This document discusses one-lung ventilation (OLV) using double-lumen tubes (DLTs). OLV separates the lungs to isolate and ventilate only one lung during thoracic surgery. It provides protection from infection/bleeding and improved surgical exposure. The document covers DLT placement techniques, checking placement, and managing gas exchange and ventilation during OLV to optimize oxygenation and prevent hypercarbia. Factors that increase the risk of desaturation during OLV like preoperative lung function abnormalities are also discussed.

1. ONE LUNG VENTILATION,
COMPLIANCE CURVES,DLTs,GAS
EXCHANGE/MANAGEMENT OF OLV
MODERATOR: DR SANJAY SHRESTHA
11th september, 2014
kmcth

2.  OLV
 separation of the two lungs
 intentional collapse of a lung on the operative side of the patient
 OLV provides:
 protection of healthy lung from infection/bleeding (lung isolation)
 diversion of ventilation away from damaged airway or lung
 improved exposure of surgical field
ONE LUNG VENTILATION (OLV)

3. Indications for One-Lung Ventilation
• ABSOLUTE
Isolation of each lung to prevent contamination of a healthy lung
– Infection (abscess, infected cyst)
– Massive hemorrhage
• Control of distribution of ventilation to only one lung
– Bronchopleural fistula
– Bronchopleural cutaneous fistula
– Unilateral cyst or bullae
– Major bronchial disruption or trauma
• Unilateral lung lavage
• Video-assisted thoracoscopic surgery

4. • RELATIVE
Surgical access
– Thoracic aortic aneurysm
– Pneumonectomy
– Lobectomy
– Esophageal surgery
– Mediastinal surgery- mass resection, thymectomy
Thoracic spinal surgery
?Severe hypoxemia due to unilateral lung disease

5. Physiology

6. Pulmonary compliance

7. Change in compliance

8. Physiology of OLV
(Arterial Oxygenation and Carbon Dioxide Elimination)
Blood passing through :
 non ventilated lung , retains CO2 and does not take O2.
 over ventilated lung , gives off more than a normal amount of CO2 but cannot take up a
proportionately increased amount of O2 .

9. Thus, during one-lung ventilation
 more decreased oxygenation than during two-lung ventilation in LDP
due to an obligatory Rt-Lt transpulmonary shunt through the nonventilated
nondependent lung. Consequently, lower PaO2 & larger P(A-a)O2
 usu CO2 elimination is not a problem; but retention of CO2 by blood
traversing the nonventilated lung slightly exceeds the increased
elimination of CO2 from blood traversing the ventilated lung, and the PaCO2
will usually slowly increase and P(A-a)CO2 decreases .

10. Physiology of the Lateral
Decubitus Position

11. – Lateral position, awake, breathing
spontaneously, chest closed
perfusion
gravity-dependent, the vertical
hydrostatic pressure gradient is
smaller in the lateral than in the
upright position
ventilation
the dependent hemidiaphragm is
pushed higher into the chest by
the abdominal contents >
conserved ability to contract
result in adequate Vt
Dependent lung has
↑perfusion & ↑ventilation

12. Lateral position, awake, breathing
spontaneously, chest open
• e.g thoracoscopy under intercostal block
• Two complications can arise
– Mediastinal Shift, usually occurring during inspiration >> can lead to
shock and respiratory distress
– Paradoxical Breathing
– Inspiration : negative pressure in intact hemithorax compared with
atmospheric pressure in the open hemithorax can cause movement of
air from the nondependent to dependent lung. opposite occurs during
expiration (gas movement reversal)
– wasted ventilation and decreased amount of gas exchange
– increased by a large thoracotomy or by an increase in airway
resistance in the dependent lung
– Positive-pressure ventilation or adequate sealing prevents it

13. Lateral position, anesthetized, breathing
spontaneously, chest closed
• GA causes ↓vol. in both lungs
• More so in dependent lung due to
cephalad displacement of diaphragm
pressure due to mediastinal structures
• Thus, Most Vt enters the nondependent lung (underperfused)
• So significant V/Q mismatch

