Running head: ONE-LUNG VENTILATION CONSIDERATIONS 1

One-Lung Ventilation Considerations Regarding Anesthesia Practice

Emily A. Covington
The University of Kansas















ONE-LUNG VENTILATION CONSIDERATIONS 2
One-Lung Ventilation Considerations Regarding Anesthesia Practice
When delivering general anesthesia, bilateral lung mechanical ventilation is generally
performed to maximize the patients pulmonary status and safety. Conversely, there are several
disease processes and surgical procedures that require an alternative to two-lung ventilation.
One-lung ventilation (OLV) separates the right and left lungs, allowing each lung to function
independently. The anesthesia provider can provide safe thoracic anesthesia, by selectively
ventilating one lung per surgeon request (Rieker, 2010). There are many indications for lung
separation; this technique provides the surgeon with a methodical surgical field (Rieker, 2010).
In addition, while OLV delivers an auspicious operating environment, numerous perioperative
and anesthesia considerations exist influencing patient outcomes.
Separation of the right and left lung is indicated as either absolute or relative (Rieker,
2010). Absolute indications for lung separation include prevention of contamination, control of
distribution of ventilation, and unilateral bronchopulmonary lavage (Rieker, 2010). Frequently,
thoracic surgeons believe pulmonary surgeries should utilize the lung separation technique
(Rieker, 2010). Surgical exposure and unilateral pulmonary embolectomy are classified as
relative indications (Rieker, 2010). Nonetheless, relative indications of OLV can be safely
implemented without the use of lung separation (Rieker, 2010).
There are two methods utilized to achieve lung separation: double-lumen endotracheal
tube (DLT) and bronchial blockers (Twite, 2011). The DLT technique is most commonly used
in the operating room setting to attain OLV. Appropriate selection of the DLT should include
the largest tube that will atraumatically advance through the glottis and fit in the bronchus while
maintaining a minor air leak when the cuff is deflated (Twite, 2011). This approach is
designated for lung protection, bronchoalveolar lavage, and surgical exposure (Levine, 2010).
ONE-LUNG VENTILATION CONSIDERATIONS 3
By using a DLT for severe hemoptysis or unilateral infection, lung protection is provided by
segregating the contaminated lung from the healthy lung (Twite, 2011). Specifications
associated with the DLT are the endotracheal and endobronchial lumen (Twite, 2011). The
bifurcated tube is used to separate and provide selective ventilation; however, this approach also
predisposes patients to independent lung collapse (Twite, 2011).
When the typical DLT method cannot be utilized, the bronchial blocker method is best
used to separate the right lung from the left (Levine, 2010). By using this approach, the
bronchus is impeded distal to the blocker permitting lung collapse and isolation (Twite, 2011).
Pediatric populations and individuals with difficult airway anatomy benefit most from the
bronchial blocker technique (Levine, 2010).
In comparison, both the DLT and bronchial blocker technique provided equivalent lung
separation (Dugas et al., 2009). However, positioning of the bronchial blocker required
approximately 110 seconds longer than placement of the DLT. The bronchial blocker also
necessitated additional intraoperative positioning (Narayanaswamy et al., 2009). The
aforementioned are imperative considerations when developing the anesthetic plan.
While OLV has several benefits, it also has various associated complications. Adverse
events accompanying lung separation leading to hypoxemia include bronchial cuff herniation,
malposition, tracheal rupture, postoperative hoarseness, and vocal cord lesions (Neustein,
Eisenkraft, & Cohen, 2009). During OLV, the inspired oxygen concentration is typically
delivered at 100% to prevent hypoxemia (Brodsky & Lemmens, 2003). During each position
change, the anesthesia provider should protect the endobronchial tube or blocker to prevent
malposition and ventilation perfusion alterations (Rieker, 2010). If hypoxemia occurs, the
provider should immediately assess the tube for malposition (Rieker, 2010). Hypoxemia may be
ONE-LUNG VENTILATION CONSIDERATIONS 4
due to bronchospasm, decreased cardiac output, hypoventilation, intrapulmonary shunting of the
operative lung, or a dependent lung pneumothorax (Rieker, 2010). Since the 1970s, a marked
reduction in the incidence of intraoperative hypoxemia has occurred due to new technology and
research (Slinger, 2009).
When providing OLV, adequate arterial oxygenation is the primary goal (Rieker, 2010).
According to Camici et al. (1997), pressure-controlled and volume-controlled ventilation
demonstrated no substantial difference in improving arterial oxygenation; however, pressure
