One Lung VentilationOne Lung Ventilation

Paul Alfille

Disclaimers and Commercial hSponsorships

• NoneNone

Andrea Pisano 1437 “The Creation of Eve”

Goals and ObjectivesGoals and Objectives

• What are the indications for one lungWhat are the indications for one lung ventilation

• What is best practice for managing one lung• What is best practice for managing one‐lung ventilationWh h h i f l• What are the techniques for one‐lung ventilation

Indications for Lung IsolationIndications for Lung Isolation

• Surgical exposure • Differential ventilationSurgical exposure• Lung resection• Airway protection

Differential ventilation– Post transplant– Giant blebAirway protection

– Hemoptysis– Infection

– Bronchopleural fistula– bronchial disruption

• Lung lavage

How to chooseHow to chooseSurgical exposure

Differential ventilation

Lavage Difficult airway

Small patient

Bronchial lesionexposure ventilation airway patient lesion

DLT √√ √√ √√ xx xx √√

Blocker √√ xx xx √√ √√ xx

Bronchialtube

√√ xx xx √√ √√ √√

Spontaneous  √√ xx xx √√ √√ √√ptx

CarlensCarlens

• Left sidedLeft sided with carinalhookhook

• Right sided versionversion called the White tubeWhite tube

RobertshawRobertshaw

• Both left and rightBoth left and right sided version

• No carinal hook• No carinal hook• RUL window for right 

iversion• Multiple modern designs

Right sided tubesRight sided tubes

• Asymmetric cuffhttp://www.sumi.com.pl/en/double‐lumen‐bronchial‐tube‐right‐sided/

Asymmetric cuff• RUL orifice• Often avoided by• Often avoided by the inexperienced

Mallincrodt

Bronchial lengths

•FOB, casts, cadavers

•Female slightly smaller

• Benumof JL Partidge BL Salvatierra C Keating J

g y

•Design of tube important

Benumof JL, Partidge BL Salvatierra C, Keating J.Margin of safety in positioning positioning modern double‐lumen endotracheal tubesAnesthesiology 1987 67:729

Tips for positioning

Is a RDLT time efficient?Is a RDLT time efficient?Right DLT Left DLT

Initial placement min 3.37 2.08

Left lung collapse min 13 10

FOB exams number 2 2

Surgical exposure ExcellentFair

19/190/19

19/201/20Fair 0/19 1/20

RUL expansion Post‐op Xray Full 17/17 Full 18/18

Campos JH, et al. The Incidence of Right Upperlobe Collapse When Comparing Right‐sided Double Lumen Tube Versus a Modified Left Double‐Lumen Tube for Left‐Sided Thoracic Surgery. Anesth Analg 2000; 90:535‐40

Porcine bronchusPorcine bronchus• Incidence < 1%• Some or all segments of RUL start above carina

• Very occasionally on L side, too.side, too.

• Contraindication for ipsilateral DLT (oripsilateral DLT (or blocker)

MallinckrodtMallinckrodt

• Left DLT– 28 32 35 37 39 41

• Right DLT– 35 37 39 4135 37 39 41

• Left with Hook35 37 39 41– 35 37 39 41

RÜSCHRÜSCH

• Left RobershawLeft Robershaw– 26 28 35 37 39 41

• Right Robershaw• Right Robershaw– 26 28 35 37 39 41

• Carlens– 35 37 39 41

• Dr. White– 35 37 39 41

PortexPortex

• Nicest design for theNicest design for the top of the tube

Phycon (Fuji Systems)Phycon (Fuji Systems)

• “Silbroncho”Silbroncho• Left and Right DLT

l ibl il i• Flexible silocone wire‐reinforced bronchial lumen

• 33,35,37,39 Fr• Less kinkingg

Endobronchial tubeEndobronchial tube

• Long tubeLong tube• Flexible wire‐reinforcedS ll ff• Small cuff

• Short distance cuff to tip• 5.5 6.5 7.5 mm I.D.

VivaSightVivaSight

• 37Fr L DLT37Fr L DLT• Embedded (disposible) fiberoptic camera and lightlight

• View of carina• Continuous monitoring

Arndt Blocker• Loop to capture bronchoscope• Loop to capture bronchoscope• Sizes 5, 7, and 9• Good for selective blockade• Can “catch” on carina

Endobronchial tubeEndobronchial tube

.

