One Lung Ventilation

Moderator: Dr. Geeta Tayal

Presentation by: Dr. Ira Dhawan
Dr. Varun
Definition
One-lung ventilation consists of mechanical ventilation of the
selected lung and intentional airway blocking of the other.

During one-lung ventilation, the nonventilated lung is excluded
from the ventilation, with all tidal volume directed into the
ventilated lung.

This technique facilitates viewing of intrathoracic structures,
thereby providing optimal surgical conditions, since adequate
pulmonary exposure facilitates resection and reduces surgical
time.
Physiology of OLV
Upright position
Lateral decubitus position

Effects on ventilation in LDP in awake
spontaneously breathing patient

The distribution of ventilation in the patient in the
LDP when awake (A) and when anesthetized (B).
Closed-chested anesthetized condition with open-
chested anesthetized and paralyzed condition.
Absolute indications of OLV
Isolation of one lung from the other to avoid spillage/
contamination
Infection (bronchietasis, lung abscess)
Massive haemorrhage
To control the distribution of ventilation
BPF
BPCF
Giant unilateral lung cyst or bullae
Surgical procedures on major conducting airways
Tracheo-bronchial tree disruption
Life threatening hypoxemia due to u/l lung disease
Unilateral Bronchopul lavage: Pulmonary alveolar
protenosis
To facilitae surgical exposure: VATS

Relative indications of OLV
To facilitate surgical exposure: High priority
Thoracic aortic aneurysm
Pneumonectomy
Upper lobectomy
Mediastinal exposure
To facilitate surgical exposure: Low priority
Esophageal resection.
Middle & lower lobectomy & segmental resection.
Procedures on thoracic spine.

Severe hypoxemia d/t unilateral lung disease.


Right mainstem bronchus is shorter, straighter and has a
larger diameter than the left.
It takes off from trachea at an angle of 25 in adults vs 45
on the left.
Right upper lobe bronchus takes off very close to the origin of
the right mainstem bronchus.

It is easier to intubate the right bronchus but high
likelihood of obstructing the right upper lobe orifice.
TECHNIQUES OF LUNG SEPERATION
Lung isolation can be achieved by 3 methods:

Double Lumen Endo-tracheal Tube ( DLT)
The DLT is a bifurcated tube with both an endotracheal and
an endobronchial lumen and can be used to achieve
isolation of either the right or the left lung

DLT is the most commonly employed technique

DOUBLE LUMEN TUBES
A DLT is essentially two single-
lumen tubes bonded together and
designated either as right- or left-
sided, depending on which
mainstem bronchus the tube is
designed to fit.
The tracheal lumen is designed to
terminate above the carina.
The distal portion of the bronchial
lumen is angled to fit into the
appropriate mainstem bronchus.

ROBERTSHAW DLT

Disposable DLTs are supplied in
sterile packages, which include a stylet,
connectors, and suction catheter(s).
DOUBLE-LUMEN TUBE: tracheal colourless low-pressure cuff
with colourless pilot balloon and blue pilot balloon, valves for
Luer and Luer-lock syringe tips, continues X-ray marker and
addition cuff markers.
SUCTION CATHETER: Graduated,transparent, siliconized;
plastics suction catheter, with suction control.
Two angled connecting pieces with standard connector &
double sealing cap.
Plastic Y-connector : The connector allows both lumens to
attach to a breathing system at the same time.
STYLET


Essential features and parts of left-sided
and right-sided double-lumen
endotracheal tubes.
Sizes
Both sided DLTs are available in sizes 41, 39,37,35 FR .

32,28 and 26 FR are available as only left sided DLT.

DLT size correlates with height and weight.


Height and DLT sizes
Short height patients
(46 to 5 5 )

35 &37 FR

medium height
patients (5 5 to 5
10)

37 &39 FR
Tall height patients (5
11 to 6 4 )

39 &41 FR

Age and DLT sizes
8-10 yrs 26
10-12 yrs 26,28
12-14 yrs 32
14-16 yrs 35
Comparative Diameters of Single- and
Double-Lumen Tubes
SINGLE LUMEN
TUBES
DOUBLE LUMEN TUBES
ID (mm) ED (mm) French
size
ED (mm) Bronchial
ID (mm)
*FOB size
(mm)
6.5 8.9 26 8.7 3.2 2.4
7.0 9.5 28 9.3 3.4 2.4
8.0 10.8 32 10.7 3.5 2.4
8.5 11.4 35 11.7 4.3 >3.5
9.0 12.1 37 12.3 4.5 >3.5
9.5 12.8 39 13 4.9 >3.5
10.0 13.5 41 13.7 5.4 >3.5
*The max diameter of FOB that will pass through both lumens of a given size
of DLT.
The french scale is the external diameter of the tracheal scale X 3.


