ONE-LUNG VENTILATION(OLV):

TECHNIQUE AND ANAESTHETIC

CONSIDERATIONS

Cechina Elena,
Medic Rezident ATI
Catedra Anestesteziologie si
Reanimatologie Nr 1 “V. Ghereg”
INTRODUCTION
-One-lung ventilation, OLV, means separation of
the two lungs and each lung functioning
independently by preparation of the airway
- 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
because of:
• Difficult to place lung isolation equipment
• Ability to overcome hypoxic pulmonary
vasoconstriction
• Patient population is comparably
• OLV provides:
• Protection of healthy lung from infected/bleeding one
• Diversion of ventilation from damaged airway or lung
• Improved exposure of surgical field
• OLV causes:
• More manipulation of airway, more damage
• Significant physiologic change and easily development of
hypoxemia
• 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
ABSOLUTE INDICATION FOR
OLV
•Isolation of one lung from the other
to avoid spillage or contamination
• Infection
• Massive hemorrhage
•Control of the distribution of
ventilation
• Bronchopleural / - cutaneous fistula
• Surgical opening of a major conducting airway
• giant unilateral lung cyst or bulla
• Tracheobronchial tree disruption
• Life-threatening hypoxemia due to unilateral lung disease
•Unilateral bronchopulmonary lavage
RELATIVE INDICATION
• Surgical exposure ( high priority)
• Thoracic aortic aneurysm
• Pneumonectomy
• Upper lobectomy
• Mediastinal exposure
• Thoracoscopy
• Surgical exposure (low priority)
• Middle and lower lobectomies and subsegmental resections
• Esophageal surgery
• Thoracic spine procedure
• Minimal invasive cardiac surgery (MID-CABG, TMR)
• Postcardiopulmonary bypass status after removal of
totally occluding chronic unilateral pulmonary emboli
• Severe hypoxemia due to unilateral lung disease
OLV is achieved by either:

-Double lumen ETT (DLT)

-Bronchial blocker

-Endobronchial single tube

Double-lumen endotracheal tube, DLT

Single-lumen ET with a built-in bronchial blocker,
Univent Tube Single-lumen ET with an isolated bronchial blocker
Arndt (wire-guided) endobronchial blocker set
Balloon-tipped luminal catheters
Endobronchial intubation of a single-lumen ET
Anatomy of the Tracheobronchial Tree
Features of DLT

RUL, right upper lobe; LUL, left upper lobe

 DLT

• Type:
• Carlens, a left-sided + a carinal hook
• White, a right-sided Carlens tube
• Bryce-Smith, no hook but a slotted cuff/Rt
• Robertshaw, most widely used
• All have two lumina/cuffs

• Available size: 41,39, 37, 35, 28

French (ID=6.5,
6.0, 5.5, 5.0 and 4.5 mm
respectively)
 Left DLT…
• Most commonly used
• The bronchial lumen is longer, and a simple round opening and symmetric cuff
Better margin of safety than Rt DLT
• Easy to apply suction and/or CPAP to either lung
• Easy to deflate lung
• Lower bronchial cuff volumes and pressures
• Can be used
• Left lung isolation: clamp
bronchial + ventilate/
tracheal lumen
• Right lung isolation:
clamp tracheal +
ventilate/bronchial lumen
…Left DLT
• More difficult to insert (size and curve, cuff)
• Risk of tube change and airway damage if kept in
position for post-op ventilation
• Contraindication:
• Presence of lesion along DLT pathway
• Difficult/impossible conventional direct vision
intubation
• Critically ill patients with single lumen tube in situ who
cannot tolerate even a short period of off mechanical
ventilation
• Full stomach or high risk of aspiration
• Patients, too small (<25-35kg) or too young (< 8-12 yrs)
Right DLT: bronchoscopic view
Different types of DLT

