Thoracic anaesthesia One lung ventilation

Anaesthesia for thoracic surgery
Dr gaurav joshi JR2 (presenter)
Dr Jyoti SR (Moderator)

Pre op Evaluation
 To asses patients for anaesthesia it is necessary to
understand to risk specific about type of surgery and
risk related to surgery in general
 Respiratory complications are the major cause of
perioperative morbidity and mortility thoracic
patients.
 Preoperative evaluation includes History, Physical
examinations, Investigations

History
 H/o smoking and symptoms suggestive of COPD and
ischemic heart diease should be elicited.
 H/o of chemotherapy taken pre op.
 H/o of lethargy, weight loss, anorexia…etc….
 H/o BRONCHO PULMONARY SYMPTOMS • Cough with
expectoration - mc
 Dyspnoea
 Chest pain
 Wheezing
 Look for any metastasis and involvement of other systems
as in paraneoplastic syndrome
 Detailed medical history for any co-existing disease

Physical examination:
 Inspection: look for respiratory rate if any use of
accessory muscle
 Palpation : see for mediastinal shift
Auscultation : presence of any abnormal sounds
like Rhonchi or crepts present, in which zone of
lungs -Air entry in each area of lung
Percussion: assess the overall severity of chronic
lung disease and indicate the presence of
consolidation, atelectasis or pleural effusion.

BASELINE INVESTIGATIONS
 CBC: look for anemia (HB), polycythemia and leukocytosis
 RBS , LFT & RFT in the view of age, metastasis and if pt had
received CTH
 CXR: - tracheal deviation or obstruction - signs of pleural effusion -
signs of pulmonary edema, atelectasis and consolidation
 ECG : See for any rt /lt side heart dysfunction –
 signs of any ischemic changes / signs of CAD
 Sputum culture Qualitative index of infection and specific
antibiotic therapy
 Serum protein and s. albumin
 CT SCAN - Asses the which part of the lung and up to which extent
lungs are involved . Helps in staging of the ca lung and all the CXR
findings can be seen in more detail in CT SCAN. Which no. of DLT,
we have to use can be assess by CT SCAN

 ABG : COPD pts are CO2 retainers and low PaO2
 ECHOCARDIOGRAPHY • Rt ventricular dysfunction occur in
50% of COPD pts and 30-40% pts with post op
pneumonectomy. • Recurrent hypoxemia is main cause of rt
ventricular dysfunction which increase the pulmonary
vascular resistance.
 In all patients baseline spirometry is necessary
 Respiratory function assessment includes: - respiratory
mechanics - gas exchange - cardio respiratory assesssment

Preoperative respiratory assessment.
Three aspects of respiratory function need to be assessed
preoperatively. These include:
1)lung mechanics.
• The assessment of lung mechanics includes spirometry and determination
of lung volumes.

2)Lung parenchymal function:
 Conventionally, preoperative arterial blood gas values were
used to assess patients undergoing lung resection, with
PaCO2 more than 45 mm Hg, PaO2 less than 60 mm Hg and
SaO2 less than 90% being considered risk factors.
 Diffusing capacity of the lung for carbon monoxide (DLCO)
is most useful test of gas exchange.
 Predicted postoperative DLCO values (ppoDLCO %) can be
calculated using the same formula as for ppoFEV1.
ppoDLCO less than 40% is a predictor of increased
respiratory and cardiac complications.

3)Cardiopulmonary interaction:
• Exercise testing for maximum o2 consumption( VO2max)
greater than 15 mL/kg/min is considered acceptable and
these patients should tolerate pneumonectomy;
• less than 10 mL/kg/min deems the patient inoperable;
• those with 10–15 mL/kg/min are considered high risk and
require careful evaluation before surgery

• Alternative test: stair climbing, shuttle
walk test, and 6 minute walk test.
Nutshell of preoperative respiratory
assessment for thoracotomy

ppoFEV1 %= preoperative FEV1 %×( 1 −% functional lung tissue
removed/100)

VENTILATION PERFUSION
SCINTTIGTAPHY
 Assess contribution of the part of a lung or a lobe to
be resected, in ventilation and perfusion
 Should be done in all pts posted for
pneumonectomy and preop FEV1 or Dlco < 80%.