Preparing the Double-lumen Tube

The tracheal and bronchial cuffs should be inflated and
checked for leaks and symmetrical cuff inflation
Make certain that each inflation tube is associated with
the proper cuff.
The cuffs and stylet should be lubricated with a water-
soluble lubricant and the stylet placed inside the
bronchial lumen.
The connector should be assembled so that it can be
quickly fitted to the tube and breathing system after
intubation.

INSERTION
Two techniques are used .

1. Blind technique
2. Fibreoptic guided under direct vision

BLIND METHOD:

The DLT is advanced through the larynx with the angled tip directed
anteriorly.

After the bronchial cuff has passed the cords, the tube is turned 90 degrees
so that the bronchial portion points toward the appropriate bronchus.

Leaving the stylet in place for the entire intubation procedure rather than
removing it once the bronchial cuff has passed the vocal cords may result in
more rapid and accurate placement . However, some recommend that the
stylet be removed just after the tube passes the vocal cords to prevent
trauma.
CONFIRMING DLT POSITION
Position should be checked after insertion, after repositioning
the patient, and before beginning one-lung ventilation, as
these tubes often move during patient positioning or surgical
manipulations.
The most frequent DLT movement is during lateral decubitus
positioning.
While movement is usually outward, distal migration may also
occur.

METHODS
Auscultation and clamping
Flexible fibreoptic bronchoscope
Chest x-ray
Broncho spirometery
Auscultatory method for left DLT
Auscultatory method for left DLT
Only tracheal
cuff inflated
Tracheal lumen connected to
breathing system
On auscultation B/L Air entry present
Both cuffs
inflated
Both lumens connected to
breathing system
On auscultation B/L Air entry present
Both cuffs
inflated
Attachment between breathing
system and tracheal lumen
occluded and tracheal lumen
opened to atmosphere
On auscultation breath sounds only
over left lung


Both cuffs
inflated
Attachment B/W breathing
system and bronchial lumen
should be clamped and patient
ventilated through tracheal
lumen. Bronchial lumen opened
to atmosphere
On auscultation breath sounds only over
right lung
Disadvantages of auscultatory
technique
1. Breath sounds conducted between transmitted
from one region of lung to adjacent areas
2. Once patient is cleaned and drapped chest is
no longer available for auscultation
3. Presence of U/L or B/L lung disease may
obscure the auscultation finding
4. Slight malpositioned tubes cannot be
diagnosed with this method.

FLEXIBLE FIBREOPTIC BRONCHOSCOPY

Auscultation alone is unreliable for confirmation of proper DLT
placement.
Flexible endoscopy is the most accurate method for determining DLT
position.

During bronchoscopy, the tracheal
cartilaginous rings are anterior and
the tracheal membrane is posterior.
Therefore, right versus left can be
discerned by the relationship of the
mainstem bronchi to the anterior
cartilaginous ring and the posterior
membrane.
FLEXIBLE FIBREOPTIC BRONCHOSCOPY
Auscultation alone is unreliable
for confirmation of proper DLT
placement.
Fiberoptic bronchoscopy is
performed first through the
tracheal lumen to ensure that the
endobronchial portion of the DLT
is in the left bronchus and that
there is no bronchial cuff
herniation over the carina after
inflation.
The blue endobronchial cuff
ideally should be seen approx
5 mm below the tracheal carina
in the left bronchus.

FLEXIBLE FIBREOPTIC BRONCHOSCOPY
It is crucial to identify the takeoff of the right upper lobe
bronchus through the tracheal view.

Going inside this right upper lobe with the bronchoscope
should reveal three orifices (apical, anterior, and
posterior). This is the only structure in the
tracheobronchial tree that has three orifices.