Fogarty Embolectomy CatheterFogarty Embolectomy Catheter

• No suction/CPAP lumenNo suction/CPAP lumen••• Various sizes• Connections difficult

Univent TubeUnivent Tube

• Integral blockerIntegral blocker

Tube variability – bronchial lumenTube variability  bronchial lumen

W. J. RUSSELL, T. S. STRONG Dimensions of Double‐Lumen Tracheobronchial TubesAnaesthesia and Intensive Care, Vol. 31, No. 1, February 2003

Tube diameterTube diameter

Paul with calipers: SLTs vs Left Mallinckrodt outer diameter at cords.

ResistanceResistanceChart TitleHigh resistance

8

10

12

4

6

8

0

2

Left Right

C 37 C 39 C 41 L RS sm L RS med L RS lgW 37 W 39 W 41 R RS sm R RS med R RS lg

Low resistance

Hammond JE, Wright DJ. Comparison of the Resistances of Double‐Lumen EndobronchialTubes. Be J Anaesth 1984; 56:299‐302

ResistanceResistance

• Overall resistance ~ 7 0 to 8 0 ETTOverall resistance   7.0 to 8.0 ETT– (both lumen)

• Better than Univent tube• Better than Univent tube• Unclear comparison with blockers

– (resistance to both lumen low and comparable)

• Use in ICU discouraged because of unfamiliarity rather than resistance.

Chiaranda M, et al. Measurement of the flow‐resistive properties of double‐lumen bronchial tubes in vitro. Anaesthesia 1989; 44:335‐40

Hypoxia and OLVHypoxia and OLV

• Unique is pure • Oxygenation vs LungUnique is pure anatomic shunt

• Definitions vary

Oxygenation vs Lung protection

y– 10% had Sat < 90

• Pre‐op conditionsp• Position• Ventilatione a o• FiO2• DrugsDrugs

Factors Effecting ShuntFactors Effecting Shunt

• Ventilated side:Ventilated side:– Improve gas exchange

– Keep low PVR• Non‐ventilated:

– Keep PVR high– Add O2

• Improve mixed venous O2

Shunt and oxygenationShunt and oxygenation

• Dependent onDependent on HPV

• FiO2 has littleFiO2 has little effect at high shunt fraction

• Cardiac output and mixed venous content important

Mixed venous concentrationMixed venous concentration

• More importantMore important at high shunt

• Metabolic rate• Metabolic rate• Anemia• Cardiac output

PositionPosition

• Gravity has pO2Gravity has strong effect on 1LV 200

250

300

on 1LV• Supine < Lateral

100

150

200

pO2

Lateral0

50

Ventilated below Supine Ventilated above

Szegedu LL, et al. Gravity is an important determinant of oxygenation during one‐lung il i hi l S d 20 0 6 0ventilation. Acta Aneasthiol Scand 2010; 6:744‐50

Cardiac OutputCardiac Output

• HigherHigher cardiac outputoutput improves oxygenationoxygenation

• Confounds some studiessome studies

Singer P, Scott WAC. Arterial Oxygenation during One‐lung ventilation. AnesthesiologySinger P, Scott WAC. Arterial Oxygenation during One lung ventilation. Anesthesiology 1995; 82:940‐6

AssymetryAssymetry

• Sicker non‐ventilatedSicker non ventilated lung helps

• Higher Δ between lung• Higher Δ between lung• Better oxygenation• Prior lobectomy

Yamamoto Y, et al. Gradient of bronchial end‐tidal CO2 during two‐lung ventilation in lateral decubitus position is predictive of oxygenation disorder during subsequent one‐lung ventilation. J Anesth 2009; 23:192‐7

Inhalation vs TIVAInhalation vs TIVA500• Multiple studies

300

400

O2

u t p e stud es• Confounding variables

100

200pO SevofluranePropofol

• Weak effect on oxygenation

00 20 40

minutes

• Titrated to BIS• Inflammatory attenuation

Pruszkowski O, et al. Effects of propofol vs sevoflurane on arterial oxygenation duringPruszkowski O, et al. Effects of propofol vs sevoflurane on arterial oxygenation during one‐lung ventilation. Br J Anaesth 2007; 98:539‐44

Inflammation and Anesthetic

• BAL samples fromBAL samples from ventilated lung

• No difference in• No difference in oxygenationD i• Decrease in markers

• Clinical import unclear

Schilling T et al Effects of Volatile and Intravenous Anesthesia on the Alveolar and SystemicSchilling T, et al. Effects of Volatile and Intravenous Anesthesia on the Alveolar and Systemic Inflammatory Response in Thoracic Surgical Patients. Anesthesiology 2011; 115:65‐74

DexmedetomidineDexmedetomidine500

200

300

400

Dexmedetomidine

0

100

200 Control

0TLV OLV‐1 OLV‐2

Anesthetic sparing effect?

