Dr Gagan Pal Singh

 Preoperative assessment
 Intraoperative management
 Monitoring
 Lung isolation techniques
 Positioning
 One lung Ventilation
 Postoperative management
 Postoperative analgesia
 Complications
Preoperative Assessment

 Aim
 Identify patients at high risk
 Use that risk assessment to stratify perioperative
management and focus resources on the high-risk
patients to improve their outcome.
Assessment of Respiratory function

 Detailed history
 Baseline Spirometry
 Respiratory Mechanics
 Lung parenchymal function
 Cardiopulmonary interaction
Respiratory mechanics
ppoFEV1% = preop FEV1% ×
(1- %Functional lung tissue removed/100)

For example, after a right lower

lobectomy a patient with a preoperative
FEV1 (or DLCO) 70% of normal would
be expected to have a postoperative

FEV1 = 70% × (1 - 29/100) = 50%

Ppo FEV1
>40% -Low risk
30-40%- mod risk
< 30% - high risk

Slinger PD, Johnston MR: Preoperative assessment: an anesthesiologist's perspective. Thorac Surg Clin 15:11, 2005.
Lung Parenchymal Function

 Diffusing capacity for CO (DLCO)

 Useful predictor of perioperative mortality but not
long term survival.
 ppoDLCO <40% predicted correlates with both
increased respiratory and cardiac complications
and is independent of the FEV1.
 Cardiopulmonary Interaction
 Maximum oxygen consumption (Vo2max)
 Most useful predictor of post-thoracotomy outcome.
 Morbidity and mortality is unacceptably high- Vo2max
<15 mL/kg/min.
 Few patients with a Vo2max >20 mL/kg/min have respiratory
complications
 Stair climbing
 5 flights - Vo2max >20 mL/kg/min
 2 flights - Vo2max of 12 mL/kg/min
 6-minute test (6MWT)
 <2000 ft (610 m) - Vo2max <15 mL/kg/min
 Patients with a decrease of Spo2 greater than 4% during exercise are at
increased risk for morbidity and mortality.
Ventilation-Perfusion Scintigraphy

 Pneumonectomy patient who has a

preoperative FEV1 and/or DLCO less than
40%.

Split Function Tests

 Unilateral exclusion of a lung or lobe with an
endobronchial tube/blocker or by pulmonary artery
balloon occlusion of a lung or lobe artery, or by
both.
Comorbid Conditions
Cardiovascular Diseases
 Ischemia
 “intermediate risk” procedure in terms of perioperative
cardiac ischemia.
 Documented incidence is 5% and peaks on 2 to 3 POD.
 History, physical examination, and electrocardiogram.
 Noninvasive testing is indicated in patients with
 Active cardiac conditions (unstable coronary syndromes,
Decompensated CHF, severe valvular disease, significant arrhythmia)
 Therapeutic options for patients with significant cad
 optimization of medical therapy
 coronary angioplasty
 coronary artery bypass, either before or at the time of lung resection.
 Timing of lung resection surgery

ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery .
Age >70 Yrs

 Respiratory complications – 40%

 (double than expected)

 Cardiac complications – 40%

 particularly arrhythmias
 (3 times than expected).
Age
Renal Dysfunction

 Mortality – 18-20%
 Factors
 H/o of previous renal impairment
 Diuretic therapy
 Pneumonectomy
 Postoperative infection
 Blood transfusion
Chronic Obstructive Airway Disease