In the supine patient the takeoff of the right upper lobe is
normally on the lateral wall of the right mainstem
bronchus at the 3- to 4-oclock position in relation to the
main carina

Fiberoptic bronchoscopic examination of a Mallinckrodt left-sided DLT.
A, The edge of the endobronchial cuff around the entrance of the left mainstem
bronchus when the bronchoscope is passed through the tracheal lumen. A white
line marker is seen above the tracheal carina.
B, Clear view of the bronchial bifurcation (left upper and left lower bronchi) when
the left-sided DLT is in the optimal position and the fiberoptic bronchoscope is
being advanced through the endobronchial lumen.
C, Clear view of the right upper lobe bronchus and its three orifices: apical,
anterior, and posterior segments
The view from the distal bronchial lumen of a well-positioned left-sided DLT.
Both the orifices of the left upper lobe (LUL) and left lower lobe (LLL) can be
identified.
Note the longitudinal elastic bundles (LEB, arrow). These extend down the
posterior membranous walls of the trachea and mainstem bronchi. They are
useful landmarks to orient the bronchoscopist to anteroposterior directions.
In the left mainstem bronchus they extend into the left lower lobe and are a
useful landmark to distinguish the lower from the upper lobe.
Looking down the tracheal lumen, the bronchial cuff's upper surface should be seen
below the carina in the right mainstem bronchus. The fiberscope is then placed in the
bronchial lumen. The right middle lower lobe bronchial carina should be seen below
the end of the tube. The endoscopist should be able to look into the right upper lobe
orifice by flexing the tip of the fiberscope superiorly.
RIGHT-SIDED TUBES
Abnormally high takeoff of the right upper lobe bronchus (RUL,
arrow) at the level of the main carina. A right double-lumen tube in
this patient would block the RUL orifice.
Single lumen Endo-Bronchial tubes (SLT)

use either a SLT or endobronchial tube that is advanced into
the contralateral mainstem bronchus, protecting this lung
while allowing collapse of the lung on the side of surgery.

This technique is rarely used today in adult practice (except
in some cases of difficult airways, emergencies, or after a
pneumonectomy), owing to the limited access to the
nonventilated lung and the difficulty in positioning a standard
SLT in the bronchus.

This technique is still used when needed in infants and small
children: an uncuffed uncut pediatric size endotracheal is
advanced into the mainstem bronchus under direct guidance
with an infant bronchoscope.

Bronchial blockers

The second method involves blockade of a mainstem
bronchus to allow lung collapse distal to the occlusion.
These bronchial blockers can be used with a standard
endotracheal tube or contained within a separate
channel inside a modified SLT such as the Univent tube.

Pre-operative evaluation of thoracic surgery
patient
Assessment of Respiratory Function
Respiratory Mechanics:

Many tests of respiratory mechanics and volumes show correlation with post-
thoracotomy outcome:
forced expiratory volume in 1 second (FEV
1
),
forced vital capacity (FVC),
maximal voluntary ventilation (MVV),
residual volume/total lung capacity ratio (RV/TLC) etc.

Most valid single test for post-thoracotomy respiratory complications is the predicted
postoperative FEV
1
(ppoFEV
1
%), which is calculated as follows:

ppoFEV
1
%= preoperative FEV
1
% * (1- % functional lung tissue removed/100)
One method of estimating the percent of functional lung tissue
is based on a calculation of the number of functioning
subsegments of the lung removed. Patients with a ppoFEV
1
:

> 40% are at low risk for post resection respiratory
complications.
< 40% (Increased risk although not all patients in this subgroup
develop respiratory complications), and
<30% are at high risk.

Lung Parenchymal Function
The most useful test of the gas exchange capacity of the lung is the
diffusing capacity for carbon monoxide (DLCO). The DLCO correlates
with the total functioning surface area of the alveolar-capillary
interface. This simple noninvasive test, which is included with
spirometry and plethysmography by most pulmonary function
laboratories, is a useful predictor of perioperative mortality but not
long-term survival. The corrected DLCO can be used to calculate a
postresection (ppo) value using the same calculation as for the FEV
1
.
A ppoDLCO less than 40% predicted correlates with both increased
respiratory and cardiac complications and is, to a large degree,
independent of the FEV
1
.

