TJ

ISSN 0300-8916
Tumori 2017; 103(6): 495-503
DOI: 10.5301/tj.5000638

REVIEW

One-lung ventilation for thoracic surgery: current

perspectives
Filippo Bernasconi1, Federico Piccioni2
1
School of Anesthesia and Intensive Care, University of Milan, Milan - Italy
2
Department of Anesthesia, Intensive Care and Palliative Care, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan - Italy

ABSTRACT
One-lung ventilation (OLV) is an anesthesiological technique that is increasingly being used beyond thoracic sur-
gery. This requires specific skills and knowledge about airway management, maintenance of gas exchange and
prevention of acute lung injury. Sometimes maintaining adequate gas exchange and minimizing acute lung injury
may be opposing processes. Parameters validated for OLV titration still have not been found, but a multimodal
approach based on low tidal volume, end-expiratory pressure application and alveolar recruitment maneuvers is
considered the best way to ensure protective ventilation and reduce lung damage. The purpose of this review is
to analyze all these factors using the latest scientific evidence and the opinions of the most influential authors.
Keywords: Acute lung injury, Airway management, One-lung ventilation, Positive-pressure ventilation,
Thoracic surgery, Ventilator-induced lung injury

Introduction tion effect on the lung parenchyma as an acute lung injury

One-lung ventilation (OLV) is a technique that allows to
ventilate one lung, leaving the other deflated. The target is
to guarantee good surgical exposure while maintaining suffi-
cient oxygenation. The indications for OLV have recently been
revised according to 2 general goals: lung isolation and lung
separation (1). The former is required to avoid contamina-
tion of one lung by the other, including massive hemorrhage,
purulent infection, alveolar proteinosis and bronchopleural
fistula; the latter is needed when surgical exposure is the
main target, not only for thoracic surgery but also for mini-
mally invasive cardiac procedures, esophagectomy and dorsal
spine surgery. Most of these operations might be managed in
video-assisted thoracoscopy (VATS), which requires good pul-
monary exclusion. Therefore the division into absolute and
relative indications for OLV as has been used to date no lon-
ger makes sense; moreover, it is also unpredictable given that
a relative indication may become absolute (2, 3). In addition
to intraoperative hypoxemia, there are other problems that
may occur during OLV, which include the mechanical ventila-
Accepted: April 7, 2017
Published online: June 7, 2017
Corresponding author:
Dr. Federico Piccioni
Department of Anesthesia
Intensive Care and Palliative Care
Fondazione IRCCS Istituto Nazionale dei Tumori
Via Venezian 1
20133 Milan, Italy
federico.piccioni@istitutotumori.mi.it
(ALI) risk factor (4).
This review summarizes the state of the art of OLV, from
airway management to the ventilatory approach to counter-
act hypoxemia and prevent ALI.
Airway management
One of the major unsolved questions in thoracic anesthe-
sia is, what is the best airway device for performing OLV: a
double-lumen tube (DLT) or bronchial blocker (BB). Recently,
2 European surveys clearly demonstrated a preference for
the use of DLT over BB, and showed the worrying data that
19% of respondents in the UK and 23.5% in Italy never used
a BB (5, 6).
Narayanaswamy et al (7) compared 3 BB models with left
DLT and found that the time to lung isolation was significantly
less for DLTs (93 ± 62 seconds) than BBs (203 ± 132 seconds).
Moreover, the number of repositionings was smaller with
DLTs than BBs, but the authors found no difference in the
performance and quality of lung collapse. In any case, a dif-
ference of 110 seconds is clinically irrelevant. Similar results
were observed in a recent meta-analysis: the DLT was easier
to position and required less time but was burdened with a
higher incidence of airway injuries, sore throat and hoarse-
ness in the postoperative period (8). In 2016, Bussières et al
(9) reported faster and better lung deflation with the Fuji Uni-
blocker than the left DLT.
Probably The most important thing is to know which is
the best practice in each condition, taking into account the
safety of the patient, the need for surgical exposure and the
comfort of the anesthesiologist (10). The use of DLT is man-
datory in lung isolation and in lung resections involving the

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main bronchus, while BB is recommended in case of difficult
airway management (2, 11), rapid sequence induction, OLV
in children, and when postoperative ventilatory support is
needed (10). The correct size of the left DLT can easily be de-
rived from the measurement of the left bronchus on CT scan
(12). Undersizing the tube increases the risk of auto-positive
end-expiratory pressure (autoPEEP) through increased air-
flow resistance, injurious high bronchial cuff pressure, and
risk of failure to collapse the lung (13).