CARDIOVASCULAR SYSTEM
 2nd MC cause of mortality in post op period
 ISCHEMIA :
– Incidence is 5%
– In high risk pts only physical exam and ECG is not enough but
non invasive testing like echocardiography, angiography etc..
Should be done.
– prophylactic use of B-blockers reduce risk of ischemia
 Arrythmias
• Incidence is 30% to 40% (60 to 70 % are atrial fibrilation)
• prophylaxis - Diltiazem (most useful), B-
blockers,verapemil,amiodarone
• Digoxin not useful
• Thoracic epidural analgesia

Anesthetic Considerations in Lung
Cancer Patients (the “4 Ms”)
 Mass effects: Obstructive pneumonia, lung abscess, superior
vena cava syndrome, tracheobronchial distortion, Pancoast's
syndrome, recurrent laryngeal nerve or phrenic nerve paresis,
chest wall or mediastinal extension
 Metabolic effects: Lambert-Eaton syndrome, hypercalcemia,
hyponatremia, Cushing's syndrome
 Metastases: particularly to brain, bone, liver, and adrenal
 Medications: chemotherapy agents, pulmonary toxicity
(bleomycin, mitomycin C), cardiac toxicity

1
8
Preoperative Preparation
Proper, vigorous preoperative preparation can improve the
patient’s ability to face the surgery with a decreased risk of
morbidity and mortality.
Stop Smoking
For 2-3
month
For 4 - 6 weeks
For 48 hours
→ improves in ciliary function,
→ improves closing volume, and
→ reduction in sputum production
→ decreases incidence of post-operative
complications.
→ decrease the level of
carboxyhemoglobin
Infection: broad spectrum antibiotics.

1
9
Preoperative Preparation…
Hydration and removal of Bronchial Secretions:-
Hydrating the patient decreases the viscosity of the
bronchial secretions and facilitates their removal from
the air ways.
Acetylcysteine (Mucomyst)
Potassium iodide
Postural drainage, Vigorous coughing, Chest
percussion
Wheezing
The presence of acute wheezing represents a medical
emergency, and elective surgery should be postponed until
effective proper treatment has been instituted.

2
0
Preoperative Preparation….
Preparation of Bronchodilator drugs
Sympathomimetic Drugs(adrenalin,
albuterol, salbutamol)
Phosphodiesterase
Inhibitors(aminophylline)
Steroids
Parasymphatolytic drugs(atropine)

2
1
Effects of Anesthesia on lung volume
andcapacity
 Total lung capacity (TLC)
 Vital capacity is decreased by 25% to 50%
 Residual volume (RV) increases by 13%.
 Expiratory reserve volume decreases by 25%
and 60%
 Tidal volume (VT) decreases by 20%.

Intraoperative Monitoring
All patients undergoing anesthesia for thoracic
surgical procedures require use of standard
American Society of Anesthesiologists orASA
monitors.
• Precordial stethoscope
• Pulse oxymetry
• NIBP
• Capnography
• ECG
• ABG analysis
• Direct Arterial Catheterization
• CV Catheterization
• PAC
2
0

Physiological considerations
• The lateral decubitus position
• The open pneumothorax
• One lung ventilation

Lateral Decubitus Position
• Optimal Access for most
operations of :
– Lungs
– Pleura
– Esophagus
– Great Vessels
– Mediastinal Structures
– Vertebrae
From: www.thoracicgroup.com/HTML/vatsmain.html

Lateral Decubitus Position
• Alteration of normal pulmonary ventilation-perfusion
relationships
• Further alterations with:
– Inductions of anesthesia
– Mechanical ventilation
– Muscle paralysis
– Open chest
– Surgical retraction
• Results in an increased risk of hypoxemia
From: Morgan & Mikhail, Clinical Anesthesiology, 3rd Ed

Awake State
 Supine → Lateral Decubitus
 Lower lung receives:
 ↑perfusion (gravity) & ↑ventilation (more efficient
hemidiaphragm contraction, more favorable compliance)
 V/Q matching preserved during spontaneous ventilation

Anesthetized State
 Supine → Lateral
Decubitus
 Upper lung receives:
 ↑ventilation (more
favorable compliance due
to ↓FRC with GA) From: ourworld.cs.com/_ht_a/doschk/onelung.htm
 Controlled Positive Ventilation favors upper lung (more
compliant)
 Muscle paralysis enhances this effect
 Opening the chest further accentuates ∆ in compliance
 V/Q mismatch matching occurs → ↑risk of Hypoxemia

Open Pneumothorax
• Should we keep patient’s SV to avoid worse V/Q
mismatch?
 Chest open → Loss of negative intrapleural pressure
→ Lung collapse due to elastic recoil of the lung
 Paradoxical respirations & Mediastinal shift during SV
→ progressive hypoxemia and hypercarbia
 Both phenomena are overcome with PPV during GA

One lung ventilation and its
indication?
• One Lung Ventilation means separation of two lungs
& each lung functioning independently of other by
airway preparation.
• Intentional collapse of a lung on the operative side
but perfusion of both lungs is maintained
• It is an anesthetic challenge as there is limited
respiratory reserve and pulmonary function, and
anesthesiologists need advanced skill and specialist
airway equipment.

