short lecture note about OLV and anesthesia consideration for thoracic surgery in when I was student at addis ababa university.

1. ANESTHESIA CONSIDERATION FOR
THORACIC SURGERY AND OLV
Prepaired by: Wasihun Aragie
Adviser: Eyayalem Melese(BSc,MSc)
1

2. Outline
 Introduction
 Preoperative evaluation and Preparation
 Intraoperative monitoring
 Definition of One Lung Ventilation
 Physiology of LDP and OLV
 Methods of lung separation
 Intra operative management
 Termination of surgery and Anesthesia
 Post operative complications and their managment
 Post operative pain control
 Conclusion
 References
2

3. Objective
At the end of the this session the learner will be able to:
 Perform Preoperative assessment for patients with Thoracic surgery.
 Prepare the patient for thoracic surgery.
 Explain about One lung ventilation .
 Explain about the methods of lung separation .
 Manage intraoperative complications associated with OLV .
 Explain about Postoperative complications and their managements.
3

4. Introduction
History
In the last century, thoracic surgery was primarily done to treat infectious
disease
Now the most common indications are related to pulmonary, esophageal, and
mediastinal malignancies.
The development of single-lung isolation techniques accelerated from 1950–1960
with the development of double-lumen endotracheal tubes.
Principle of one lung ventilation is one lung for the surgeon and one for the
anesthetist.
4

5. Anatomical and physiological Overview of air ways and
lung
5

6. 6

7. Preoperative Evaluation
Preoperative anesthetic assessment before chest surgery is a continually
evolving science and art.
The objective of the preoperative assessment is to identify patients who have
concurrent medical problems requiring further diagnostic evaluation or active
treatment before surgery.
Addition to the routine assessment focus on the extent and severity of
pulmonary disease and cardiovascular involvement .
7

8. Preoperative Evaluation…
The goals of the preoperative evaluation are:
1.To ensure that patients can safely tolerate anesthesia for planned surgical
procedures; and
2.To identify risks associated with the overall perioperative period, pulmonary or
cardiac complications.
Preoperative evaluation includes History, Physical examinations, Investigations
1.History
Dyspnea
Cough
Exercise Tolerance(MET,…)
Medications
Cigarrate Smoking
8

9. Preoperative Evaluation…
2.Physical Examination
Cyanosis
Clubbing
Respiratory Rate and Pattern
Breath Sounds
 wet sounds
dry sounds
9

10. Evaluation of Cardiovascular system
Sign and symptoms of pulmonary hypertension
Splitting of second heart sound
Pulmonic regurgitant murmur
Tricuspid regurgitant murmur
Elevated jugular venous pulse or CVP
10

11. Pulmonary Function Testing
Goals of PFT
1. To identify the patient at risk of increased postoperative morbidity and mortality.
2. To identify the patient who will need short-term or long-term postoperative
ventilator support.
3.To evaluate the beneficial effect and reversibility of airway obstruction with the
use of bronchodilators.
Suggests high risk if:
FVC<50%
FEV1 <2L
FEV1/FVC <50%
RV/TLC >50%
11

12. Difference between Restrictive and Obstructive pulmonary Diseases
Restrictive: any diseases that impair lung expansion like(ARDS, pneumothorax,
effusion)
FVC ↓
FEV1 ↓
FEV1/FVC normal
RV/TLC normal
Obstructive: result from narrowing or obstruction of the smaller bronchi and larger
bronchioles (Asthma, COPD, foreign body, any tumor)
FVC normal
FEV1 ↓
FEV1/FVC ↓
RV/TLC ↑
12

13. Assessments of respiratory function and Risk stratification
Respiratory Mechanics (FEV1, MVV, FVC, RV/TLC)
ppoFEV1 %= preoperative FEV1 %×( 1 −% functional lung tissue removed/100)
Lung Parenchymal Function
Diffusing capacity for Carbon Monoxide(DLco).
Cardiopulmonary Interaction
Formal laboratory exercise testing gold standard
Maximal oxygen consumption (VO2max)
Stair clamping (Estimate VO2max)
 6-minute walk test >> >>
 (distance/30)
 status of saturation
13