 Emphysema
 Peripheral Airway Disease
 Chronic Bronchitis

Impairement of Expiratory Airflow

Severity- FEV%
 stage I - >50% predicted
 stage II - 35% 50%
 stage III - <35%
Respiratory Drive
Earlier concept
 COPD pts relied on a hypoxic stimulus for ventilatory drive and
became insensitive to PaCO2.
 Hypercapnic coma by the administration of a high FIO2.
Now
 Minute ventilation is basically unchanged.
 Relative decrease in alveolar ventilation and an increase in alveolar
dead space
 Redistribution of perfusion away from lung areas of relatively normal
V/Q matching to areas of very lowV/Q ratio.
 A minor fraction of the increase in PaCO2 is due to a diminished
respiratory drive.
Supplemental oxygen must be administered postoperatively to
prevent the hypoxemia associated with the unavoidable fall in
FRC.
The attendant rise in PaCO2 should be anticipated and monitored.
Nocturnal Hypoxemia
 Rapid/shallow breathing pattern during REM
sleep.
 This tendency to desaturate, combined with
the postoperative fall in FRC and opioid
analgesia, places these patients at high risk for
severe hypoxemia postoperatively during
sleep.
Right ventricular dysfunction
 50% of COPD patients.
 poorly tolerant of sudden increases in afterload, such as the change
from spontaneous to controlled ventilation.
 Cor pulmonale - 40% in pts with an FEV1 <1 L
70% with an FEV1 <0.6 L.
 Pneumonectomy candidates with a ppoFEV1 less than 40% should have
transthoracic echocardiography to assess right-sided heart function.
Elevation of right-sided heart pressures places these patients in a very
high-risk group.
 The only therapy that has been shown to improve long-term survival
and decrease right-sided heart strain in COPD is oxygen.
 COPD patients with resting PaO2 <55 mm Hg & <44 mm Hg with
usual exercise should receive supplemental home oxygen. The goal of
supplemental oxygen is to maintain a PaO2 of 60 to 65 mm Hg.
Bullae
 Chances of Bullae rupture, tension pneumothorax
and bronchopleural fistula with positive-pressure
ventilation

 Keep low airway pressures

 Equipment should be available to insert a chest
drain and obtain lung isolation if necessary.
Flow Limitation

 Risk for hemodynamic collapse with the application

of positive-pressure ventilation owing to dynamic
hyperinflation of the lungs.
Difficult Endobronchial Intubation

 History
 Previous radiotherapy
 Infection
 Prior pulmonary or airway surgery
 Written bronchoscopy report with
detailed description of anatomic
features.
 Physical findings
 The most useful predictor is
plain chest radiograph
Prediction of Desaturation during
OLV
 High percentage of ventilation or perfusion to the
operative lung on preoperative ventilation- perfusion
scan   

 Poor PaO2 during two-lung ventilation, particularly in

the lateral position intraoperatively   

 Right-sided thoracotomy   

 Restrictive lung disease   

 Supine position during one-lung ventilation

Preoperative Optimization
 Stop smoking, avoid industrial
pollutants
 Dilate airways
 Loosen secretions
 Airway hydration
(humidifier/nebulizer)
 Systemic hydration
 Mucolytic and expectorant
drugs
 Remove secretions
 Postural drainage
 Coughing
 Chest physiotherapy
(percussion and vibration)
 Adjunct medication
 Antibiotics—if purulent
sputum/bronchitis
 Antacids, H2 blockers, or PPIs
—if symptomatic reflux.
 Increased education,
motivation, and facilitation of
postoperative care
 Psychological preparation
 Preoperative pulmonary care
training
 Incentive spirometry
 Secretion removal maneuvers
 Preoperative exercise
 Weight loss/gain
 Stabilize other medical
problems
Summary of initial preoperative
assessment
 All patients:  Cancer patients:
 Assess exercise tolerance  consider the “4 Ms”:
 estimate predicted  mass effects
postoperative FEV1%  metabolic effects
 discuss postoperative  Metastases
analgesia  medications   
 discontinue smoking  COPD patients:
 Patients with predicted  Arterial blood gas analysis
postoperative FEV1<  Physiotherapy
40%:  bronchodilators   
 DlCO  Increased renal risk:
 Ventilation perfusion Scan  Measure creatinine and
 VO2 max    blood urea nitrogen
Final Assessment

 Review initial assessment and test results.   

 Assess difficulty of lung isolation: examine
chest radiograph and computed tomography
scan.   
 Assess risk of hypoxemia during one-lung
ventilation.
Intraoperative Monitoring

 Oxygenation
 Capnometry
 Arterial blood pressure
 CVP
 Pulmonary artery pressure
 Fibreoptic bronchoscopy
 Urine output
 Temperature
 Transesophageal Echocardiography

Category 1 Category 2 Category 3

Hemodynamic Cardiac and/or great vessel Right ventricular

instability involvement by intrathoracic function in pulmonary
tumors resection

Assessment of Pulmonary
pericardial effusion thromboendarterectomy
or tamponade
Air emboli

Lung transplantation

Thoracic trauma
Lung Isolation Techniques

 Double lumen tube

 Bronchial blocker
 Arndt
 Cohen
 Fuji
 Univent tube
 Endobronchial tube
 Endotracheal tube advanced into bronchus
Double lumen tube
 Carlens tube
 Robertshaw tube
 Advantages
 Quickest to place successfully
 Repositioning rarely required
 Bronchoscopy to isolated lung
 Suction to isolated lung
 CPAP easily added
 Can alternate OLV to either
lung easily
 Placement still possible if
bronchoscopy not available
 Disadvantages
 Size selection more difficult
 Difficult to place in patients
with difficult airways or
abnormal tracheas
 Not optimal for postoperative
ventilation
 Potential laryngeal trauma
 Potential bronchial trauma
Size selection
Sex Height (cm) Size (Fr)
Female <160 (63 in.) 35
Female >160 37
Male <170 (67 in.) 39
Male >170 41

