review of one lung ventilation · 2018. 3. 31. · one lung ventilation 2011 pana conference daniel...

Review of

One Lung Ventilation

2011 PANA Conference

Daniel Kelly SRNA

University of Scranton/Wyoming Valley Healthcare

School of Nurse Anesthesia

1One Lung Ventilation

Goal of One Lung Ventilation

• Provide adequate ventilation and

oxygenation while providing a stable lung

field for surgical manipulation.


Objectives

• Identify surgical procedures that require one lung

ventilation.

• Describe pre-operative testing for procedures that

involve one lung ventilation

• Discuss airway devices (DLT & Bronchial blockers)

utilized to achieve one lung ventilation

• Discuss physiology related to one lung ventilation

• Analyze ventilator settings utilized during single lung

ventilation

• Identify anesthetic complications related to one lung

ventilation


Indications for One Lung

Ventilation

• Lung Resection

• Central or Peripheral Lung Cancer Lesions

• Surgery remains an appropriate form of treatment of

early stage lung cancer

• Stage I or II small cell lung cancer

• Pneumonectomy

• Lesions involving left or right mainstem bronchus

• Wedge Resection

• Small Peripheral Lesions



Ventilation• Single Lung Transplant

• Idiopathic Pulmonary Fibrosis

• Primary Pulmonary HTN

• Cystic Fibrosis

• Pediatrics

• Anesthetic Considerations in the Post

Lung Transplant Patient • Extracellular Lung Fluid less easily removed

• Deneveration – loss of cough reflex

• Aspiration and infection

• Immunosuppressive Therapy

• Cyclosporine - nephrotoxic

One Lung Ventilation 5


Ventilation

• Esophageal Surgery

• Thoracic Aneurysm Repair

• Mediastinal Procedures

• Anterior Approach to Thoracic Spine Procedures

• Dual Chamber Pacemaker insertion

• Confinement of Bleeding or Infection to one lung


Preoperative Testing

• Patients present with multiple co-morbidities

• (ASA 3 or 4)

• Pulmonary Function Tests

• Can provide insight into potential for ventilation

problems in the perioperative period


Preoperative Testing - Lung Volumes

• Total Lung Capacity

(TLC):• Sum of all Volumes

• 5-6 Liters

• Tidal Volume (TV):• Volume inspired/expired

during normal quiet respiration

• 6-8mL/Kg



• Inspiratory Reserve

Volume (IRV):• Volume inspired above a

normal TV

• Expiratory Reserve

Volume (ERV):• Volume of air that can be

forcibly expired after a normal

tidal volume breath



• Vital Capacity (VC):

• Inspiratory (IRV), and

Expiratory (ERV) Reserve

Volume, Tidal Volume (TV)

• Approximately 60mL/kg



• Functional Residual

Capacity (FRC):

• Expiratory Reserve Volume

(ERV)

• Residual Volume (RV)

• Air Remaining in Lungs

• 1000-1200mL

• Body Plethysmography

• Nitrogen Washout test

• Helium Dilution


Pulmonary Function Testing

• Forced Vital Capacity (FVC)

• Volume of air that can be exhaled after a maximal

inspiration

• Time: 4-6 seconds

• Normal Volume: 4 Liters



• Forced Expiratory Volume in one second (FEV1)

• Volume of air exhaled during a forced expiratory

maneuver

• Normal : 0.8 (80%)



• Forced Expiratory Flow (FEF 25-75)

• aka Maximum Midexpiratory Flow (MMEF)

• Middle half of FVC

• Indicative of flow in medium sized airways

• Approximate Normal Value 4.7 L/sec (70kg Adult)

• Decreased in Obstructive Disease

• Normal in Restrictive Disease



• FEV1 / FVC Ratio

• Distinguish between Restrictive and Obstructive

diseases

• Normal: 0.8 (80%)


Obstructive vs. Restrictive

• Airways obstructed• COPD

• Asthma

• Chronic Bronchitis

• FVC = Low• Air trapping

• FEV1 = Low

• FEV1/FVC Ratio:• <0.7

• Example:• FEV 1.2

• FVC 3.0

• Ratio = 0.40

• Restrictive expansion of lung/chest wall• Pulmonary Fibrosis

• Pneumonia

• Neuromuscular Disease

• Pregnancy

• FVC = Normal

• FEV1 = Low

• FEV1/FVC Ratio• >0.8

• Example:• FEV 2.8

• FVC 3.2

• Ratio = 0.85


Obstructive Restrictive



• Pneumonectomy Criteria

• Arterial Blood Gas (Room Air)

• PaCO2 < 45

• PaO2 >50

• FEV1 > 0.8 (800mL)

• Low predicted FEV1 (less than 0.8) & high PaCO2

• Pneumonectomy – contraindicated.