Carlens White Bryce Smith Robertshaw

lume
n
hoo + + - -
k
L R Lt & Lt &
side
t t Rt Rt
Rt Lt
Lt
passage of the left-sided DLT
guide for Length and Size of DLT
Length of tube , For 170 cm height, tube depth of 29 cm
For every 10 cm height change , 1 cm depth change

Patient characteristics Tube size (Fr gauge)

Tracheal width ( mm):
18 41

16 39

15 37

14 35
Patient height
4’ 6”-5’5” 35-37

5’5”-5’10” 37-39

5’11”-6’4” 39-41
Patient age ( year)
13-14 35

12 32

10 28 (lt only)

8 26 (lt only)
 Check Position of Lt -DLT
Checklist for tracheal placement
a. inflate tracheal cuff
b. ventilate rapidly by hand
c. check that both lungs are being
ventilated
d. If not, withdraw 2-3 cm & repeat
Chec klis t for Lt side Chec klis t for Rt side
a. inflate Lt cuff > 2ml a. clamp Lt tube
b. ventilate and check bilateral b. check unilateral (Rt)
breath sounds breath sounds
c.clamp Rt tube
d.check unilateral (Lt) breath
sounds
Major Malpositions of a Lt- DLT
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

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
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
DLT
Placement
To ensure correct position of DLT clinically :

* breath sounds are

- normal (not diminished) &
- follow the expected unilateral pattern with unilateral clamping

* the chest rises and falls in accordance with the breath sounds

* the ventilated lung feels reasonably compliant

* no leaks are present

*respiratory gas moisture appears and disappears with each tidal ventilation
FOB picture of Lt - DLT
FOB picture of Rt DLT
Other Methods to Check DLT Position

* Chest radiograph ;
may be more useful than conventional auscultation and clamping in some
patients, but it is always less precise than FOB. The DLT must have
radiopaque markers at the end of Rt and Lt lumina.

*Comparison of capnography;
waveform and ETCO2 from each lumen may reveal a marked discrepancy
(different degree of ventilation).

* Surgeon ;
may be able to palpate, redirect or assist in changing DLT position from
within the chest (by deflecting the DLT away from the wrong lung, etc..).
Adequacy for Sealing (air Bubble test )
 Complications of DLT

*impediment to arterial oxygenation for OLV

*tracheobronchial tree disruption, due to

-excessive volume and pressure in bronchial balloon
-inappropriate tube size
-malposition

* traumatic laryngitis (hook)

*inadvertent suturing of the DLT

to avoid Tracheobronchial tree Disruption ;
1. Be cautious in patients with bronchial wall abnormalities.

2. Pick an appropriately sized tube.

3. Be sure that tube is not malpositioned ; Use FOB.

4. Avoid overinflation of endobronchial cuff.

5. Deflate endobronchial cuff during turning.

6. Inflate endobronchial cuff slowly.

7. Inflate endobronchial cuff with inspired gases.

8. Do not allow tube to move during turning.

Relative Contraindications to Use of DLT
* full stomach (risk of aspiration);

* lesion (stricture, tumor) along pathway of DLT (may be traumatized);

* small patients;

*anticipated difficult intubation;

*extremely critically ill patients who have a single-lumen tube already in place and
who will not tolerate being taken off mechanical ventilation and PEEP even for a
short time;

* patients having some combination of these problems.

Under these circumstances , it is still possible to separate the

lungs by :
-using a single-lumen tube + FOB placement of a bronchial
blocker ; or
Advantage
s

 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

Another indication for DLT:
Reexpansion pulmonary edema
Disadvantage
s

• 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
Bronchial Blockers
(With Single-Lumen Endotracheal Tubes)

Lung separation can be effectively achieved with the use of a

single-lumen endotracheal tube and a FOB placed bronchial
blocker.

Often necessary in children as DLTs are too large to be used in

them. The smallest DLT available is a left-sided 26 Fr tube,
which may be used in patients 8 -12 years old and weighing 25
-35 kg.