Kenman S. et al. Effects of dexmedetomidine on oxygenation during one‐lung ventilation for thoracic surgery in adults. J Minim Access Surg 2011; 7:227‐31

KetamineKetaminepO2/FiO2

100

150

200

0

50

Ketamine Ketamine Control

pO2/FiO2

Ketamine 1.0mg/kg

Ketamine 0.5mk/kg

Control

Iwata M, et al. Ketamine eliminates propofol pain but does not affect hemodynamics during induction with double‐lumen tubes. J Anesth 2010; 24:31‐7

VasopressorsVasopressors

• α‐block↓ HPVα block ↓ HPV• β‐block ↑ HPV• Epidural effect from• Epidural effect from α and β block

Brimioulle S, et al. Sympathetic modulation of hypoxic pulmonary vasoconstriction in intact dogs Cardiovasc Res 1997; 34:384‐92

EpiduralEpidural

354045

500

600

• Equivocal studies

20253035

300

400 BupivSufIV

Equivocal studies• Propofol GASi il O2

5101520

100

200IVBupiv Qs/QtSuf  Qs/Qt

/

• Similar pO2• Similar Qs/Qt

05

0IV Qs/Qt

• Similar output

Jung SM, et al. The effect of thoracic epidural anesthesia on pulmonary shunt fraction andJung SM, et al. The effect of thoracic epidural anesthesia on pulmonary shunt fraction and arterial oxygenation during one‐lung ventilation. J Cardiothoracic Vasc Anesth 2010; 24:456‐62

AlmitrineAlmitrine

AlmitrineAlmitrine2.5

3

120

140

c

1.5

2

80

100ardiac

pO

Almitrine

Placebo

140

60

c

inde

O2 Almitrine2

Placebo2

0

0.5

0

20

1‐lung Load Maintainance

x

• Improves oxygenation• Little effect on cardiac outputpDailibon ND, et al. Treatment of Hypoxemia During One‐Lung Ventilation Using Intravenous Almitrine. Anesth Analg 2004; 98:590‐4

Nitric OxideNitric Oxide

• Dilates pulmonary vesselsDilates pulmonary vessels• Matched to ventilation

ff i O i l• No effect in OLV in normals• Perhaps in PAH

Pre, 40ppm, post

Rocca GD, et al. Inhaled Nitric Oxide Administration During One‐Lung Ventilation in Patients Undergoing Thoracic Surgery. J Cardiothor Vasc Anesth 2001; 15:218‐23

Tidal volumeTidal volume

• High TV improvesHigh TV improves oxygenation

• Higher PEEP may• Higher PEEP may balance (based on plateau pressureplateau pressure

• Lung injury

Kim SH, Jung KT, An TH. Effects of tidal volume and PEEP on arterial blood gases and pulmonary mechanics during one lung ventilation J Anesth 2012; 26:568 73pulmonary mechanics during one‐lung ventilation J Anesth 2012; 26:568‐73

Tidal volumeTidal volume

• Low TV protects lungLow TV protects lung• PEEP prevents collapse• Moderate FiO2Moderate FiO2• 3‐6 ml/kg for OLV

• ConventionalConventional– 10 ml/kg– FiO2 1.0– ZEEP

• Protective– 6 ml/kg– FiO2 0.5– 5 PEEP– 58% required ↑ FiO2

Yang M, et al. Does a Protective Ventilation Strategy Reduce the Risk of Pulmonary Complications After Lung Cancer Surgery. A Randomized Controlled Trial.  Chest 2011; 139:530‐37

PEEPPEEP

• Variable effect on PVRVariable effect on PVR• Dependent lung at low volumevolume

• Optimal PVR and i FRCoxygenation at FRC

Simmons DH at al. Relation Between Lung Volume and Pulmonary Vascular Resistance. Circ Res 1961; 9:465‐71

PEEPPEEP

• Variable effect on PVRVariable effect on PVR• Dependent lung at low volumevolume

• Optimal PVR and oxygenation at FRC

Simmons DH at al. Relation Between Lung Volume and Pulmonary Vascular Resistance. Circ Res 1961; 9:465‐71

PEEPPEEP

V i bl lt• Variable results• 6 ml/kg TV• Recruitment• 12/41 improved12/41 improved• No Δ CO, MAP

Hoftman N, et al. Positive end expiratory pressure during one‐lung ventilation: Selecting ideal patients and ventilator settings with the aim of improving arterial oxygenation. Ann Card Anaesth 2011;14:183‐7.yg