Indications for OLV
• Absolute: (Pus, Blood, Air, Water)
– Confine infection of one lung
– Confine bleeding of one lung
– Separate ventilation due to bronchopleural fistula,
tracheobronchial disruption, large lung cyst of bulla
– Bronchoalveolar lavage for alveolar proteinosis
• Relative: (mostly procedure related)
– Lung resection
– Esophageal surgery
– Thoracic Aneurysm repair
– Thoracoscopy
– Anterior approach to thoracic spine

TECHNIQUES OF ONE LUNG
VENTILATION
Three techniques can be employed:
1. Double-lumen endotracheal tube, DLT
2. Single-lumen ET in conjunction with a bronchial blocker
3. Endobronchial intubation of a single-lumen ET

DOUBLE LUMEN TUBE(DLT)
• DLT is a bifurcated tube that can be used to
achieve isolation of either the right or the left
lung
• All DLTs share the following characteristics:
1. A longer bronchial lumen (enters either the
right or left main bronchus) and another
shorter tracheal lumen that remains in the
lower trachea
2. A preformed curve that allows preferential
entry into either bronchus
3. A bronchial cuff
4. A tracheal cuff

• A DLT is essentially two single-lumen tubes
bonded together and designated either as right-
or left-sided, depending on which mainstem
bronchus the tube is designed to fit
• The tracheal lumen is designed to terminate
above the carina
• The distal portion of the bronchial lumen is
angled to fit into the appropriate mainstem
bronchus.
• The internal lumen of each tube is D-shaped with
the straight side of the D in the middle of the
tube

Disposable DLTs are supplied in sterile
packages, which include:
1. A STYLET
2. CONNECTORS –
• Connector with integrated Y
piece with cap and self-sealing
port
• Allows both lumens to attach
to a breathing system at the
same time.
3. SUCTION CATHETER(S)

• Ventilation can be delivered to
both lungs or to either of the
lungs individually by clamping
either the bronchial or tracheal
lumen with both cuffs inflated;
• opening the port on the
appropriate connector allows
the ipsilateral lung to collapse.
• Because of differences in
bronchial anatomy between the
two sides, tubes are designed
specifically for either the right
or left bronchus.

• The bronchial cuff for
right-sided tubes
varies in shape,
depending on the
manufacturer
– on some tubes, the
cuff has a slot to
allow ventilation of
the right upper
lobe.
– Some right-sided
DLTs have two
bronchial cuffs with
an opening for the
right upper lobe
between them.

• The resting volume and
compliance of
bronchial cuffs varies
between different sizes
and brands of DLTs.
• Most manufacturers
color the bronchial cuff
blue. They also use
blue markings on the
pilot balloon and/or
the inflation device for
the bronchial cuff.

• A few DLTs have a carinal hook to
aid in proper placement and
minimize tube movement after
placement.
• Potential problems with carinal
hooks include
– increased difficulty during
intubation
– trauma to the airway
– malposition of the tube
because of the hook
– interference with bronchial
closure during
pneumonectomy.
– The hook can break off and
become lost in the bronchial
tree.

Types
1. CARLENS- a left-
sided + a carinal
hook
2. WHITE- a right-
sided Carlens tube
3. BRYCE-SMITH - no
hook but a slotted
cuff, Right sided
4. ROBERTSHAW -
most widely used
White double-lumen
Robertshaw left
double-lumen

Carlens White Bryce
Smith
Robertsh
aw
lumen
hook + + - -
side Lt Rt Lt & Rt Lt & Rt
Types
• With tubes having carinal hooks (Carlens and White) difficulties
were often encountered in placing them through the larynx, thus
not commonly used
• The most widely used double-lumen tubes are disposable versions
of the Robert-Shaw tube.
• Clear, disposable polyvinyl chloride tubes with high-volume, low
pressure tracheal and bronchial cuffs

