One-lung ventilation in a small infant at a low-volume center: the role of structured decision-making and team preparation.

One-lung ventilation (OLV) in infants is technically demanding and is typically reported from high-volume centers. We describe here perioperative management using OLV in a 6-month-old, 3.5-kg infant undergoing resection of a large emphysematous lung lesion at a low-volume center. Due to limited institutional experiences and anticipated airway challenges, the anesthetic strategy prioritized structured decision-making, predefined withdrawal criteria, and anesthesiologist-led multidisciplinary briefings and simulations. The key elements included planned apneic oxygenation using nasal high-flow oxygen and preparation of alternative confirmation methods. During surgery, bronchial blocker dislodgement required deviation from the initial plan; however, shared situational awareness and open communication enabled flexible adaptation and maintenance of stable ventilation. This case highlights that in rare, high-risk pediatric airway management, non-technical skills-including planning, communication, and team coordination-may play a critical role in ensuring patient safety, particularly in low-volume settings.