Balloon-tipped luminal catheters have the advantage of allowing

suctioning and injection of oxygen down the central lumen.
Types of bronchial blockers

* Univent bronchial blocker system

* Arndt endobronchial blocker

* Cohen Flexitip Endobronchial Blocker

* BB independent of a single-lumen tube

Univent bronchial blocker system
Univent
Tubes
 Univent Tube...
• Developed by Dr. Inoue
• Movable blocker shaft in external
lumen of a single-lumen ET tube
• Easier to insert and properly
position than DLT (diff airway, C-s
injury, pedi or critical pts)
• No need to change the tube for
postop ventilation
• Selective blockade of some lobes
of the lung
• Suction and delivery CPAP to the
blocked lung
 ...Univent Tube

• Slow deflation (need suction)

and inflation (short PPV or jet
ventilation)
• Blockage of bronchial blocker
lumen
• Higher endobronchial cuff
volumes +pressure (just-seal
volume recommended)
• Higher rate of intraoperative leak
in the blocker cuff
• Higher failure rate if the blocker
advanced blindly
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
Univent BB vc DLT
1. Easier to insert and properly position.

2. Can be properly positioned during continuous ventilation and

in the lateral decubitus position.

3.No need to change the tube when turning from the supine to
prone position or for postoperative mechanical ventilation.

4. Selective blockade of some lobes of each lung.

5. Possible to apply CPAP to nonventilated operative lung.

 Disadvantage
s
• 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.
Limitations to the Use of Univent
Bronchial Blocker

LIMITATION SOLUTION
1. Slow inflation time (a)Deflate BB cuff and administer +ve pressure breath
through the main single lumen;
(b)carefully administer one short high pressure (20–30
psi) jet ventilation
2. Slow deflation time (c) Deflate BB cuff and compress and evacuate the lung
through the main single lumen;
(b)apply suction to BB lumen
3.Blockage of BB Suction, stylet, and then
lumen suction
( blood, pus,..)
4. High-pressure Use just-seal volume of air
cuff Make sure BB cuff is subcarinal, increase inflation volume,
5. Leak in BB cuff rearrange surgical field
Arndt endobronchial blocker
[Wire guided Endobronchial Blocker (WEB)]
Wire-Guided Endobronchial
Blockers
• Available
sizes
• Adult 9 Fr
• Pediatric 5 Fr
Comparison of Various Tube
Diameters
Wire-Guided Endobronchial
Blockers
Wire-Guided Endobronchial
Blockers
Fogarty Embolectomy
Catheters
 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
• sealing
Once the the airwayis in place, the balloon is inflated,
catheter
• 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
Cohen Flexitip Endobronchial Blocker
 Independent
Single-Lumenof a
Tube
Adults
-Fogarty (embolectomy) catheter with a 3 ml balloon.
It includes a stylet so that it is possible to place a curvature at the distal tip to facilitate entry into the
larynx and either mainstem bronchus .

-balloon-tipped luminal catheters (such as Foley type) may be used as bronchial blockers.

Very small children (10 kg or less)

- Fogarty catheter with a 0.5 ml balloon

- Swan-Ganz catheter (1 ml balloon)

* these catheters have to be positioned under direct vision; a FOB method is perfectly acceptable; the FOB outside
diameter must be approximately 2 mm to fit inside the endotracheal tube (3 mm internal diameter or greater).
Otherwise, the bronchial blocker must be situated with a rigid bronchoscope.