14. Assessments of respiratory function and Risk Strat…
14

15. 3.Evaluation and Testing
ECG
Chest Radiography
Arterial Blood Gas Analysis
 Blue bloaters:
 Pink puffers:
Significance of Bronchodilator Therapy
Regional Perfusion Test
Regional Ventilation Test
Computed Tomography
15

16. 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 → improves in ciliary function,
→ improves closing volume, and
→ reduction in sputum production
For 4 - 6 weeks → decreases incidence of post-operative complications.
For 48 hours → decrease the level of carboxyhemoglobin
Infection: broad spectrum antibiotics. Cefazolin is routinely administered
perioperatively.
16

17. 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.
17

18. Preoperative Preparation….
Preparation of Bronchodilator drugs
Sympathomimetic Drugs(adrenalin, albuterol, salbutamol)
Phosphodiesterase Inhibitors(aminophylline)
Steroids
Parasymphatolytic drugs(atropine)
18

19. Effects of Anesthesia on lung volume and capacity
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%.
19

20. Intraoperative Monitoring
All patients undergoing anesthesia for thoracic surgical procedures
require use of standard American Society of Anesthesiologists or ASA
monitors.
Precordial stethoscope
Pulse oxymetry
NIBP
Capnography
ECG
ABG analysis
Direct Arterial Catheterization
CV Catheterization
PAC 20

21. ONE LUNG VENTILATION
One Lung Ventilation (OLV) is a technique that allows isolation of the individual
lungs and each lung functioning independently by preparation of the airway
under anesthesia.
OLV provides:
Protection of healthy lung from infected/bleeding one
Diversion of ventilation from damaged airway or lung
Improved exposure of surgical field
OLV causes:
More manipulation of airway, more damage
Significant physiologic change and easily development of hypoxemia
21

22. Indication for one lung ventilation (OLV)
Absolute indication
Isolation of one lung from the other to avoid spillage or contamination
Infection
Massive hemorrhage
Control of the distribution of ventilation
Bronchopleural cutaneous fistula
Surgical opening of a major conducting airway
Giant unilateral lung cyst or bulla
Life-threatening hypoxemia due to unilateral lung disease
Unilateral bronchopulmonary lavage
Video assisted Thoracoscopic surgery
22

23. Indication for OLV…
Relative indications
Surgical exposure—high priority
Thoracic aortic aneurysm
Pneumonectomy
Upper lobectomy
Surgical exposure—low priority
Esophageal surgery
Middle and lower lobectomy
Bilateral sympathectomies
23

24. Brain storming
Lung isolation VS Lung separation??
24

25. Blood flow in the lungs
UP right position LD Position
25

26. Physiology of the Lateral Decubitus Position
In the lateral decubitus position, the distribution of blood flow and ventilation is
similar to that in the upright position, but turned by 90 degrees.
26

27. Physiology of the LDP…
1,Lateral position, awake, breathing spontaneously, chest closed
Vertical hydrostatic pressure gradient is smaller
Dependent lung has ↑perfusion & ↑ventilation
2,Lateral position, awake, breathing spontaneously, chest open
Example: Thoracoscopy under intercostal block
Two complications can arise from the patient breathing spontaneously with
an open chest.
These are: A) Mediastinal shift
B) Paradoxical breathing
27

28. Physiology of the LDP…
A) Mediastinal shift B) Paradoxical breathing
28

29. Physiology of the LDP…
3,Lateral position, anesthetized, breathing spontaneously, chest closed
4,Lateral position, anesthetized, breathing spontaneously, chest open
5,Lateral position, anesthetized, paralyzed, chest open
29

30. Physiology of the LDP…
6,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)
30

31. Physiology of One Lung Ventilation
Venous admixture
Venous admixture increases from a value of approximately 10% to 15% during
two-lung ventilation to 30% to 40% during OLV. The PaO2 range of 9–16 kPa
Shunt and OLV
Physiological shunt
About 2-5% CO.
Accounting for normal A-aDO2, 10-15 mmHg
Including drainages from:
31

