1. University College of Medical Sciences
Principle of thoracic anesthesia with determinants of operability for resection, One lung anesthesia
Dr. Rajesh Kumar
University College of Medical Sciences
& GTB Hospital, Delhi

2. Objectives Indication/contraindication of OLV
Physiological changes of OLV
Lung separation techniques and equipments

3. Introduction
One-lung ventilation, OLV, means separation of the two lungs and each lung functioning independently.
OLV provides:
Protection of healthy lung from infected/bleeding one
Diversion of ventilation from damaged airway or lung
Improved exposure of surgical field
OLV causes:
More manipulation of airway, more damage
Significant physiologic change and easily development of hypoxemia

4. Indication
Absolute
Isolation of one lung from the other to avoid spillage or contamination
Infection
Massive hemorrhage
Control of the distribution of ventilation
Bronchopleural fistula
Bronchopleural cutaneous fistula
Surgical opening of a major conducting airway
giant unilateral lung cyst or bulla
Tracheobronchial tree disruption
Life-threatening hypoxemia due to unilateral lung disease
Unilateral bronchopulmonary lavage

5. Indication (continued)
Relative
Surgical exposure ( high priority)
Thoracic aortic aneurysm
Pneumonectomy
Upper lobectomy
Mediastinal exposure
Thoracoscopy
Surgical exposure (low priority)
Middle and lower lobectomies and subsegmental resections
Esophageal surgery
Thoracic spine procedure
Minimal invasive cardiac surgery (MID-CABG, TMR)
Postcardiopulmonary bypass status after removal of totally occluding chronic unilateral pulmonary emboli
Severe hypoxemia due to unilateral lung disease

6. Physiology of the LDP
Upright position LDP, lateral decubitus position

7. Physiology of LDP
Distribution of ventilation

8. Shunt and OLV Physiological (postpulmonary) shunt
About 2-5% CO,
Accounting for normal A-aD02, mmHg
Including drainages from
Thebesian veins of the heart
The pulmonary bronchial veins
Mediastinal and pleural veins
Transpulmonary shunt increased due to continued perfusion of the atelectatic lung and A-aD02 may increase

9. Two-lung Ventilation and OLV

10. OLV and shunt fraction with and without anesthesia

11. Physiology of OLV
Protective influences in response to the obligatory pulmonary shunt includes the hypoxic pulmonary vasoconstriction, HPV .
HPV, a local response of pulmonary artery smooth muscle, decreases blood flow to the area of lung where a low alveolar oxygen pressure is sensed.

12. HPV
The mechanism of HPV is not completely understood. Vasoactive substances released by hypoxia or hypoxia itself (K+ channel) cause pulmonary artery smooth muscle contraction
HPV is graded and limited, of greatest benefit when 30% to 70% of the lung is made hypoxic.
But effective only when there are normoxic areas of the lung available to receive the diverted blood flow

13. Factors Affecting Regional HPV
HPV is inhibited by: volatile anesthetics (not N20),
vasodilators (NTG, SNP, dobutamine, many ß2-agonist),
increased PVR and hypocapnia
PEEP,
vasoconstrictor drugs (preferentially constrict normoxic lung vessels)

14. Methods of OLV Double-lumen endotracheal tube (DLT)
Single-lumen ET with a built-in bronchial blocker, Univent Tube
Single-lumen ET with an isolated bronchial blocker
Arndt (wire-guided) endobronchial blocker set
Balloon-tipped luminal catheters
Endobronchial intubation with a single-lumen ET

15. DLT
Type:
Carlens, a left-sided + a carinal hook
White, a right-sided Carlens tube
Bryce-Smith, no hook but a slotted cuff/Rt
Robertshaw, most widely used
All have two lumina/cuffs, one terminating in the trachea and the other in the mainstem bronchus
Right-sided or left-sided available
Available size: 41,39, 37, 35,32, 28,26 French (ID=,10.0,9.5,9.0, 8.5, 8.0, 7.0 and 6.5 mm respectively)