RecruitmentRecruitment

• Applied prior to 600ControlApplied prior to 

OLV• Improved pO2 300

400

500

pO2

ControlARS

• Improved pO2• Improved VD/VT

0

100

200

p

0TLV TLV 20 OLV 20 OLV 40 TLV

Unzeta C, et al. Alveolar recruitment improves ventilation during thoracic surgery: a randomized controlled trial. Br J Anaesth 2012; 108:517‐24

HypercapneaHypercapnea

• UnpublishedUnpublished• Therapeutic hypercapnea (exogenous CO2)

d d fl k• Reduced inflammatory markers

Limb ischemiaLimb ischemia• Limb Remote Ischemic Preconditioning Attenuates 

Lung Injury after Pulmonary Resection under Propofol–Remifentanil Anesthesia: A Randomized Controlled Studyy

• Li, Cai M.D.; Xu, Miao M.D.; Wu, Yan M.D.; Li, Yun‐Sheng M.D.; Huang, Wen‐Qi M.D.; Liu, Ke‐XuanM.D., Ph.D.

• Anesthesiologygy• Issue: Volume 121(2), August 2014, p 249–259

CPAPCPAP

• Very effective 600

pO2 and CPAP

Very effective• Intact airwayS i fl d

300

400

500

pO2 2cm CPAP

5 CPAP• Start inflated• Surgical  0

100

200

2 lung 1 lung CPAP 2 lung

5cm CPAP

conditions• Inject O2jHogue CW. Effectiveness of Low Levels of Nonventilated Lung Continuous Positive Airway Pressure in Improving Arterial Oxygenation During One‐Lung Ventilation. A th A l 1994 79 364 7Anesth Analg 1994; 79:364‐7

Selective ventilation

500

pO2 and CPAP

Selective ventilation

• Selective lobar

200250300350400450

pO2 0 CPAP

5 CPAP

Selective lobar blockade

• Optionally

050100150200

2 lung 1 lung +/‐CPAP Lobar 2 lung

5cm CPAPOptionally CPAP only that lobe

Campos JH. Effects on Oxygenation During Selective Lobar Versus Total Lung Collapse With of Without Continuous Positive Airway Pressure. Anesth Analg 1997; 85:583‐6 850 2850‐2

• “rescue” blocker with DLT

Sumitani M, et al. Selective lobar bronchial blockade using a double‐lumen endotracheal tube and bronchial blocker. Gen Thorac Cardiovasc Surg 2007; 55:225‐7

Selective ventilationSelective ventilation

• BronchoscopeBronchoscope in lobe

• O2 carefully• O2 carefully

Ku CM, Slinger P, Waddell TK. A Novel Method of Treating Hypoxemia During One‐Lung Ventilation for Thoracoscopic Surgery. J Cardiothor Vasc Anesth 2009;23:850‐2

• Open airwayOpen airway• HFJV vs CPAP? CO• ? COPD

• Hemodynamics

El Tahan MR, et al. Effects of Nondependent Lung Ventilation With ContinuousEl Tahan MR, et al. Effects of Nondependent Lung Ventilation With Continuous Positive‐Pressure Ventilation on Right‐Ventricular Function During 1‐Lung Ventilation. Sem Cardiothor and Vasc Anesth 2010; 14:291‐300

• Sander’s injector• Hand control Sander’s• Vary driving pressure, rate, I:E ratioR i bl d t

Sander s

• Requires blender to alter FiO2

• No pressureNo pressure monitoring

• Risk of barotra mabarotrauma

• Risk of hypoventilationhypoventilation

Monsoon Automated JetMonsoon Automated Jet

Safety cut offidifi i d h iHumidification and heating

FiO2Consistent

Extreme measuresExtreme measures

• Pulmonary artery occlusionPulmonary artery occlusion• ECMOC• CPB

ECMOECMO

• Endobronchial intubtion• Marginal oxygenation• VV• Impro e o enation• Improve oxygenation• Less need for 

anticoagulationg

Anesthetic Management of a Delayed Carinal Resection Following Traumatic  DisruptionKevin A. Blackney, Paul H. Alfille. Open Journal of Anesthesiology, 2014, 4, 231‐235

AlgorithmAlgorithm

• Severe desaturationSevere desaturation– 2 lung ventilation

• GradualGradual– Check tube position, suction, vent settings– Increase FiO2Increase FiO2– Try Recruitment and PEEP– CPAP or selective ventilation– Intermittent inflation– Adjust hemodynamicsj y– Surgical occlusion of blood flow