Management Of One-lung Ventilation Research Articles

Preoperative preparation and postoperative care in children in thoracic surgery.

Anesthesia for pediatric patients undergoing thoracic surgery continues to be distinctive due to differing anatomical and physiological characteristics compared to adults. Adequate preoperative preparation, appropriate tool selection for providing one-lung ventilation, perioperative pain management, and a multidisciplinary approach can ensure higher quality postoperative care. In this review, the perioperative anesthesia management for pediatric patients undergoing thoracic surgery will be discussed, starting from the preoperative preparation phase. Additionally, the issues related to the application and management of one-lung ventilation will also be assessed.

Right-sided Decortication in a Patient with Left Pulmonary Artery Embolism – A Case Report

This case is an anesthesia challenge and management of one-lung ventilation in a patient with pulmonary embolism of the ventilated lung. A 50 years old male with a history of pulmonary thromboembolism of segmental and subsegmental branches of the left pulmonary artery was posted for right decortication. He developed hypoxia (sp02~82-85% ) and PaC02-EtCO2 difference of ~30 mm Hg on initiation of one lung ventilation indicating significant shunting of blood and V/Q mismatch. We want to emphasize the importance of intraoperative arterial blood analysis to look for (PaCO2 –EtCO2) difference and periodic reinflation of the collapsed lung for management of patients in whom the blood supply to the dependent is compromised. The presence of pulmonary vascular compromise on the dependent side offers a great number of challenges during the management of one-lung ventilation.

Lung Isolation

Lung isolation is being used more frequently in adult patients due to increasing incidence of thoracoscopy and video-assisted thoracoscopic surgery. There are several indications for lung isolation and one-lung ventilation (OLV) during surgery. Isolation is usually achieved by double-lumen endotracheal tubes or use of some type of bronchial blocker system. The initiation of OLV frequently leads to hypoxemia, the management of which should be stepwise. Additionally, clinical outcomes are significantly improved with the use of lung protective strategies during OLV. This review covers the use of few of the most common lung isolation devices, management of OLV using lung protective ventilation strategies, and management of oxygenation and hypoxemia during OLV. This review contains 12 figures, 6 tables, and 36 references. Key Words: bronchial blockers, double-lumen tube, uninvent, hypoxemia, hypoxic pulmonary vasoconstriction, one lung ventilation, positive end expiratory pressure, tracheal anatomy, lung isolation

Anesthesia for thoracic surgery in infants and children.

The management of infants and children presenting for thoracic surgery poses a variety of challenges for anesthesiologists. A thorough understanding of the implications of developmental changes in cardiopulmonary anatomy and physiology, associated comorbid conditions, and the proposed surgical intervention is essential in order to provide safe and effective clinical care. This narrative review discusses the perioperative anesthetic management of pediatric patients undergoing noncardiac thoracic surgery, beginning with the preoperative assessment. The considerations for the implementation and management of one-lung ventilation (OLV) will be reviewed, and as will the anesthetic implications of different surgical procedures including bronchoscopy, mediastinoscopy, thoracotomy, and thoracoscopy. We will also discuss pediatric-specific disease processes presenting in neonates, infants, and children, with an emphasis on those with unique impact on anesthetic management.

Anesthesia and fast-track in video-assisted thoracic surgery (VATS): from evidence to practice.

In thoracic surgery, the introduction of video-assisted thoracoscopic techniques has allowed the development of fast-track protocols, with shorter hospital lengths of stay and improved outcomes. The perioperative management needs to be optimized accordingly, with the goal of reducing postoperative complications and speeding recovery times. Premedication performed in the operative room should be wisely administered because often linked to late discharge from the post-anesthesia care unit (PACU). Inhalatory anesthesia, when possible, should be preferred based on protective effects on postoperative lung inflammation. Deep neuromuscular blockade should be pursued and carefully monitored, and an appropriate reversal administered before extubation. Management of one-lung ventilation (OLV) needs to be optimized to prevent not only intraoperative hypoxemia but also postoperative acute lung injury (ALI): protective ventilation strategies are therefore to be implemented. Locoregional techniques should be favored over intravenous analgesia: the thoracic epidural, the paravertebral block (PVB), the intercostal nerve block (ICNB), and the serratus anterior plane block (SAPB) are thoroughly reviewed and the most common dosages are reported. Fluid therapy needs to be administered critically, to avoid both overload and cardiovascular compromisation. All these practices are analyzed singularly with the aid of the most recent evidences aimed at the best patient care. Finally, a few notes on some of the latest trends in research are presented, such as non-intubated video-assisted thoracoscopic surgery (VATS) and intravenous lidocaine.

An alternative method to achieve one-lung ventilation by surgical pneumothorax in difficult lung isolation patient: a case report

It is challenging to establish one-lung ventilation in difficult airway patients. Surgical pneumothorax under spontaneous breathing to obtain well-collapsed lung is a feasible method for thoracic surgery. A 76-year-old man with right empyema was scheduled for decortication. The patient had limited mouth opening due to facial cellulitis extending from the left cheek to neck. Generally, lung isolation is achieved by double-lumen endotracheal tube or bronchial blocker. Double-lumen tube insertion is difficult for patients with limited mouth opening and right-side placement of bronchial blocker usually causes insufficient deflation. We introduce an alternative lung isolation technique by surgical pneumothorax under spontaneous breathing simply with an endotracheal tube placement. This technique has never been applied into the management of difficult one-lung ventilation. By this method, we provide an ideal surgical condition with safer, less time-consuming, and less skill-demanding anesthesia. It would be an alternative choice for management of one-lung ventilation in the difficult lung isolation patient.