• Split Lung Function Tests

• Regional Perfusion Test

• Xenon Injection – Insoluble radioactive isotope to

determine perfusion of lung fields

• Regional Ventilation Test

• Inhaled Radioactive Gas to determine ventilation of

lung fields.



• History & Physical Exam

• Labs: CBC, BMP, Coagulation Profile, ABG (baseline)

• EXG

• Right Atrial & Ventricular Changes

• Radiographic Films (CT, CXR)

• Location of Lesions:

• Central vs. peripheral

• Structures to be involved during a procedure


Anatomy Review

• Left Main Bronchus: 45-55 degree angle, 4-5 cm

• Right Main Bronchus: 25 degree angle, 2.5 cm• Right Upper Lobe Bronchus – 90 degree angle off of Right

Mainstem


Anatomy Review


Anatomy Review


Anatomy Review


VIDEO Page

• Two Lung Ventilation

• http://www.youtube.com/watch?v=YbwXAurQr30

• Right Lung Ventilation

• http://www.youtube.com/user/SchCnty#p/a/u/1/BOVn

3Rb0bQo

• Left Lung Ventilation

• http://www.youtube.com/watch?v=mWdpZ7JNvM8


Airway Devices


Double Lumen ETT • Robertshaw Design

• Sizes 26 - 41 Fr• Adult Female: 35-37 Fr

• Average depth 27cm

• Adult Male: 39-41 Fr• Average depth 29 cm

• Size selection – largest that can be safely inserted.

• Sources cite Macintosh Blade provides better visualization• Decrease chance of balloon rupture

on teeth

• GLIDESCOPE

• Placement MUST be confirmed with fiberoptic bronchoscopy• Movement of DLT of 1 cm can cause

serious ventilation/oxygenation problems


Double Lumen ETT


Right vs Left Double Lumen ETT

Placement

• Teaching has focused on Left Sided DLT placement for

most thoracic procedures

• Potential to block ventilation of Right upper lobe

• Potential to migrate across carina

• A challenge to conventional wisdom: placement of

Bronchiole (distal) Lumen into the non-operative lung

• Right DLT for Left lung surgery

• Left DLT for Right lung surgery


Right vs Left Double Lumen ETT

Placement

• Opposite Sided DLT Placement Advantages

• No interference or stapling of DLT into bronchus

during lobectomy or pneumonectomy

• Allows the trachea lumen to be clamped

• Bronchoscopy through trachea lumen to assess

distal balloon – not interrupt ventilation

• Tracheal (Proxmial) cuff damage during intubation

• One Lung Ventilation can still be achieved by the

functional bronchial (distal) balloon


Right vs Left Double Lumen ETT Placement


Double Lumen ETT Placement

• Bronchial cuff passed through cords & turned 90

degrees as tracheal cuff passes cords.

• Trachea Cuff inflated – placement confirmed

• Bronchial Cuff inflated – fiberoptic confirmation


Double Lumen ETT Placement

• Bronchial Cuff can be passed deeper into bronchus to

facilitate placement

• Easier to withdraw DLT when it becomes warm &

malleable

• Position re-confirmed after patient position change

• Supine to Lateral

• Fiberoptic Bronchscopy


Achievement of One Lung Ventilation

• Achievement of One Lung Ventilation

• Operative Lung clamped on Adaptor to Vent Circuit

• Port on Operative lung opened and allowed to deflate


Bronchial Blocker Tubes

• Univent:



• Single Lumen Tube with an Endobronchial Blocker

device to isolate a Right or Left Mainstem Bronchus

• Indicated in patients with difficult airway anatomy

• Thoracic Trauma Situations

• Pediatric Patients

• Does not need to be exchanged .