17. Schematic diagram depicting passage of the left-sided double-lumen endotracheal tube in a supine patient.
A, The tube is held with the distal curvature concave anteriorly and the proximal curve concave to the right and in a
plane parallel to the floor. The tube is then inserted through the vocal cords until the bronchial cuff passes the vocal
cords. The stylet is then removed. B, The tube is rotated 90 degrees counterclockwise so that the distal curvature is
concave anteriorly and the proximal curvature is concave to the left and in a plane parallel to the floor. C, The tube is
inserted until either mild resistance to further passage is encountered or the end of the common molding of the two
lumens is at the teeth. Both cuffs are then inflated, and both lungs are ventilated. Finally, one side is clamped while the
other side is ventilated and vice versa

18. Method of insertion Blind technique
Caution: DLT should pass without any resistance
Optimal depth of insertion for a left sided DLT is ~ patients height ~ 12 +(patients height/10) cm
Direct vision technique:
uses fiberoptic bronchoscope,
however both methods results in successful placement in approx equal number of patients

19. Confirming position of DLT
Alternately blocking the tracheal and bronchial lumen and checking for the air entry.
With the help of fiberoptic bronchoscopy
Chest –x ray

20. Confirming Position of DLT………

21. Selection of DLT based on adult patient sex and height
Height(cm)
Size(Fr)
Female
<160 (63 inches) 35
>160 37
Male
<170 (67 inches) 39
>170 41

22. Right sided DLT Margin of safety is low :
1. Rt. Upper lobe bronchus is short
2. Rt. u/l bronchus originates at a distance of cm from the carina
Fewer indications
Doughnut shaped cuff
Additional opening for the ventilation of right upper lobe.

23. Indications for a right sided DLT
Distorted anatomy of the entrance of a left main stem bronchus
External or intraluminal tumaour compression
Descending thoracic artery aneurysm
Site of surgery involving the left main stem bronchus
Left lung transplantation
Left sided tracheobronchial disruption
Left sided pneumonectomy
Left sided sleeve resection

24. Left DLT Most commonly used
The bronchial lumen is longer, and a simple round opening and symmetric cuff.
Better margin of safety than Rt DLT
Can be used
Left lung isolation:
clamp bronchial +
ventilate/ tracheal lumen
Right lung isolation:
clamp tracheal +
ventilate/bronchial lumen

25. Univent Tube... Developed by Dr. Inoue
Movable blocker shaft in external lumen of a single- lumen ET tube
Easier to insert and properly position than DLT (diff airway, C-s injury, pedi or critical pts)
No need to change the tube for postop ventilation
Selective blockade of some lobes of the lung
Suction and delivery CPAP to the blocked lung

26. Arndt Endobronchial Blocker set
Invented by Dr. Arndt, an anesthesiologist
Ideal for diff intubation, pre-existing ETT and postop ventilation needed
Requires ETT > or = 8.0 mm
Similar problems as Univent
Inability to suction or ventilate the blocked lung

27. Other Methods of OLV Single-lumen ETT with a balloon-tipped catheter
Including Fogarty embolectomy catheter, Magill or Foley, and Swan-Ganz catheter (children < 10 kg)
Not reliable and may be more time-consuming
Inability to suction or ventilate the blocked lung
Endobronchial intubation of single-lumen ETT
The easiest and quickest way of separating one lung from the other bleeding one, esp. from left lung
More often used for pedi patients
More likely to cause serious hypoxemia or severe bronchial damage

28. Comparision of lung isolationtechniques
OPTIONS
ADVANTAGES
DISADVANTAGES
Double lumen tube
Direct laryngoscopy
Via tube exchanger
Fibre optically
Quickest to place successfully
Reposition rarely required
Bronchoscopy to isolated lung
Suction to isolated lung
CPAP easily added
Can alternate OLV to either lung easily
Placement possible without bronchoscopy
Size selection more difficult
Difficult to place in difficult or in abnormal trachea
Not optimal for postop ventilation
Potential laryngeal trauma
Potential bronchial trauma
Bonchial blocker
Arndt
Cohen
fugi
Size selection rarely an issue
Easily added to regular ETT
Allows ventilation during placement
Easier placement in DA and children
Postoperative two-lung ventilation easy
Selective lobar lung isolation possible
CPAP to isolated lung possible
More time needed
Repositioning needed more often
Bronchoscope essential
nonoptimal Rt lung isolation
Bronchoscopy to isolated lung impossible
Minimal suction to isolated lung
Difficult to alternate OLV to either lung