Depth of insertion

12 + (patient height/10) cm
 Method of insertion
Blind technique:
• DLT is passed with direct
laryngoscopy
• Turn 90 ° counterclockwise (for a
left-sided DLT placement) after
the endobronchial cuff has passed
beyond the vocal cords.
• The DLT should pass the glottis
without any resistance.

Bronchoscopic guidance
• Tip of the endobronchial lumen is
guided into the correct bronchus
after the DLT passes the vocal
cords using direct vision with a
flexible fiberoptic bronchoscope
Confirmation of tube placement
Auscultation “three-step”
method: 
Step 1. During bilateral ventilation,
the tracheal cuff is inflated to the
minimal volume that seals the air
leak at the glottis. confirm
bilateral ventilation. 
Step 2. The tracheal lumen is clamped
proximally and the port distal to
the clamp opened. During
ventilation via the bronchial
lumen the bronchial cuff is
inflated to the minimal volume
that seals the air leak from the
open tracheal lumen port.
Auscultate to confirm correct
unilateral ventilation. 
Step 3. The tracheal lumen clamp is
released and the port closed.
Auscultate to confirm resumption
of bilateral breath sounds.
 Fiberoptic bronchoscopy
 Tracheal View
 Confirm endobronchial portion in the left
bronchus
 Bronchial cuff herniation over the carina
after inflation.
 identify the takeoff of the right upper lobe
bronchus through the tracheal view.
 Going inside this right upper lobe with the
bronchoscope should reveal three orifices
(apical, anterior, and posterior).
 Endobronchial view
 check for patency of the tube
 Determination of margin of safety
 The orifices of both the left upper and lower
lobes must be identified to avoid distal
impaction in the left lower lobe and
occlusion of the left-upper lobe
view from the distal bronchial
lumen Tracheal view
Right-Sided Double-Lumen
Endobronchial Tubes
 Distorted Anatomy of the Entrance of Left
Mainstem Bronchus
 External or intraluminal tumor compression
 Descending thoracic aortic aneurysm
 Site of Surgery Involving the Left Mainstem
Bronchus
 Left lung transplantation
 Left-sided tracheobronchial disruption
 Left-sided pneumonectomy
 Left-sided sleeve resection
Bronchial blockers

 Pts with previous oral or neck surgery who

present with a challenging airway
 Pts with previous contralateral pulmonary
resection
 when postoperative mechanical ventilation is
being considered after prolonged thoracic or
esophageal surgery.
 Cohen Blocker Arndt Blocker Fuji Uniblocker
Size 9 Fr 5 Fr, 7 Fr, and 9 Fr 5 Fr, 9 Fr
Spherical or
Balloon shape Spherical Spherical
elliptical
Nylon wire loop that
Guidance Wheel device to is coupled with the
None, preshaped tip
mechanism deflect the tip fiberoptic
bronchoscope
Smallest 5 Fr (4.5 ETT), 7 Fr
recommended ETT 9 Fr (8.0 ETT) (7.0 ETT), 9 Fr (8.0 9 Fr (8.0 ETT)
for coaxial use ETT)
Murphy eye Present Present in 9 Fr Not present
Center channel 1.6 mm ID 1.4 mm ID 2.0 mm ID
Cohen Blocker
 Wheel in the proximal part of the unit deflects the
tip of the distal part of the blocker into the desired
bronchus.
 Distal tip is preangled to facilitate insertion into a
target bronchus.
 Arrow on the distal shaft above the balloon

 To position the Cohen blocker, the arrow is

aligned with the bronchus to be intubated, the
proximal wheel is turned to deflect the tip toward
the desired side and then the blocker is advanced
with fiberoptic guidance.
Arndt Blocker
Disadvantages of Bronchial Blockers