control ventilation is still the preferred method as it provides lower peak airway pressures
(Neustein et al., 2009). When delivering thoracic anesthesia, dual-lung ventilation should be
sustained until the surgeon declares lung separation necessary (Rieker, 2010). Providing a
physiologic tidal volume and positive end-expiratory pressure (PEEP) improves oxygenation and
reduces partial pressures of arterial carbon dioxide (Rieker, 2010). Former OLV standards
included delivery of high tidal volumes, yet high volumes portray indications associated with
acute lung injury (Rieker, 2010). Current research advises against high tidal volumes due to the
risk of volutrauma, the increase of inflammatory mediator release, and the outflow of
procoagulant substances (Rieker, 2010).
Initially the inspired oxygen concentration is delivered at 100%; however, 30 minutes
following adequate OLV the anesthesia provider should decrease the oxygen concentration to
prevent absorptive atelectasis (Rieker, 2010). Supplying the nonventilated lung with continuous
positive airway pressure (CPAP) results in increasing the partial pressure of arterial oxygen;
conversely, delivering too much positive pressure diminishes the surgical field due to inflation of
the nondependent lung (Rieker, 2010, p. 643). To prevent reduction of the surgical environment,
the provider should begin CPAP delivery at 2 cm of water (Rieker, 2010).
ONE-LUNG VENTILATION CONSIDERATIONS 5
If this technique does not improve oxygenation, applying PEEP to the ventilated lung will
promote oxygenation by recruiting collapsed alveoli, promoting lung compliance, and improving
functional residual capacity (Rieker, 2010). Conversely, delivery of vast amounts of PEEP will
create over inflation of the alveoli leading to additional dead space ventilation (Rieker, 2010). If
CPAP and PEEP delivery is ineffective, communication with the surgeon regarding pulmonary
artery ligation is essential. Subsequently, absence of adequate oxygenation indicates the need for
two-lung ventilation (Rieker, 2010).
General anesthesia in combination with a thoracic epidural is the recommended treatment
of choice for lung separation (Levine, 2010). Benefits include reduction of atelectasis,
prevention of pneumonia, and abatement of respiratory failure (Rieker, 2010). However, high
dose local anesthetic epidurals are linked to intrapulmonary shunting and hypoxemia (Levine,
2010). The goal for induction is to administer an anesthetic that prevents reaction of the airway
and produces bronchodilation (Neustein et al., 2009). Sevoflurane is primarily used for
induction due to its modicum pungency (Neustein et al., 2009). Thiopental and propofol are also
safe for induction, thus ketamine may be preferred because of its bronchodilatory effects
(Neustein et al., 2009). Both intermediate and long-acting neuromuscular blocking agents depict
post-operative residual curarization; therefore, shorter-acting relaxants are recommended
(Rieker, 2010). Isoflurane provides cardiovascular stability and is utilized intraoperatively
(Neustein et al., 2009). Research suggests that no disadvantages are associated with opioid and
hypnotic administration when providing lung isolation (Rieker, 2010). The anesthesia provider
should avoid using nitrous oxide due to the risk of decreasing oxygen saturation (Rieker, 2010).
Chen, Ran, Story, Wang, and Zhong (2009) compared postoperative complications
accompanying DLT and bronchial blocker placement. Postoperative hoarseness and vocal cord
ONE-LUNG VENTILATION CONSIDERATIONS 6
lesions were more prominently detected with the DLT technique (Chen et al., 2009).
Postoperative hoarseness is a nuisance associated with OLV; contrariwise, bilateral vocal cord
paralysis may present as a more severe complication (Neustein et al., 2009). Ipsilateral damage
to the vocal cord abductor muscles can result in atypical adduction leading to hoarseness
(Wilson, 2011). Furthermore, bilateral destruction of the recurrent laryngeal nerves may lead to
complete airway obstruction and is classified as an emergent situation (Wilson, 2011).
Overall, there are many aspects of the anesthetists armamentarium concerning the
delivery of innocuous thoracic anesthesia. Lung isolation is frequently utilized in thoracic
surgery to provide effortless manipulation of the surgical field. Like any surgical procedure,
OLV has numerous clinical benefits, but it is not without its disadvantages. Various patient
situations determine which anesthesia technique is acceptable for outcome promotion. Many
serious complications are possible with OLV; therefore, the anesthesia provider should be
vigilant in maintaining an adequate airway and communicating with the surgeon.










ONE-LUNG VENTILATION CONSIDERATIONS 7
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