Pathophysiology of hypoxemia during OLV
Hypoxemia, intended as arterial oxygen saturation (SpO2)
<90% (or partial pressure of oxygen in arterial blood (PaO2)
<60 mmHg) is frequent during OLV (10-24%) and increases the
incidence of postoperative complications such as atrial fibrilla-
tion, cognitive dysfunction, pulmonary hypertension and renal
failure (14-16). Figure 1 summarizes the factors influencing oxy-
genation during OLV. The mechanism underlying hypoxemia is
multifactorial. The induction of general anesthesia itself leads
to a decrease in functional residual capacity. If the lung volume
drops too low, below the so-called closing capacity, the airways
start to close, leading to lung tissue collapse and subsequent
atelectasis that causes reduction of the ventilation/perfusion
ratio (Va/Q) and intrapulmonary shunt increase (Qs/Qt) (17).
In lateral decubitus, ventilation is affected not only by the
cranial shift of the diaphragm but also by the downward dis-
placement of the mediastinum. Therefore, ventilation is dis-
tributed preferentially in the nondependent (upper) regions of
the lung, while the dependent (lower) regions are poorly aer-
ated down to the bottom where the lung is atelectatic (18).
The influence of gravity on lung perfusion is debated:
Szegedi et al (19) found that PaO2 during OLV is significant-
ly better in lateral than supine position. In contrast, a study
Management of one-lung ventilation
Fig. 1 - Graphical representation of
factors involved in hypoxia during
one-lung ventilation and compensa-
tory mechanisms. The raising of the
diaphragm, the mediastinal shift and
airway closure explain the reduction
of lung volumes. Gravity promotes
perfusion of the ventilated lung.
Pulmonary exclusion leads to acti-
vation of hypoxic pulmonary vaso-
constriction favoring the passage of
blood through the ventilated lung.
The amount of blood that passes
through the nonventilated lung is
the intrapulmonary shunt. RV = Right
Ventricle.
carried out on primates showed that lung perfusion is a het-
erogeneous phenomenon and is influenced only up to 28%
by gravity (20).
These paraphysiological alterations, due to the patient’s
decubitus and the Va/Q mismatch, are always present during
general anesthesia. OLV leads always to a certain increase in
Qs/Qt, intended as a part of the cardiac output that passes
through the deflated lung without ventilation. Wang et al
(21), using transesophageal echocardiography, estimated a
shunt fraction at 30 and 60 minutes during OLV of 35% and
37%, respectively, showing an inverse correlation between
PaO2 and Qs/Qt. The counterbalance to this shunt is given by
the hypoxic pulmonary vasoconstriction (HPV). HPV is a re-
flex contraction of vascular smooth muscle in the pulmonary
circulation in response to low regional PaO2. HPV has 2 phas-
es, the first starting immediately with OLV and the second
30-40 minutes later, so that PaO2rises gradually during the
subsequent 2 hours. Alveolar partial pressure of oxygen (PO2)
is the major determinant of this response, but many other
factors affect pulmonary vascular resistance: partial pressure
of oxygen in venous blood (PvO2), acidosis/alkalosis, temper-
ature, airway pressure, and medication (22). Also drugs used
for general anesthesia may affect HPV. Old volatile anesthet-
ics like halotane and isoflurane blunt HPV at high concentra-
tions, while sevoflurane and desflurane at 1 minimal alveolar
concentration (MAC) do not affect this reflex. Propofol, an
intravenous anesthetic agent, shows no inhibition of HPV
(22). A recent meta-analysis reported a detrimental effect
of epidural analgesia combined with general anesthesia on
HPV and PaO2compared with general anesthesia through an
increase in the shunt fraction (23). It is to be noted that this
meta-analysis suffered from a small sample size (653 patients
from 14 studies) and high heterogeneity between studies.