Patients with a preoperative FEV
1
or DLCO less than 20% had an
unacceptably high perioperative mortality rate.
Cardiopulmonary Interaction
The final and perhaps most important assessment of respiratory function is an
assessment of the cardiopulmonary interaction. Formal laboratory exercise
testing is currently the gold standard for assessment of cardiopulmonary
function, and the maximal oxygen consumption (VO
2max
) is the most useful
predictor of post-thoracotomy outcome. The risk of morbidity and mortality is
unacceptably high if the preoperative VO
2max
is less than 15 mL/kg/min.
20 steps at 6 in/step- ONE FLIGHT
The ability to climb five flights correlates with a VO
2max
greater than 20 mL/kg/min,
and climbing two flights corresponds to a VO
2max
of 12 mL/kg/min. A patient
unable to climb two flights is at extremely high risk.
A 6MWT distance of less than 2000 ft (610 m) correlates to a VO
2max
less than
15 mL/kg/min and also correlates with a fall in oximetry (SpO
2
) during exercise.
Patients with a decrease of SpO
2
greater than 4% during exercise (stair climbing
two or three flights or equivalent) are at increased risk for morbidity and mortality.
Ventilation-Perfusion Scintigraphy

Split-Lung Function Studies
A variety of methods have been described to try and
simulate the postoperative respiratory situation by
unilateral exclusion of a lung or lobe with an
endobronchial tube/blocker or by pulmonary artery
balloon occlusion of a lung or lobe artery, or by both.
These tests have not shown sufficient predictive validity
for universal adoption in lung resection patients.
For the present, split-lung function studies have
been replaced in most centers by a combination
assessment involving, spirometry, DLCO, exercise
tolerance, and V/Q scanning.
Concomitant Medical Conditions
Cardiovascular Disease
Cardiac complications represent the second most common
cause of perioperative morbidity and mortality in the
thoracic surgical population.
Ischemia-The overall documented incidence of post-
thoracotomy ischemia is 5% and peaks on days 2 to 3
postoperatively.
Arrhythmia- incidence is 30% to 50% of patients in the first week
postoperatively when Holter monitoring is used.
[19]
Of these arrhythmias,
60% to 70% are atrial fibrillation. Several factors correlate with an increased
incidence of arrhythmias: extent of lung resection (pneumonectomy, 60%,
versus lobectomy, 40%, versus nonresection thoracotomy, 30%)
intrapericardial dissection, intraoperative blood loss, and age of the patient.
Age
Renal Dysfunction




Anesthetic Considerations in Lung Cancer
Patients (the 4 Ms)

Mass effects: Obstructive pneumonia, lung abscess,
superior vena cava syndrome, tracheobronchial
distortion, Pancoast's syndrome, recurrent laryngeal
nerve or phrenic nerve paresis, chest wall or mediastinal
extension.
Metabolic effects: Lambert-Eaton syndrome,
hypercalcemia, hyponatremia, Cushing's syndrome.
Metastases: particularly to brain, bone, liver, and
adrenal.
Medications: chemotherapy agents, pulmonary toxicity
(bleomycin, mitomycin C), cardiac toxicity (doxorubicin),
renal toxicity (cisplatin).


Preoperative medication
Avoid inadvertent withdrawal of those drugs that are taken for
concurrent medical conditions (e.g., bronchodilators,
antihypertensives, -blockers).
For some types of thoracic surgery, such as esophageal reflux
surgery, oral antacid and H
2
-blockers or proton-pump inhibitors are
routinely ordered preoperatively.
Mild sedation such as an intravenous short-acting benzodiazepine is
often given immediately before placement of invasive monitoring
lines and catheters.
In patients with copious secretions, an antisialagogue (e.g.,
glycopyrrolate) is useful to facilitate fiberoptic bronchoscopy for
positioning of a double-lumen tube (DLT) or bronchial blocker.
It is a common practice to use short-term intravenous antibacterial
prophylaxis such as a cephalosporin in thoracic surgical patients.



Factors That Correlate with an Increased
Risk of Desaturation during One-Lung
Ventilation

High percentage of ventilation or perfusion to the
operative lung on preoperative V/Q scan
Poor PaO
2
during two-lung ventilation, particularly in
the lateral position intraoperatively.
Right-sided thoracotomy.
Normal preoperative spirometry (FEV
1
or FVC) or
restrictive lung disease.
Supine position during one-lung ventilation.
Intraoperative Complications That Occur with
Increased Frequency during Thoracotomy
COMPLICATION ETIOLOGY
Hypoxemia Intrapulmonary shunt during one-lung
ventilation
Sudden severe hypotension Surgical compression of the heart or
great vessels
Sudden changes in ventilating
pressure or volume
Movement of endobronchial
tube/blocker, air leak
Arrythmia Direct mechanical irritation of the
heart
Bronchospasm Direct airway stimulation, increased
frequency of reactive airways disease
Massive Haemorrhage Surgical blood loss from great vessels
or inflamed pleura
Hypothermia Heat loss from the open hemithorax
INTRA-OPERATIVE MONITORING
Majority of these operations are major procedures of
moderate duration (2-4 hours) and performed in the lateral
position with the hemithorax open.
So, consideration for monitoring and maintenance of body
temperature and fluid volume should be given to all of these
cases.
Monitors will initially be placed in the supine position and
have to be rechecked and often repositioned after the
patient is turned.

