Abstract
Despite more reliable methods to ensure lung isolation, hypoxia during one-lung ventilation (OLV) can still be a challenge for the anesthesiologist. While a true lower acceptable limit of saturation has not been defined, and is likely different for different patients, cerebral oxygenation does fall significantly during thoracic anesthesia cases, and decreased cerebral oxygenation has been associated with adverse outcomes. Different management strategies can be employed to prevent and treat hypoxia during OLV. These include optimal ventilatory management of the dependent lung, techniques to deliver oxygen to the non-ventilated lung, regulation of physiologic parameters such as circulation, and control of pharmacological factors. This chapter will also cover the issue of the inadequately deflating lung that the anesthesiologist may have to deal with from time to time. A case discussion will follow.
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References
Maloney JV Jr, Schmutzer KJ, Raschke E. Paradoxical respiration and “pendelluft”. J Thorac Cardiovasc Surg. 1961;41:291–8.
Brassard CL, Lohser J, Donati F, Bussieres JS. Step-by-step clinical management of one-lung ventilation: continuing professional development. Can J Anesth. 2014;61:1103–21.
Stub D, Smith K, Bernard S, et al. Air versus oxygen in ST-segment-elevation myocardial infarction. Circulation. 2015;131:2143–50.
Eastwood GM, Tanaka A, Espinoza ED, et al. Conservative oxygen therapy in mechanically ventilated patients following cardiac arrest: a retrospective nested cohort study. Resuscitation. 2016;101:108–14.
Panwar R, Hardie M, Bellomo R, et al. Conservative versus liberal oxygenation targets for mechanically ventilated patients. A pilot multicenter randomized controlled trial. Am J Respir Crit Care Med. 2016;193:43–51.
Tobias JD, Johnson GA, Rehman S, Fisher R, Caron N. Cerebral oxygenation monitoring using near infrared spectroscopy during one-lung ventilation in adults. J Minim Access Surg. 2008;4:104–7.
Hemmerling TM, Bluteau MC, Kazan R, Bracco D. Significant decrease of cerebral oxygen saturation during single-lung ventilation measured using absolute oximetry. Br J Anaesth. 2008;101:870–5.
Kazan R, Bracco D, Hemmerling TM. Reduced cerebral oxygen saturation measured by absolute cerebral oximetry during thoracic surgery correlates with postoperative complications. Br J Anaesth. 2009;103:811–6.
Tang L, Kazan R, Taddei R, Zaouter C, Cyr S, Hemmerling TM. Reduced cerebral oxygen saturation during thoracic surgery predicts early postoperative cognitive dysfunction. Br J Anaesth. 2012;108:623–9.
Mahal I, Davie SN, Grocott HP. Cerebral oximetry and thoracic surgery. Curr Opin Anesthesiol. 2014;27:21–7.
Talbot NP, Balanos GM, Dorrington KL, Robbins PA. Two temporal components within the human pulmonary vascular response to ~2h of isocapnic hypoxia. J Appl Physiol. 2005;98:1125–39.
Silva PL, Moraes L, Santos RS, Samary C, Ramos MB, Santos CL, Morales MM, Capelozzi VL, Garcia CS, de Abreu MG, Pelosi P, Marini JJ, Rocco PR. Recruitment maneuvers modulate epithelial and endothelial cell response according to acute lung injury etiology. Crit Care Med. 2013;41:e256–65.
Ferrando C, Mugarra A, Gutierrez A, et al. Setting individualized positive end-expiratory pressure level with a positive end-expiratory pressure decrement trial after a recruitment maneuver improves oxygenation and lung mechanics during one-lung ventilation. Anesth Analg. 2014;118:657–65.
Kim KN, Kim DW, Jeong MA, Sin YH, Lee SK. Comparison of pressure-controlled ventilation with volume-controlled ventilation during one-lung ventilation: a systematic review and meta-analysis. BMC Anesthesiol. 2016;16(1):72.
Hogue CW Jr. Effectiveness of low levels of non-ventilated lung continuous positive airway pressure in improving oxygenation during one-lung ventilation. Anesth Analg. 1994;79:364.
Russell WJ. Intermittent positive airway pressure to manage hypoxia during one-lung anaesthesia. Anaesth Intensive Care. 2009;37(3):432–4.
Shoman BM, Ragab HO, Mustafa A, Mazhar R. High frequency/small tidal volume differential lung ventilation: a technique of ventilating the nondependent lung of one lung ventilation for robotically assisted thoracic surgery. Case Rep Anesthesiol. 2015;2015:631450., 3 p.
Campos JH. Effects on oxygenation during selective lobar versus total lung collapse with or without continuous positive airway pressure. Anesth Analg. 1997;85(3):583–6.
Ku CM, Slinger P, Waddell T. A novel method of treating hypoxemia during one-lung ventilation for thoracoscopic surgery. J Cardiothorac Vasc Anesth. 2009;37:432.