Moreover, the decrease in cardiac output and venous oxygen
© 2017 Wichtig Publishing
Bernasconi and Piccioni
TABLE I - M
 ain risk factors for acute lung injury after thoracic sur-
gery
Major risk factors Minor risk factors
Pneumonectomy OLV duration
High inspiratory pressure Neoadjuvant chemotherapy
Chronic alcohol consumption Intravenous anesthesia
Fluid overload Multiple transfusions
OLV = one-lung ventilation.
saturation (SvO2) induced by vasodilation of neuroaxial block-
ade reduces the PaO2 but does not directly affect HPV (24).
Summarizing, it is difficult to find effective and reliable
predictors of hypoxemia, but many factors must be consid-
ered: the patient’s position, the degree of perfusion of the
2 lungs, the side of the surgery, possible abnormal lung func-
tion, and even low cardiac output, high oxygen extraction and
high shunt fraction (14, 15, 24).
OLV and acute lung injury
Besides intraoperative hypoxemia, OLV exposes the patient
to the risk of postoperative ALI. Acute respiratory distress syn-
drome (ARDS) was reported in 2.9% of patients after lobec-
tomy and 7.9% after pneumonectomy with a mortality rate of
42% and 50%, respectively (25). Applying the new ARDS crite-
ria (26), the incidence after thoracic surgery was lowered to
2% while maintaining a very high mortality rate of 54.5% (27).
In a retrospective cohort study on patients undergoing
surgery for lung cancer, Licker et al (28) found a biphasic
distribution of ARDS: primary ARDS (which was more fre-
quent) manifested in the first 3 postoperative days and
secondary ARDS occurred after the third postoperative day.
The risk factors for the primary form included chronic alco-
hol consumption, pneumonectomy, high inspiratory pres-
sure during mechanical ventilation, and fluid overload. The
delayed form was triggered by complications such as bron-
choaspiration and pneumonia. Other known risk factors are
the duration of OLV, severe pulmonary dysfunction, neo-
adjuvant chemotherapy, and multiple transfusions (Tab. I)
(29). Unfortunately, to date no large prospective studies
have been conducted to clarify the real weight of the listed
risk factors for post-thoracic-surgery ARDS.
Given the above, today the anesthesiologist is clearly re-
sponsible for intraoperative fluid administration and mechani-
cal ventilation strategies as well as postoperative pain therapy.
With regard to fluid administration, there is still no clarity
regarding the best regimen. The liberal regimen predisposes
to fluid overload, while the restrictive regimen may induce
renal failure. Unfortunately, it is difficult to perform a goal-
directed therapy during thoracic surgery. The widely adopted
dynamic indices (pulse pressure variation and stroke volume
variation) to optimize fluid administration in other surgical
settings are not reliable in open chest conditions (30). Thus,
some authors propose basal maintenance fluid infusion
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497
equal to 1.5 mL/kg/hour to keep normovolemia and replace
intraoperative losses (31). This might be a reasonable choice
during intra- and postoperative periods, while resuming oral
intake as soon as possible. However, it is far from being prov-
en what is the best fluid therapy protocol for thoracic surgery.
The new concept of the endothelial structure, based on the
glycocalyx layer, a complex network of proteins and glycos-
aminoglycans, has changed the knowledge of the mechanisms
regulating the fluid shift, edema formation and modulating
inflammation (32, 33). Surgical manipulation, lung overdis-
tention, ischemia/reperfusion injury, hypoperfusion and oxi-
dative damage are all mechanisms that lead to alteration of
the endothelium structure and lymphatics. Thus, it is easy to
understand the lung’s vulnerability to fluid overload during
and after thoracic surgery.
The factors involved in ventilator-induced lung injury
(VILI) have been extensively studied, especially in critical
patients, and include a high tidal volume (TV) linked with
overdistention, low TV linked with alveolar opening/closure
injury (atelectrauma), and the damage of the alveolar-capil-
lary membrane until the release of inflammatory mediators
(34). In patients with ARDS it has been shown that protective
mechanical ventilation based on low TV and the application
of positive end-expiratory pressure (PEEP) reduces mortal-
ity (35, 36). Thus, the same approach has been proposed for
the operating room. The PROVHILO trial suggested that, us-
ing low TV (8 mL/kg ideal body weight), an open-lung strat-
egy based on high PEEP application and alveolar recruitment
maneuvers (ARM) do not reduce postoperative pulmonary
complications after abdominal surgery (37). A recent meta-
analysis showed that protective mechanical ventilation rather
than PEEP reduces the risk of postoperative pulmonary com-
plications and ARDS in the postoperative period (38). So, the
role of PEEP and ARM in influencing postoperative compli-
cations after abdominal surgery is not clear yet. As regards
OLV, high TV is unanimously considered the most important
risk factor for VILI. Kozian et al (39), using piglets undergo-
ing OLV and surgical manipulation of the left lung, found that
histological examination of lung tissue revealed neutrophil
infiltrates, microhemorrhages, microatelectasis and edema,
especially in the ventilated lung.
