One-lung anesthesia - NYSORA

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One-lung anesthesia

Learning objectives

  • Describe the indications & contraindications of one-lung anesthesia
  • Perform one-lung anesthesia
  • Manage hypoxia during one-lung anesthesia

Background

  • One-lung anesthesia defines the process of complete functional separation of the lungs
  • Involves ventilating one lung and collapsing the other
  • Facilitates certain types of surgery, but causes significant physiological disadvantages

Indications

  • Protective isolation
    • Prevent contamination or spillage of infectious material (pus or secretions) from the contralateral lung
    • Prevent massive hemorrhage
  • Control the distribution of ventilation between the two lungs in the presence of:
    • Bronchopleural fistula
    • Giant unilateral cyst/bulla
    • Surgical opening of major airway
    • Tracheobronchial tree disruption
  • Unilateral bronchopulmonary lavage (e.g., for alveolar proteinosis)
  • Video-assisted thoracoscopic surgery 
  • Facilitate surgical exposure (e.g., pneumonectomy, lobectomy, thoracoscopy, esophageal surgery, thoracic aneurysm, thoracic spinal surgery)

Contraindications

  • Patient dependent on bilateral ventilation
  • Intraluminal airway masses 
  • Hemodynamic instability
  • Severe hypoxia
  • Severe COPD
  • Severe pulmonary hypertension 
  • Known or suspected difficult intubation

Lung separation

  • Double lumen tube: Allows rapid transition between one-lung ventilation and two-lung ventilation, most commonly used technique
  • Bronchial blockers: Do not facilitate ventilation or suction distal to the blocker
  • Uncut tracheal tube: Can be advanced into the relevant main bronchus, generally only used in emergency situations
  • Papworth BiVent tube: New double lumen tube designed to facilitate rapid and reliable lung isolation using a bronchus blocker without endoscopic guidance

Technique (double lumen tube)

one-lung anesthesia, blood count, urea, electrolytes, x-ray, endobronchial intubation, arterial blood gas, ecg, cpet, airway inflation, flow/volume loop, nerve stimulator, total intravenous, inhalational, neuromuscular blocking, double lumen tube, laryngoscopy, macintosh blade, dlt, stylet, fiberoptic bronchoscope,cuff, ventilation, ausculation, analgesia, physiotherapy

Complications

  • Hypoxemia is one of the most important complications encountered during one-lung anesthesia
  • Management of hypoxemia:
    • Increase inspired oxygen to 100%
    • Check the position of the tube with a fiberoptic bronchoscope
    • Ensure adequate blood pressure and cardiac output
    • Positive end-expiratory pressure 5-10 cmH2O to the dependent lung to decrease atelectasis and increase functional residual capacity
    • Continuous positive airway pressure 5-10 cmH2O with 100% oxygen to the non-ventilated lung
    • If hypoxemia is severe and does not resolve with the aforementioned steps: Abandon one-lung ventilation and intermittently ventilate the collapsed lung after warning the surgeon
    • Early clamping of the appropriate pulmonary artery to stop the shunt

Suggested reading

  • Mehrotra M, Jain A. Single Lung Ventilation. [Updated 2022 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK538314/
  • Ashok V, Francis J. A practical approach to adult one-lung ventilation. BJA Educ. 2018;18(3):69-74.
  • Pollard BJ, Kitchen, G. Handbook of Clinical Anaesthesia. Fourth Edition. CRC Press. 2018. 978-1-4987-6289-2.

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