1. Llalando L. Austin II, MHSc, AA-C, RRT Nova Southeastern University
One Lung Ventilation
Llalando L. Austin II, MHSc, AA-C, RRT
Nova Southeastern University

2. 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

4. Thoracotomy

5. Thoracotomy with Lung Deflated

6. VATS
Video-assisted thoracic surgery (VATS) is a recently developed type of surgery that enables doctors to view the inside of the chest cavity after making only very small incisions. It allows surgeons to remove masses close to the outside edges of the lung and to test them for cancer using a much smaller surgery than doctors needed to use in the past. It is also useful for diagnosing certain pneumonia infections, diagnosing infections or tumors of the chest wall, and treating repeatedly collapsing lungs

7. VATS

8. VATS

9. 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”

10. 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

11. 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

12. Double Lumen Tubes

13. 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

14. 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

15. 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

16. 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

17. Double Lumen Endobronchial Tubes

18. Double Lumen Endobronchial Tubes

19. 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

20. 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

21. DLT Placement Prepare and check tube Lubricate 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.

22. 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

23. 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

24. DLT Placement

25. Wire-Guided Endobronchial Blockers

26. 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

27. 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.

28. 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

29. Wire-Guided Endobronchial Blockers

30. Wire-Guided Endobronchial Blockers

31. Wire-Guided Endobronchial Blockers
Available sizes
Adult 9 Fr
Pediatric 5 Fr

32. Wire-Guided Endobronchial Blockers

33. Wire-Guided Endobronchial Blockers

34. Wire-Guided Endobronchial Blockers

35. Wire-Guided Endobronchial Blockers

36. Fogarty Embolectomy Catheters

37. 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

38. Univent Tubes

39. 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

40. Comparison of Various Tube Diameters

41. 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

42. Complications - Bronchial Rupture

43. Hypoxic Pulmonary Vasoconstriction
Hypoxia is a powerful stimulus for pulmonary vascular constriction
Body’s 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
Body’s way to decrease the shunt that was created by change
Position
V/Q mismatch

44. HPV Body’s compensatory mechanism for hypoxia Clinical Notes: No HPV =
Direct acting vasodilators inhibit HPV response
Volatile agents at higher concentrations inhibit HPV response
No HPV =
Increases shunt
Decreases PaO2

45. 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

46. 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!!

47. References http://ourworld.cs.com/_ht_a/doschk/onelung.htm
Finucane and Santora
Morgan and Mikhail
Barash, Cullen, Stoelting