Dear Editor, Congenital pulmonary airway malformation (CPAM) is a rare cystic lung anomaly that presents unique challenges during anaesthesia in neonates.1 Risks of cyst rupture, mediastinal shift, impaired venous return, and sudden desaturation necessitate meticulous perioperative planning. With advances in foetal ultrasonography and magnetic resonance imaging (MRI), most cases are now diagnosed antenatally, allowing for a multidisciplinary approach.2,3 We managed four full-term neonates (mean age 14 days) with antenatally diagnosed CPAM at our tertiary centre between 2024 and 2025 Figure 1.Figure 1: Contrast-enhanced computed tomography of the chest demonstrating multiple cystic lesions consistent with congenital pulmonary airway malformation in the affected lung lobeAll underwent lobectomy (three left lower lobes, one right upper lobe). Anticipating cyst expansion, bag–mask ventilation was avoided during induction. Anaesthesia was induced intravenously with fentanyl, propofol, and atracurium, followed by smooth tracheal intubation. Maintenance was with sevoflurane in oxygen–air mixture, supplemented with opioids and muscle relaxants. Gentle lung-protective ventilation was employed: tidal volume 6–7 mL/kg, airway pressures <20 cm H2O, permissive hypercapnia, and avoidance of nitrous oxide. Despite extensive cystic lesions, one-lung ventilation was not required; open thoracotomy and lobectomy were completed uneventfully Figure 2.Figure 2: Intraoperative photograph showing the resected lung lobe with multiple cystic components following lobectomy for congenital pulmonary airway malformationAll intraoperative courses were stable, without desaturation, arrhythmia, or barotrauma. Postoperatively, the neonates were electively shifted intubated to the neonatal intensive care unit (NICU) for short-term ventilation (3–5 h) and extubated when they were stable. Multimodal analgesia included intravenous paracetamol, small opioid doses, and surgeon-administered intercostal nerve blocks. Recovery was smooth, with discharge on postoperative day 7–8 in all the cases. The novelty of our experience lies in the consistent avoidance of bag–mask ventilation, adoption of lung-protective strategies, and uniform elective NICU ventilation post-surgery. This approach provided stable intraoperative courses and safe recovery in a highly vulnerable population. Unlike earlier reports, our cases demonstrated that satisfactory surgical exposure can be achieved without one-lung ventilation, simplifying management in neonates. Our observations reinforce that antenatal diagnosis, avoidance of positive pressure before airway control, meticulous ventilatory strategies, and planned postoperative NICU care are the keys for safe outcomes in neonatal CPAM lobectomy. Study data availability The data supporting the findings of this case series are available with the corresponding author. Disclosure of use of artificial intelligence (AI)-assistive or generative tools The authors declare that no artificial intelligence (AI)-assistive or generative tools were used in the preparation of this manuscript. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patients' parents/guardians has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The parents understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Mir et al. (Thu,) studied this question.