14. Closed chest

15. Lateral position, anesthetized, breathing
spontaneously, chest open
• Little impact on perfusion
• Upper lung free to expand (without chest wall restriction)
• Increase in V/Q mismatch as the nondependent lung is
preferentially ventilated

16. Lateral position, anesthetized, paralyzed, chest open
Two lung ventilation
• Due to positive-pressure ventilation, diaphragmatic
displacement is maximal over the nondependent lung, where
there is the least amount of resistance to diaphragmatic
movement caused by the abdominal contents
• Depended (relatively perfused) less ventilated
• increases the V/Q mismatch.

18. Two-lung ventilation versus OLV
during OLV, the nonventilated lung has some blood flow and therefore has an
obligatory shunt, which is not present during two-lung ventilation & is the most
important reason for increased P(A-a)O2.

19. One-lung ventilation, anesthetized, paralyzed,
chest open
• two-lung ventilation in the lateral position : nondependent
lung 40% C.O. 60% dependent lung
• Shunt 5% in each lung
• C.O participating in gas exchange 35% nondependent 55% in
the dependent
• right-to-left transpulmonary shunt
• active HPV, blood flow nondependent hypoxic lung will be
decreased by 50% (35/2) = 17.5%+5%=22.5%+5%=27.5%(Pao2
= 150 mm Hg )

20. Blood Flow distribution during OLV
The major determinants of
blood flow distribution
between both lungs :
•gravity,
•amount of lung disease,
•magnitude HPV,
•surgical interference nondependent ,
•ventilation mode dependent

21. Anatomy of the Tracheobronchial Tree

22. RT SIDED DLT

23. Rt Lt

24. Lt

25. guide for Length and Size of DLT
Length of tube , For 170-180 cm height, tube depth of 29 cm
For every 10 cm height change , 1 cm depth change
oR (Ht in cm/10)+12
Patient characteristics Tube size (Fr gauge)
Tracheal width (mm):
18
16
15
14
41
39
37
35
Patient height
4’ 6”-5’5”
5’5”-5’10”
5’11”-6’4”
35-37
37-39
39-41
Patient age (year)
13-14
12
10
8
35
32
28 (lt only)
26 (lt only)

26. 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
through cords to avoid trauma to them.

27. 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

28. DLT Placement
• Checking tube placement with the fiberoptic bronchoscope
• When auscultation maneuvers unreliable preexisting lung disease so
that breath sounds are not very audible, or if the tube is only
slightly malpositioned
• In patients with double-lumen tubes whose position seemed
appropriate to auscultations, 48% had some degree of malposition.
So always check position with fiberoptic if available.
• After advancing the fiberoptic scope thru the “tracheal” tube should
see the “bronchial blue balloon” in a semi lunar shape, just peeking
out of the bronchus

29. passage of the left-sided DLT

30. Major Malpositions of a Lt- DLT
Both cuffs inflated
Clamp Rt lumen
Both cuffs inflated
Clamp Lt lumen
Deflate Lt cuff
Clamp Lt lumen
Left
None / Very
minimal
left
Left
Right
Both
Both
None / Very
minimal
Both
Right
None / Very
minimal
Right
Breath Sounds Heard
Lt

31. FOB picture of Lt - DLT

32. FOB picture of Rt DLT

33. 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..).

34. Adequacy for Sealing (air Bubble test )

35. Indications for a Right-Sided Double-
Lumen Tube
Distorted Anatomy of the Entrance of Left Mainstem Bronchus
External or intraluminal tumor compression
Descending thoracic aortic aneurysm
Site of Surgery Involving the Left Mainstem Bronchus
Left lung transplantation
Left-sided tracheobronchial disruption
Left-sided pneumonectomy †
Left-sided sleeve resection

36. Advantages of DLT
 Relatively easy to place
 Allows conversion back and forth from OLV to two-
lung ventilation
 Allows suctioning of both lungs individually
 Allows CPAP to be applied to the non-dependent
lung
 Allow sPEEP to be applied to the dependent lung
 Ability to ventilate around scope in the tube

37. 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;
Under these circumstances, it is still possible to separate the lungs
by :
-using a single-lumen tube + FOB placement of a bronchial blocker
; or FOB placement of a single-lumen tube in a main stem
bronchus.