• Mediastinoscopy followed by Thoracotomy

• Bilateral Lung Transplantation

• Post-op ventilator management.


Bronchial Blocker Insertion

• Regular intubation technique

• Rotation towards operative lung

• Trachea cuff is inflated

• Fiberoptic assisted placement of Blocker into

operative lung

• Collapse of operative lung

• Exhalation via distal opening in Blocker



• Univent Tube

• Bronchial Block in a small channel bored into the tube

• Silastic Construction

• Disadvantages:

• May be difficult to place blocker

• Prolonged collapse of operative lung

• May become dislodged with surgical manipulation



• Arndt Endobronchial Blocker

• Regular Endotracheal Tube

• Adaptor placed on ETT

• Blocker is guided by a snare attached to a fiberoptic

bronchoscope

• Aerosol Lubricant

• Disadvantages:

• Difficult positioning into operative bronchus

• Can be caught on Murphy’s Eye or Carina during

insertion


Positioning:

• Supine

• Sternotomy or Anterior Thoracotomy

• Lateral

• Lateral or Posterior Lateral Thoracotomy


Physiology

• Lateral Decubitis Positioning for Thoracic Procedures

• Presents additional challenges to OLV

• Dependent lung has pressure of medistinal structures

• Relaxed diaphragm will increase intrathoracic pressure

from abdominal contents moving cephalad


Physiology

• Ventilation and perfusion are greatest in the dependent

lung field

• Minute Ventilation = 4 liters/min

• Cardiac Output = 5 liters/min

• Normal V/Q Ratio = 0.8

• Determines Shunt State vs. Dead Space


West Lung Zones

• Zone 1 – Alveolar Deadspace

• Upper Lung Field

• PA>Pa>Pv

• Zone 2 – Waterfall Region

• Falls into pulmonary

venous system

• Pa>PA>Pv

• Zone 3 – Dependent Lung

Field

• Pa>Pv>PA

• Continuous Blood Flow


SHUNT DEADSPACE

• Shunt – perfusion no

ventilation

• V/Q = 0

• Normal Physiologic Shunt

2-5%

• Causes:

• Airway Obstruction

• Alveolar Collapse

• Alveolar Obstruction

• Pneumonia

• Edema

• Deadspace – ventilation

no perfusion

• V/Q = infinity

• Normal Anatomic

Deadspace 2mL/kg

• Causes:

• Clots

• PE

• Fat Embolism


Physiology of Shunt

• Ventilation/Perfusion Mismatch

• While one lung is being ventilated – both lungs are still

receiving deoxygenated blood form the heart

• Creates the situation of pulmonary shunt

• Blood enters the arterial system WITHOUT being

oxygenated


V/Q Shunt & Deadspace

SHUNT DEADSPACE

NORMAL

Perfusion, No

Ventilation

V/Q <0.8

Alveolar

Collapse

Alveolar Block

V/Q = 0.8

Ventilation, No

Perfusion

V/Q > 0.8

Clots

PE

Physiology:

Lateral Decubitus Positioning


Lung Field Awake

Respirations

Anesthetized

Ventilation Perfusion Ventilation Perfusion

Non-

dependent

Lung

(Up Lung)

Dependent

Lung

(Down Lung)

Calculation of Alveolar Oxygen Level

• Determination of Hypoxemia

• V/Q Mismatch

• Hypoventilation

• Alveolar:arterial Gradient (A:a Gradient)

• Calculation to determine the effectiveness of gas

exchange at the Alveolar level

• PAO2 – PaO2

• Normal 5-15 mmHG (Room Air)

• Normal Physiologic V/Q Mismatch

• Hypoxia + Normal A:a Gradient = Hypoventilation

• Hypoxia + Elevated A:a Gradient = V/Q Mismatch



• Alveolar Oxygen Calculation (PAO2)

• PAO2 = FiO2 (PB – PH2O) – PaCO2/RQ

• Respiratory Quotient (RQ) = 0.8

• 250 mL of Oxygen diffuses from alveoli to pulmonary circulation

• 200 mL of Carbon Dioxide moves from pulmonary circulation to

alveoli

• Oxygen 250mL/Carbon Dioxide 200mL = 0.8


Barometer

Pressure760mmHg

Partial

Pressure of

Water47mmHg

Respiratory

Quotient


• Example:

• ABG on Room Air (FiO2 = 0.21)

• PaO2 90

• PaCO2 40

• PAO2 = FiO2 (PB – PH2O) – PaCO2/RQ

• PAO2 = 0.21 (760 – 47) – 40/0.8

• PAO2 = 0.21 (713) = 149.7 (40/0.8 = 50)

• PAO2 = 149.7- 50 = 99.7

• PAO2 - PaO2

• 99.7 – 90 = 9.7


Physiology:

Hypoxic Pulmonary Vasoconstriction

• Pulmonary compensatory mechanism which redirects

blood to areas of better ventilation/oxygenation

• Hypoxia causes vasoconstriction in the pulmonary

vasculature

• Opposite then systemic circulation

• Hypoxia = Vasodilation

• Decrease in shunt flow

• Alveolar arterioles constrict

• Intrapulmonary feedback mechanism

• Activated by Alveolar hypoxia

• Atelectasis

• Hypoxic mixtureOne Lung Ventilation 51

Physiology:


• Mechanism of Pulmonary Vasoconstriction not

completely understood

• Redox theory – possible explanation

• Alveolar hypoxemia reduces the activated oxygen species

• Leads to inhibition of voltage gated Potassium channel

• Inflow of extracellular calcium

• Results in localized vasoconstriction

• HPV is reported to decrease Cardiac Output to non-

ventilated lung 20-25%


Physiology:


• Factors that effect of efficiency of HPV

• High Cardiac Output /Hypervolemia• Recruit constricted vasculature

• Hypovolemia

• Vasculature constriction of well ventilated lung fields

• Excessive Tidal Volume or high PEEP

• Hypocapnia

• Hypothermia

• Infection


Physiology:


• Medications that effect of efficiency of HPV

• Inhalational Gases > 1 to 1.5 MAC

• All volatile anesthetics inhibit HPV

• Calcium Channel blockers

• Verapamil, Nifedipine, Nicardipine

• Direct acting vasodilators

• Nitroglycerin, Nitroprusside, Hydralzine

• Beta Agonists - Dobutamine

• Vasoactive Medications

• Potential to vasoconstrict blood flow to oxygenated area

• Epinephrine, Dopamine & Phenylephrine


Physiology:


• Potentiation of perfusion to well oxygenated lung fields

• Nitric Oxide

• Endothelial smooth muscle vasodilator

• Selective vasodilation of ventilated lung fields

• Studies found little effect on improving oxygenation

• Almitrine (Duxil)

• Has effects on peripheral chemoreceptors in Carotid Bodies

• Respiratory stimulate to improve oxygenation in patients with

COPD

• Studies utilizing Nitric and Almitrine – found an increase in oxygenation

• Approved in Europe for short term therapy

• Elevation of pulmonary vascular resistance - result in RV dysfunction

• Neuro toxic effects on myelinated fibers


Ventilator Techniques

• Maintain two lung ventilation as long as possible.

• Inspired Flow of 100% Oxygen

• Bleomycin – cause oxygen toxicity

• Adjust FiO2 as necessary

• Keep peak airway pressure < 30mmHG

• Pressure Control Ventilation preferred

• Study in PCV vs. VCV – no significant difference in PaO2

• PaCO2 30-40 mmHG

• Prevent Hyperventilation

• Hypocapnia in the ventilate lung field with increase vascular

resistance – inhibit HPV



• Tidal Volume (TV) Strategies:

• High Tidal Volume No PEEP

• Low Tidal Volume with PEEP

• TV of 8-15 mL/kg are reported to have minimal

effect on HPV

• TV of less than 6 mL/kg has been implicated with

atelectasis in the dependent lung



• Higher Tidal Volumes (10-15 mL/kg)

• Larger TV were recommended to prevent atelectasis

in the dependent lung field

• Volutrauma

• Overdistention of Lung Segments

• Increased pulmonary resistance

• Shunt blood towards the non ventilated

• Implicated with inflammatory mediators

• Fibrin Deposits

• Acute Lung Injury



• Physiologic Tidal Volume

• 6-8 mL/kg TV (cited by numerous sources)

• Avoid acute lung injury

• Small Amount of PEEP

• Higher settings of PEEP can constrict alveolar circulation

and increase shunt.

