A Novel Method of Treating Hypoxemia During One-Lung Ventilation for Thoracic Surgery

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We read with great interest the article written by Ku et al1Ku C.M. Slinger P. Waddell T.K. A novel method of treating hypoxemia during one-lung ventilation for thoracic surgery.J Cardiothorac Vasc Anesth. 2009; 23: 850-852Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar suggesting the use of the fiberoptic bronchoscope (FOB) to provide selective ipsilateral segmental insufflation of oxygen to improve oxygenation during video-assisted thoracoscopic surgery (VATS) without interfering with the surgical exposure. We acknowledge the importance of this article because VATS is becoming more and more popular for patients with very poor respiratory function (forced expiratory volume in 1 second <40% of predicted) undergoing one-lung ventilation. We realize that VATS surgery for pulmonary lobectomies recently has been introduced, and the originality of this technique consists in the possibility of using the supine position and a modified retractor for lower lobectomies.3Muscolino G. A new thoracoscopic technique for pulmonary lobectomies.Minim Invasive Ther Allied Technol. 2009; 1: 1-3Google Scholar Nevertheless, the VATS procedure generally is performed in the full lateral decubitus rather than in the supine position.2Sakurai H. Videothoracoscopic surgical approach for spontaneous pneumothorax: Review of the pertinent literature.World J Emerg Surg. 2008; 3: 23Crossref PubMed Scopus (17) Google Scholar Therefore, we would like to know if the authors believe that the selective oxygenation of 1 segment would have been as effective as it was if the patient would have needed the lateral position for surgery. We looked at the limitations the FOB might have moving inside a double-lumen tube. The length of these tubes is identical regardless of the size; however, narrow tubes reduce the mobility of the scope, particularly in the left side. We are concerned with the possibility of performing a selective ipsilateral insufflation with the FOB for upper-lobe segments. The major limitation for the right upper lobe is the anatomy, whereas the major limitation for the left upper-lobe selective oxygenation might be the length of the bronchial tube of the double-lumen tube, which might restrict the movement of the FOB. Therefore, we would like to know if the authors believe, given their experience, that this technique is useful for the treatment of hypoxemia in all VATS procedures or just for those limited to upper-lobe surgery, requiring lower segments selective oxygenation. Finally, we are concerned regarding the authors' statement in the discussion suggesting that “there was no impairment of the surgical field because the insufflation of oxygen was selective and directed only into the nonoperated lobe of the lung” and the evidence that each oxygenation was performed for no more than 20 seconds. Given the fact that the FOB could sit nicely without interfering with the procedure, why was it necessary to do this maneuver only for 20 seconds? Why could it not last longer? Why did the authors wait until a new desaturation before performing it again? What were the major problems the authors faced when repeating a new oxygenation? We believe this is a very challenging and interesting technique, and we hope it can be used more often in a wider range of procedures. We question the potential harm and benefits compared with other techniques such as the application of positive end-expiratory pressure in the ipsilateral lung. A broader use of this technique might answer most of our questions. A Novel Method of Treating Hypoxemia During One-Lung Ventilation for Thoracoscopic SurgeryJournal of Cardiothoracic and Vascular AnesthesiaVol. 23Issue 6PreviewHYPOXEMIA DURING one-lung ventilation (OLV) for video-assisted thoracoscopic surgery (VATS) is a difficult problem for the anesthesiologist to manage. The standard therapy recommended for this problem is the application of continuous positive airway pressure (CPAP) to the nonventilated lung.1 However, CPAP interferes with surgical exposure in the hemithorax.2 A novel technique to treat hypoxemia in this context using fiberoptic bronchoscopic segmental oxygen insufflation and recruitment that does not impede surgery is described. Full-Text PDF Reply to Drs Courtois and RubulottaJournal of Cardiothoracic and Vascular AnesthesiaVol. 25Issue 3PreviewWe thank the doctors from St Mary's Hospital for their letter. We believe that selective oxygenation of 1 segment would have been as effective if the patient were in the lateral position because the technique improves hypoxemia by apneic oxygenation. The technique is suitable for the treatment of hypoxemia in most VATS procedures and not just for those limited to upper-lobe surgery requiring lower-segment selective oxygenation. It must be emphasized, however, that segmental lung insufflation should be performed under direct vision of the thoracoscope to ensure that the field of the surgery is not impeded. Full-Text PDF