 More time consuming

 Repositioning needed more often
 Bronchoscope essential for positioning
 Nonoptimal right lung isolation due to RUL
anatomy
 Bronchoscopy to isolated lung impossible
 Minimal suction to isolated lung
 Difficult to alternate OLV to either lung
Univent Bronchial blockers
 Enclosed bronchial blocker
is fully retracted into the
standard lumen of the tube.
 Conventional endotracheal
tube intubation technique is
used.
 Then a fiberoptic
bronchoscope is passed into
the main lumen through a
bronchoscopy adaptor.
 Under direct vision the
enclosed bronchial blocker
is advanced into the
targeted bronchus
Positioning

 Position Change
 W/f hypotension
 Secure all lines and monitors
 Make an initial “head-to-toe” survey
 Check oxygenation, ventilation, hemodynamics,
lines, monitors, and potential nerve injuries.
 Reassess after repositioning
 Recheck Endobronchial tube/blocker position and
the adequacy of ventilation by auscultation and
fiberoptic bronchoscopy after repositioning.
Neurovascular Complications
Brachial Plexus Injury
 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
“Head-to-Toe” Survey
 Dependent eye  
 Dependent ear pinna  
 Cervical spine in line with thoracic spine
 Dependent arm:   
 Brachial plexus
 Circulation  
 Nondependent arm:   
 Brachial plexus
 Circulation  
 Dependent and nondependent suprascapular nerves  
 Nondependent leg: sciatic nerve  
 Dependent leg:
 Peroneal nerve  
 Circulation
Lateral decubitus position for
thoracotomy
Awake Vs Anaesthetized In Lateral
position
 Non dependent lung moving
from a flat, noncompliant
portion to a steep, compliant
portion
 Dependent lung moving from
a steep, compliant part to a
flat, noncompliant part.
 Thus, an anesthetized patient
in a lateral decubitus position
has more of the tidal
ventilation in the
nondependent lung (where
 perfusion is the least) and less
of the tidal ventilation in the
dependent lung
Open paralyzed Chest in lateral
position
 Opening the chest increases
nondependent lung
compliance

 Paralysis also reinforces or

maintains the larger part of
tidal ventilation going to
the nondependent lung
because the pressure of the
abdominal contents (PAB )
pressing against the upper
part of the diaphragm is
minimal
compliance of a single lung during
position changes in an anesthetized,
paralyzed patient during controlled
mechanical ventilation
One Lung Ventilation
Determinants of pulmonary blood
flow
Hypoxic Pulmonary
Vasoconstriction
 Decrease the blood flow to the nonventilated lung by
50%.
 Primary stimulus is PAO2
 ↓ PAO2 stimulates precapillary vasoconstriction
redistributing pulmonary blood flow via a pathway involving
NO and/or cyclooxygenase synthesis inhibition
 Rapid onset over the first 30 minutes and then a
slower increase to a maximal response at
approximately 2 hours.
 Preconditioning effect
 response to a second hypoxic challenge will be greater than
to the first challenge
One-Lung Ventilation…

 Thoroughly de-
nitrogenate the operative
lung, before collapse

 Recruitment maneuver
(holding the lung at an
end-inspiratory pressure
of 20 cm H2O for 15 to
20 sec) immediately after
the start of OLV to
decrease atelectasis
Hypoxemia during OLV

 Incidence
 1950-1980 -20% to 25%
 1990s - <10%
 Factors:
 Improved lung-isolation techniques such as routine
fiberoscopy to prevent lobar obstruction from
DLTs
 Improved anesthetic techniques that cause less
inhibition of HPV
 Better understanding of the pathophysiology of
OLV
Treatment of Hypoxemia
 Severe or precipitous desaturation:
 Resume two-lung ventilation (if possible).

 Gradual desaturation:  
 Ensure that delivered FIO2 is 1.0
 Check position of DLT or blocker with fiberoptic bronchoscopy
 Ensure cardiac output is optimal; decrease volatile anesthetics to < 1
MAC
 Apply a recruitment maneuver to the ventilated lung
 Apply PEEP 5 cm H2O to the ventilated lung
 Apply CPAP 1-2 cm H2O to the nonventilated lung (apply a
recruitment maneuver to this lung immediately before CPAP)
 Intermittent reinflation of the nonventilated lung  
 Partial ventilation techniques of the nonventilated lung:
 Oxygen insufflation
 High-frequency ventilation  
 Lobar collapse (using a bronchial blocker)
 Mechanical restriction of the blood flow to the nonventilated lung
Anesthetic Management
 Fluid Management
 First 24-hour perioperative total positive fluid balance should not
exceed 20 mL/kg.   
 crystalloid administration should be limited to < 3 L in the first 24
hours.
 No fluid administration for third space fluid losses during
pulmonary resection.   
 Urine output > 0.5 mL/kg/hr is unnecessary.
 If increased tissue perfusion is needed postoperatively, it is
preferable to use invasive monitoring and inotropes rather than to
cause fluid overload.
 Avoid N2O - more prone to cause atelectasis in poorly
ventilated lung regions
 Maintenance of body temperature
 Prevention of Bronchospasm
 Ventilation Strategies
Parameter Suggested Guidelines/ Exceptions
Maintain:
Tidal volume 5-6 mL/kg
Peak airway pressure <
  