Some authors have also suggested a protective role of
volatile anesthetics during mechanical ventilation and OLV.
Schilling et al (40) have shown that the use of anesthetic gases
(sevoflurane and desflurane) during thoracic surgery reduces
the release of proinflammatory cytokines in the bronchoal-
veolar lavage of the ventilated lung. Another study on mouse
models with VILI showed a protective effect of sevoflurane
and isoflurane, probably due to their antiinflammatory and
antioxidative properties (41). Nevertheless, a multicenter
randomized controlled trial on 460 patients undergoing lung
surgery did not demonstrate any difference in the occurrence
of postoperative complications between inhalational and
intravenous anesthesia (42).
How to perform protective mechanical ventilation
during OLV?
The purpose of protective mechanical ventilation is
to keep the lung open, minimize lung injury and ensure
498
adequate pulmonary gas exchange. Thus, the current ap-
proach is multimodal and based on 3 main components: low
TV, PEEP application and ARM.
Michelet et al (43) measured the levels of serum inter-
leukins during OLV for esophagectomy, finding lower levels,
better oxygenation and less extravascular lung water in the
protective-ventilation group (TV 5 mL/kg + PEEP 5 cmH2O)
compared to the conventional-ventilation group (TV 9 mL/kg +
zero end expiratory pressure (ZEEP). Licker and colleagues
(44) retrospectively compared 2 cohorts of patients (over 500
each) before and after implementation of protective ventila-
tion during thoracic surgery. They found significantly better
results in the protective group (TV 5 mL/kg + PEEP 6 cmH2O +
ARM vs. TV 7 mL/kg + PEEP 3 cmH2O and no ARM): fewer hos-
pital stays, fewer ICU admissions, reduced formation of atel-
ectasis and lower incidence of ALI. Similar findings emerged
in a recent randomized controlled trial that has shown better
gas exchange and a lower incidence of atelectasis and ALI in
the group receiving protective ventilation (TV 5 mL/kg + PEEP
5 cmH2O) (45). These data support the idea that lower TVs are
protective. PEEP application and ARMs are useful to improve
oxygenation during OLV, while their influence on ALI is still
uncertain. Currently, 2 large multicenter randomized clinical
trials evaluating the effect of TV, PEEP and ARM on postoper-
ative pulmonary complications after OLV are ongoing (46, 47).
Low tidal volume
Today, experts suggest to use a TV of 5-6 mL/kg (based
on ideal body weight) during OLV (3, 4), which is quite physi-
ological. However, Blank et al (48) in a recent retrospective
study of over 1,000 patients undergoing OLV found an in-
verse relationship between TV and postoperative respira-
tory complications. Moreover, they showed a significant
direct but not strong relation between the driving pressure
(defined as ∆P = Pplat – PEEP) during OLV and postoperative
complications. This is consistent with the findings of Amato
et al (49), who showed the predictive role of ∆P over TV
and PEEP values in predicting survival in ARDS patients. We
always must remember that the underlying mechanisms
of VILI are stress and strain of the lung (50). Stress is the
pressure necessary to counterbalance the transpulmonary
pressure, which is the pressure required to distend the lung
overlying the pleural pressure. Strain is the lung distortion
that follows after stress (51). Unfortunately it has been ob-
served that airway pressure (Paw) or plateau pressure (Pplat)
are often not entirely reliable parameters of stress and
strain (52). Thus, driving pressure may serve as a surrogate
for dynamic alveolar strain.
Another important aspect to consider is that protective
ventilation with small TV favors the formation of dead space
and hypercapnia. Increasing the respiratory rate to reach nor-
mocapnia could be a harmful solution: shortening the inspira-
tory and expiratory times favors the formation of auto-PEEP
and increased respiratory pressure (3, 4). Therefore, during
protective ventilation moderate hypercapnia up to a maxi-
mum of PaCO2= 70 mmHg is usually well tolerated by healthy
subjects, whereas it is to be avoided in patients with pulmo-
nary arterial hypertension, right heart dysfunction and intra-
cranial hypertension (4, 50).