Types
BRONCHO-CATH™ DOUBLE
LUMEN TUBES WITH CPAP
SYSTEM
• Designed to deliver continuous
positive airway pressure (CPAP)
to the nonventilated,
nondependent lung during one-
lung anesthesia
• tubes also incorporate all the
features of the standard DLT.
• An adjustable dial allows
delivery of approximate CPAP
levels between 1 and 10cm H2O. Device for
applying CPAP to
the

Size Selection
• Selecting an appropriately sized DLT for a given patient is
critical to minimize the frequency of complications
 A DLT that is too small
– may fail to provide lung isolation
– may require bronchial cuff volumes and pressures that could
produce mucosal ischemia or bronchial rupture.
– can result in the tube advancing too far into the bronchus
– a higher level of autoPEEP (positive end-expiratory pressure)
– Barotrauma
– more likely to be displaced
– Ventilation and suctioning are more difficult

Size Selection
• Using a large DLT will result in
– less resistance to gas flow
– facilitate suctioning and passage of a fiberscope, and
– reduce the risk of advancing the DLT too far into the
bronchus
– may result in trauma
• A tube is oversized if the bronchial lumen will not fit into
the bronchus or there is no air leak with the bronchial cuff
deflated
• Not more than 3 cc of air in the bronchial cuff should be
required to create a seal.

Size Selection
Available sizes: Adult DLTs commonly come in sizes
35, 37, 39, and 41 Fr (internal diameters of about
5.0, 5.5, 6.0, and 6.5 mm, respectively). A 39 Fr
tube is used for most males, whereas a 37Fr tube
is selected for most females.. Some manufacturers
also provide 26, 28, and 32 Fr tubes for younger
patients

Selection of Double-Lumen Tube Size Based on Adult
Patients’ Sex and Height
Sex Height (cm) Size (Fr)
Female <160 (63 in.) * 35
>160 37
Male <170 (67 in.) † 39
>170 41
*For females of short stature (< 152 cm or 60 in.), examine
bronchial diameter on CT scan and consider 32 Fr.
† For males of short stature (<160 cm or 63 in.), consider
37 Fr.

Size Selection
Compared with SLTs, DLTs have a large
external diameter and they should not
be advanced against significant resistance.
Chest radiographs and CT scans
• proven value in assessment of abnormal
tracheobronchial anatomy
• valuable tools for selection of proper DLT
size
• Thus must be reviewed before the
placement of the DLT.

Tracheal
width
(mm):
Tube size
(Fr gauge)
18
16
15
14
41
39
37
35
A properly sized, left-sided
DLT should have a
bronchial tip 1 to 2 mm
smaller than the patient's
left bronchus diameter to
allow for the space
occupied by the deflated
bronchial cuff.

Anatomic Considerations
• The adult trachea -
– 11–13 cm long (Vocal cord to
carina)
– begins at the level of the cricoid
cartilage (C6)
– bifurcates behind the
sternomanubrial joint (T5) into
right and left main bronchus
• Mean distance from lips to carina –
28-31 cm
• Mean tracheal diameter – 2.5cm

MAJOR DIFFERENCES BETWEEN
THE RIGHT AND LEFT MAIN
BRONCHI ARE:
 Right bronchus is wider than left
 the right bronchus diverges away
from the trachea at a 25° angle
(STRAIGHTER), whereas the left
bronchus diverges at a 45° angle
 the right bronchus has upper,
middle, and lower lobe branches,
whereas the left bronchus divides
into only upper and lower lobe
branches

 the orifice of the right upper lobe bronchus
is about 1–2.5 cm from the carina, whereas
that of the left upper lobe is about 5 cm
distal to the carina.
• Length of right main bronchus: 1-2.5cm
• Length of left main bronchus : 4-6cm
 As the right bronchus divides within 2.5cm of
carina the Right-sided bronchial tubes
must have a slit in the bronchial cuff for
ventilating the right upper lobe

 Anatomic variations between
individuals in the distance between
the right carina and the upper lobe
orifice often result in difficulties in
ventilating that lobe with right-sided
tubes.
 Right-sided tubes were designed for
left thoracotomies, whereas left-
sided tubes were designed for right
thoracotomies.
 However most anesthesiologists, use
a left-sided tube regardless of the
operative side