* Paediatric patients of intermediate size require intermediate size occlusion catheters and judgment on the mode of
placement (i.e., via rigid versus FOB).
Lung separation with a single-lumen tube, FOB, and Rt
lung bronchial blocker
 Single-Lumen Tubes
* In adults, is often the easiest, quickest way for lung separation in patients
presenting with haemoptysis , either
-blind, or
-FOB , or
-guidance by surgeon from within chest

* In children it may be the simplest way to achieve OLV

Disadvantages
-inability to do suctioning or ventilation of operative side.
-difficult positioning bronchial cuff with inadequate ventilation of
Rt upper lobe after Rt endobronchial intubation.
 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
Complications - Bronchial
Rupture
Comparing Up Right & Lateral
Decubitus Position

05/21/15
• Distribution of blood flow and ventilation is similar to that in the
upright position but turned by 90 degrees.
• Blood flow and ventilation to the dependent lung are significantly
greater than to the nondependent lung.
• Good V/Q matching at the level of the dependent lung results in
adequate oxygenation in the awake patient breathing
spontaneously.

• In Lateral Decubitus Position (LDP), ordinarily less Zone 1- due to

vertical hydrostatic gradient is less in LDP than upright.
• % of Blood flow to lungs according to position; In upright/Supine-Rt
55% Lt 45%; In LDP Rt NDL 45% Lt DL 55%; In LDP Lt NDL 35% RT
DL 65%
74
1) Ldp/ awake/ Spont Breath/ Closed
Chest
• Dependent lung (DL) receives
• >perfusion (gravity)
• >ventilation

• Reasons why >ventilation:

• Contraction of dependent hemidiaphragm became > efficient as it
assumes higher position in the chest due to its disproportionate dome
shape supporting the weight of abdominal content
• Dependent lung > favorable part of compliance curve

• Thus in LDP/ Awake/Spont/ Closed; -DL receives > ventilation

regardless which side pt is lying

05/21/15 HSNZ KT
2) Ldp/ awake/ Spont Breath/ open Chest

2 complications
1. Mediastinal shift, occurring during inspiration.
Negative pressure more in intact hemithorax
cause the mediastinum to move vertically
downward and push into the dependent
hemithorax.
• create circulatory & reflex changes, result in a clinical
picture similar to that of shock and respiratory distress.
• Eg. Thoracoscopy  LA, pt may need intubated
immediately, with initiation of positive-pressure
ventilation
Ldp/ awake/ Spont Breath/ open Chest

2. Paradoxical breathing:
• During inspiration, movement of gas from the exposed
lung into the intact lung and movement of air from the
environment into the open hemithorax cause collapse
of the exposed lung.
• During expiration, the reverse occurs, and the exposed
lung expands
2) Ldp/ awake/ Spont Breath/ open Chest

05/21/15 HSNZ KT
Respiratory Physiology (lateral
decubitus position) in anaesthetised pt
Factors affecting respiratory physiology
in lateral decubitus position
The changes further accentuated by several factors:
1) Induction of anesthesia
2)Initiation of mechanical ventilation
3)Use of neuromuscular blockade
4)Opening the chest/pleural space
5)Surgical Retraction/ Compression
6)Pressure by mediastinum/
Abdominal content

• Perfusion continue to favor dependent lung (Due to gravitational

effect)
• Ventilation favor the less perfused lung.
• End result is V/Q mismatch(shunt) giving rise to hypoxemia.
Olv/ Anaesthetized / Paralysed/ Open Chest

05/21/15 HSNZ KT
 Awake/Closed Anaesthetised
Closed
V/Q V Q V Q V Q
Open

NDL
DL

SUMMARY OF V/Q RELATIONSHIP

IN AWAKE & ANAESTHETISED PT
05/21/15 HSNZ KT
 Physiology of OLV
• The principle physiologic change of OLV is the redistribution of
lung perfusion between the ventilated (dependent) and blocked
(nondependent) lung
• Many factors contribute to the lung perfusion, the major
determinants of them are hypoxic pulmonary vasoconstriction
(HPV) and gravity.
 Summary of factors influencing
pulmonary/ lung perfusion

05/21/15 HSNZ KT
 Physiology of OLV
(Arterial Oxygenation and Carbon Dioxide Elimination)

Blood passing through :

