This document describes the anesthetic management of a 40-year-old female undergoing left thoracotomy for resection of the lower lobe due to bilaterally bronchiectasis. Key details include: the patient was induced with propofol and rocuronium and intubated with a double lumen endotracheal tube. Anesthesia was maintained with oxygen, nitrous oxide, isoflurane and rocuronium infusions. Intraoperatively vital signs were stable and fluids/blood were administered as needed. Post-operatively the patient was extubated in the ICU and recovered uneventfully with epidural analgesia.

1. 24/09/2010 1

2. CASE - SCENARI
O
A 40 yr old female came to surgical OPD with,
Chief complaint : breathlessness since 2 years,
recurrent attacks of cold and fever on & off.
H/O Pr Ill : Pt. was asymptomatic 2 yrs back,
developed difficulty in breathing associated with cough.
recurrent attacks of cold & fever (low grade).
no h/o evening rise in temperature.
no h/o weight loss.
24/09/2010 2

3.  Past history : Pt is a k/c/o bronchial asthma since 2 yrs,
on regular treatment.
no other significant history
 Family history : not significant
• Personal history: veg, good appetite, normal bowel & bladder
habits
No addiction, no history of allergy to any
drug.
GENERAL EXAMINATION
Pt. was conscious & oriented to time, place & person, moderately
built
Pulse : 78 bpm, regular rhythm & normal volume
B.P. : 110/70 mm of Hg, left arm sitting position
R.R. : 16 bpm , afebrile.
Pallor, icterus, cyanosis, lymphadenopathy, oedema – absent
Clubbing: +++
24/09/2010 3

4. SYSTEMIC
EXAMINATION
R/S: b/l rhonchi ++ (L >> R)
lt. lower lobe air entry
CVS: S1 S2 normal, no murmur
P/A: soft, non tender, bowel sounds ++
CNS : Higher functions - WNL
Cranial nerves - WNL
24/09/2010 4

5. INVESTIGATION
S
 Hb% : 11.4 gm %
 Haematological, RFT, LFT, PT/INR,
serum electrolytes, BSL– WNL
 CXR- COPD changes
 ECG- sinus rhythm, normal axis
24/09/2010 5

6. 24/09/2010 6

7.  Pt. DIAGNOSED as a case of “BILATERAL
BRONCHIECTASIS with severly affected left lower
lobe”.
 Planned for LEFT THORACOTOMY for resection of
LOWER LOBE.
 Pre- anaesthetic checkup done.
 Airway assessment done - MPC I.
 NECK MOVEMENTS : normal extension and flexion.
 Breath holding test : 20 sec
24/09/2010 7

8. AnaesthetIc manag
ement
 Posted for LEFT THORACOTOMY for resection of LOWER
LOBE in right lateral decubitus position under GA as ASA II
 An i/v line with 18G cannula established and pulse, NIBP
, SpO2, ECG monitors were connected.
 Premedication : Inj. glycopyrrolate 0.2 mg i/v
Inj. midazolam 1 mg i/v
Inj. butorphanol 1 mg i/v
Inj. Hydrocortisone 100 mg
 Induction : done in supine position
pre-oxygenated with 100% O2 for 3 minutes
Inj. propofol 2mg/kg i/v
Inj rocuronium bromide 0.6 mg/kg(36mg i/v)
contd…
24/09/2010 8

9.  Intubated with double lumen endobronchial tube right side (32Fr).
24/09/2010 9

10.  B/L air entry checked & tube fixed.
24/09/2010 10

11.  Anaesthesia m/o O2(40%) + N20(60%) +isoflurane +
Inj. Rocuronium bromide on controlled ventilation.
 A central line in right IJV established.
 Patient position carefully changed to right lateral decubitus
position.
24/09/2010 11

12.  Proper positioning done & support applied.
 Air entry rechecked and the surgeon was asked to
proceed further
24/09/2010 12

13.  Intra – operatively : pulse, NIBP , SpO2, ECG, etCO2,
urine output were continuously
monitored & were WNL.
 I/O charts maintained.
 I/v drugs given : incremental doses of Inj. Rocuronium
bromide 10mg given as & when required.
 Fluids : peripheral line : 1 colloid + 3 crystalloids
central line : 2 crystalloids
 Blood loss replaced as required.
24/09/2010 13

14.  Surgery lasted for 3 hours & 30 minutes.
 Thoracic epidural catheter inserted in T8-9 Interspace for
post operative analgesia.
 Endobronchial tube removed and replaced with ET tube no.
7.0.
 Residual Neuromuscular blockade was reversed with
Inj. Neostigmine 2.5 mg i/v + Inj. Glycopyrrolate 0.4mg i/v.
 Pt. shifted to SICU on T- piece for further management.
24/09/2010 14

15.  It was decided that pt. not to be electively
ventilated and thus pt. was extubated in SICU
because of
 Uneventful intraoperative course
 Duration of surgery was optimum
 Patient was having good spontaneous efforts
 Pt. was maintaining good SpO2
And to prevent the post operative
complications like
 Chances of stump blow out due to positive pressure
ventilation
 Development of tension pneumothorax
 Ventilator dependence and difficulty in weaning off
24/09/2010 15

