One Lung Ventilation

Ventilate one lung to create a quiet field for the surgeon

Indications

Absolute Indications

Isolation of one lung due to purulent secretions/massive pulmonary hemorrhage

Control of distribution of ventilation

• Bronchopleural fistula, blebs, unilateral hypoxemia, unilateral lavage

Relative Indications

Surgical exposure

• Thoracic aortic aneurysm, pneumonectomy, upper lobectomies, procedures on the thoracic spine, esophageal resection, Video-Assisted Thoracoscopic Surgery (VATS)

Preoperative Evaluation

Respiratory risk factors

• Smoking, air pollution, industrial chemical exposure

Possible COPD

• Hyperinflation of lung tissue - may have increased PVR - possible R heart failure

Cancer patients - the 4Ms

• Mass effects
  • Obstructive pneumonia, lung abscess, superior vena cava syndrome, tracheal distortion, recurrent laryngeal nerve or phrenic nerve paresis, chest wall abnormalities
• Metabolic effects
  • Lambert-Eaton syndrome (muscle weakness due to decreased release of Ach), hypercalcemia, hyponatremia, Cushing syndrome (increased cortisol production)
• Metastases
  • To the brain, bone, liver, and adrenals
• Medications
  • Chemotherapy-induced lung changes
    • Bleomycin

Nutritional status - may have low albumin

CXR

ECG - right ventricular hypertrophy and strain

ABG - preoperative hypoxemia with SpO2<90% can be predictive of post-op complications

Pulmonary function tests

Low-risk patients

• FEV1 >2 L or 80% of predicted
• Predicted postoperative (PPO) function test FEV1 >40%
• VO₂ max >20 mL/kg/min
  • Ability to climb five flights of stairs (indicates maximal oxygen consumption

High-risk patients

• FEV1 <0.7-2 L
• Predicted PPO <40%
• Carbon monoxide diffusion capacity <40-60% (sources vary)
• VO₂ max <10 mL/kg/min
  • Inability to climb one flight of stairs

Treat infections, excess bronchial secretions, bronchospasm, and nutritional deficiencies

Encourage the stoppage of smoking before surgery, if possible, to optimize patient outcomes

Double Lumen Tubes (DLT)

One lumen reaches the mainstem bronchus - blue cuff

• BB - blue for bronchus

One lumen ends in the trachea - clear cuff

Left is safer than right due to the takeoff of the upper lobe

• L = 5 cm
• R = 2 cm from the carina

Sizes

Left 41, 39, 37, 35, 28, 26

Right 41, 39, 37, 35

Female

<63 inches (160 cm)

• Size 35

>63 inches

• Size 37

Male

<67 inches (170 cm)

• Size 39

>67-inch

• Size 41

Always have sizes above and below

Insertion

Lubricate the distal end, including the cuff, use a MAC blade, insert until black ring through cords, remove the stylet, and rotate 90 degrees towards the bronchus you want to intubate

Depth

• 29 cm +/- 1 cm for every 10 cm of height above or below 170 cm

Tracheal cuff 5-10 mL of air, bronchial 1-2 mL of air

Placement

Check placement - both auscultation and fiber-optically

• Bilateral breath sounds with both cuffs inflated
• Clamp the tracheal side and open it to air - should only have breath sounds on the bronchial side
• Close the port and unclamp
• Repeat with the bronchial side - should only have breath sounds on the tracheal side.

Ways to Improve HPV (Hypoxic Pulmonary Vasoconstriction)

Narcotic Anesthesia

CPAP 5-10 cm to the non-ventilated lung - improve oxygenation

PEEP 5-10 cm to the ventilated lung - stents airways open

Early ligation of pulmonary artery - pneumonectomy only

Periodic inflation of non-ventilated lung

Insufflation of oxygen into the collapsed lung

Limit MAC to <1

Reduce vasodilator usage - Cardene is the best option if needed

Postoperative Complications after Lung Resection

Arrhythmia

Myocardial infarction

Pulmonary embolism

Pneumonia and empyema