottic opening and rotated 90° toward
the desired bronchus. Fiberoptic bronchoscopy is recom-
mended to confirm placement such that the proximal por-
tion of the bronchial cuff is visualized at the level of the
carina.56 Unfortunately, the smallest DLT is 26F, which is
roughly equivalent to a 6.5 ETT.57 As a result, they are typ-
ically not used in children younger than 8–10 years of age.
In adolescents and adults, the sizing of a DLT depends on
sex and height.58 In adolescent females shorter than 160
cm, a 35F DLT may be used, while a 37F DLT may be used
in females taller than 160 cm. In adolescent males shorter
than 170 cm, a 39F DLT may be used, while a 41F DLT
may be used in males taller than 170 cm.58
The advantages of a DLT include its ease of inser-
tion, high quality of isolation when positioned cor-
rectly, application of CPAP, or suctioning the operative
lung, and the ability to quickly alternate from OLV to
2-lung ventilation. The major disadvantage of DLTs
remain their larger relative size and the potential for
glottic or tracheal injury.
PERIOPERATIVE MANAGEMENT OF OLV IN
CHILDREN
Key Points
1. At this time, there is no consensus on how to venti-
late children during OLV, although at least 1 study
would suggest that tidal volumes during OLV
should be limited to 4 mL/kg and positive end-
expiratory pressure (PEEP) should be employed to
reduce intraprocedural atelectasis.
2. Children will frequently become hypercarbic even
with effective OLV, but this will typically resolve once
the patient is placed back on two-lung ventilation.
8   
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Copyright © 2020 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Currently, there are no evidence-based recommen-
dations for ventilation strategies during OLV in
children. One recent prospective study examined
the role of lung-protective ventilation (LPV) during
OLV in children and divided patients into 2 groups:
a LPV group with 4 mL/kg during OLV and 6 mL/
kg during two-lung ventilation, with 6 cm H2O PEEP
throughout and a control group with 8 mL/kg during
OLV and 10 mL/kg during two-lung ventilation, with
no PEEP.59 They reported that LPV during OLV for
VATS decreased postoperative pulmonary complica-
tions. Another similar study showed that LPV could
be an effective intraoperative ventilation strategy
for infants undergoing OLV during VATS, although
it should be noted that neither of these studies used
PEEP in the control group, which may be a significant
confounder.60 The clinician should expect some degree
of hypercarbia.43,61 Hypercarbia will typically resolve
once the patient returns to two-lung ventilation.
In most cases, patients should initially be placed on
100% oxygen to facilitate lung collapse via absorption
atelectasis as well as to maintain adequate oxygen-
ation, especially if the clinician is using an endobron-
chial intubation technique. Following isolation and
confirmation of good operative conditions, the frac-
tion of inspired oxygen (Fio2) could, if possible, be
reduced to maintain oxygen saturation (Spo2) >92%.
With a BB or DLT, low suction (20 cm H2O) can be
applied to expedite deflation. Another technique for
deflation of the nonventilated lung is to ask the sur-
geon to actively compress the lung, with the breathing
circuit open to the atmosphere, followed by immedi-
ate inflation of the occlusive BB balloon or clamping
of the desired lumen of the DLT.
On completion of the procedure, reexpansion of the
nonventilated lung is accomplished with sustained
inflation with 20–30 cm H2O of positive airway pres-
sure for 10–15 seconds.2 When feasible, lung reexpan-
sion should be performed with direct observation to
ensure complete recruitment of residual atelectasis.
Further, this is sometimes done with the operative lung
submerged in saline to look for bubbles to evaluate for
a new bronchopleural connection as a result of airway
injury. Higher airway pressures (>30 cm H2O) should
be avoided due to the risk of acute lung injury. A major-
ity of these patients are extubated in the operating room
following their procedures. If the patient remains intu-
bated postoperatively, the BB should be removed or the
DLT should be replaced with a single lumen ETT.
HYPOXEMIA DURING OLV
The incidence of intraprocedural hypoxemia during
OLV in children is largely unknown. Unless there are
extenuating circumstances, children should probably
be maintained with a Spo2 ≥90%. In situations where
the Spo2 is 90% for >2 minutes, the clinician should
ANESTHESIA & ANALGESIA
 EE Narrative Review Article