It is difficult to add additional monitoring, particularly
invasive vascular monitoring, after the case is started if
complications arise.

Intra-operative monitoring
ROUTINE MONITORING


NIBP
5 Lead ECG
Pulse oximetery
Et CO
Temperature
Urine output

INVASIVE HEMODYNAMIC
MONITORING

CVP
ARTERIAL LINE
PULMONARY ARTERY
CATHETARS
FOB
Continuous spirometry
TEE

Anesthetic Management
Positioning
The majority of thoracic procedures are performed with the patient in the
lateral position, most often the lateral decubitus position.

Monitors will be placed and anesthesia will usually be induced with the
patient in the supine position and the anesthetized patient will then be
repositioned for surgery.

Because of the loss of venous vascular tone in the anesthetized patient it
is not uncommon to see hypotension on turning the patient to or from the
lateral position.

All lines and monitors will have to be secured during position change and
their function reassessed after repositioning.
Neurovascular Injuries Specific to the
Lateral Position: Routine Head-to-Toe
Survey


1. Dependent eye
2. Dependent ear pinna
3. Cervical spine in line with thoracic spine
4. Dependent arm: a. Brachial plexus b. Circulation
5. Nondependent arm : a. Brachial plexus b. Circulation
6. Dependent and nondependent suprascapular nerves
7. Nondependent leg: sciatic nerve
8. Dependent leg: a. Peroneal nerve b. Circulation
Fluid Management
Total positive fluid balance in the first 24-hour perioperative
period should not exceed 20 mL/kg.

For an average adult patient, crystalloid administration should
be limited to < 3 L in the first 24 hours.

There should be no fluid administration for third space fluid
losses during pulmonary resection.

Urine output > 0.5 mL/kg/hr is unnecessary.

If increased tissue perfusion is needed postoperatively, it is
preferable to use invasive monitoring and inotropes rather
than to cause fluid overload.
Maintenance of body temperature :

Heat loss from the open hemithorax.

HPV is inhibited during hypothermia.

Increasing the ambient room temperature, fluid
warmers, and the use of lower- or upper-body forced-
air patient warmers are the best methods to prevent
inadvertent intraoperative hypothermia.

Prevention of Bronchospasm

Because of the high incidence of coexisting reactive airways disease in
these pts, use an anesthetic technique that decreases bronchial
irritability.

This is particularly important because the added airway manipulation
caused by placement of a DLT is a potent trigger for
bronchoconstriction.

Avoid manipulation of the airway in a lightly anesthetized patient, use
bronchodilating anesthetics, and avoid drugs that release histamine.

For intravenous induction : propofol or ketamine

For maintenance of anesthesia, propofol and/or volatile anaesthetics .
Sevoflurane may be the most potent bronchodilator of the volatile
anesthetics.

Nitrous Oxide

Nitrous oxide/oxygen (N
2
O/O
2
) mixtures are more prone
to cause atelectasis in poorly ventilated lung regions
than oxygen by itself.

Although N
2
O is relatively insoluble compared with other
volatile anesthetics, it is more soluble than atmospheric
gases (nitrogen, oxygen, argon).

The rate of uptake of an N
2
O/O
2
mixture from an
unventilated lung exceeds that of pure oxygen.

Maximal uptake is with a mixture of N
2
O/O
2
with an FIO
2

of 0.4 - 0.5.



The use of N
2
O/O
2
mixtures is associated with a higher
incidence of post-thoracotomy radiographic atelectasis
(51%) in the dependent lung than when air/oxygen
mixtures are used (24%).

NO also tends to inc PAP in patients who have
pulmonary hypertension, N
2
O inhibits HPV, and N
2
O is
contraindicated in patients with blebs or bullae.


N
2
O is usually avoided during thoracic anesthesia.

Management of one lung ventilation
HYPOXEMIA
INCIDENCE

Hypoxia used to be the major concern during OLA.
Earlier reports: incidence of 40-50%

Over the years the incidence has been declining. In 1993,
incidence of hypoxia (SpO < 90%) was quoted to be 9%.. By
2003, reported incidence was down to 1%.