29. Options
Advantages
Disadvantages
Univent tube
Same as BBs
Less repositioning compared with BBs
ETT portion has higher airflow resistance than regular ETT
ETT portion has larger diameter than regular ETT
Endobronchial tube
Like regular ETTs , easier placement in patients with DA
Longer than regular ETT
Short cuff designed for lung isolation
Bronchoscopy neseccary or placement
Does nat allow for bronchoscopy, suctioning or CPAP to isolated lung
Difficult right lung OLV
Endotracheal tube (ETT) advanced into bronchus
Easier placement in patients with difficult airways
Does not allow for bronchoscopy , suctioning or CPAP to isolated lung
Cuff not designed for isolated lung
Extremely difficult right OLV

30. Difficult airway and OLV
5%-8% of patients with primary lung carcinoma have a carcinoma of the pharynx as well
Many of these patients have previous radiation exposure or previous surgery done.
They might have distorted anatomy at or beyond carina. eg…descending thoracic aortic aneurysm, intraluminal or extraluminal tumour
Can be detected by chest-x ray and CT scan

31. Approach to difficult airway
A flexible fiberoptic bronchoscopy is essential
Primary goal is to establish an airway with the help of a SLT (awake or anesthetised) f/b the insertion of bronchial blockers.
An alternative is to insert a SLT and then insert DLT with the help of a tube exchanger

32. In a tracheostomised patient
Insertion of a SLT f/b an independent bronchial blocker
Use of a disposable cuffed tracheostomy cannula with an independent bb passed coaxially
Replacement of the tracheostomy canula with a short DLT such as NARUKE DLT
Placement of a small DLT through tracheostomy stoma
Oral access to the airway for standard placement of a DLT or blocker

33. objectives Preanesthetic assessment Anesthetic management
Postoperative management

34. Fundamentals to anesthetic management of thoracic procedures
Lung isolation to facilitate surgical access
Management of one lung anesthesia

35. Preoperative evaluation done in two disjoint phases:
The initial clinical assessment
The final assessment on the day of admission

36. Primary function of PAC
To identify patients at elevated risk,
To stratify perioperative management and focus resources
Feasibility of lung resection in a high risk patient

37. Perioperative complications (overall mortality 3-4%)
incidence
Respiratory
(atelectasis, pneumonia,respiratory failure)
15-20 %
Cardiovascular
(arrhythmia and ischemia)
10-15%

38. Assessment of respiratory functions
History
Detailed history regarding the quality of life preoperatively
Respiratory mechanics
All patients should have a baseline spirometry:
FEV1, FVC, MVV, RV/TLC
FEV1% ( % of predicted volume corrected for age,gender and height).
ppo FEV1 % ( predicted post operative FEV1 )
Calculated as ppoFEV1 % = preop FEV1 % (1-% functional lung tissue removed/100)
ppo FEV1 % > 40%  low risk
ppoFEV1 % <40% major complication
ppo FEV1 % <30% high risk

40. Assessment of respiratory functions continued……………
Lung parenchymal tests
ABG parameter : PaO2 < 60mm Hg
PaCO2 >45 mmHg
( warning indicator of increased risk, however resections are done with these figures nowadays)
Most useful test : DLCO
ppo DLco can be calculated like ppo FEV1
ppo DLco < 40 % increases respiratory and cardiac complications
PREOP. FEV1 OR DLco < 20% Is UNACCEPTABLE and is the absolute MINIMAL value required. ( national emphysema treatment trial )

41. Assessment of respiratory functions continues……… cardiopulmonary interactions (most important assessment of respiratory function)
Laboratory exercise testing
Gold standard
Vo2 max (maximum oxygen consumption) is the most useful predictor of post operative outcome.
Vo2 max < 15 ml/kg/min is unacceptable
Vo2 max >20 ml/kg/min has fewer complication
EXPENSIVE
Stair climbing tests
5 flights of stairs ~ V02 max >20 ml/kg/min
2 fight of stairs ~ Vo2 max ~ 12 ml/kg/min -- very high risk
(climbing should be at patients own pace without stopping,
1 flight of stairs = 20 steps withs each step of 6 inches )

42. Assessment of repiratory functions continues……………
Six minute walk test(6MWT)
< 610 m/ 2000 ft  Vo2 max< 15 ml/kg/min
~fall in SpO2 > 4% during exercise
( increased morbidity and mortality)
ppo V02 max
< 10 ml/kg/min is an absolute contraindication
mortality rate is approximately 100%
V-P scintigraphy
Should be considerd for any patient of pneumonenctomy having a preop FEV1 &/or Dlco <80%
performed at rest while FEV1 is a forced maneuver

43. Assessment of repiratory functions continued……………
Split lung function test
These tests have not shown sufficient predictive value or validity for universal adoption and are hence not recommended any longer
Replaced by spirometry/ DLco/ exercise tolerance & V/Q scaning.

