One Lung Ventilation

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One Lung Ventilation

• Llalando L. Austin II, MHSc, AA-C, RRT
• Nova Southeastern University

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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

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Thoracotomy
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Thoracotomy with Lung Deflated
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VATS
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VATS
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VATS
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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

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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

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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

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Double Lumen Tubes
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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

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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

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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

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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

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Double Lumen Endobronchial Tubes
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Double Lumen Endobronchial Tubes
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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

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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

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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.

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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

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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

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DLT Placement
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Wire-Guided Endobronchial Blockers
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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

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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.

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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

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Wire-Guided Endobronchial Blockers
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Wire-Guided Endobronchial Blockers
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Wire-Guided Endobronchial Blockers

• Available sizes
• Adult 9 Fr
• Pediatric 5 Fr

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Wire-Guided Endobronchial Blockers
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Wire-Guided Endobronchial Blockers
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Wire-Guided Endobronchial Blockers
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Wire-Guided Endobronchial Blockers
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Fogarty Embolectomy Catheters
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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

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Univent Tubes
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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

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Comparison of Various Tube Diameters
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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

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Complications - Bronchial Rupture
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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

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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

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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

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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!!

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References

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