Acquired bronchoesophageal fistula: an anesthetic challenge

We report a rare case of acquired esophageal traction diverticulum, associated with tuberculous lymphadenitis leading to benign bronchoesophageal fistula of the right lower lobe bronchus. A 30-year-old male patient was admitted to our hospital with history of pulmonary tuberculosis 2 years back and complaints of cough and choking sensation after swallowing for 1 year. The diagnosis of bronchoesophageal fistula was made by contrast esophagogram and confirmed on computed tomographic scan. He was posted for thoracoscopic ligation of the fistula. Anesthetic management included thoracic epidural and general anesthesia with one-lung ventilation. Preoperative optimization, management of one-lung ventilation, optimum fluid management guided by central venous pressures, excellent analgesia with thoracic epidural, postoperative ICU care, and team efforts were important to make us succeed in this rare case of acquired benign bronchoesophageal fistula.

Back To Blockers?

Back To Blockers?

Delayed Onset of Contralateral Pulmonary Edema Following Reexpansion Pulmonary Edema of a Collapsed Lung After Video-assisted Thoracoscopic Surgery

This case report describes a 61-year-old man who developed reexpansion pulmonary edema (RPE) of the collapsed left lung after video-assisted thoracoscopic surgery because of left thoracic empyema, complicated with secondary contralateral pulmonary edema later. The left lung was gently reexpanded after surgery under one-lung ventilation anesthesia for 2.5 hours. The patient developed RPE of the left lung immediately after surgery, and required mechanical ventilation with positive end-expiratory pressure support. RPE was resolved within 24 hours. Nevertheless, delayed onset of contralateral pulmonary edema manifested on chest radiography 4 days later without clinical symptoms such as tachypnea or dyspnea. There was no evidence of pulmonary infection, fluid overload, postoperative renal insufficiency or cardiogenic onslaught. Late manifestation of contralateral pulmonary edema in the wake of previous left-sided RPE was suspected from exclusion of possible culprits. Response to steroid therapy made inflammation-related pulmonary edema a likely diagnosis. This case demonstrates that delayed contralateral pulmonary edema with only radiographic evidence can emerge 4 days after resolution of RPE of a collapsed lung. Methods to prevent RPE and management of one-lung ventilation are described.

Fisiopatologia e manejo clínico da ventilação seletiva

A ventilação seletiva consiste em ventilar um pulmão mecanicamente enquanto o outro é ocluído ou exposto ao ar ambiente. Essa técnica permite visualizar as estruturas intratorácicas e, assim, fornecer excelentes condições cirúrgicas. Todo o volume corrente é administrado apenas para um único pulmão. Entretanto, este procedimento está associado à redução da pressão parcial arterial de oxigênio, principalmente em pacientes com comprometimento pulmonar prévio, por diminuição na superfície da área de troca gasosa e perda da auto-regulação pulmonar normal. Sendo assim, a manutenção da oxigenação e a eliminação de gás carbônico adequadas representam o maior desafio durante o manejo da ventilação seletiva. Preconiza-se que o pulmão dependente seja ventilado com um volume corrente similar àquele utilizado para ventilar ambos os pulmões na ventilação mecânica convencional, além de altas frações inspiradas de oxigênio. Entretanto, vários outros métodos vêm sendo propostos a fim de minimizar a hipoxemia durante a ventilação seletiva: conferir o correto posicionamento do tubo de duplo-lúmen, uso de pressão positiva ao final da expiração, pressão contínua nas vias aéreas, uso de óxido nítrico, ventilação de alta freqüência e recrutamento alveolar. O manejo da ventilação seletiva continua sendo um desafio à prática clínica.

Physiology of One-Lung Ventilation

The understanding of the physiology and management of one-lung ventilation (OLV) has advanced over the last two decades. OLV induces an obligatory shunt through the nonventilated lung that causes varying degrees of arterial hypoxemia. Shunt may also occur in the venti lated lung. The optimal mode of ventilation of the dependent lung has not been well defined. The optimal tidal volume, respiratory rate, inspired oxygen concen tration, and positive end-expiratory pressure (PEEP) during OLV are not known. Functional residual capacity (FRC) of the ventilated lung can be lower than during two-lung ventilation, causing atelectasis and arterial hypoxemia. Patients who desaturate might be expected to show improvement in oxygenation with dependent lung PEEP, because of increased FRC and reduced V/Q mismatch. Not all patients have low lung volumes, and not all patients who have low lung volumes will desatu rate. Therefore, prophylactic PEEP is not usually neces sary or appropriate. Because the predominant cause of hypoxemia during OLV is shunt in the nondependent lung, therapies to improve arterial oxygenation during OLV should be primarily directed toward the nondepen dent lung. Partial reinflation of the nondependent lung with O2will reduce the physiological shunt fraction of the lung. Continuous positive airways pressure (CPAP) is an effective prophylactic and therapeutic treatment for hypoxemia. All studies examining CPAP have found it to be effective, provided it is preceded by lung reinflation.