44. The three legged stool of pre thoracotomy respiratory assessment
Respiratory mechanics
FEV1(ppo>40%)
MVV, RV/TLC, FVC
Cardiopulmonary reserve
Vo2 max >15ml/kg/min
Stair climbing>2 flight
6MWT>610m/2000ft
Exercise SpO2 < 4 %
Lung parenchymal function
Dlco (ppo >40%)
PaO2 >60
PaCO2 <45

45. Concomitant medical conditions
cardiovascular
Ischemia : intermediate risk surgery
5% incidence post thoracotomy
peaks on 2 and 3rd post op day
ACC/AHA guidelines to be followed
Arrhythmias
Right ventricular dysfunction
Renal dysfunction
Perioperative mortality is 19% in pt. developing deranged KFT in periop. Period as against 0% in those having normal KFT
Increased risk in pt. having h/o renal impairment
use of diuretic
use of NSAIDS
Hence I/op fluid management and intensive perioperative fluid management is essential
Age
Rate of respiratory complication doubles(40%) and cardiac complications (40%) triples in elderly

46. Concomitant medical conditions continues…….
Problems in a COPD patient
Respiratory drive,
CO2 retainers,
Increased role of HPV
Nocturnal hpoxemia because of rapid shallow breathing in a REM sleep
Right ventricular dysfunction
Bullae
Flow limitation :
stage I :FEV!>50% no significant dyspnoea ,hypoxemia or hypercapnia
Stage III :FEV1 <35% --life expectancy <3 years post thoracotomy

47. Beneficial effects of smoking cessation and time course
12–24 hr
Decreased CO and nicotine levels
48–72 hr
COHb levels normalized, ciliary function improves
1–2 wk
Decreased sputum production
4–6 wk
PFTs improve
6–8 wk
Immune function and metabolism normalizes
8–12 wk
Decreased overall postoperative morbidity and mortality

48. Anesthetic considerations in lung cancer patients (“the 4 Ms” )
Mass effects
Obstructive pneumonia,lung abscess, superior vena cava syndrome, tracheobronchial distortion , pancoast syndrome, recurrent laryngeal nerve or phrenic nerve palsy, chest wall or mediastinal extension
Metabolic effect
Lambert – Eaton syndrome, hypercalcemia, hyponatremia, cushing syndrome
Metastases
Particularly to brain, bone , liver and adrenal
Medications
Chemotherapy agents , pulmonary toxicity ( bleomycin,mitomycin C), cardiac toxicity(doxorubicin), renal toxicity ( cisplatin )

49. Preoperative therapy for COPD

50. To discuss post op analgesia
the risks and benefits of the various forms of post-thoracotomy analgesia should be explained to the patient
Potential contraindications such as coagulation problems, sepsis, or neurologic disorders should be determined
American Society of Regional Anesthesia (ASRA)
an interval of 2 to 4 hours before or 1 hour after catheter placement for prophylactic heparin administration.
an interval of 12 to 24 hours before and 24 hours after catheter placement is recommended for LMWH

51. Think about post thoracotomy anesthetic management (based on ppo FEV1%)
>40%
Extubate in the OR
Patient AWaC (alert ,warm and comfortable)
30-40%
Extubation on the basis of
Exercise tolerance,Dlco,V/Q scan, associated diseases
<30%
Staged weaning
Consider extubation if >20% + thoracic epidural analgesia

52. Summarise preoperative assesment
Initial assessment
Final assessment
COPD patients : ABG, physiotherapy , bronchodilators
Assess exercise tolerance,estimate ppo FEV1, discuss post op. analgesia, discontinue smoking
Patients with ppo FEV1<40%:Dlco,V/Q scan,Vo2 max
Cancer patient: consider 4Ms
Increased renal risk : measure creatinine and BUN
Review initial assessment and test results.
Assess difficulty of lung isolation: chest Xray and CT scan.
Assess risk of hypoxemia during one lung ventilation