- non ventilated lung , retains CO2 and does not take O2.
but cannot take up a
- over ventilated lung , gives off more than a normal amount of CO2
proportionately increased amount of O2 .
Hypoxic pulmonary vasoconstriction
(hpv)
• HPV, a local response of pulmonary vascular smooth muscle
(PVSM), decreases blood flow to the area of lung where a low
alveolar oxygen pressure is sensed.
• Intrinsic response of lung, no neuronal control, immediately
present in transplanted lung.
• The mechanism of HPV is not completely understood. Vasoactive
substances released by hypoxia or hypoxia itself (K+ channel)
cause pulmonary artery smooth muscle contraction.
• All pulmonary arteries and veins vasoconstric in response to
hypoxia, but greatest effect is to small pumonary
arteriesm(200mm)
Hypoxic pulmonary vasoconstriction
(hpv)

• HPV aids in keeping a normal V/Q relationship by diversion of blood

from underventilated areas, responsible for the most lung perfusion
redistribution in OLV.
• HPV is graded and limited, of greatest benefit when 30% to 70% of
the lung is made hypoxic.
• But effective only when there are normoxic areas of the lung
available to receive the diverted blood flow

05/21/15 HSNZ KT
Factors that might determine the amount of regional HPV
1. Distribution of the alveolar hypoxia is probably not a determinant of the amount of HPV; all regions of the lung
respond to alveolar hypoxia with vasoconstriction.

2. Atelectasis, most of blood flow reduction in acutely atelectatic lung is due to HPV and none of it to passive
mechanical factors (such as vessel tortuosity).

3. Vasodilator drugs, most of them inhibit regional HPV

4. Anaesthetic drugs

5. Pulmonary vascular pressure, HPV response is

-maximal at normal PVP and
-decreased at either high or low PVP.

6. Pv¯O2 , HPV response also is

-maximal when Pv¯O2 is normal and
-decreased by either high or low Pv¯O2.

7. FIO2 selectively decreasing the FIO2in the normoxic compartment causes an increase in normoxic lung vascular
tone, thereby decreasing blood flow diversion from hypoxic to normoxic lung.

8. Vasoconstrictor drugs constrict normoxic lung vessels preferentially, thereby disproportionately increasing
normoxic lung PVR causing decrease normoxic lung blood flow and increase atelectatic lung blood flow.

9. PaCO2 , hypocapnia inhibits & hypercapnia directly enhances regional HPV.

10. PEEP
Other Causes of Hypoxaemia During OLV

* Failure of the oxygen supply.

* Gross hypoventilation of the dependent lung.

* Blockage of the dependent lung airway lumen e.g. by secretions

*Malposition of the DLT (decreased cardiac output, increased

* Decrease of Pv¯O2
consumption [excessive oxygen sympathetic nervous
hyperthermia, shivering]) system stimulation,

*Transfusion of blood may cause pulmonary dysfunction attributed to the

action of isoantibodies against leukocytes, which causes cellular
aggregation, microvascular occlusion, and capillary leakage.
Shunt and OLV
• Physiological (postpulmonary) shunt
• About 2-5% CO,
• Accounting for normal A-aD02, 10-15 mmHg
• Including drainages from
• Thebesian veins of the heart
• The pulmonary bronchial veins
• Mediastinal and pleural veins

• Transpulmonary shunt increased due to continued

perfusion of the atelectatic lung and A-aD02 may
increase
Cardiac output and OLV

• Decreased CO may reduce SvO2 and thus impair

SpO2 in presence of significant shunt
• Hypovolemia
• Compression of heart or great vessels
• Thoracic epidural sympathetic blockade
• Air trapping and high PEEP

• Increased CO increases PA pressures which

increases perfusion of the non-ventilated lung →
increase of shunt fraction
Management of OLV...