32. Physiology of OLV…
Cardiac output and OLV
Decreased CO may reduce SvO2 and thus impair SpO2 in presence of
significant shunt
Hypovolemia
Compression of heart or great vessels
Thoracic epidural sympathetic blockade
Air trapping and high PEEP
Increased CO increases PA pressures which increases perfusion of the non-
ventilated lung → increase of shunt fraction
Gravity and V-Q
32

33. Physiology of OLV…
Hypoxic Pulmonary Vasoconstriction
HPV is a physiological response of the lung to alveolar hypoxia, which
redistributes pulmonary blood flow from areas of low oxygen partial pressure
to areas of high oxygen availability.
Mechanism of action:
HPV is graded and limited, of greatest benefit when 30% to 70% of the lung is
made hypoxic.
HPV is effective only when there are normoxic areas of the lung available to
receive the diverted blood flow
33

34. Physiology of OLV…
HPV is inhibited directly by volatile anesthetics (less with N2O), vasodilators
(NTG, NO, dobutamine, ß2-agonist), increased PVR (MS, MI, PE) and
hypocapnia.
HPV is indirectly inhibited by PEEP; vasoconstrictor drugs (epinephrine,
norepinephrine, phenylephrine, and dopamine) constrict normoxic lung
vessels preferentially.
34

35. Physiology of OLV…
Potentiators of HPV
Almitrine may potentiate HPV. Almitrine is nonspecific pulmonary
vasoconstrictor.
Prostaglandins may play a role in HPV inhibition, & therefore prostaglandin
inhibitors have been investigated as potentiators of HPV.
Ibuprofen & a cyclooxygenase inhibitor have been found to potentiate HPV
in Hypoxic lung.
35

36. Methods of Lung Separation
OLV is achieved by either;
1,Double lumen ETT (DLT)
2,Bronchial blocker
 Single-lumen ET with a built-in bronchial blocker (univent tube)
Single-lumen ET with an isolated bronchial blocker(ardnt, wire guided tube)
3, Endobronchial tube
 Endobronchial intubation of a single-lumen ET
36

37. Double-Lumen Endobronchial Tube
Are currently the most widely used. Types of DLT are:
A. Carlens Tube
The first DLT used for OLV
A left sided DLT with a carinal hook
B, White, a right-sided Carlens tube
C, Robertshaw Tube
All have two cuffs, one terminating in the trachea and the other in the
mainstem bronchus
Right-sided or left-sided available
Available size: 41,39, 37, 35, 28 French (ID=6.5, 6.0, 5.5, 5.0 and 4.5 mm
respectively)
37

38. Left sided Robert show Double Lumen
Characteristics:
Most commonly used
The bronchial lumen is longer, and a simple round opening and
symmetric cuff
Better margin of safety than Rt DLT
Easy to apply suction and/or CPAP to either lung
Easy to deflate lung
Lower bronchial cuff volumes and pressures
Can be used Left lung isolation: clamp bronchial + ventilate/
tracheal lumen
Right lung isolation: clamp tracheal + ventilate/bronchial lumen
38

39. DLT…
Guide for Length and Size of DLT.
For 170 cm height, tube depth of 29 cm for every 10 cm height change, 1 cm
depth change or (Ht in cm/10) +12
39

40. Size of DLT
40

41. DLT Placement
Before insertion prepare &check the tube, stylate, FOB, 10ml syringe for
tracheal cuff and 3ml syringe for bronchial cuff, connector, large hemostat
Use mackintosh blade 3
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.
41

42. DLT Placement…
Check its location
1st step :-the tracheal cuff –inflate &equal ventilation of both lungs
2nd step: - is to clamp the right side (in case of left sided tubes), inflate bronchial
cuff slowly
3rd step:- remove the clamp & check both lungs are ventilated with both cuffs
inflated.
Final step :- selectively clamp each side &watch for absences of movement
&breath sounds on the ipsilateral (clamped) side.
42

43. DLT Placement…
Other methods to ensure position of a DLT
fluoroscopy
chest x-ray
selective capnography
pediatric fiberoptic bronchoscope
Continuous spirometry &clinical observation
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.).
43

44. Problems of Malposition of the Double-Lumen Tube
DLT in wrong bronchus
DLT may be passes too far down either the right or left mainstem bronchus
DLT not inserted for enough
A right-sided DLT may occlude the right upper lobe orifice.
The left upper lobe orifice may be obstructed by a left side DLT.
Bronchial cuff herination & may obstruct the bronchial lumen
Rare complication
tracheal rupture,
over inflation of the bronchial cuff,
44