Improvements in anesthetic technique including

improved lung isolation,
confirmation of lung isolation by FOB, and
use of anaesthetic agents with less effect on HPV are being
credited for decreased incidence of hypoxemia.

HYPOXIC PULMONARY VASOCONSTRICTION
Oxygen sensing mechanisms are active throughout the
human body (carotid body, placenta, ductus arteriosus,
pulmonary arteries).

HPV of the pulmonary arterial bed is one such
mechanism.

Alveolar hypoxia, whether caused by a low FIO
2
,
hypoventilation, or atelectasis, causes pulmonary
vasoconstriction. The phenomenon is called hypoxic
pulmonary vasoconstriction (HPV).
The selective increase of vascular resistance in the
hypoxic lung diverts blood away from the hypoxic lung to
the better ventilated normoxic lung.

The diversion of blood flow decreases the amount of
shunt flow that can occur throughout the hypoxic lung.

Therefore, the regional HPV response is an auto
regulatory mechanism to prevent ventilation/perfusion
mismatch and improve arterial oxygenation

HYPOXIC PULMONARY VASOCONSTRICTION
MECHANISM:
Low partial pressure of O results in inhibition of K currents,
membrane depolarisation and opening of L-type Ca channels
s.m contraction primarily in small resistance pulmonary
arteries

STIMULUS:

The predominant stimulus is alveolar oxygen partial pressure
(P
A
O).
HPV is active in the physiological range (P
A
O
2
40-100 mm Hg)
& propotional to the severity of hypoxia

The mixed venous oxygen partial pressure (P
V
O
2
)
HPV is max when PvO is normal.
Low PvO(e.g low CO) lowers the P
A
O in the ventilated lung
(HPV occurs in ventilated lung).
High PvO(e.g sepsis) inc P
A
O in the nonventilated lung (HPV is
dec in non ventilated lung)
Stimulus oxygen partial pressure (PsO): defined as if the sensor
were at a discrete site in the precapillary arteriole influenced by
the alveolar and mixed venous oxygen tensions.
PsO = P
V
O
2
0.39
X P
A
O
2
0.61


PaCO: HYPOCARBIA INHIBITS HPV.



HYPOXIC PULMONARY VASOCONSTRICTION
MAGNITUDE:

HPV is thought to be able to decrease the blood flow to
the nonventilated lung by 50%.


Consequently, the nondependent lung should be able to
reduce its blood flow from 40% to 20% of total blood
flow, the nondependent/dependent lung blood flow ratio
during single-lung ventilation should be 20% : 80%.




ONSET:

HPV in humans has a rapid onset over the first 30
minutes and then a slower increase to a maximal
response at approximately 2 hours.

HPV is a reflex that has a preconditioning effect, and the
response to a second hypoxic challenge will be greater
than to the first challenge.
Poor PaO
2
during TLV: The most important predictor of PaO
2
during
OLV is the PaO
2
during TLV, specifically the intraoperative PaO
2

during TLV in the lateral position before OLV. PaO should be
measured by ABG before OLV and 20 min after start of OLV.

Preoperative V/Q scan :If the operative lung has little perfusion
preoperatively due to unilateral disease, the patient is unlikely to
desaturate during OLV.

Side of thoracotomy: Patients having right-sided thoracotomies tend to
have a larger shunt and lower PaO
2
during OLV because the right lung
is larger and normally 10% better perused than the left. The overall
mean PaO
2
difference between left and right thoracotomies during
stable OLV is approximately 100 mm Hg.

TREATMENT OF HYPOXEMIA
During OLV fall in arterial oxygenation reaches its peak
20 to 30 min after the initiation of OLV; then the
saturation will stabilize or may rise slightly as HPV
increases over the next 2 hours.

A majority of patients who desaturate do so quickly and
within the first 10 minutes of OLV.

Hypoxemia during OLV responds readily to treatment in
the vast majority of cases.

Treatment of hypoxemia

Mild hypoxemia (90-95%) & Gradual desaturation:

1. Ensure that delivered FIO
2
is 1.0.

2. Check position of double-lumen tube or blocker with fiberoptic
bronchoscopy.

3. Ensure that cardiac output is optimal; Decrease volatile anesthetics to < 1
MAC

4. Apply a recruitment maneuver to the ventilated lung.

5. Apply PEEP 5 cm H
2
O to the ventilated lung (except in patients with
emphysema).

6. Apply CPAP 1-2 cm H
2
O to the nonventilated lung (apply a recruitment
maneuver to this lung immediately before CPAP).