• Maintain two-lung ventilation as long as possible

•Start OLV with 100% O then start backing off the FiO if
2 2

saturations are OK
• Manual ventilation for the first few minutes of OLV to
get a sense of pulmonary compliance / resistance
• Be attentive to inspiratory pressures and tidal volumes
and adjust the ventilator to optimize oxygenation and
alveolar ventilation, with minimal barotrauma
• Look at the surgical field to see if the non-dependent
lung is collapsed
...Management of OLV

• Tidal volume = 4-6-8-10 ml/kg

• Adjust RR (increasing 20-30%) to keep PaCO = 40 mmHg
2

• No PEEP (or very low PEEP, < 5 cm H O)

2

• Continuous monitoring of oxygenation and ventilation (SpO , ABG and ET CO )

2 2
Other causes of hypoxemia
in OLV
•Mechanical failure of O2 supply or airway
blockade
• Hypoventilation
•Resorption of residual O2 from the clamped
lung

•Factors that decrease SvO2 (CO,  O 2

consumption)
Management of hypoxemia during
OLV
•FiO2 = 1.0
•Manual ventilation
•Check DLT position with FOB
•Check hemodynamic status
•CPAP (5-10 cm H2O, 5 L/min) to nondependent lung, most
effective

•PEEP (5-10 cm H2O) to dependent lung, least effective

•Intermittent two-lung ventilation
 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
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
Ventilatory Management of OLV

• Conventional Ventilatory Management

• Differential Lung Ventilation Management

• High-Frequency Ventilation Management

• Low-Flow Apnoeic Ventilation (Apnoeic Insufflation)

Conventional Ventilatory Management

•Maintain two-lung ventilation as long as possible.

•Use FIO2 = 1.0

•Begin OLV with tidal volume of 10 ml / kg.

•Adjust respiratory rate so that PaCO2 ~ 40 mmHg.

•Continuous monitoring of oxygenation and

ventilation.
Differential Lung Ventilation Management

-Intermittent Inflation of the Nondependent Operative Lung

may be expected to increase PaO2 for a variable period of time.

- Selective Dependent Lung PEEP

- Selective Nondependent Lung CPAP (without tidal ventilation)

-Differential Lung PEEP/CPAP

 The Mallinckrodt Broncho-Cath CPAP System
(Photography courtesy of Mallinckrodt Medical, Inc., St. Louis, MO.)
High-Frequency Ventilation (HFV)
Management

HFV delivers , very small VT (<2 ml/kg)

at high rates (60 - 2,400 breaths/min)

• can be delivered through very small catheters

• it decreases PAWP

it may be uniquely useful in facilitating the performance of thoracic surgery in

the following three ways;
-Use in Major Conducting Airway Surgery
-Use in Bronchopleural Fistula
-Use in Minimizing Movement of the Operative Field
Low-Flow Apnoeic Ventilation
(Apnoeic Insufflation)
• If left
ventilation is stopped during administration of 100 % O2 and airway is
connected to a fresh gas supply, O2 will be drawn into the lung by mass
movement to replace the diffused O2 . There is usually no difficulty in
maintaining an adequate PaO2 (especially if 5–10 cmH2O of CPAP is used) at
least for 20 minutes .

• If flow of O is relatively low (<0.1 L/kg/min) almost all CO produced is retained, and
2 2

PaCO2 rises approximately 6 mmHg in the 1st minute and then 3 - 4 mmHg
each minute thereafter .

• Safe period < 10 min

• arterial oxygen saturation monitoring via pulse oximetry is mandatory.

Thoracotom
y
Thoracotomy with Lung
Deflated
VAT
S
VAT
S
VAT
S
 Take away messages
• OLV widely used in cardiothoracic surgery
• Many methods can be used for OLV. Optimal
methods depends on indication, patient factors,
equipment, skills and level of training
• FOB is the key equipment for OLV
• Principle physiologic change of OLV is the
redistribution of pulmonary blood flow to keep an
appropriate V/Q match
• Management of OLV is a challenge for the
anesthesiologist, requiring knowledge, skill,
vigilance, experience, and practice
Thank you!