Marshall C, Lindgren L, Marshall BE. Effects of halothane, enflurane, and isoflurane on hypoxic pulmonary vasoconstriction in rat lungs in vitro. Anesthesiology. 1984;60:304.
Domino KB, Borowec L, Alexander CM, Williams JJ, Chen L, Marshall C, Marshall BE. Influence of isoflurane on hypoxic pulmonary vasoconstriction in dogs. Anesthesiology. 1986;64:423–9.
Wang JY, Russel GN, Page RD, et al. A comparison of the effects of sevoflurane and isoflurane on arterial oxygenation during one-lung anesthesia. Br J Anesth. 2000;81:850.
Wang JY, Russel GN, Page RD, et al. A comparison of the effects of desflurane and isoflurane on arterial oxygenation during one-lung ventilation. Anaesthesia. 2000;55:167.
Reid CW, Slinger PD, Lewis S. Comparison of the effects of propofol-alfentanil versus isoflurane anesthesia on arterial oxygenation during one-lung anesthesia. J Cardiothroac Vasc Anesth. 1996;10:860.
Pruszkowski O, Dalibon N, Moutafis M, Jugan E, Law-Koune JD, Laloë PA, Fischler M. Effects of propofol vs sevoflurane on arterial oxygenation during one-lung ventilation. Br J Anaesth. 2007;98(4):539–44.
Sharifian Attar A, Tabari M, Rahnamazadeh M, Salehi M. A comparison of effects of propofol and isoflurane on arterial oxygenation pressure, mean arterial pressure and heart rate variations following one-lung ventilation in thoracic surgeries. Iran Red Crescent Med J. 2014;16:e15809.
Cho YJ, Kim TK, Hong DM, Seo J-H, Bahk J-H, Jeon Y. Effect of desflurane-remifentanil vs. Propofol-remifentanil anesthesia on arterial oxygenation during one-lung ventilation for thoracoscopic surgery: a prospective randomized trial. BMC Anesthesiol. 2017;17(1):9.
Schilling T, Kozian A, Senturk M, et al. Effects of volatile and intravenous anesthesia on the alveolar and systemic inflammatory response in thoracic surgical patients. Anesthesiology. 2011;115:65–74.
De Conno E, Steurer M, Wittlinger M, et al. Anesthetic- induced improvement of the inflammatory response to one- lung ventilation. Anesthesiology. 2009;110:1316–26.
Potočnik I, Novak Janković V, Šostarič M, et al. Anti-inflammatory effect of sevoflurane in open lung surgery with one-lung ventilation. Croat Med J. 2014;55(6):628–37.
Casati A, Mascotto G, Iemi K, Nzepa-Batonga J, De Luca M. Epidural block does not worsen oxygenation during one-lung ventilation for lung resections under isoflurane/nitrous oxide anaesthesia. Eur J Anaesthesiol. 2005;22(5):363–8.
Ozcan PE, Senturk M, Sungur Ulke Z, et al. Effects of thoracic epidural anaesthesia on pulmonary venous admixture and oxygenation during one-lung ventilation. Acta Anaesthesiol Scand. 2007;51(8):1117–22.
Garutti I, Quintana B, Olmedilla L, Cruz A, Barranco M, Garcia de Lucas E. Arterial oxygenation during one-lung ventilation: combined versus general anesthesia. Anesth Analg. 1999;88:494–9.
Xia R, Yin H, Xia ZY, et al. Effect of intravenous infusion of dexmedetomidine combined with inhalation of isoflurane on arterial oxygenation and intrapulmonary shunt during single-lung ventilation. Cell Biochem Biophys. 2013;67:1547–50.
Lee SH, Kim N, Lee CY, Ban MG, Oh YJ. Effects of dexmedetomidine on oxygenation and lung mechanics in patients with moderate chronic obstructive pulmonary disease undergoing lung cancer surgery: a randomised double-blinded trial. Eur J Anaesthesiol. 2016;33:275–82.
Silva-Costa-Gomes T, Gallart L, Valle’s J, et al. Low vs high-dose almitrine combined with nitric oxide to prevent hypoxia during open-chest one-lung ventilation. Br J Anaesth. 2005;95(3):410–6.
Schwarzkopf K, Klein U, Schreiber T, et al. Oxygenation during one-lung ventilation: the effects of inhaled nitric oxide and increasing levels of inspired fraction of oxygen. Anesth Analg. 2001;92(4):842–7.
Moutafis M, Liu N, Dalibon N, et al. The effects of inhaled nitric oxide and its combination with intravenous almitrine on Pao2 during one-lung ventilation in patients undergoing thoracoscopic procedures. Anesth Analg. 1997;85(5):1130–5.
Della Rocca G, Coccia C, Pompei L, et al. Inhaled aerosolized prostaglandin E1, pulmonary hemodynamics, and oxygenation during lung transplantation. Minerva Anestesiol. 2008;74(11):627–33.