Management of one-lung ventilation
Positive end-expiratory pressure
The rationale for using pressure at end-expiration is to
maintain a lung volume above the closing capacity, thus
avoiding alveolar collapse and preventing intrapulmonary
shunt. The important thing is to understand that the applica-
tion of low TV, if not associated with adequate PEEP, can be
deleterious, promoting tidal recruitment and atelectasis.
Furthermore, the continuous recruitment and derecruit-
ment of lung units leads to high stress, endothelial and
epithelial damage, resulting in increased alveolar-capillary
permeability and release of proinflammatory cytokines (53).
In other circumstances, PEEP can lead to dangerous over-
distention, subsequently increasing the alveolar dead space
and diverting blood flow (54).
Slinger and colleagues (55) observed increased PaO2 in pa-
tients in whom the application of PEEP was close to the lower
inflection point of the curve (LIP). Conversely, PaO2 worsened
(or did not change) when application of PEEP was increasing
the distance between end-expiratory pressure and LIP. Va-
lenza et al (56) demonstrated that PEEP during OLV was more
effective for patients with force expiratory volume in the first
second (FEV1) >72% of predicted than patients with poor pre-
operative FEV1 values in terms of oxygenation and respiratory
mechanics. Thus, PEEP has no established default value but
should be titrated to the respiratory mechanics with careful
assessment of the presence of auto-PEEP through the flow-
time curve, or with an end-expiratory pause to avoid dynamic
hyperinflation (57).
PEEP titration based on respiratory system compliance
seems the most reasonable method, although it will not nec-
essarily improve PaO2. The most practical approach may be
to start OLV with a low PEEP level (5 cmH2O) and, if hypoxia
occurs or a high driving pressure is noted, find the best PEEP
level for the patient using a decremental trial after an ARM
(see text below and Fig. 2).
Alveolar recruitment maneuvers
ARM refers to the provisional application of high airway
pressure aimed at restoring ventilation in lung units that were
previously collapsed. The ARM effect is also crucial to exploiting
PEEP application. As a general rule this pressure in healthy lungs
must be at least 40 cmH2O (18), but it must be carefully applied
in emphysematous lungs. Tusman and coworkers (58, 59) have
extensively studied the ARM effect on gas exchange. ARM per-
formed during OLV produced an improvement of PaO2 in one
study (58). ARMs were performed in pressure-control ventila-
tion (PCV) mode, with an inspiratory-to-expiratory time ratio of
1:1, while maintaining a difference between Ppeak and PEEP of 20
cmH2O, increasing PEEP by 5 cmH2O every minute to reach Ppeak
and a PEEP value of 40 and 20 cmH2O, respectively. With the
same maneuver they also found, through capnography, a better
distribution of ventilation and Va/Q matching after ARM (59).
The results of other studies confirm the usefulness of ARM
during OLV to increase PaO2 and lung compliance with negli-
gible hemodynamic effects (60-64). So, ARMs are useful with
PEEP to keep the lung open and should be performed before
OLV in case of hypoxemia, during prolonged OLV, and at the
end of surgery.
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Bernasconi and Piccioni 499

Fig. 2 - Schematic exemplification of an alveolar recruitment maneuver (ARM) together with a PEEP decrement trial (PDT). To semplify the
figure, no single breaths are represented but the reached pressure levels. The ventilator is switched to the pressure-control ventilation
mode (PCV) with a driving pressure of 20 cmH2O. The inspiratory-to-expiratory time ratio is set to 1:1 and the respiratory rate to 10 bpm.
At the beginning PEEP is set to 5 cmH2O and increased in 5-cmH2O steps every 5-10 breaths. This cycling ARM is applied until a peak pres-
sure of 40 cmH2O is reached. After the ARM is completed, PDT is performed, decreasing PEEP in 2-cmH2O steps until the maximal dynamic
compliance is obtained (defined by the PEEP value at which the obtained tidal volume is highest). Finally a new ARM must be carried out
before the ventilator is switched to the OLV setting (in volume-control or pressure-control mode as preferred). In the shown example the
optimal PEEP is 10 cmH2O.