• Debate over PEEP

• Replenish FRC

• Shunt blood away from ventilated lung fields

• Hemodynamic compromise



• Termination of OLV

• Manual Ventilation of 20-30 cmH2O

• Recruitment maneuver to re-expand atelectatic lung

tissue

• Surgical assessment of lung tissue / hemorrhage



• Extubation or Exchange

• Type of Procedure

• Complex Lung Resection, Esophagogastrectomy, Thoracic

Aortic Aneurysm repair

• Need for post-op ventilation

• Unexpected fluid shifts/blood loss

• Airway edema

• Facial edema

• Sustained neuromuscular blockade


Hypoxemia – One Lung Ventilation

• Reported to occur in 5 -10% of OLV Procedure

• Improve Alveolar Ventilation & Pulmonary Perfusion

• Assessment of of DLT or Bronchial Blocker Device

placement

• Fiberoptic Bronchscopy

• High Peak Airway Pressures

• Pneumonectomy – early compression/clamping of the

surgical side pulmonary artery

• Divert blood flow to ventilated lung field


Hypoxemia

• Application of PEEP to ventilated lung

• Continuous Insufflation of oxygen into operative lung

• Changing TV & respiratory rate


Hypoxemia

• Periodic inflation of the collapsed lung with oxygen

• CPAP to Nondependent/Nonventilated lung

• 5 -10 cmH2O to non ventilated lung

• Can interfere with surgical exposure

• Closed chest procedure (Thoracoscopy)

• RE-EXPANSION of Collapsed Lung until Oxygen

Saturation Stabilized

• Communication with Surgeon


CPAP to Non Ventilated Lung


Complications

• Displacement of Airway Device during positioning

• Inability to place airway device

• Lesion involving mainstem bronchus

• Airway Fire

• Application of CPAP or continuous oxygen to the non-

ventilated/surgical side lung field can increase the risk

of fire

• Suturing of Airway Device into a mainstem bronchus


Complications

• Pneumothorax of dependent/ventilated lung

• Tracheal Injury from airway device

• Laryngeal Edema

• Bilateral Vocal Cord Paralysis

• Recurrent Laryngeal nerve injury

• Acute Lung Injury

• Re-expansion Pulmonary Edema

• Rare not well understood phenomena

• Similar to ARDS

• Result from alveolar-capillary membrane disruption


Complications - Positioning

• Brachial Plexus Injuries

• Overextension of Neck

• Overextension of Arms

• Rib retraction

• Pneumonectomy - severe the long thoracic nerve

• Serratus Anterior Muscle

• Ulnar Injuries

• Improper padding of elbows (cubital tunnel)

• Dependent Eye Injury

• Hypotension

• Improper padding of head


Complications - Positioning

• Dependent Ear Injury• Use of foam donut to prevent pressure

• Rhadomyolysis

• Breakdown of muscle fibers

• Prolonged Procedure

• Compression of flank/gluteal muscles

• Hypotension


Summary

• Thoracic procedures involving one lung ventilation

provide a special challenge to the anesthesia team

• Careful pre-operative evaluation can provide useful data

on a patient’s lung function prior to one lung ventilation

• Double lumen and bronchial blocker airway devices can

provide suitable means to conduct one lung ventilation


Summary

• Physiologic lung changes such as hypoxic

vasoconstriction and position need to be considered

during one lung ventilation.

• Ventilator settings can to be tailored to the patient

condition to promote adequate oxygenation and a stable

surgical field

• Complications related to thoracic procedures can be

thwarted by proper planning and set-up

• Above all - Prevention of Hypoxia is Paramount


Questions


References

• Barash, P., Cullen, B., Stoeling, R., Cahalan, M., Stock, M.C., (2009). Clinical Anesthesia (6th ed). Philadelphia:

Lippincott Williams

• Denkovich, A. (2010). One-lung ventilation for video-assisted thoracic surgery. International Student Journal of

Nurse Anesthesia, 9(1), 27-30. Retrieved from

http://search.ebscohost.com.ezp2.scranton.edu/login.aspx?direct=true&db=c8h&AN=2010628134&site=ehost-live