Khan TA, Schnickel G, Ross D, et al. A prospective, randomized, crossover pilot study of inhaled nitric oxide versus inhaled prostacyclin in heart transplant and lung transplant recipients. J Thorac Cardiovasc Surg. 2009;138(6):1417–24.
Raghunathan K, Connelly NR, Robbins LD, Ganim R, Hochheiser G, DiCampli R. Inhaled epoprostenol during one-lung ventilation. Ann Thorac Surg. 2010;89(3):981–3.
Ko R, Mcrae K, Darling G, et al. The use of air in the inspired gas mixture during two-lung ventilation delays lung collapse during one-lung ventilation. Anesth Analg. 2009;108:1092–6.
Pfitzner J, Peacock MJ, McAleer PT. Gas movement in the non- ventilated lung at the onset of single-lung ventilation for video- assisted thoracoscopy. Anaesthesia. 2000;54:437–43.
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Case Discussion
Case Discussion
Your next patient is a 65 year-old man awaiting a VATS right upper lobectomy for adenocarcinoma of the lung. He is 169 cm tall and weighs 74.0 kg. He has a preoperative FEV1 of 82% predicted with an obstructive FEV1/FVC ratio and a DLCO of 58%. He quit smoking 3 years ago and is on an ACE inhibitor for hypertension but has no other comorbidities. He climbs two flights of stairs without difficulty.
After a smooth induction and placement of your 39 Fr DLT, you turn the patient on his left side. Because of the obstructive lung disease, you isolate the lung early and pass a suction catheter down the tracheal lumen at 20 cm H2O to encourage lung deflation. The ventilator is set at 15 × 380 with a PEEP of 5, and FiO2 has been turned down to 80%. The surgery begins, and the surgeon is pleased with lung collapse. After 5 min, you notice that the saturation has fallen gradually and is now hovering at 87%.
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Is this desaturation surprising in this case?
Early after lung isolation, desaturation may happen because of either tube malposition or because of the slow onset of HPV which has not kicked in fully yet. In this case risk factors include the fact that surgery is taking place on the right lung which implies a potentially larger shunt, and the poor preoperative DLCO which suggests that the PaO2 prior to OLV may already be suboptimal. The patient is also taking a systemic vasodilator drug that can impair HPV.
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Describe your management at this point.
The FiO2 and flows should be turned up in order to deliver 100% oxygen. If it appears that the saturation is falling precipitously, it would be prudent to notify the surgeon and resume TLV. Since the fall described here is gradual, bronchoscopy may be performed to confirm adequate tube positioning, and a stepwise approach to hypoxia on one lung can be performed.
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3.
The blue cuff is situated well beyond the carina but when scoping down the bronchial lumen, you note that you cannot see the left upper lobe bronchus suggesting that the tube is too far. A larger shunt is likely the cause of the hypoxia because of complete or partial exclusion of the left upper lobe which is not being ventilated due to malpositioning of the tube. You reposition the tube under bronchoscopic guidance by entering the tracheal lumen, pulling the tube back and then confirming through the bronchial lumen that the tip is well situated in the left main bronchus. What do you do next?
Prior to resuming ventilation to the dependent lung, a manual recruitment maneuver may be performed with a gentle sustained pressure of 30 cm H2O for 10 s, as the poorly ventilated left upper lobe has likely developed some atelectasis during this time. You may then proceed to titrate your FiO2 down to aim for a saturation of 92–96%.
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4.
The saturation improves to 96% but 10 min later has drifted down again to 88%. Bronchoscopy confirms that the DLT is well positioned. How do you proceed?
Initial steps may include ruling out physiologic derangements that would impair saturation such as decreased perfusion or inadequate or over-ventilation. You may check for hypotension from surgical compression, hypovolemia, or excessive anesthesia and send an ABG to assess PaCO2. An optimal ventilator strategy in the dependent lung is one that avoids the development of atelectasis but doesn’t over distend alveoli to the point that PVR increases in that lung. Following another manual recruitment maneuver, a PEEP decrement trial may be employed, searching for the PEEP that provides optimal compliance. If more than one MAC of volatile is being used, a balanced technique should be employed, or TIVA may be considered if it is not possible to reduce the dose of volatile.
If the saturation has not improved, the surgeon should be made aware and a plan agreed upon. As this case is a VATS, the surgeon will likely be very reluctant to employ CPAP to the non-ventilated lung. They may in fact prefer intermittent gentle re-expansion with 100% oxygen, repeating as needed. An alternate approach would be using a bronchoscope with oxygen attached to the suction port to selectively insufflate the lower lobe segments. This needs to be done in collaboration with the surgeons who can direct their cameras to observe the insufflated segment and avoid overdistension.
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Shafiepour, D.S. (2019). Troubleshooting One-Lung Ventilation. In: Slinger, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-00859-8_26
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