ARM can be perfomed in several ways. Manual ARM, using
bag squeezing, is less used today. Many anesthesiologists use
the ventilator to reach a plateau pressure of 35-40 cmH2O in
combination with a stepwise increase in PEEP. Currently there
is no reference ARM. In a recent clinical trial Ferrando et al (65)
adopted a pragmatic approach taking advantage of ARM fol-
lowed by a PEEP decrement trial (PDT) over a non-individualized
PEEP protocol. In the experimental group, ARM was performed
by increasing the PEEP gradually, mantaining a driving pres-
sure of 20 cmH2O, until a Ppeak of 40 cmH2O was reached. So,
with the lung recruited, PEEP was progressively reduced until
the best dynamic compliance was found. In the control group
the same ventilatory strategy was adopted but using a non-in-
dividualized PEEP. In the study group, mean individualized PEEP
was 10 cmH2O and led to significantly better results in terms of
gas exchange and compliance (65). Figure 2 shows a schematic
exemplification of an ARM followed by a PDT.
Keep an eye on the curves
The current literature on how low must be the TV or what
is the optimal level of PEEP suggests that anesthesiologists
should always control the pressure curves during mechani-
cal ventilation. Gama de Abreu and colleagues (66) evaluated
lung injury during OLV in isolated rabbit lung models. They
compared nonprotective (high-TV + ZEEP) and protective
(low-TV, PEEP + ARM) ventilation, also observing the mor-
phology of the dynamic pressure-time (P-t) curve as proposed
by Ranieri et al (67). The P-t curve of the nonprotective group
had an upward concavity (overdistention) and this group later
showed signs of lung injury. Conversely, protectively ventilat-
ed lungs maintained a straight P-t curve during the inspira-
tory phase (constant compliance) and no later signs of lung
injury were detected. Thus, observation of the morphological
characteristics of the P-t curve in a volume-cycled mode of
ventilation is an easy and safe way to monitor and optimize
OLV. A downward concavity of the curve (stress index <1) sug-
gests the need for alveolar recruitment and/or PEEP increase.
An upward concavity (stress index >1) prompts to reduce TV
and/or PEEP (Fig. 3).
What to do in case of hypoxemia during OLV?
The mechanisms underlying hypoxemia during OLV have
been discussed above. Maintaining an SpO2>90% is certainly a
primary objective with low-moderate fraction of inspired oxy-
gen (FiO2) (30%-50%). Hyperoxia should be avoided if possible
because it promotes the formation of reactive oxygen inter-
mediates (ROI) that trigger inflammation and cell damage by
peroxidation of lipids, nucleic acids and proteins (68).
The first step in addressing the problem is to consider
DLT or BB malpositioning (69). Obviously, this check can be
performed with FiO2>50% in case of severe desaturation.
It is therefore necessary to verify the correct positioning of
the tubes and the absence of obstructing secretions (Tab. II)
(3, 24, 70). For this purpose fiberoptic bronchoscopy (FOB)
is mandatory (2). After that, it is reasonable to try an ARM
followed by a DPT (4, 24, 50).
If this is not enough, the application of continuous posi-
tive airway pressure (CPAP) ≤5 cmH2O to the nonventilated
lung appears to be useful as it improves oxygenation and
reduces local production of proinflammatory cytokines
(71). Authors disagree on CPAP application during VATS
surgery because it worsens the surgical exposure (3, 50).
If these measures are not sufficient to restore an adequate
SpO2, then it is justified to increase the FiO2. In extreme

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Fig. 3 - Dynamic pressure-time (P-t) curve during constant flow ventilation. (A) Straight line = constant compliance; (B) downward con-
cavity = tidal recruitment; (C) upward concavity = overdistention. The downward concavity of the P-t curve indicates the possibility of
recruiting a certain part of the unventilated lung parenchyma. In this circumstance it is advisable to adjust the ventilation by performing
an ARM and setting a higher PEEP. Conversely, the upward concavity of the P-t curve suggests overdistention of the lung due to excessive
TV or high PEEP. In this case it is mandatory to revise the ventilation strategy by decreasing TV, PEEP or both.