38. Disadvantages
Size selection more difficult
Difficult to place in patients with difficult
airways or abnormal tracheas
Not optimal for postoperative ventilation
Potential laryngeal trauma
Potential bronchial trauma

39. Clinical Approach to OLV management
 Maintain two-lung ventilation until pleura is
opened
 Check tube after change in position
 Dependent lung
• FIO2 = 1.0
• VT = 6-8 ml / Kg
• RR , so that PaCO2 ~ 35-40 mmHg
• PEEP = 5 - 10 cmH2O
 Frequent recruitment maneuvers
 Avoiding fluid overload
 ?TIVA over inhalational anesthetics

40. Factors That Correlate with an ↑Risk
of Desaturation during One-Lung
Ventilation
• High % of V or Q to operative lung pre-
operatively
• Poor PaO2 during 2LV, esp in lat. Position
• Rt sided thoracotomy (lt lung 10% smaller)
• Normal pre-op spirometry or restrictive lung
disease
• Supine position during OLV

41. 1. If hypoxaemia occurs
• Check DLT position by FOB/clinically
• Check haemodynamic status
• Non dependent lung CPAP (5 - 10 cmH2O)
• Dependent lung PEEP
• Intermittent two lung ventilation
• Clamp pulmonary artery (pneumonectomy)

42. 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.

43. Indications for Use of Bronchial Blockers
1st , limitations to DLT (severely distorted airway, small patients ,
anticipated difficult intubation)
2nd , 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.
3rd , situations in which both lungs may need to be blocked (e.g.,
bilateral operations)

44. Types of bronchial blockers
Univent bronchial blocker system
Arndt endobronchial blocker
Cohen Flexitip Endobronchial Blocker
BB independent of a single-lumen tube

45. Univent bronchial blocker system

46. steps of FOB-aided method of positioning the Univent bronchial blocker
in lt main stem bronchus
One- or two-lung ventilation is achieved simply by inflating or deflating, respectively, the bronchial blocker balloon

47. Advantages of the Univent Bronchial Blocker Tube
( Relative to 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.

48. 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 (a) Deflate BB cuff and compress and evacuate the lung
through the main single lumen;
(b) apply suction to BB lumen
3. Blockage of BB lumen
( blood, pus,..)
Suction, stylet, and then suction
4. High-pressure cuff Use just-seal volume of air
5. Leak in BB cuff Make sure BB cuff is subcarinal, increase inflation volume,
rearrange surgical field

49. Arndt endobronchial blocker
[Wire guided Endobronchial Blocker (WEB)]

52. Cohen Flexitip Endobronchial Blocker

53. Bronchial Blockers that are Independent of a
Single-Lumen 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).

54. Lung separation with a single-lumen tube, FOB, and Rt lung
bronchial blocker

55. Endobronchial Intubation with 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.

56. Disadvantages of a blocker that is independent of the
single-lumen tube as compared with DLT
 inability to suction and/or to ventilate the lung distal to the
blocker.
 increased placement time.
 the definite need for a fiberoptic or rigid bronchoscope.
 if bronchial blocker backs out into the trachea, the seal
between the two lungs will be lost and the trachea will be at
least partially obstructed by the blocker, and ventilation will
be greatly impaired.

57. Post-operatively
• Non-ventilated lung suctioned and
preferentially inflated
• CXR to rule out pneumo/hemothorax, collapse
• High care unit
• Adequate pain relief (thoracic epidural),
oxygen/inhaler therapy,