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Onelungventilationbyshadab 150521183623 Lva1 App6892
Onelungventilationbyshadab 150521183623 Lva1 App6892
DR SHADAB
INTRODUCTION
One-lung ventilation, OLV, means separation of
the two lungs and each lung functioning
independently by preparation of the airway
It is the intentional collapse of a lung on the
operative side of the patient which facilitates most
thoracic procedures.
Requires much skill of the anesthesia team
because of
• Difficult to place lung isolation equipment
• Ability to overcome hypoxic pulmonary
vasoconstriction
• Patient population is comparably
• 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
• Dependent Lung or Down Lung
– The lung that is ventilated
• Non-dependent Lung or Up Lung
– The lung that is collapsed to facilitate
the surgery
ABSOLUTE INDICATION FOR
OLV
•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
• Tracheobronchial tree disruption
• Life-threatening hypoxemia due to unilateral lung disease
•Unilateral bronchopulmonary lavage
RELATIVE INDICATION
• Surgical exposure ( high priority)
• Thoracic aortic aneurysm
• Pneumonectomy
• Upper lobectomy
• Mediastinal exposure
• Thoracoscopy
• Surgical exposure (low priority)
• Middle and lower lobectomies and subsegmental resections
• Esophageal surgery
• Thoracic spine procedure
• Minimal invasive cardiac surgery (MID-CABG, TMR)
• Postcardiopulmonary bypass status after removal of
totally occluding chronic unilateral pulmonary emboli
• Severe hypoxemia due to unilateral lung disease
OLV is achieved by either;
-Bronchial blocker
-Endobronchial tube
Double-lumen endotracheal tube, DLT
Single-lumen ET with a built-in bronchial blocker, Univent Tube
Single-lumen ET with an isolated bronchial blocker
Arndt (wire-guided) endobronchial blocker set
Balloon-tipped luminal catheters
Endobronchial intubation of a single-lumen ET
Anatomy of the Tracheobronchial Tree
Features of DLT
• Type:
• Carlens, a left-sided + a carinal hook
• White, a right-sided Carlens tube
• Bryce-Smith, no hook but a slotted cuff/Rt
• Robertshaw, most widely used
• All have two lumina/cuffs, one minating
ter in the trachea and the other in thetem
mains 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)
Left DLT…
• 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
…Left DLT
• More difficult to insert (size and curve, cuff)
• Risk of tube change and airway damage if kept in
position for post-op ventilation
• Contraindication:
• Presence of lesion along DLT pathway
• Difficult/impossible conventional direct vision
intubation
• Critically ill patients with single lumen tube in situ who
cannot tolerate even a short period of off mechanical
ventilation
• Full stomach or high risk of aspiration
• Patients, too small (<25-35kg) or too young (< 8-12 yrs)
Right DLT: bronchoscopic view
Carlens DLT Robertshaw DLT
Different types of DLT
lume
n
hoo + + - -
k
L R Lt & Lt &
side
t t Rt Rt
Basic pattern of a Right-Sided DLT
Rt Lt
Lt
passage of the left-sided DLT
guide for Length and Size of DLT
Length of tube , For 170 cm height, tube depth of 29 cm
For every 10 cm height change , 1 cm depth change
Checklist for tracheal placement Chec klis t for Lt side Chec klis t for Rt side
a. inflate tracheal cuff a. inflate Lt cuff > 2ml a. clamp Lt tube
b. ventilate rapidly by hand b. ventilate and check bilateral b. check unilateral (Rt)
c. check that both lungs are being breath sounds breath sounds
ventilated c.clamp Rt tube
d. If not, withdraw 2-3 cm & repeat d.check unilateral (Lt) breath
sounds
Major Malpositions of a Lt- DLT
Lt
Br eath Sounds
Heard
Both cuffs Lef Lef Bot Righ
inflated
t t h t
Clamp Rt lumen
Both cuffs
Righ None / None / None /
inflated
t Very Very Very
Clamp Lt lumen
minimal minimal minimal
Deflate Lt cuff
Bot le Bot Righ
Clamp Lt lumen
h ft h t
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.
