Chapter 48: One-Lung Ventilation

INDICATIONS FOR ONE-LUNG VENTILATION (OLV)

Lung separation to prevent pus or blood spillage from an infected or bleeding source is an absolute indication for OLV. Bilateral contamination may lead to life-threatening infection or inability to oxygenate or ventilate a patient. Fistulas may provide a low resistance pathway for positive-pressure ventilation (PPV) that compromises alveolar ventilation. Large cysts or bullae are susceptible to rupture under PPV. Many thoracic procedures involving the lungs or mediastinum are technically difficult and benefit from OLV. Lung isolation assists with optimal surgical exposure and a “quiet” surgical field. OLV can also help minimize lung trauma from retractors and manipulation.

Absolute Indications

1. Isolation of each lung to prevent contamination of a healthy lung

   1. Infection (abscess, infected cyst)

   2. Massive hemorrhage

2. Control of distribution of ventilation to only one lung

   1. Bronchopleural fistula

   2. Bronchopleural cutaneous fistula

   3. Unilateral cyst or bullae

   4. Major bronchial disruption or trauma

3. Unilateral lung lavage

4. Video-assisted thorascopic surgery

Relative Indications

1. Surgical exposure—high priority

   1. Thoracic aortic aneurysm

   2. Pneumonectomy

   3. Upper lobectomy

2. Surgical exposure—low priority

   1. Esophageal surgery

   2. Middle and lower lobectomy

   3. Thoracoscopy under general anesthesia

LUNG SEPARATION TECHNIQUES

Double-Lumen Tube (DLT)

A double-lumen endobronchial tube has two bonded plastic tubes that allow for ventilation of each of the two lungs. This allows for isolated ventilation of one or two lung ventilation depending on the procedural needs. The DLT is named right or left depending on which of the two lumens is engineered to fit into a specific main stem bronchus. The opposite lumen terminates in the trachea. The tracheal and bronchial lumens each have their own cuff to assist with lung isolation. The more distal bronchial lumen has a blue cuff that can be more easily identified with bronchoscopy during placement.

The majority of DLTs are left-sided because uniform ventilation to all lobes is most feasible. Possible blockage of the right upper lobe take off may occur with right-sided DLT placement. However, right-sided DLT placement may be indicated due to pathology of the left mainstem such as endoluminal tumors, strictures, or bronchial stenosis. Fiber-optic confirmation is required for all right-sided DLT intubations due to the high likelihood for the bronchial lumen to be advanced to deeply. Up to 90% of right-sided DLTs that rely on physical examination alone are malpositioned.

During placement of the DLT, the bronchial cuff is advanced beyond the vocal cords and the tube is rotated 90° as it is advanced further into the left main stem bronchus where moderate resistance is encountered. Force should not be applied in order to avoid airway trauma. Following initial placement of a DLT, one must confirm appropriate positioning with fiber-optic bronchoscopy and physical exam findings that include observation of chest rise and chest auscultation. A malpositioned tube may involve a DLT too deep into the left mainstem, ...