One-Lung Ventilation for Neonatal Pneumonectomy in a Hydropic Premature Infant: Fiberoptic-guided Left Mainstem Intubation

Congenital cystic adenomatoid malformation (CCAM) is a rare lung anomaly that can cause severe respiratory distress and hydrops fetalis. One-lung ventilation (OLV) in neonates poses extreme anatomical challenges due to the lack of appropriately sized double-lumen tubes or bronchial blockers. A male neonate (2500 g, 30 weeks' gestation) presented with hydrops fetalis and a massive right-sided thoracic CCAM. Due to progressive respiratory failure and hemodynamic instability, an emergency right pneumonectomy was scheduled on postnatal day 3. To achieve OLV, a 3.5-mm cuffed endotracheal tube (with the cuff left deflated) was advanced into the left main bronchus under fiberoptic bronchoscopy (FOB) guidance. Removal of the tube adaptor facilitated rapid, pragmatic placement while minimizing interruptions to ventilation during apneic oxygenation. Pressure-controlled lung-protective ventilation was maintained. Transient desaturation episodes during mediastinal manipulation were successfully managed. The 3-hour procedure was completed without intraoperative complications. In premature neonates in whom commercial lung-isolation devices are impractical, FOB-guided selective mainstem bronchial intubation is a rapid, feasible, and effective strategy for OLV. Individualized airway planning and FOB guidance are instrumental in ensuring accurate placement and maintaining oxygenation.