Anesthesia for thoracic surgery- OLV

Dr. P. Gayatri, MD, FRCA, FFA Associate Professor, Anesthesia SCTIMST, TVM

Case History
67 yrs, smoker, c/o chest pain, dyspnea, hemoptysis for 6 months.

Preanesthetic assessment
the primary function of the pre-anesthetic assessment. Routine- past history, allergies, medications, upper airway Additional-

Respiratory function assessment

  

Respiratory mechanics, Gas exchange and Cardio-respiratory interaction

Preanesthetic assessment
Exercise tolerance- VO2 max- 15 ml/kg/min FEV1- ppoFEV1= preop FEV1*(1-% lung tissue removed/100) DLCO V/Q scan COPD- ABG Renal function

Symptoms
Bronchopulmonary- Cough, sputum, chest pain, dyspnea, wheeze Extrapulmonary intrathoracic- Pleural effeusion, pain, dysphagia, SVC syndrome,pericarditis, arm pain, hoarseness,etc Extrathoracic metastatic- Brain, skeleton, Liver, Adrenal, GI, kidney, pancreas. Extrathoracic non metastatic- Paraneoplastic Nonspecific

Lung tumors- the 4 Ms

Mass effect Metabolic effect Metastases Medications Cessation of smoking, physiotherapy, brochodilators, antibiotics

Smoking
12-24 hrs- CO and nicotine 48-72 hrs-COHb levels , ciliary function 1-2 wks- sputum production 4-6 wks- PFTs improve 6-8 wks- immune fn, metabolism 8-12 wks- PO morbidity and mortality

Monitoring
Tier1- SpO2, PETCO2, PIP, ECG, NIBP, ABP, CVP, FOB after DLP Tier2- ABG, Spirometry, FOB supine+LDP,ABP, CVP, PA, TEE Tier3- VBG, QS/QT, resisitance, Frequent FOBs,PA, ABP, CVP, TEE

Indications for One-Lung Ventilation

Absolute 1. One lung isolation to prevent contamination of the healthy lung a. Infection b. Hemorrhage 2. Regulate distribution of ventilation to one lung a. Bronchopleural fistula b. Bronchopleural cutaneous fistula c. Unilateral cyst or bullae d. Major bronchial disruption or trauma 3. Unilateral lung lavage

Indications for One-Lung Ventilation- Contd.

Relative 1. Surgical exposure a. Thoracic aortic aneurysm b. Pneumonectomy c. Upper lobectomy d. Esophageal surgery e. Middle and lower lobectomy f. Thoracoscopy under general anesthesia g. Video assisted thoracoscopic procedures

Methods of lung isolation

placement of a double-lumen endobronchial tube-DLT use of a single-lumen endotracheal tube in conjunction with a bronchial blockerFogarty, Arnoldt,Coopdec, univent tube use of a single lumen endobronchial tube.

DLT
Carlens Robertshaw PVC Robertshaw- Mallinckrodt, Sheridan, Rusch and Portex Two tubes held side by side

DLT

Available DLT
35, 37, 39, 41 Fr Newer sizes are- 26 Fr (left), 28 Fr (Left) and 32 Fr.

Size selection of DLT

Height
  

46 to 55-35 to 37 Fr 55 to 510- 37 to 39 Fr 511 to 64- 39 to 41 Fr

Measured tracheal width in CXR Measured bronchial diameter in CT scan Age 32, 28, 26 Fr for 12, 10 and 8 year old

Sizing of DLT
Tracheal width (mm) 18 16 15 14 12.5 11 Bronchial diameter (mm) 12 12 11 10 <10 L DLT (Fr) 41 39 37 35 32 28

Side of DLT- Choice

General- Non operated bronchus be intubated R DLT more chance of malposition L DLT for all surgery

FOB

Size relashionship

Placement and positioning of DLT

Blind technique Directed fibreoptic technique

L DLT placement

Confirmation- Auscultation

FOB confirmation- L DLT

FOB confirmation- R DLT

Other methods
CXR Capnography, spirometry and flow-vol/ pressure- vol loops Manual palpation by surgeon

Other points
Depth of insertion Cuff seal pressure-15-30 mm Hg Bronchial cuff- 1-3 ml Adequate cuff seal in bronchopulmonary lavage DLT in difficult airway DLt to SLT at the end of surgery

Contraindications to DLT
Known or anticipated difficult DLT placement Distorted airway anatomy Small airway or patient Unstable patient

Contraindications to L DLT
L sided carinal lesion L bronchial lesion L bronchial stent/ stricture Aortic aneurysm L lung transplant Sleeve resection of L main bronchus

Complications of DLT
Tracheal or bronchial disruption Malpositioning of DLT Traumatic laryngitis Suturing of DLT with intrathoracic structure

Univent tube

Advantages of univent tube

Less traumatic than DLT Easy to insert and position Can be positioned during surgery Can be used to collapse either a lobe or a lung Useful in difficult airway Can be used in tracheostomy patients Rapid lung isolation can be achieved Postoperative ventilation tube change not required

Limitation
Slow deflation of the lung Slow re-inflation Blockade of the BB lumen intraop Leak of BB cuff

BB cuff seal
Air bubble detection test Capnography

Indications for univent tube

Planned PO ventilation Alteration of patient position- thoracic surgery Distorted airway Alternate blockade of both lungs

Complications
Malposition and dislodgement Inadequate seal Inclusion in surgical suture Tracheal lumen obstruction by BB Negetive pressure pulmonary edema

BB placement

Arndt blocker

Spont vent with open chest

LDP- Physiology

LDP- Anesthesia

OLV- Blood flow

Shunt in OLV

Risk of desaturation
V/Q in operated lung PaO2 in two lung ventilation in LDP Side of thoracotomy Normal spirometry preop Supine one lung ventilation

Management of OLV
Confirm proper tube placement and patency Two lung ventilation until pleura open Initial conventional OLV- FIO2, TV, RR Modified OLV for hypoxemia

Hypoxia during OLVtreatment

High FIO2 CPAP to non-dependent lung Cardiac output PEEP to dependent lung? Clamping Pulm artery HFJV to the non-dependent lung Pharmacological- iNO, almitrene

PO complications
Herniation of heart Pulmonary torsion Hemorrhage BPF Respiratory insufficiency Pulmonary edema R heart failure Neural injuries

Pain management
Cryoanalgesia Thoracic epidural Interpleural analgesia