RIGHT Vs LEFT Sided DLT
Difference RIGHT DLT LEFT DLT
Length of intrabronchial
extension
Shorter Longer
Shape of bronchial cuff Doughnut shaped Symmetric Cuff
Direction of Intrabronchial
extension (with proximal
curve of tube pointing
upwards)
Faces right Faces left
Bronchial lumen
Rounded terminal opening +
Additional proximal opening
for Rt upper lobe bronchus
opening
Single rounded terminal
opening
Placement Harder Easier
Complication during use
Rt Upper lobe bronchus may
be blocked with <1cm of
movement
Relative safety of
blockage of bronchus
with even >1-2cm

INDICATIONS FOR A RIGHT-SIDED
DLT
1. Distorted Anatomy of the Entrance of Left
Mainstem Bronchus
• External or intraluminal tumor compression
• Descending thoracic aortic aneurysm
2. Site of Surgery Involving the Left Mainstem
Bronchus
• Left lung transplantation
• Left-sided tracheobronchial disruption
• Left-sided pneumonectomy †
• Left-sided sleeve resection

Placement
PREPARING THE DOUBLE-LUMEN TUBE
1. The tracheal and bronchial cuffs should
be inflated and checked for leaks and
symmetrical cuff inflation, making
certain that each inflation tube is
associated with the proper cuff.
2. The cuffs and stylet should be
lubricated with a water-soluble
lubricant
3. the stylet should be placed inside the
bronchial lumen, making certain that it
does not extend beyond the tip.
4. The connector should be assembled so
that it can be quickly fitted to the tube
and breathing system after intubation.

Placement
Laryngoscopy done
with a curved
(Macintosh) blade
DLT passed through
the vocal cords with
the distal curvature
concave anteriorly
rotated 90° (toward
the side of the
bronchus to be
intubated) after the
tip enters the larynx
Advanced until
resistance is felt
Position confirmed

Placement
DEPTH OF PLACEMENT
• An estimate of the appropriate depth of placement
of the DLT can be based on the patient's height.
• The average depth of insertion referenced to the
corner of the mouth is 29 cm for patients 170 cm tall,
and for each 10-cm increase or decrease in height,
the average depth of placement correspondingly
changes by 1 cm.
• Force should never be used during advancement of
the tube; resistance usually indicates impingement
within the main stem bronchus

Placement
If The Patient Is Anatomically Difficult To
Intubate
• a single-lumen tracheal tube may be placed by
any of the means that facilitate difficult
intubations. An exchange catheter can then be
inserted into the single-lumen tube and the DLT
inserted over the catheter after the single-
lumen tube has been withdrawn
• A DLT can be placed by using a lighted stylet in
the bronchial lumen or a retrograde intubation
technique .

• Awake fiberoptic bronchial intubation with
a DLT may be tried
• A DLT may be introduced over a gum
elastic bougie. It may be helpful to pass the
bougie through the opening for the right
upper lobe orifice on right DLTs
• A DLT may be inserted through a
tracheostomy

Cuff Inflation
• Once the tip is thought to be in a mainstem
bronchus, the tracheal cuff should be inflated in
a manner similar to that of a tracheal tube
• It is more difficult to inflate the bronchial cuff
correctly because an overinflated bronchial cuff
is more likely to
– herniate into the trachea
– cause the carina to be pushed toward the
opposite side
– result in narrowing of the bronchial segment
lumen
– may result in dangerously high pressure

DOUBLE LUMEN
TUBE(DLT)
Cuff Inflation
• The bronchial cuff should be inflated with small
incremental volumes until an airtight seal is just
attained. The total volume should be less than 3
mL
• Inflating the bronchial cuff to an airtight seal may
not prevent the spread of blood or secretions.
• The bronchial cuff may also be inflated with
water

Adequacy for Sealing - Air Bubble test
• Both cuffs inflated
• Lungs ventilated through the
endobronchial lumen
• Tracheal lumen connected to a
beaker filled with water
• Air bubble in the beaker
indicates ineffective separation
• Variations of this are to
connect a balloon or a
capnograph to the tracheal
lumen
• Apply suction to the tracheal
lumen. Absence of bronchial
seal will cause the reservoir
bag in a breathing system that
is connected to the bronchial
lumen to collapse.

