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Video-assisted thoracoscopic surgery (VATS) has emerged as an innovative and popular procedure for the management of postpneumonic empyema in children refractory to medical response. Alternative uses of two- and one-lung ventilations have been required during VATS. This study evaluated the efficacy of alternating one- and two-lung ventilation through intraoperatively through the same single-lumen endobronchial tube using a tube exchanger during a thoracoscopic procedure for pediatric empyema.Between May 1995 and August 2001, 62 consecutive pediatric patients undergoing VATS for evacuation of the loculated empyema cavity were studied. The same single-lumen endobronchial tube was used, with an indwelling endotracheal tube exchanger in place for readjustment of the tube position to provide alternation of one- and two-lung ventilations in a thoracosopic procedure. Duration of operation, heart rate, mean arterial pressure, peak airway pressure, an partial pressure of oxygen (PaO(2)) and carbon dioxide (PaCO(2)) changes during one- and two-lung ventilations were recorded. The quality of lung deflation and inflation was rated by the surgeon using direct visualization as excellent, fair or poor.The mean operating time was 90 min (range, 50-120 min). No differences were found in heart rate, mean arterial pressure, or PaO(2) during one- and two-lung ventilations. Peak airway pressure and PaCO(2) during two-lung ventilation were significantly higher than during one-lung ventilation. The quality of lung deflation and inflation was judged excellent for all the patients.The VATS procedure can be performed safely and effectively in children using proper anesthetic technique. Retention of a tube exchanger within a single-lumen endobronchial tube an easily provide alternative one- and two-lung ventilations without inducing any significant airway flow obstruction during the operation.