follow the algorithm in Supplemental Digital Content,
Figure 3, http://links.lww.com/AA/D159. Initial steps
should include informing the surgeon and perform-
ing a recruitment maneuver to reduce atelectasis and
shunting in the ventilated lung as well as increasing
the Fio2 to 1.0. Other steps to evaluate and manage this
should include fiberoptic bronchoscopy to check the
position of the lung isolation device and ensure that
the ETT is clear of blood or secretions. In practice, this
may be difficult if there is a significant burden of secre-
tions or other sanguine debris in the airway. Additional
steps may include adding an additional 1–2 cm of H2O
PEEP to the dependent lung. Finally, adding 5–10 cm
H2O of CPAP to the nondependent lung may reduce the
overall shunt. If all these maneuvers do not improve the
patient’s oxygenation to an acceptable level, the patient
may be intermittently returned to two-lung ventilation.
SPECIAL CONSIDERATIONS
OLV in Children With a Tracheostomy
Key Point
1. OLV in children with a tracheostomy should be
performed with either an extraluminal BB or endo-
bronchial intubation.
OLV in children with a tracheostomy presents a unique
challenge. The 2 available options include either a BB
or endobronchial intubation.51 For the BB approach, the
patient is typically induced, and the tracheostomy tube is
removed. A BB is then inserted into the stoma, followed
by an ETT adjacent to it.62 The clinician should take care
to avoid injuring or denuding any granulation tissue or
mucosa at or around the stoma to minimize blood and
sanguineous debris within the airway. In smaller chil-
dren, the clinician must be aware of the shorter distance
to the carina and potentially inserting the blocker too
distally.63 In larger children, it may be possible to use an
intraluminal BB approach; however, the shorter distance
between the end of the ETT and the carina may make it
challenging to position the BB. Finally, it is also feasible
to use an endobronchial intubation approach, guided by
bronchoscopy or fluoroscopy to achieve OLV.64
OLV in Children With a Difficult Airway
In children with a difficult airway, safe airway man-
agement must take priority over the institution of
OLV. In infants and small children, it is preferable
to use an endobronchial intubation approach once
the airway has been secured. In larger children, OLV
using the Arndt BB placed through a supraglottic air-
way has been described.65 In children large enough to
accommodate at least a 4.5 or 5.0 ETT, it is possible to
use an intraluminal approach for BB placement and
OLV, once the airway has been secured.
CONCLUSIONS
OLV in young children has evolved during the past
15 years with the advent of new BBs and various
approaches to blocker placement. That said, endo-
bronchial intubation still remains an effective and
simple approach for OLV. A summary of the differ-
ent techniques for OLV along with the advantages
and disadvantages of each technique is included
in Table 2.

Table 2.  Summary of Strategies for OLV in Infants and Young Children

Strategy Appropriate
for OLV Age Advantages Disadvantages
Endobronchial <5 y • Easy to perform • Difficult to change to two-lung ventilation
intubation • No special blocker or tube required • ETT can become occluded with blood and/or
• Can be performed blindly, with fiberoptic assistance or secretions
under fluoroscopy • Easy to occlude right upper lobe bronchus with
• Good quality isolation right-sided endobronchial intubation
• Technique of choice in young children with a difficult airway • Inability to suction nonventilated lung or apply CPAP
Bronchial All age • High quality of isolation • Can be technically challenging to position
blocker groups • Rapidly change from OLV to two-lung ventilation • CPAP to nonventilated lung may be ineffective
• Appropriate for all ages depending on size and type of blocker • Can be easily dislodged as a result of surgical
• Intra or extraluminal use manipulation
• Appropriate for children with a tracheostomy
• Can be used in combination with a supraglottic airway
Univent tube >8 y • High quality of isolation • Appropriate for children ≥8 y of age
• May be more positionally stable than a bronchial blocker • Smaller ventilating lumen relative to patient size
• Easy to change from OLV to two-lung ventilation may lead to increased resistance
Double lumen >8 y • Usually straight forward to position • Appropriate for children ≥8 y of age
tube • High quality of isolation
• Positionally stable
• Easy to change from OLV to two-lung ventilation • Potentially increased rates of glottic or tracheal injury
• Can suction and apply CPAP to nonventilated lung • Not appropriate in most children with a difficult
airway
See Supplemental Digital Content, Table 1, http://links.lww.com/AA/D159, for the indications for OLV in children.
Abbreviations: CPAP, continuous positive airway pressure; ETT, endotracheal tube; OLV, one-lung ventilation.

XXX XXX • Volume XXX • Number XXX www.anesthesia-analgesia.org 9

Copyright © 2020 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
 One-Lung Ventilation
At this time, the rarity of these cases at any single
institution has prohibited the development of pro-
spective trials to compare techniques or stratify risk
and develop evidence-based guidelines, although this
has started to change.59,60 Hopefully, future multi-insti-
tution collaborations will create a platform for further
retrospective and possibly prospective trials to hone
our understanding and improve the care for young
children undergoing thoracic surgery using OLV. E
‍DISCLOSURES
Name: T. Wesley Templeton, MD.
Contribution: This author helped write and revise the manuscript.
Name: Federico Piccioni, MD.
Contribution: This author helped review and revise the manuscript.
Name: Debnath Chatterjee, MD, FAAP.
Contribution: This author helped write and revise the manuscript.
This manuscript was handled by: James A. DiNardo, MD, FAAP.
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