Positioning
Methods To Ensure Proper Positioning Of DLT:
1. Auscultation
2. Flexible fiberoptic bronchoscope
3. Others
– Chest radiograph
– Comparison of capnography
– Surgeon – can palpate, redirect or assist in changing
DLT position from within the chest

Inflate the
tracheal cuff
(5–10 mL of
air) • Check for
bilateral
breath
sounds
Inflate the bronchial cuff
(1–2 mL) and Clamp the
tracheal lumen
• Check for
unilateral
left-sided
breath
sounds
Unclamp the tracheal
lumen and clamp the
bronchial lumen.
• Check for
unilateral
right-sided
breath
sounds
Positioning - Auscultation

Unilateral breath
sounds
that the tube is
too far down
(tracheal opening
is bronchial)
Malpositioning
Inflate the
tracheal cuff
(5–10 mL of
air) • Check for
bilateral
breath
sounds
tracheal lumen
• Check for
unilateral
left-sided
breath
sounds
lumen and clamp the
bronchial lumen.
• Check for
unilateral
right-sided
breath
sounds

Inflate the
tracheal cuff
(5–10 mL of
air) • Check for
bilateral
breath
sounds
tracheal lumen
• Check for
unilateral
left-sided
breath
sounds
lumen and clamp the
bronchial lumen.
• Check for
unilateral
right-sided
breath
sounds
Persistence of
right-sided breath
sounds
Unilateral right-
sided breath
sounds
Absence of breath
sounds over the
entire right lung
and the left upper
lobe
bronchial
opening is still
in the trachea
(tube should be
advanced)
tube is too far
down the left
bronchus
entry of the
tube in the right
bronchus
Malpositioning

Inflate the tracheal cuff
(5–10 mL of air)
• Check for bilateral
breath sounds
tracheal lumen
• Check for unilateral
left-sided breath
sounds
lumen and clamp the
bronchial lumen.
• Check for unilateral
right-sided breath
sounds
Absence or
diminution of
breath sounds
tube is not far
enough down
and the bronchial
cuff is occluding
the distal
Malpositioning

• Most double-lumen tubes easily
accommodate bronchoscopes
with a 3.6- to 4.2-mm outer
diameter
• Fiberscope is initially passed
through the tracheal lumen.
Correct position of the DLT is
confirmed by
– visualization of the carina
– a non-obstructed view of the right main
stem bronchus
– bronchial tip of the tube seen entering the
left bronchus and
– the top of blue bronchial cuff seen below
the carina
Positioning – Fiberoptic bronchoscope

Positioning – Fiberoptic
bronchoscope
• Fiberoptic
visualization
through the
bronchial lumen
reveals the
bronchial carina
and the left lower
and upper lobes

Complications
1. Hypoxemia due to tube malplacement or occlusion,
2. traumatic laryngitis (particularly with tubes that have a
carinal hook)
3. Tracheobronchial tree disruption, due to
• Excessive volume and pressure in bronchial
balloon
• Inappropriate tube size
• Malposition
4. inadvertent suturing of the tube to a bronchus during
surgery (detected as the inability to withdraw the tube
during attempted extubation).

Relative Contraindications
• 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.

BRONCHIAL BLOCKERS
Bronchial blockers are inflatable devices that are
passed alongside or through a single-lumen tracheal
tube to selectively occlude a bronchial orifice
TYPES:
• 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

BRONCHIAL BLOCKERS
INDICATIONS
1. Limitations to DLT (severely distorted airway, small
patients , anticipated difficult intubation)
2. To avoid a risky change of DLT to single-lumen tube
– Whenever postoperative ventilation is anticipated
– In cases of thoracic spine surgery in which a
thoracotomy in the supine or LDP is followed by
surgery in the prone position.
3. Situations in which both lungs may need to be
blocked (e.g., bilateral operations, indecisive
surgeons).

UNIVENT TUBE
• Developed by Dr. Inoue
• A single-lumen tracheal
tube with a built-in side
channel for a retractable
bronchial blocker
• Endotracheal intubation
can be performed in the
conventional manner, just
like a single lumen
endotracheal tube

• One-lung ventilation can be achieved by
placement of the blocker to either the left or
right lung, or to lung segments
• Insufflation and CPAP can be achieved through
the lumen of the blocker shaft
• Blocked lung can be collapsed by aspirating air
through the lumen of the blocker shaft
• The blocker can be retracted into its pocket to
facilitate post-operative ventilation

1. Easy to insert and positioned
properly.
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.
UNIVENT TUBE
Advantages ( Relative to DLT )

ARNDT ENDOBRONCHIAL
BLOCKER
[Wire guided Endobronchial Blocker (WEB)]