7. Intermittent reinflation of the nonventilated lung

8. Partial ventilation techniques of the nonventilated
lung:
a. Oxygen insufflation
b. High-frequency ventilation
c. Lobar collapse (using a bronchial blocker)

9. Ensure adequate oxygen carrying capacity
(hemoglobin)

10. Mechanical restriction of the blood flow to the
nonventilated lung.
Severe (<<90%) or refractory hypoxemia:
1. Resume two-lung ventilation (if possible).
2. If not possible consider
1. Pulmonary artery clamp on operative side
during pneumonectomy, transplant.
2. Inhaled NO(20 ppm) and infusion of
almitrine/Phenylepherine
3. Extracorporeal support during lung
transplantation


PEEP to ventilated lung

Apply PEEP to the ventilated lung.
It is necessary to perform a recruitment maneuver before applying PEEP to
get the maximal benefit .
PEEP will raise the end-expiratory volume of the ventilated lung toward the
FRC in patients with normal lung mechanics and in those with increased
elastic recoil due to restrictive disease.
PEEP will increase the end-expiratory lung volume of patients with
significant levels of auto-PEEP (e.g., emphysema patients).
Unlike CPAP, application of PEEP does not require reinflation of the
nonventilated lung and interruption of surgery.
PEEP has been shown to be as effective for increasing PaO
2
levels during
OLV in patients with normal lung function as CPAP . For patients with
normal pulmonary function it is logical to routinely apply a recruitment
maneuver and PEEP from the start of OLV.

CPAP to Non ventilated lung

CPAP to the nonventilated lung is the most useful ventilatory
manipulation in patients with COPD and the next line of therapy
after application of PEEP in patients with normal pulmonary
function.
CPAP with 100% O maintains the patency of the operated
alveoli so the unsaturated mixed venous blood perfusing the
lung becomes oxygenated.

CPAP must be applied to a fully inflated (recruited) lung to be
effective.

Initially relatively high pressures are required when applying the
CPAP to open the atelectic alveoli.
The opening pressure of atelectatic lung regions is
greater than 20 cm H
2
O, and these units will not be
recruited by simple application of CPAP levels of 5 to
10 cm H
2
O.

When CPAP is applied to a fully inflated lung, levels
of CPAP as low as 1 to 2 cm H
2
O can be used.

Levels of 5 to 10 cm H
2
O CPAP applied to a fully
recruited lung result in a large-volume lung that impedes
surgery.




Because surgical exposure is the most common indication for
OLV, it is preferable to use lower levels of CPAP that, result in
a nonventilated lung that is one third to one half of its resting
FRC volume and during open thoracotomy does not interfere
with surgical access into the operative hemithorax.


CPAP levels less than 10 cm H
2
O do not interfere with
hemodynamics.

The beneficial effects of low levels of CPAP are primarily
due to oxygen uptake from the nonventilated lung and
not due to blood flow diversion to the ventilated lung.

CPAP is most effective when FIO
2
1.0

CPAP is effective only when there is no major
disruptions of the airway because a nonintact bronchus
will not allow distending pressures to be maintained.



CPAP is therefore not useful in BPF, during sleeve resection,
massive pulmonary haemorrhage or BPL.


Any airway obstruction by blood, mucus or tumour will not
allow the airway pressures to reach the alveoli.


CPAP is not normally used during VATS (compromise surgical
exposure)


CPAP can be applied with either a DLT or through the
suction channel of a bronchial blocker.

Anesthetic systems to apply CPAP :. Essentially all that
is required is a CPAP (or PEEP) valve and an oxygen
source. Ideally, the circuit should permit variation of the
CPAP level and include a reservoir bag to allow easy
reinflation of the nonventilated lung and a manometer to
measure the actual CPAP supplied.

