One Lung Ventilation

Llalando L. Austin II, MHSc,

AA-C, RRT
Nova Southeastern University
 Objectives
Describe One Lung Ventilation
Understand the methods for securing one lung
ventilation
Learn the indications and contraindications for
each procedure
Understand hypoxic pulmonary vasoconstriction
(HPV)
Understand commonly associated surgical
procedures that require one lung ventilation
Common techniques and supplies for one lung
ventilation
Understand the case setup and patient
preparation for the procedure
Thoracotomy
Thoracotomy with Lung
Deflated
VATS
VATS
VATS
 What is One Lung Ventilation
(OLV)?
It is the intentional collapse of a lung on
the operative side of the patient which
facilitates most thoracic procedures.
Requires much skill of the anesthesia
team
Difficult to place lung isolation equipment
Ability to overcome hypoxic pulmonary
vasoconstriction
Patient population is comparably sicker
 Definition of Terms
Dependent Lung or Down Lung
The lung that is ventilated
Non-dependent Lung or Up Lung
The lung that is collapsed to facilitate
the surgery
Methods of Lung Separation
Bronchial blockers
Single-lumen tracheal tubes w/ a bronchial blocker
(Univent)
Arterial embolectomy catheter (ie Fogarty)
Single-lumen endobronchial tubes
Gordon-Green tube (carinal hook)
Double-lumen endobronchial tubes
Robert-Shaw (R or L), Carlens (R), White (L)
Carlens and White both have carinal hooks
From 35Fr to 41Fr (35, 37, 39, 41)
26Fr smallest size
Used for children as young as 8 years
28Fr and 32Fr used for pediatric patients 10 and older
Double Lumen Tubes
 Patient Monitoring
Considerations
Direct arterial catheterization (a-line)
essential for nearly all thoracic cases
Allows for beat-to-beat blood pressure analysis
Sampling for determination of ABG
Central venous pressure monitoring (central line)
essential for measuring right atrial and right ventricular
pressures
Useful in monitoring:
large volume shifts
hypovolemia
need for vasoactive drugs
Pulmonary artery catheterization
left sided filling pressures, cardiac output
Calculation of derived hemodynamic and respiratory
parameters and clinical use of Starling curve
Most PA catheters (more than 90%) float to and locate in the
right lung due to increased pulmonary blood flow
Create inaccurate reading for R thoracotomies
 Patient Monitoring
Considerations
Oxygenation and Ventilation
Monitoring inspired oxygen
Sampling of arterial blood for ABGs
Pulse oximetry
Transcutaneous oxygen tension
for neonates
Qualitative signs
chest expansion
observation of reservoir bag
auscultation of breath sounds
EtCO2 measurement, capnograph
 Indications for One-Lung
Ventilation
Absolute
Isolation of one lung from another to
prevent spillage or contamination
(infection, massive hemorrhage)
Control of distribution of ventilation
Bronchopleural fistula
Surgical opening of major conducting airway
Unilateral bronchopulmonary lavage
Ex: pulmonary alveolar proteinosis
 Indications for One-Lung
Ventilation
Relative
Surgical exposure- high priority
Thoracic aortic aneurysm
Pneumonectomy
Upper lobectomy
Surgical exposure- lower priority
Middle lobe lobectomies
Esophageal resection
Thoracoscopy
Thoracic spine procedures
Post-removal of totally-occluding chronic
unilateral pulmonary emboli
Double Lumen Endobronchial
Tubes
Double Lumen Endobronchial
Tubes
 Advantages
Relatively easy to place
Allow conversion back and forth from OLV to
two-lung ventilation
Allow suctioning of both lungs individually
Allow CPAP to be applied to the non-
dependent lung
Allow PEEP to be applied to the dependent
lung
Ability to ventilate around scope in the tube
 Disadvantages
Cannot take patient to PACU or the
Unit
Must be changed out for a regular
ETT if post-op ventilation
Correct positioning is dependent on
appropriate size for height of patient
Length of trachea
 DLT Placement
Prepare and check tube
Ensure cuff inflates and deflates
Lubricate tube
Insert tube with distal concave curvature facing
anteriorly
Remove stylet once through the vocal cords
Rotate tube 90 degrees (in direction of desired
lung)
Advancement of tube ceases when resistance is
encountered. Average lip line is 29 2 cm.
*If a carinal hook is present, must watch hook go
through cords to avoid trauma to them.
 DLT Placement
Check for placement by auscultation
Inflate tracheal cuff- expect equal lung ventilation
Clamp the white side (marked "tracheal" for left-sided tube)
and remove cap from the connector
Expect some left sided ventilation through bronchial lumen,
and some air leak past bronchial cuff, which is not yet inflated
Slowly inflate bronchial cuff until minimal or no leak is
heard at uncapped right connector
Go slow- it only requires 1-3 cc of gas and bronchial rupture is
a risk
Remove the clamp and replace the cap on the tracheal side
Check that both lungs are ventilated
Selectively clamp each side, and expect visible chest
movement and audible breath sounds only on the right
when left is clamped, and vice versa
 DLT Placement
Checking tube placement with the fiberoptic
bronchoscope
Several situations exist where auscultation maneuvers are
impossible (patient is prepped and draped), or when they
do not provide reliable information (preexisting lung disease
so that breath sounds are not very audible, or if the tube is
only slightly malpositioned)
The double-lumen tube's precise position can be most
reliably determined with the fiberoptic bronchoscope
In patients with double-lumen tubes whose position seemed
appropriate to auscultations, 48% had some degree of
malposition. So always check position with fiberoptic
After advancing the fiberoptic scope thru the tracheal
tube you should see the bronchial blue balloon in a semi
lunar shape, just peeking out of the bronchus
DLT Placement
Wire-Guided Endobronchial
Blockers
 Advantages
Quickly and precisely navigate the airway
The guide wire loop couples the pediatric fiberoptic
bronchoscope and the wire-guided endobronchial blocker
yet both remain able to move independently of each other and
the pediatric fiberoptic bronchoscope may navigate the airway
independent of its role in carrying the endobronchial blocker
The pediatric bronchoscope acts as a guide, allowing the
endobronchial blocker to be advanced over it into the
correct position
In addition, the wire-guided endobronchial blocker allows
one-lung ventilation with a single-lumen endotracheal tube
Thus, one-lung ventilation is not dependent on installing a
special device in the airway, such as a double-lumen tube or a
Univent endotracheal tube
Allows one-lung ventilation in the critically ill patient in whom
reintubation may be difficult or impossible and in patients with
a known difficult airway requiring fiberoptic intubation with a
conventional endotracheal tube
Unnecessary to convert from a conventional double-lumen
endotracheal tube to a single-lumen tube at the end of surgery
 Disadvantages

