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Dr Fazal H Khan,
Department of Anaesthesia, Aga Khan University

Anesthesia management for thoracic surgery has undergone tremendous advancement during the last
century. In the early 1900s most of the thoracic surgery procedures were limited to empyema
drainage procedures (1). Thereafter the requirement for lung separation was identified and techniques
and equipment were evolved which causes isolation of lung.
Management of one lung ventilation has advanced to a stage whereby arterial oxygenation levels are
close to those achieved during one lung ventilation.
This article briefly reviews Preoperative
evaluation and preparation, Monitoring during thoracic anesthesia and Indications and Management of
one lung ventilation.
Preoperative evaluation:
Most of the cases presenting for thoracic surgery have bronchial carcinoma, Mediastinal masses or
esophageal disease. In order to assess patients for thoracic anesthesia it is necessary to have an
understanding of the risks specific to this type of surgery. Respiratory complications are the major
cause of peri-operative morbidity and mortality in thoracic surgery patients.
Most of these patients give history of Cough with sputum, chest pain, dyspnoea, and wheeze. There
is also history of anemia, weight loss, lethargy, and malaise.
Physical examination:
Inspection, palpation, auscultation and percussion assess the overall severity of chronic lung disease
and indicate the presence of consolidation, atelectasis or plural effusion.
Complete Blood Count
White Blood Cell
Sputum gram stain and cultures
BUN and creatinine and urinalysis
Chest x-ray and CT scan.
Pulmonary function testing:
It is generally agreed that when pneumonectomy is being planned, pulmonary function testing should
be proceed in three phases (2). In the first phase total lung function is evaluated by room air blood gas
analysis and doing spirometry and determining lung volumes. Carbon monoxide diffusing capacity
and exercises testing is also indicated. Increased risk is present when
PaCO2 is >45mmHg on room air
FEV1 or MBC or both is<50% of predicted value or
RV is >50% of TLC or any combination of these three conditions
If any of these whole lung pulmonary function values is worse than the stated limits, second phase of
testing is done which evaluates the function of each lung separately. This consists of measurement of
ventilation and perfusion of each lung separately by radioisotope. This combined with spirometry
gives an idea of predicted postoperative FEV1 which should be more than 0.85L. If this is not the
case then temporary balloon occlusion of right or left pulmonary artery is done and an increased in
mean pulmonary artery pressure to greater than 40mmHg, an increased in PaCO 2 of greater than

60mmHg or a decrease in PaO2 to less than 40mmHg or a combination of these three criteria indicates
an inability to tolerate removal of this amount of lung.
Preoperative preparation:
The peri-operative events need to be explained to the patient in particular and they should be explained
about the potential risks and benefits of the post thoracotomy pain management strategies.
Premedication should be light especially in those patients who are prone to develop hypoxia due to
respiratory depression.
The patients undergoing thoracic surgery are prone to develop postoperative respiratory complications
(3, 4). It is therefore advisable to do preoperative preparation efforts following preoperative
evaluation to optimize any preexisting pulmonary disease. All these patients should undergo
following steps before subjecting them to surgery:
1. Stoppage of smoking
2. Airway dilatation
3. Loosening and removing secretions
4. Treatment of infection
5. Measures to increase motivation and education and facilitate postoperative care

Smoking Cessation:
There is a decrease in airway secretion and reactivity and improvement in ciliary function after
several weeks of cessation of smoking (5, 6). It is therefore suggested to stop smoking at least 12 weeks prior to surgery. This reduces airway secretions and reactivity. Even stopping smoking
for 12-48 hours decreases carboxyhaemoglobin levels and shift the oxygen hemoglobin
dissociation curve to the right(7)


Airway dilatation:
Airway dilatation is needed for patients who have hyperactive airways such as smokers (8),
Asthmatics (9), or COPD (10). This airway dilatation is done by use of inhaled 2 agonist.