Suggested ventilation parameters for OLV
PARAMETER SUGGESTED
GUIDELINE/EXCEPTIONS
TIDAL VOLUME 5-6 ml/kg Maintain :
peak airway presure < 35 cm HO
Plateau pressure < 25 cm HO
PEEP 5 cm HO Patients with COPD: no external
PEEP
RR 12 breaths/min Maintain normal PaCO. PaETCO
will usually inc 1-3 mm during OLV
MODE VCV or PCV PCV for patients at risk of lung
injury(e.g bullae, pneumonectomy,
post lung transplant)
VENTILATION STRATERGIES
F
I
O
2:

Routine mangement of OLV has long included FiO of 1.0
because:
High rate of desaturation events in the past.
High FiO causes vasodilatation in the dependent
lung

Recent concerns:
Oxygen toxicity involves ischemia reperfusion injury
Absorption atelectasis & increase in shunt

Lung reexpansion should occur at a lower FiO as
hypoxemic reperfusion has been shown to attenuate
reperfusion syndrome.

At the initiation of OLV, FiO of 0.8 may be appropriate
but after 15-20 min, FiO should be decreased to the
minimum that is required to mainatain saturation above
90%.

Studies have shown that FiO as low as 0.4 may provide
adequate oxygenation during OLV in lateral decubitus
position.

VENTILATION STRATERGIES
MINUTE VENTILATION & PERMISSIVE HYPERCAPNIA

Permissive hypercapnia has been the hallmark of the
management of ALI/ARDS in critical care settings.

It should become a routine component of OLV
management
Reduced MV allows for a dec in TV & ventilation
pressures, thereby dec mechanical stress and
volutrauma and barotrauma.
Moderate Hypercapnia potentiates HPV.


Assuming a reasonable cardiovascular reserve, Pa CO
levels upto 70 mm Hg are likely to be well tolerated and
clearly benefitial in terms of avoidance of lung injury.

Signifiacant hypercapnia can be detrimental: raised ICP,
pulmonary hypertension, dec myocardial contractility,
dec RBF, release of endogenous catecholamines.

At high levels, CO can be lethal because of excessive
sympathetic stimulation, cardiac arrythmias and arrest.

VENTILATION STRATERGIES
I.E ratio and Respiratory Rate

In severe obstructive disease, an I:E ratio of 1:4 with a
low RR of 6-8 breaths/min allows for maximal expiratory
time, thereby minimizing the risk of auto PEEP and
dynamic hyperinflation.

In restrictive lung disease , equalizing the I:E ratio to 1:1
and dividing the MV by higher RR of 10-15 breaths/min
help to maximize inspiratory time per volume breath,
thereby reducing peak and plateau pressures.
PEAK and PLATEAU PRESSURES :
Application of the full TLV minute volume to a single
lumen of the DLT results in 55% inc in peak airway
pressure and 42% inc in plateau pressure.
With implementation of permissive hypercapnia , P
peak
<
35-40 cm HO and P
plateau
< 25 cm HO is achievable in
most patients.
VENTILATORY MODE:
VCV uses a constant inspired flow (square wave), creating
a progressive inc in airway pressures towards the peak
inspiratory pressure which is reached when full TV is
delieverd

PCV uses a decelerating flow pattern with maximal flow at the beginning of
inspiration until the set pressure is reached, after which flow rapidly
decreases, balancing the decreasing compliance of the expanding lung.

The decelerating flow pattern results in more homogenous distribution of
TV, improving static and dynamic lung compliance because of recruitement
of poorly ventilated lung regions and improve PaO and dead space
ventilation.

The recent availability of anesthesia ventilators with pressure-control modes
has made it possible to use this form of ventilation during thoracic surgery.

PCV has not been shown to improve oxygenation versus volume-controlled
ventilation for most patients, although the peak airway pressures are lower.
There is a report suggesting that pressure-controlled ventilation may lead to
improved oxygenation in COPD patients.


Pressure-controlled ventilation will avoid sudden increases in peak airway
pressures & will be of benefit in patients at increased risk for lung injury
from high volumes or pressures such as after lung transplantation or during
a pneumonectomy.
Post operative Analgesia
There are multiple sensory afferents that transmit
nociceptive stimuli after thoracotomy. These include
the incision (intercostal nerves T4-T6),
chest drains (intercostal nerves T7-T8),
mediastinal pleura (vagus nerve, CN X),
central diaphragmatic pleura (phrenic nerve, C3-C5), and
ipsilateral shoulder (brachial plexus).

There is no one analgesic technique that can block all
these various pain afferents, so analgesia should be
multimodal.
Systemic analgesia
Opioids
NSAIDs
Ketamine
Dexmedetomidine

Local anesthetics/nerve blocks
Intercostal nerve blocks
Intrapleural analgesia
Epidural analgesia
Paravertebral block