35 cm H2O
Plateau airway pressure <
  
25 cm H2O
Positive end-expiratory Patients with COPD: no
5 cm H2O
pressure added PEEP
Maintain normal PaCO2;
Pa-ETCO2 will usually
Respiratory rate 12 breaths/min
increase 1-3 mm Hg during
OLV
Pressure control for
patients at risk of lung
Volume or pressure
Mode injury (e.g., bullae,
controlled
pneumonectomy, post lung
transplantation)
Postoperative mangement-
Analgesia
 Systemic Analgesia
 Opioids
 Nonsteroidal Anti-inflammatory Drugs
 Ketamine
 Dexmedetomidine
 Local Anesthetics/Nerve Blocks
 Intercostal Nerve Blocks
 Intrapleural Analgesia
 Epidural Analgesia
 Paravertebral Block
Thoracic Epidural Analgesia

 Better preservation of the functional residual

volume
 Efficient mucociliary clearance
 Alleviation of the inhibiting reflexes acting on
the diaphragm
 prevention of atelectasis and secondary
infections
Postoperative Complications

 Early Major Complications

 Torsion of a remaining lobe after lobectomy
 Dehiscence of a bronchial stump
 Hemorrhage from a major vessel
 Respiratory Failure
 Cardiac Herniation
Respiratory Failure

 Acute onset of
 hypoxemia (PaO2 < 60 mm Hg)
 hypercapnia (PaCO2 > 45 mm Hg)
 use of postoperative mechanical ventilation for >24
hours
 Reintubation for controlled ventilation after
extubation
 Incidence - 2% - 18%
Respiratory Failure…

 Predictors
 Preoperatively decreased respiratory function
 Age
 Presence of coronary artery disease
 Extent of lung resection
 Crossover contamination
 Prolonged mechanical ventilation postoperatively
Respiratory Failure…

 Chest physiotherapy, incentive spirometry, and

early ambulation are crucial

 Early extubation is desirable for an uncomplicated

lung resection.

 Current therapy to treat acute respiratory failure is

supportive therapy to provide better oxygenation,
treat infection, and provide vital organ support
without further damaging the lungs.
Cardiac Herniation
 If the pericardium is incompletely closed or the closure
breaks down
 immediately or within 24 hours after chest surgery
 Mortality -50%.
 Clinical presentation after a right pneumonectomy
 Impairment of the venous return to the heart
 Increase in central venous pressure
 Tachycardia
 Profound hypotension
 Shock.
 Acute SVC syndrome due to the torsion of the heart.
 Clinical presentation after a left pneumonectomy
 There is less cardiac rotation but the edge of the pericardium
compresses the myocardium
 myocardial ischemia
 Arrhythmias
 ventricular outflow tract obstruction.
Cardiac Herniation - management

 consider as dire emergent surgery.

 The differential diagnosis
 massive intrathoracic hemorrhage
 pulmonary embolism
 mediastinal shift from improper chest drain
management.
 Early diagnosis and immediate surgical treatment
by relocation of the heart to its anatomic position
with repair of the pericardial defect or by the use
of analogous or prosthetic patch material is key to
patient survival.
 Arrhythmias
 Incidence - 30% to 50%
 60% to 70% are atrial fibrillation
 Factors:
 Extent of lung resection
 Pneumonectomy – 60%
 Lobectomy – 40%
 Nonresection thoracotomy - 30%)
 Intrapericardial dissection
 Intraoperative blood loss
 Age of the patient.
 Extrapleural pneumonectomy
  Antiarrhythmic Prophylaxis
 Diltiazem
 Thoracic epidural analgesia
 Due to increasing myocardial refractory period,
decreasing ventricular diastolic pressures, and
improving endocardial/epicardial blood flow ratios.

Oka T, Ozawa Y, Ohkubo Y: Thoracic epidural bupivacaine attenuates supraventricular tachyarrhythmias

after pulmonary resection.  Anesth Analg  2001; 93:253.