Loosening and removing secretion:

The thick secretions are usually loosened by adequate hydration using humidifier or ultrasonic
nebulization. The secretions are than removed by postural drainage, coughing and chest
percussion and vibration for 15-20minutes several times a day (11)


Control of infection:
Chest infection if present should be treated by antibiotics according to culture and sensitivity.

Measures to increase motivation and postoperative care:

These include nutrition improvement, weight reduction, psychological preparation, and instructions
about incentive spirometry, chest physiotherapy and postural drainage.
Monitoring During Thoracic Anaesthesia:
The monitoring requirements for patients undergoing thoracic anesthesia depend not only on the type
of surgery but also on the underlying cardiopulmonary status of the patient. The monitoring includes
ECG, NIBP, SaO2, CO2 and anesthetic agent analysis. Invasive blood pressure monitoring is useful
when repeated blood gas analysis may be necessary such as pneumonectomy.
CVP or PA catheters are of limited use intra-operatively as fluid volume shifts are usually not large
and the values recorded may be difficult to interpret due to the effects of the lateral position and lung
collapse. They may be of more use for postoperative fluid management, particularly following
pneumonectomy where it is essential to avoid fluid overload.

Indications for One Lung Ventilation:

The indications for one lung ventilation are usually relative as most thoracic procedures can be
performed with a single lumen endotracheal tube. The absolute indications for one lung ventilation
a. To prevent cross contamination of a non-involved lung from blood or pus
b. To control the distribution of ventilation in cases where there is a major air leaks such as
broncho-pleural fistula, trachea-bronchial trauma or in major airway surgery.
c. To perform bronchopulmonary lavage
The relative indications are subdivided into high and low priority. High priority indications are
procedures such as thoracic aneurysm repair, pneumonectomy and upper lobectomy. Lower priority
indications include middle and lower lobectomy, oesophagectomy, thoracoscopy and thoracic spinal
Management of the lung ventilation
One lung ventilation causes hypoxia in patients undergoing thoracic anaesthesia and as such it is
important to optimally manage dependent lung ventilation.
1. Inspired oxygen concentration :
When starting one lung ventilation the FiO 2 is usually increased to 1.0.
possibilities of pulmonary oxygen toxicity does not occur (12).

The theoretical

Tidal volume
The dependent lung is ventilated with a tidal volume of 8-10ml/kg as larger tidal volume increase
pulmonary vascular resistance (13) and airway pressure and smaller tidal volume causes
Dependent lung PEEP:
It is advisable to use a PEEP of 5mmHg in the dependent lung to improve oxygenation (14)
Respiratory rate:
Respiratory rate is adjusted to keep the PaCO 2 to around 40mmHg. Hypocapnia should be
avoided as it may directly inhibit HPV in the independent lung and may increase the dependent
lung vascular resistance.
If the above mentioned measures fail to improve oxygenation then differential lung management
techniques given below are used
2. Intermittent inflation of the non-dependent lung:
If there is life threatening hypoxia and no measures taken to correct it are working then the nondependent lung is usually inflated intermittently with 100% FiO 2
Dependent lung PEEP:
For the improvement of oxygenation PEEP can be applied to the dependent lung. One drawback
of this is that it may increase pulmonary vascular resistance and diverts the blood away to the nondependent non ventilated lung thereby increasing the shunt and decreasing PaO 2. This strategy
has been found to be helpful in patients who have disease dependent lung whereby application of
PEEP improves oxygenation. Studies therefore have shown either no effect (15) or increase or a
decrease in oxygenation (16) when PEEP is applied selectively to dependent drug.
Non-dependent lung CPAP:
CPAP can be applied to the nondependent non ventilated lung and it causes a significant increase
in oxygenation. In clinical studies (17) the application of 5-10cm H2O CPAP has not interfered
with the performance of surgery but have significantly improved PaO 2 during one lung ventilation

Differential lung PEEP/CPAP:

In this methodology PEEP is applied to the dependent lung and CPAP to the nondependent lung
.Using this strategy blood will receive oxygen irrespective of whether it is going to dependent or
non-dependent lung.

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