TABLE II - Practical approach to hypoxemia during OLV
Step by step approach
  1)  Increase FiO2 (for sudden and severe desaturation)
  2)  Check tube position and exclude its obstruction with FOB
  3)  ARM and subsequent PDT
  4)  CPAP to the nonventilated lung (if possible)
  5)  Increase FiO2 until SpO2 ≥90%
  6)  Pulmonary artery clamping
  7)  Lung reexpansion
ARM = alveolar recruitment maneuver; CPAP = continuous positive airway
pressure; FiO2 = fraction of inspired oxygen; FOB = fiberoptic bronchoscopy;
OLV = one-lung ventilation; PEEP = positive end-expiratory pressure; PDT =
PEEP decrement trial; SpO2 = arterial oxygen saturation.
circumstances, it is interesting to consider the FOB use
described by Ku et al (72) to give oxygen selectively to a
lobe of the operative lung away from the surgical site. How-
ever, this approach is not easy to perform and not always
feasible.
If hypoxemia persists, the last step to take is to inform the
surgeon of the need to ventilate the lung or to provide for
pulmonary artery clamping (70).
High-frequency jet ventilation and OLV
In a small case series, El-Baz et al (73) compared high-
frequency jet ventilation (HFV) OLV with conventional OLV,
reporting better oxygenation in HFV-treated patients. Lucan-
gelo and colleagues (74) reported better oxygenation during
OLV and better clearance of secretions during the postopera-
tive period in patients in whom high-frequency percussive
ventilation rather than CPAP was applied to the nondepen-
dent lung. Considering the results reported by other authors,
HFV seems effective in increasing oxygenation when applied
to the nondependent lung during OLV (75, 76). Some case re-
Management of one-lung ventilation
ports also described the successful use of HFV through DLT
or BB to counteract hypoxemia during OLV (77, 78). Finally,
HFV has been used for tracheal sleeve resection or transplant
(79, 80). However, the widespread use of HFV for OLV is lim-
ited by the necessity of expertise and specialized ventilator
machines, difficulties in ventilation parameter monitoring,
and fear of barotrauma.
Conclusions
Anesthetic management of OLV should be performed by
a properly trained person, from the preoperative evaluation
(outside the focus of this review) and the choice of the device
for lung separation up to the management of mechanical ven-
tilation. Proper management of OLV must avoid intraoperative
hypoxemia and at the same time protect the lung from injury.
Modern protective mechanical ventilation during OLV
is multimodal and comprises low TV, PEEP application and
ARM. There are no absolute values of TV and PEEP to be ap-
plied; rather, values must be adjusted according to the pa-
tient’s respiratory mechanics while avoiding overdistention
and tidal recruitment. Evaluation of the P-t curve is a useful
parameter for monitoring and titrating inspiratory pressures.
Today, the management of hypoxemia occurring during
OLV, if not related to tube displacement, is primarily based on
optimization of lung ventilation rather than a simple increase
in TV or FiO2.
Abbreviations
ALI acute lung injury
ARDS acute respiratory distress syndrome
BB bronchial blocker
CPAP continuous positive airway pressure
DLT double-lumen tube
FEV1 Forced expiratory volume in the first second
FiO2 Fraction of inspired oxygen
FOB fiberoptic bronchoscopy
HFV high-frequency jet ventilation
HPV hypoxic pulmonary vasoconstriction
LIP lower inflection point
MAC minimal alveolar concentration
© 2017 Wichtig Publishing
Bernasconi and Piccioni
OLV one-lung ventilation
PaO2 Partial Pressure of Oxygen in Arterial Blood
Paw airway pressure
PCV pressure-control ventilation
PDT PEEP decrement trial
PEEP positive end-expiratory pressure
PO2 Partial pressure of oxygen
Ppeak peak pressure
Pplat plateau pressure
P-t curve pressure-time curve
PvO2 Partial pressure of oxygen in venous blood
Qs/Qt pulmonary shunt fraction
ROI reactive oxygen intermediates
SpO2 Arterial oxygen saturation
SvO2 Venous oxygen saturation
TV tidal volume
Va/Q ventilation/perfusion ratio
VATS video-assisted thoracoscopy
VILI ventilator-induced lung injury
Acknowledgment
The authors thank Dr. Cecilia Piantanida (University of Oxford, UK)
for linguistic revision of the manuscript.
Disclosures
Financial support: None.
Conflict of interest: The authors have no competing interests related
to this article.
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