Satisfactory bronchial seal and lung separation are sometimes

difficult to achieve
The blocked lung collapses slowly (and sometimes
incompletely)
The balloon may become dislodged during surgery and enter
the trachea proper, causing a complete airway obstruction
In situations of acute increases in airway pressure, the
endobronchial blocker balloon should be immediately deflated and
the blocker re-advanced
It will then re-enter the correct segment (as the tip remains in the
correct bronchus and only the proximal balloon portion has entered
the trachea)
In this case, a pediatric fiberoptic bronchoscope should be re-
introduced into the airway and the balloon re-positioned
In order to prevent barotrauma, the initial balloon inflation volume
should not be exceeded
It is important that the balloon be fully deflated when not in use
and only be re-inflated with the same volume used during
positioning and bronchoscopy.
 Indications for Wire-Guided
Endobronchial Blockers vs. DLT
Critically ill patients
Rapid sequence induction
Known and unknown difficult airway
Postoperative intubation
Small adult and pediatric patients
Obese adults
Wire-Guided Endobronchial
Blockers
Wire-Guided Endobronchial
Blockers
 Wire-Guided Endobronchial
Blockers
Available sizes
Adult 9 Fr
Pediatric 5 Fr
Wire-Guided Endobronchial
Blockers
Wire-Guided Endobronchial
Blockers
Wire-Guided Endobronchial
Blockers
Wire-Guided Endobronchial
Blockers
Fogarty Embolectomy
Catheters
 Fogarty Embolectomy
Catheter
Single-lumen balloon tipped catheter with a removable
stylet
In the parallel fashion, the Fogarty catheter is inserted
prior to intubation
In the co-axial fashion, the Fogarty catheter is placed
through the endotracheal tube
Both techniques require fiberoptic bronchoscopy to
direct the Fogarty catheter into the correct pulmonary
segment
Once the catheter is in place, the balloon is inflated,
sealing the airway
Clinical limitations to the Fogarty technique
Difficult to direct and cannot be coupled to a fiberoptic bronchoscope
No accessory lumen for either removal of gas from the blocked segment or
insufflation of oxygen to reverse hypoxemia
Ventilate w/ 100% O2 prior to balloon inflation to aid in gas removal
Univent Tubes
 Univent Tubes
Endotracheal intubation can be performed in the conventional
manner, just like a single lumen endotracheal tube
One-lung ventilation can be achieved by placement of the blocker
to either the left or right lung, or to lung segments
Insufflation and CPAP can be achieved through the lumen of the
blocker shaft
Blocked lung can be collapsed by aspirating air through the lumen
of the blocker shaft
The blocker can be retracted into its pocket to facilitate post-
operative ventilation
Improved "torque control" bronchial blocker:
- Easier to direct by twisting than previous nylon catheter
- High torque control malleable shaft for smooth intubation
- Flexible blocker shaft with softer open lumen tip
- Latex-free
Comparison of Various Tube
Diameters
 Complications of One Lung
Ventilation
All difficult airway complications
Injury to lips, mouth, teeth
Injury to airway mucosa from stylet
Bronchial Rupture
Decreased saturation
HPV
Inability to isolate lung
Complications - Bronchial
Rupture
 Hypoxic Pulmonary
Vasoconstriction
Hypoxia is a powerful stimulus for
pulmonary vascular constriction
Bodys mechanism to divert blood flow
away from areas of no ventilation to areas
of ventilation
Vasoconstriction that decreases blood flow
from alveoli that are not ventilated to
alveoli that are ventilated
Bodys way to decrease the shunt that was
created by change
Position
V/Q mismatch
 HPV

Bodys compensatory mechanism for

hypoxia
Clinical Notes:
Direct acting vasodilators inhibit HPV response
Volatile agents at higher concentrations inhibit
HPV response
No HPV =
Increases shunt
Decreases PaO2
Management of Hypoxia in One
Lung Ventilation
100% FIO2
10 mL/kg tidal volume
Do not change the tidal volume from 2 lung ventilation
Maintain normocapnia
Maintain correct tube position
Suction both lungs
Apply PEEP to dependant lung
Apply CPAP to non-dependant lung
Re-inflate collapsed lung at various intervals
Extreme cases
Clamp the pulmonary artery to collapsed lung
 Case Setup for DLT & OLV
MSMAID
Preferred blade and handle
Airway Have standard supplies &
assortment of sizes for DLT or other OLV
choice equipment
Fiberoptic cart
Hemostats or clamps to clamp off lumens
of the tube
Suction!!
 References
http://ourworld.cs.com/_ht_a/doschk/onelung.
htm
Finucane and Santora
Morgan and Mikhail
Barash, Cullen, Stoelting