ARNDT ENDOBRONCHIAL
BLOCKER
[Wire guided Endobronchial Blocker (WEB)]
• Invented by Dr. Arndt, an
anesthesiologist
• Quickly and precisely
navigate the airway
• Ideal for difficult intubation,
pre-existing ETT and when
postop ventilation needed
• Requires ETT > or = 8.0 mm
• Similar problems as Univent
• Inability to suction or
ventilate the blocked lung

A - Coupling of the nylon wire
loop and the fiberoptic
bronchoscope through a
single-lumen endotracheal
tube
B - The Arndt blocker along
with the fiberoptic
bronchoscope is advanced
together inside the left
mainstem bronchus.
C - Disengagement of the
blocker by withdrawing the
fiberoptic bronchoscope.
ARNDT ENDOBRONCHIAL
BLOCKER
Placement

BRONCHIAL BLOCKERS THAT ARE
INDEPENDENT OF A
SINGLE-LUMEN TUBE
Including Fogarty
embolectomy catheter,
Magill or Foley, and Swan-
Ganz catheter
Adults
Fogarty (embolectomy)
catheter with a 3 ml
balloon.
Balloon-tipped luminal
catheters (such as Foley
type) may be used as
bronchial blockers.
Fogarty Embolectomy Ca

Very small children (10 kg or less)
Fogarty catheter with a 0.5 ml balloon
Swan-Ganz catheter (1 ml balloon)
• Not reliable and may be more time-consuming
• Inability to suction or ventilate the blocked lung
• These catheters have to be positioned under
direct vision; ( preferably FOB)

SINGLE-LUMEN ENDOBRONCHIAL
TUBES
• Utilized for several decades
• Replaced by double-lumen
tubes today
• Two versions
– MacIntosh-Leatherdale left
tube
– Gordon-Green right tube
• An ordinary, uncut single-
lumen tracheal tube may be
used as a bronchial tube in an
emergency situation
(unilateral pulmonary
hemorrhage)
standard single-lumen endotracheal
tube
specifically designed single-lumen
endobronchial tube

• Placed blind/with FOB/with guidance by
surgeon from within chest
• In adults, The easiest and quickest way of
separating one lung from the other bleeding
one(haemoptysis ) esp. from left lung
• In children it may be the simplest way to
achieve OLV
SINGLE-LUMEN
ENDOBRONCHIAL TUBES

Disadvantages
– inability to do suctioning or ventilation of
operative side.
– difficult positioning bronchial cuff with
inadequate ventilation of Right upper lobe
after Right endobronchial intubation.
– More likely to cause serious hypoxemia or
severe bronchial damage

HPV – HYPOXIC PULMONARY
VASOCONSTRICTION
• HPV is an autoregulatory mechanism that protects
the PaO2 by redirecting blood flow away from hypoxic
or poorly ventilated lung units toward the remaining
normoxic or hyperoxic ventilated lung.
• Pulmonary vascular endothelium release potent
vasoconstrictor peptides called endothelins resulting
in HPV
• HPV rapid onset over first 30 mins, then slowly
increase to maximal response at 2 hours

Factors that inhibit HPV worsen right to
left shunting-
1. very high pulmonary artery pressures
2. hypocapnia
3. high or very low mixed venous PO2
4. Increase in cardiac output, increases
pulmonary artery pressure
5. vasodilators such as nitroglycerin,
nitroprusside, β agonist, CCB
6. pulmonary infection
7. inhalation anesthetics - All of the volatile
anesthetics inhibit HPV in a dose-
dependent fashion halothane > enflurane
> isoflurane esp if > 1 MAC

Predictors of Hypoxemia in OLV
• Preoperative Ventilation/perfusion Scan
• Side of Operation- Right sided thoracotomies
have a larger shunt and lower PaO2 with OLV, as
right lung is 10% better perfused than left
• Two lung Oxygenation-patients who have better
PaO2 during two lung ventilation in LDP tend to
have better oxygenation with OLV (individual
variability to HPV & they have less atelectasis of
dependent lung)
• Preoperative Spirometry

Management Of Hypoxemia During
OLV
• Severe or precipitous desaturation: Resume two-lung
ventilation (if possible).
• Gradual desaturation:
 Ensure that delivered FiO2 = 1.
 Check DLT or blocker position with Fiberoptic
bronchoscope
 Check hemodynamic status - Ensure that cardiac output
is optimal; decrease volatile anaesthetics to < 1 MAC
 Apply a recruitment maneuver to the ventilated lung