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
DLT
Placement
• Checking tube placement with the fiberoptic
bronchoscope
• Several situations exist where auscultation maneuvers are
impossible (patient is prepped and draped), or when they do
not
provide reliable information (preexisting lung disease so that
breath sounds are not very audible, or if the tube is only
slightly malpositioned)
• The double-lumen tube's precise position can be most
reliably determined with the fiberoptic bronchoscope
• In patients with double-lumen tubes whose position seemed
appropriate to auscultations, 48% had some degree
of malposition. So always check position with
fiberoptic
• After advancing the fiberoptic scope thru the “tracheal” tube you
should see the “bronchial blue balloon” in a semi lunar shape,
just peeking out of the bronchus
DLT
Placement
To ensure correct position of DLT clinically :
the chest rises and falls in accordance with the breath sounds
respiratory gas moisture appears and disappears with each tidal ventilation
FOB picture of Lt - DLT
FOB picture of Rt DLT
Relationship of FOB Size to Adult DLT
FOB Size (mm) Adult DLT Size Fit of FOB inside DLT
(OD) (French)
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..).
Adequacy for Sealing (air Bubble test )
Complications of DLT
small patients;
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;
One- or two-lung ventilation is achieved simply by inflating or deflating, respectively, the bronchial blocker balloon
Indications for Wire-Guided
Endobronchial Blockers vs. DLT
• Critically ill patients
• Rapid sequence induction
• Known and unknown difficult
airway
• Postoperative intubation
• Small adult and pediatric patients
• Obese adults
Advantages of the Univent Bronchial Blocker Tube
( Relative to DLT )
3.No need to change the tube when turning from the supine to
prone position or for postoperative mechanical ventilation.
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 (c) Deflate BB cuff and compress and evacuate the lung
through the main single lumen;
(b)apply suction to BB lumen
3.Blockage of BB Suction, stylet, and then
lumen suction
( blood, pus,..)
4. High-pressure Use just-seal volume of air
cuff Make sure BB cuff is subcarinal, increase inflation volume,
5. Leak in BB cuff rearrange surgical field
Arndt endobronchial blocker
[Wire guided Endobronchial Blocker (WEB)]
Wire-Guided Endobronchial
Blockers
• Available
sizes
• Adult 9 Fr
• Pediatric 5 Fr
Comparison of Various Tube
Diameters
Wire-Guided Endobronchial
Blockers
Wire-Guided Endobronchial
Blockers
Wire-Guided Endobronchial
Blockers
Wire-Guided Endobronchial
Blockers
Fogarty Embolectomy
Catheters
Fogarty Embolectomy
Catheter
• Single-lumen balloon tipped catheter with a
removable stylet
• In the parallel fashion, the Fogarty catheter is
inserted prior to intubation
• In the co-axial fashion, the Fogarty catheter is
placed through the endotracheal tube
• Both techniques require fiberoptic bronchoscopy to
direct the Fogarty catheter into the correct pulmonary
segment
• sealing
Once the the airwayis in place, the balloon is inflated,
catheter
• Clinical limitations to the Fogarty technique
• Difficult to direct and cannot be coupled to a fiberoptic bronchoscope
• No accessory lumen for either removal of gas from the blocked segment
or insufflation of oxygen to reverse hypoxemia
• Ventilate w/ 100% O2 prior to balloon inflation to aid in gas removal
Cohen Flexitip Endobronchial Blocker
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.
* 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).
Lung separation with a single-lumen tube, FOB, and Rt
lung bronchial blocker
Disadvantages of a blocker that is independent of
the single-lumen tube as compared with DLT
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
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.
In summary,
DLT is the method of choice for lung separation in most
adult patients. The precise location can be determined by
FOB .
In situations where insertion of a DLT may be difficult and/or
dangerous, separating the lungs is achieved either with a
single-lumen tube alone or in combination with a bronchial
blocker (e.g., the Univent tube).
Therefore,
regardless of what method of lung separation chosen, there
is a real need of a small-diameter FOB (for checking
the position of the DLT, placing a single-lumen
tube in a mainstem bronchus, and placing a
bronchial blocker) .
Complications of One Lung
Ventilation
• All difficult airway complications
• Injury to lips, mouth, teeth
• Injury to airway mucosa from
stylet
• Bronchial Rupture
• Decreased saturation
• HPV
• Inability to isolate lung
Complications - Bronchial
Rupture
Comparing Up Right & Lateral Decubitus
Position
05/21/15 HSNZ KT
• Distribution of blood flow and ventilation is similar to that in the
upright position but turned by 90 degrees.