• Ishikawa S Shirasawa M Fujisawa M Kawano T Makita K (2010) Compressing the non-dependent lung during

one-lung ventilation improves arterial oxygenation, but impairs systemic oxygen delivery by decreasing cardiac

output. Journal of Anesthesia 24 (1) 17-23

• Jaffe, R., & Samuels, S. (2009) Anesthesiologists Manual of Surgical Procedures. (4th ed). Philadelphia:

Lippincott Williams

• Karzai, W., & Schwarzkopf, K. (2009). Hypoxemia during one-lung ventilation: Prediction, prevention, and

treatment. Anesthesiology, 110(6), 1402-1411. Retrieved from

http://search.ebscohost.com.ezp2.scranton.edu/login.aspx?direct=true&db=c8h&AN=2010289747&site=ehost-live

• Kachare S., Dexter E.U., Nwogu C., Demmy T.L., & Yendamuri, S. (2011). Perioperative outcomes of

thoracoscopic anatomic resections in patients with limited pulmonary reserve. Journal of Thoracic and

Cardiovascular Surgery, 141 (2):459-62.

• Lytle FT, Brown DR. (2008) Appropriate ventilatory settings for thoracic surgery: intraoperative and postoperative. Seminars in Cardiothoracic and Vascular Anesthesia 12 (2), 97-108

• Madershahian, N., Wippermann, J., Sindhu, D., & Wahlers, T. (2009). Unilateral re-expansion pulmonary edema:

A rare complication following one-lung ventilation for minimal invasive mitral valve reconstruction. Journal of

Cardiac Surgery, 24(6), 693-694. Retrieved from http://search.ebscohost.com.ezp2.scranton.edu/login.aspx?direct=true&db=c8h&AN=2010533589&site=ehost-live

•

•One Lung Ventilation 73

References

• Miller, R., Eriksson, L., Fleisher, L., Wiener-Kronish, J., Young, William. (2009). Miller’s Anesthesia (7th ed).

Philadelphia: Elsevier

• Miranda A, Zink R, McSweeney M. (2005) Anesthesia for lung transplantation. Seminars in Cardiothoracic and

Vascular Anesthesia 9(3):205-12 Retrieved from

http://search.ebscohost.com/login.aspx?direct=true&db=mnh&AN=16151553&site=ehost-live">Anesthesia for lung

transplantation.</a>

• Morgan, G., Mikhail, M., Murray, M. (2006). Clinical Anesthesiology (4th ed). McGraw-Hill: New York

• Nagelhout, J.J., Plaus, K.L. (2009). Nurse Anesthesia (4th ed.). St Louis: Elsevier Saunders

• Raynauld Ko, Karen McRae, Gail Darling, Thomas Waddell, Desmond McGlade, Ken Cheung, et al. (2009). The

use of air in the inspired gas mixture during two lung ventilation delays lung collapse during one lung ventilation.Anesthesia & Analgesia, 108(4), 1092.

• Rozé H, Lafargue M, Ouattara A.(2011) Case scenario: Management of intraoperative hypoxemia during one-lung

ventilation. Anesthesiology. 114(1):167-74.

• Shaw JP, Dembitzer FR, Wisnivesky JP, Litle VR, Weiser TS, Yun J, Chin C, Swanson SJ. (2008). Video-assisted

thoracoscopic lobectomy: state of the art and future directions. Annuals of Thoracic Surgery, 85 (2), s705-9

• Tusman G, Böhm SH, Sipmann FS, Maisch S (2004) Lung recruitment improves the efficiency of ventilation and

gas exchange during one-lung ventilation anesthesia. Anesthesia and Analgesia 98 (6), 1604-9

• One Lung Ventilation 74

Special Thanks:

• Carol Raskiewicz CRNA, DNP

• Ann Culp CRNA, DNP

• Sue Elczyna CRNA, MS

• Wilkes-Barre General Hospital Anesthesia Dept

• U of S/ WVHCS School of Nurse Anesthesia

• Class of 2011

• Class of 2012


review of one lung ventilation · 2018. 3. 31. · one lung ventilation 2011 pana conference daniel...

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