 Apply PEEP (5-10 cm H2O) to the ventilated lung
(except in patients with emphysema).
 Apply CPAP (5-10 cm H2O) to the nonventilated lung
(most effective)
 Use Intermittent reinflation of non-ventilated lung
 Partial ventilation technique to non-ventilated lung
 Use Mechanical restriction of the blood flow to the
nonventilated lung

9
4
Choices of Anesthesia for ThoracicSurgery
 A choice of anesthesia for thoracic surgery depends on:-
 The patient's cardiovascular & respiratory status
The particular effects of anesthetic drugs on CVS and RS &
other organ systems.
 The ideal thoracic anesthetic technique would be:
Rapid in onset and offset and produce inhibition of airway
reflexes and bronchodilation
It would allow the use of a high FiO2 without
inhibiting hypoxic pulmonary vasoconstriction.
 It would also produce no adverse cardiovascular effects.

9
5
Choices of Anesthesia for Thoracic
Surgery…
Before induction
 IV - lidocaine allow used to treated brochospasm
occurring during anesthesia.
Atropine - for antimuscarinic effects of acetylcholine
& protect cholinergic induced bronchoconstriction
Induction
Propofol Satisfactory in most patients.
Etomidate elderly or those with cardiovascular instability
ketamine may be the drug of choice for reactive airway
 Halothane is preferable for inhalation induction as it is
least pungent

9
6
Choices of Anesthesia for Thoracic
Surgery…
Neuromuscular blockade
Consider suxamethonium for difficult intubation,
Avoid drugs which have histamine release effect
Use vecronium and pacronium
Maintenance of anaesthesia
Isoflurance most suitable
Avoid halothane: has marked inhibitory effect on
hypoxic pulmonary vasoconstriction
Nitrous oxide is contraindicated in patients with cysts or
bullae because it can expand the air space and cause
rupture.
TIVA(propofol and fentanyl)

9
7
Fluid Management
There is an increased potential for pulmonary
oedema to develop. Right pneumonectomy is
associated with the highest risk of this complication.
Pulmonary oedema may develop due to several
factors.
Raising pulmonary vessel hydrostatic pressures.
Loss of lymphatic drainage occurs.
Decreased pulmonary capillary oncotic pressures
No more than 10ml/kg of crystalloid in the first hour
intraoperatively and
1.5L in the first 24 hours postoperatively.

9
9
Termination of surgery and
Anesthesia
Placed in supine position before extubation.
Both lumens of the DLT should be suctioned to remove
any mucus, blood, or debris from each lung
Reinflating the collapsed lung; Hyperinflation of the
lungs is an important maneuver to remove air from the
pleural space at the conclusion of thoracic surgery
The surgeon pours warm saline into the pleural cavity
while the anesthesiologist applies increasing levels of
inflation pressures (up to 30–40 cmH2O) by manually
compressing the reservoir bag

1
0
0
Termination of surgery andAnesthesia…
Both lungs must be fully re-expanded and the mediastinum must be
midline at the completion of one-lung ventilation.
If mechanical ventilation of the lungs must be continued into the
postoperative period, it will be necessary to replace the DLT with a
single- lumen tube.
 Anesthesia is lightened &spontaneous ventilation reestablished
Place-sitting position after removal of DLT allowed to breath O2
enriched air.

Complications and their management
Following Thoracic Surgery
1
0
1
Atelectasis (most common)
cardiovascular herniation
hemorrhage from a major vessel
Pneumothorax,
Dysrhythmias

1
0
2
Neurovascular injury specific
to LDP
 Dependent eye
 Dependent ear pinna
 Brachial plexus (dependent and nondependent)
 Suprascapular nerve(dependent and
nondependent)
 Sciatic nerve (nondependent)
 Peroneal nerve (dependent)

1
0
3
PostoperativeAnalgesia
Thoracotomy is among the most painful of all
operative procedures. Good analgesia is essential
hypoventilation due to pain may increase the risk of
postoperative pulmonary complications
Thoracic epidural analgesia
Paravertebral blocks
Intrathecal opioids
Intercostal nerve blockage

Systemic opioids:
Systemic opioids remain the mainstay of post-
thoracotomy analgesic techniques.
Their major clinical limitation is a narrow therapeutic
window.
Well-controlled opiate infusion may provide
comparable analgesia.

Thoracic anaesthesia One lung ventilation

Thoracic anaesthesia One lung ventilation

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