• Blood flow and ventilation to the dependent lung are significantly
greater than to the nondependent lung.
• Good V/Q matching at the level of the dependent lung results in
adequate oxygenation in the awake patient breathing
spontaneously.
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2) Ldp/ awake/ Spont Breath/ open Chest
2 complications
1. Mediastinal shift, occurring during inspiration.
Negative pressure more in intact hemithorax
cause the mediastinum to move vertically
downward and push into the dependent
hemithorax.
• create circulatory & reflex changes, result in a clinical
picture similar to that of shock and respiratory distress.
• Eg. Thoracoscopy LA, pt may need intubated
immediately, with initiation of positive-pressure
ventilation
05/21/15 HSNZ KT
Ldp/ awake/ Spont Breath/ open Chest
2. Paradoxical breathing:
• During inspiration, movement of gas from the exposed
lung into the intact lung and movement of air from the
environment into the open hemithorax cause collapse
of the exposed lung.
• During expiration, the reverse occurs, and the exposed
lung expands
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2) Ldp/ awake/ Spont Breath/ open Chest
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Respiratory Physiology (lateral
decubitus position) in anaesthetised pt
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Factors affecting respiratory physiology
in lateral decubitus position
The changes further accentuated by several factors:
1) Induction of anesthesia
2)Initiation of mechanical ventilation
3)Use of neuromuscular blockade
4)Opening the chest/pleural space
5)Surgical Retraction/ Compression
6)Pressure by mediastinum/
Abdominal content
05/21/15 HSNZ KT
Induction of Anaesthesia
• Reduce FRC
• Non dependent lung moves to favorable part of compliance
• Dependent lung moves to less compliance
• Result in > ventilation in nondependent lung than dependent
• But perfusion still favor the dependent lung (gravitational effect)
• Thus V/Q mismatch occur causing hypoxia
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Other factors involved
• Positive Pressure Ventilation (PPV in mechanical ventilation)
favors ND lung as it is > compliant
• Use of neuromuscular blockade- causing paralysis of the
diaphragm. Allowing abdominal to push the dependent
hemidiaphram & impede further ventilation of DL
• Suboptimal positioning (usage of sand bag to maintain pt in LDP)
further restrict movement of DL
• Opening of NDL cause increase compliance of NDL, as the lungs
less restricted. This further attenuates differences of compliance
between two lungs.
05/21/15 HSNZ KT
3) Ldp/ Anaesthetized / Spont Breath/ Closed
Chest
• In awake/ anaesthetised- distribution of pulmonary blood flow
influenced by gravitational effect
• But Induction of GAC cause significant changes in distribution of
ventilation
• Reasons:
• Ventilation favors NDL due to
• GAC reduce both lungs FRC (both loss of volume)
• Effect of muscle relaxation- paralysis of both hemidiaphragm. The curve
effect of diaphragm gives no Advantages
• Pressure effect by medialstinal structure- rest on dependent lung
physically impedes DL.
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3) Ldp/ Anaesthetized / Spont Breath/ Closed
Chest
05/21/15 HSNZ KT
4) Ldp/ Anaesthetized / Spont Breath/ Open
Chest
• No changes in pulmonary blood flow- >perfusion to DL
(gravitational effect)
• But it caused significant changes on ventilation
• NDL overventilation (remain unperfused)- increase compliance
due to no restriction of chest wall/ free to expand
• DL relatively non compliance (poor ventilation/ overperfused)
• Surgical retraction/compression of NDL provide partial solution:
expansion of NDL when externally restricted, ventilation will be
diverted to dependent, and better perfused lung.
05/21/15 HSNZ KT
6) Olv/ Anaesthetized / Paralysed/ Open Chest
• Dependent lung is no longer on the steep (compliant) portion of
the volume–pressure curve because of reduced lung volume and
FRC.
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6) Olv/ Anaesthetized / Paralysed/ Open Chest
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Summary of V-Q relationships in the anesthetized,
open-chest and paralyzed patients in LDP
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SUMMARY OF V/Q RELATIONSHIP IN
AWAKE & ANAESTHETISED PT
Awake/Closed Anaesthetised
Closed
V/Q V Q V Q V Q
Open
NDL
DL
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Summary of V-Q relationships in the anesthetized,
open-chest and paralyzed patients in LDP
05/21/15 HSNZ KT
Physiology of OLV
• The principle physiologic change of OLV is the redistribution of
lung perfusion between the ventilated (dependent) and blocked
(nondependent) lung
• Many factors contribute to the lung perfusion, the major
determinants of them are hypoxic pulmonary vasoconstriction
(HPV) and gravity.