53. Increased risk of hypoxemia
High percentage of ventilation or perfusion to the operative lung preoperatively
Poor PaO2 during two-lung ventilation particularly in the lateral position intraoperatively
Right sided thoracotomy
Normal preoperative spirometry or restrictive lung disease
Supine position during OLV

54. Premedication
avoid inadvertent withdrawal of those drugs that are taken for concurrent medical conditions
For surgeries like oesophageal reflux surgeries aspiration prophylaxis are routinely ordered preoperatively
do not routinely order preoperative sedation or analgesia for pulmonary resection patients
Mild sedation short-acting benzodiazepine is often given immediately before placement of invasive monitoring lines and catheters.
an antisialagogue (e.g., glycopyrrolate) is useful to facilitate fiberoptic bronchoscopy
It is a common practice to use short-term intravenous antibacterial prophylaxis

55. Intraoperative monitoring
Oxygenation :
significant desaturation( SpO2<90%) occurs in 1-10% of patients inspite of high FiO2 (1.0).
PaO2 offers a better margin of safety then SpO2
Decreased initial PaO2 and rapid fall in PaO2 after initiation of OLV is a good indicator of subsequent desaturation.
Useful to measure PaO2 before and 20 minutes after OLV
Capnometry
Less reliable then PaCO2
PaCO2-EtCO2 gradient increased
Other components of minimum mandatory monitoring : BP,ECG,temperature

56. Invasive monitoring
Arterial line:Surgical compression of heart & great vessels l/t hypotension
CVP : non reliable , useful postoperatively
Pulmonary artery catheters: less reliable for OLV
unsurety about the location of the tip
signficant u/l differences in lung perfusion.
complications
Continuous spirometry monitoring of inspired and expired volume  auto-PEEP
aids in assessing and managing pulmonary air leak during pulmonary resection
Transesophageal echocardiography :continuous real time monitoring ofmyocardial function and preload
Potential indication: hemodynamic instability,pericardial effusion,cardiac involvement by tumour,air emboli,pulmonary thromboendarterectomy, thoracic trauma,lung transplantation.
Difficult in pt. having esophageal pathology,

57. Conditions during thoracotomy in the lateral decubitus position when pulmonary artery (PA) catheter data
may be inaccurate.

58. Positioning
The majority of thoracic procedures are performed with the patient in the lateral position
monitors will be placed and anesthesia will usually be induced with the patient in the supine position
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
anesthesiologist should take responsibility for the head, neck, and airway during position change
Endobronchial tube/blocker position and the adequacy of ventilation must be rechecked by auscultation and fiberoptic bronchoscopy after patient repositioning.

59. “Head-to-toe” survey for neurovascular injury after position change
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

60. Factors Contributing to Brachial Plexus Injury in the Lateral Position
Dependent Arm (Compression Injuries)   
Arm directly under thorax   
Pressure on clavicle into retroclavicular space   
Cervical rib   
Caudal migration of thorax padding into the axilla Nondependent Arm (Stretch Injuries)
Lateral flexion of cervical spine   
Excessive abduction of arm (>90%)   
Semiprone or semisupine repositioning after arm fixed to a support

61. Anesthetic management
Fluid Management for Pulmonary Resection Surgery 1. Total positive fluid balance in the first 24-hour perioperative period should not exceed 20 mL/kg. 2. For an average adult patient, crystalloid administration should be limited to < 3 L in the first 24 hours. 3. There should be no fluid administration for third space fluid losses during pulmonary resection. 4. Urine output > 0.5 mL/kg/hr is unnecessary. 5. If increased tissue perfusion is needed postoperatively, it is preferable to use invasive monitoring and inotropes rather than to cause fluid overload.