16.  Patient observed for vital
parameters in SICU in post
operative period i.e.
pulse, NIBP, spO2 which were
WNL.
 Post–operative period was
uneventful & post operative
analgesia was maintained with
local anaesthetics & opioids
through epidural catheter.
• Pt. remained stable and transferred to female
surgical ward on 6th post-operative day.
24/09/2010 16

17. DISCUSSION
• One-lung ventilation (OLV) means physiological separation of
both lungs from each other and each lung ventilating
independently with a special airway device like double lumen
endobroncheal tube.
 OLV provides:
 Protection of healthy lung from infected/bleeding one.
 Diversion of ventilation from damaged airway or lung.
 Improved exposure of surgical field.
 Precautions during OLV:
 More manipulation of airway, more damage – hence gentle
handling is advisable.
 Significant physiologic change and easy development of
hypoxemia – hence adequate oxygenation recquired.
24/09/2010 17

18. Technique
 The principle advantages of double-
lumen tubes are relative ease of
placement, the ability to ventilate
either or both lungs, and the ability
to do suction either lung.
 Double lumen endobronchial tube
right side (32Fr) has to be placed
with specific technique .
24/09/2010 18

19. Physiology of
One Lung
Ventilation
24/09/2010 19

20. Effects of gravity on the distribution of pulmonary blood flow in
Upright Position
 In Zone 1, PA > Ppa
this region functions as alveolar dead space or
“wasted” ventillation.
 In Zone 2, Ppa > PA > Ppv
perfusion pressure increases, and flow steadily
increases down the zone.
 In Zone 3, Ppa > Ppv > PA
and therefore flow increases.
 In Zone 4, Ppa > Pisf > Ppv > PA
zone 4 blood flow is less than zone 3 blood flow.
In the upper zone perfusion is less and ventilation is
more – hence wasted ventilation .
In zone 2 & 3 perfusion increases as we go lower down
– hence well ventilated and well perfused.
PA =alveolar pressure
Ppa =pulm. arterial pressure
In zone 4 perfusion is good but ventilation is less .
Ppv = pulm. Venous Pressure
Pisf = pulm. Interstitial pressure
24/09/2010 20

21. Effects of gravity on the distribution of pulmonary blood flow in
Lateral Decubitus Position (LDP)
 The vertical gradient in the lateral
decubitus position is less than in the
upright position i.e. there is less zone 1
and more zone 2 & 3 blood flow in the
lateral decubitus position.
 Gravity causes a vertical gradient in
the distribution of pulmonary blood
flow in the LDP, 40% of total blood
flow perfusing the non dependent
lung & 60% of total blood flow
perfusing the dependent lung.
 In LDP, the lower diaphragm contracts
more efficiently during spontaneous
respiration, because it is pushed
higher into the chest by abdominal
contents, thus the increase perfusion
is matched by increase in ventilation.
PA =alveolar pressure
Ppa =pulm. arterial pressure
Ppv = pulm. Venous Pressure
Pisf = pulm. Interstitial pressure
24/09/2010 21

22. CIRCULATORY & RESPIRATORY EFFECTS IN THE
LATERAL DECUBITUS POSITION
 CIRCULATORY EFFECT- pooling of blood in
dependent half of body can result in decreased venous
return & a subsequent fall in cardiac output. This
effect is intensified by raising the kidney bar or hyper
extending the table.
 RESPIRATORY EFFECT-
1. the lateral position causes mechanical
interference with chest movement & therefore limitation
of lung expansion.
2. mismatching of ventilation and perfusion in
the lateral position.
The ventilation/ perfusion ratio increases in the upper
lung, resulting in an increased physiologic dead space &
CO2 retention. The ventilation/ perfusion ratio decreases
in the lower lung, resulting in an increased intrapulmonary
shunt & hypoxemia. The application of positive end
expiratory pressure to both lungs restores ventilation to
the lower lung.
General anaesthesia causes a decrease in FRC. i.e. in
anaesthezed and paralysed patient in the LDP has better
ventilation in the non dependent lung and better perfusion
in the dependent lung, leading to significant ventilation-
24/09/2010 22
perfusion mismatch.

23. When the chest is opened, the nondependent lung is free to expand much more.
Therefore ventilation, in the non dependent lung improves further, and worsens
V/Q mismatch. Application of PEEP to lower lung moves it to the compliant portion
of the pressure volume curve and helps to decrease the V/Q mismatch.
24/09/2010 23

24. Summary
 The body cavity surgeries specifically thoracotomy interferes two important systems
i.e. respiratory & CVS. Which pose major problem & challenges to anaesthesiologists.
 OLV widely used in cardiothoracic surgery as it is the important technique which has to
be employed to achieve good surgical conditions without compromising pt. safety.
 Many methods can be used for OLV. Each of them have advantages + disadvantages.
Optimal methods depends on indication, patient factors, equipment, skills + training.
 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
24/09/2010 24

25. Thank you
24/09/2010 25