Summary of factors influencing
pulmonary/ lung perfusion
05/21/15 HSNZ KT
Physiology of OLV
(Arterial Oxygenation and Carbon Dioxide Elimination)
& l ar ger P( A- a) O2
d ur i ng OLV, t he no nv e nt i l a t e d l ung ha s s o me b l oo d f l o w a nd t he r e f
o r e ha s a n o b l i g a t o r y s hunt , whi c h i s no t p r e s e nt d ur i ng t wo - l ung
v e nt i l a t i o n & i s t he mo s t i mp o r t a nt r e a s o n f o r i nc r e a s e d P( A- a
) O2.
Blood Flow distribution during OLV
•gravity,
•amount of lung disease,
•magnitude HPV,
•surgical interference
nondependent ,
2. absorption atelectasis can occur in regions with low V/Q when they are exposed to
high FIO2 .
4. maintaining the LDP for prolonged periods may cause fluid to transude into the
dependent lung and cause further decrease in lung volume and increase in airway
Blood Flow Distribution During OLV , cont.
05/21/15 HSNZ KT
Hypoxic pulmonary vasoconstriction
(hpv)
05/21/15 HSNZ KT
ring OLV , cont.
Magnitude of HPV
1. Distribution of the alveolar hypoxia is probably not a determinant of the amount of HPV; all regions of the lung
respond to alveolar hypoxia with vasoconstriction.
2. Atelectasis, most of blood flow reduction in acutely atelectatic lung is due to HPV and none of it to passive
mechanical factors (such as vessel tortuosity).
4. Anaesthetic drugs
7. FIO2 selectively decreasing the FIO2in the normoxic compartment causes an increase in normoxic lung vascular
tone, thereby decreasing blood flow diversion from hypoxic to normoxic lung.
8. Vasoconstrictor drugs constrict normoxic lung vessels preferentially, thereby disproportionately increasing
normoxic lung PVR causing decrease normoxic lung blood flow and increase atelectatic lung blood flow.
10. PEEP
Other Causes of Hypoxaemia During OLV
saturations are OK
• Manual ventilation for the first few minutes of OLV to
get a sense of pulmonary compliance / resistance
• Be attentive to inspiratory pressures and tidal volumes
and adjust the ventilator to optimize oxygenation and
alveolar ventilation, with minimal barotrauma
• Look at the surgical field to see if the non-dependent
lung is collapsed
...Management of OLV
• Hypoventilation
• Resorption of residual O from the clamped lung
2
• Manual ventilation
• Check DLT position with FOB
• Check hemodynamic status
• CPAP (5-10 cm H O, 5 L/min) to nondependent lung, most effective
2
CPAP is created by the free flow of oxygen into the lung versus the restricted outflow of
oxygen from the lung by the pressure relief valve.
The Mallinckrodt Broncho-Cath CPAP System
(Photography courtesy of Mallinckrodt Medical, Inc., St. Louis, MO.)
Recommended Combined Conventional and
Differential Lung Management of OLV
1. Maintain two-lung ventilation until pleura is
opened
2. Dependant lung
• FIO2 = 1.0
• VT = 10 ml / Kg
• PEEP = 5 - 10 cmH2O
So,
• can be delivered through very small catheters
• it decreases PAWP
So,
it may be uniquely useful in facilitating the performance of thoracic surgery in
the following three ways;
-Use in Major Conducting Airway Surgery
-Use in Bronchopleural Fistula
-Use in Minimizing Movement of the Operative Field
Types of HFV
ball Activ e
e
Low-Flow Apnoeic Ventilation (Apnoeic Insufflation)
• If left
ventilation is stopped during administration of 100 % O2 and airway is
connected to a fresh gas supply, O2 will be drawn into the lung by mass
movement to replace the diffused O2 . There is usually no difficulty in
maintaining an adequate PaO2 (especially if 5–10 cmH2O of CPAP is used) at
least for 20 minutes .
• If flow of O is relatively low (<0.1 L/kg/min) almost all CO produced is retained, and
2 2
PaCO2 rises approximately 6 mmHg in the 1st minute and then 3 - 4 mmHg
each minute thereafter .