62. Use of nitrous oxide
use of N2O/O2 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%).
also tends to increase pulmonary artery pressures in patients who have pulmonary hypertension
N2O inhibits HPV
N2O is contraindicated in patients with blebs or bullae
N2O is usually avoided during thoracic anesthesia

63. Temperature
heat loss from the open hemithorax
Most of the body's physiologic functions, including HPV, are inhibited during hypothermia
particularly a problem at the extremes of the age spectrum.
Increasing the ambient room temperature, fluid warmers, and the use of lower- or upper-body forced-air patient warmers (or both)

64. Cardiovascular and Respiratory goals
anesthetic technique should optimize the myocardial oxygen supply/demand
Thoracic epidural anesthesia/analgesia is recommended
high incidence of coexisting reactive airway disease, added airway manipulation by the DLT or bronchial blocker
Thus, need anesthetic technique that decreases bronchial irritability, causes bronchodilation, and avoids release of histamine
For intravenous induction of anesthesia either propofol or ketamine, & for maintenance of anesthesia, propofol and/or any of the volatile anesthetics are recommended

65. Choice of Anesthetic
All of the volatile anesthetics inhibit HPV in a dose-dependent fashion :
halothane > enflurane > isoflurane
In doses less than or equal to 1 MAC, the modern volatile anesthetics depress HPV minimally
Hence TIVA has no proven benefit against 1 MAC inhalational anesthesia

66. Suggested ventilatory parameters for OLV
Guidelines/ Exceptions
Tidal volume
5-6 mL/kg
Maintain:   
Peak airway pressure < 35 cm H2O
Plateau airway pressure < 25 cm H2O
Positive end-expiratory pressure
5 cm H2O
Patients with COPD: no added PEEP
Respiratory rate
12 breaths/min
Maintain normal Paco2; Pa-ETco2 will usually increase 1-3 mm Hg during OLV
Mode
Volume or pressure controlled
Pressure control for patients at risk of lung injury (e.g., bullae, pneumonectomy, post lung transplantation)

67. Therapies for Desaturation during One-Lung Ventilation
Severe or precipitous desaturation: Resume two-lung ventilation (if possible).
Gradual desaturation:
   1.    Ensure that delivered Fio2 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 (this will transiently make the hypoxemia worse).
   5.    Apply PEEP 5 cm H2O to the ventilated lung (except in patients with emphysema).
   6.    Apply CPAP 1-2 cm H2O 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.    Mechanical restriction of the blood flow to the nonventilated lung

68. Post operative complications Early major
Respiratory failure
cardiac herniation
torsion of a remaining lobe after lobectomy
dehiscence of a bronchial stump
hemorrhage from a major vessel
Where

69. Post operative respiratory failure
leading cause of postoperative morbidity and mortality
Acute respiratory failure after lung resection is defined as:
acute onset of hypoxemia (Pao2 < 60 mm Hg) or hypercapnia (Paco2 > 45 mm Hg
use of postoperative mechanical ventilation for more than 24 hours
reintubation for controlled ventilation after extubation
incidence of respiratory failure after lung resection is between 2% and 18%

70. To minimise pulmonary complications postoperatively
thoracic epidural analgesia :
prevention of atelectasis and secondary infections
better preservation of the functional residual volume
efficient mucociliary clearance
alleviation of the inhibiting reflexes acting on the diaphragm
Chest physiotherapy, incentive spirometry, and early ambulation are crucial
provide better oxygenation, treat infection, and provide vital organ support without further damaging the lungs.

71. multiple sensory afferents :
Post operative analgesia
multiple sensory afferents :
incision (intercostal nerves T4-T6),
chest drains (intercostal nerves T7-T8),
mediastinal pleura (vagus nerve, CN X),
central diaphragmatic pleura (phrenic nerve, C3-C5),
ipsilateral shoulder (brachial plexus).
Hence there is no one analgesic technique that can block all these various pain afferents, so analgesia should be multimodal.
The ideal post-thoracotomy analgesic technique will include three classes of drugs: opioids, anti-inflammatory agents, and local anesthetics.

72. Post op analgesia continues…
Systemic Analgesia:
Opioids:effective in controlling background pain but the acute pain component associated with cough or movement requires plasma levels that produce sedation and hypoventilation
NSAIDS :reduce opioid consumption more than 30%.particularly useful treating the ipsilateral shoulder pain
Ketamine: less respiratory deppression
Dexmedetomidine: described as an useful adjunct
Local Anesthetics/Nerve Blocks:
Intercostal nerve blocks
Interpleural blocks
Epidural analgesia

73. Thank you