45. Contraindications to Use of DLT
Full stomach
Lesion (stricture, tumor) along pathway of DLT (may be traumatized);
 Patients, too small (<25-35kg) or too young (< 8-12 yrs.)
 Anticipated difficult intubation;
Extremely critically ill patients who have a single-lumen tube already in
place
Under these circumstances, -using a single-lumen tube ,a bronchial blocker
45

46. Clinical Approach to OLV management
After positioning recheck the position of DLT
Two-lung ventilation should be maintained for as long as possible
Use FIO2 of 1.0
VT =Two strategies:
high tidal volume (10-12 ml/kg) without PEEP or
moderate tidal volume (6-8 ml/kg) with PEEP
 Adjust RR to keep PaCO2 = 35+/-3 mmHg
CPAP(5 to 10 cm H2O) keeps this lung “quiet” and prevents it from collapsing
completely.
46

47. Management of hypoxemia during OLV
FiO2 = 1.0
Intermittent two-lung ventilation
Manual ventilation
Check DLT position with FOB
Check hemodynamic status
CPAP (5-10 cm H2O, 5 L/min) to nondependent lung, most effective
PEEP (5-10 cm H2O) to dependent lung, least effective
Clamp pulmonary artery
47

48. Choices of Anesthesia for Thoracic Surgery
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.
48

49. 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
49

50. 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)
50

51. 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.
51

52. 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
52

53. Termination of surgery and Anesthesia…
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.
53

54. Complications and their management Following
Thoracic Surgery
Atelectasis (most common)
cardiovascular herniation
hemorrhage from a major vessel
Pneumothorax,
Dysrhythmias
54

55. 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)
55

56. Postoperative Analgesia
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
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.
56

57. Postoperative Analgesia…
NSAIDS: NSAIDs have opioid-sparing benefits when commenced
postoperatively. They do not produce respiratory depression.
Epidural analgesia: Thoracic epidural infusions of opiates appear to be more
effective than lumbar
Intercostal nerve blocks: Intercostal nerve blocks performed
intraoperatively are of benefit for a short period immediately postoperatively.
Interpleuaral analgesia: Interpleural analgesia is performed by directly
infusing local anaesthetic into the pleural cavity.
57

58. Thoracic Anesthesia in ETHIOPIA
58

59. Thoracic Anesthesia in ETHIOPIA
59

60. SUMMERY
Adequate preoperative evaluation can help influence and thereby improve
perioperative care.
Proper, vigorous preoperative preparation can improve the patient’s ability to
face the surgery with a decreased risk of morbidity and mortality.
Management of OLV is a challenge for the anesthesiologist, requiring
knowledge, skill, vigilance, experience, and practice.
Many methods can be used for OLV. Optimal methods depends on indication,
patient factors, equipment, skills and level of training.
FOB is the key equipment for OLV.
A choice of anesthesia depends on patient's cardiovascular &respiratory status.
Adequate postoperative pain control is necessary to ensure a good respiratory
effort.
60

61. Reference
 Miller's Anesthesia 8th Edition, Ronald D. Miller, MD, Lars I. Eriksson, MD,
PhD, Lee A. Fleisher, MD, Jeanine P. Wiener-Kronish, MD, William L. Young,
MD
Clinical Anesthesia 8th Edition, Paul G. Barash, MD, Bruce F. Cullen, MD,
Robert K. Stoelting, MD, Michael K. Cahalan, MD, M. Christine Stock , MD
Practical Handbook of Thoracic Anesthesia
Tortora principle of physiology and anatomy 13rd (biological text book 2012th
edition).
G. Edward Morgan, Jr., Maged S. Mikhail, Michael J. Murray Clinical
Anesthesiology, 6th Edition
Harrison’s Principles of Internal Medicine. New York: McGraw- Hill, 2008,
19th edition.
 Stoelting Anesthesia and Co-existing disease. Philadelphia: Churchil
Livingstone, 2008, 5th edition.
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62. Thanks for Your Attention
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