• Andreas VogtEmail author


This chapter aims to summarize (i) monitoring, (ii) airway and ventilation strategy, and (iii) anesthetic implications and perioperative analgesia. Important aspects of lung separation and one-lung ventilation are knowledge of distal airway anatomy, fiber-optic bronchoscopy, and correct interpretation of radiological chest imaging. Double-lumen tubes or bronchial blockers controlled by fiber-optic bronchoscopy are suitable for lung separation and one-lung ventilation. Hypoxic pulmonary vasoconstriction reduces the right-to-left shunt during one-lung ventilation. No advantage could be found for intravenous or inhalational anesthesia in terms of intraoperative oxygenation, but sevoflurane might reduce inflammatory response and postoperative adverse events. Thoracic paravertebral block provides effective perioperative pain treatment with fewer incidences of side effects compared with epidural analgesia.


Continuous Positive Airway Pressure Hypoxic Pulmonary Vasoconstriction Thoracic Epidural Anesthesia Main Stem Bronchus Paravertebral Block 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. 1.
    The Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301–8Google Scholar
  2. 2.
    Bassi A, Milani WR, El Dib R et al (2008) Intravenous versus inhalation anaesthesia for one-lung ventilation. Cochrane Database Syst Rev: CD006313Google Scholar
  3. 3.
    Benumof JL (1985) One-lung ventilation and hypoxic pulmonary vasoconstriction: implications for anesthetic management. Anesth Analg 64:821–833PubMedCrossRefGoogle Scholar
  4. 4.
    Brodsky JB (2004) Fiberoptic bronchoscopy need not be a routine part of double-lumen tube placement. Curr Opin Anaesthesiol 17:7–11PubMedCrossRefGoogle Scholar
  5. 5.
    Brodsky JB, Lemmens HJ (2003) Left double-lumen tubes: clinical experience with 1,170 patients. J Cardiothorac Vasc Anesth 17:289–298PubMedCrossRefGoogle Scholar
  6. 6.
    Campos JH (2009) Fast track in thoracic anesthesia and surgery. Curr Opin Anaesthesiol 22:1–3PubMedCrossRefGoogle Scholar
  7. 7.
    Campos JH (2009) Update on selective lobar blockade during pulmonary resections. Curr Opin Anaesthesiol 22:18–22PubMedCrossRefGoogle Scholar
  8. 8.
    Campos JH (2010) Lung isolation techniques for patients with difficult airway. Curr Opin Anaesthesiol 23:12–17PubMedCrossRefGoogle Scholar
  9. 9.
    Casati A, Mascotto G, Iemi K et al (2005) Epidural block does not worsen oxygenation during one-lung ventilation for lung resections under isoflurane/nitrous oxide anaesthesia. Eur J Anaesthesiol 22:363–368PubMedCrossRefGoogle Scholar
  10. 10.
    Chow MY, Liam BL, Thng CH et al (1999) Predicting the size of a double-lumen endobronchial tube using computed tomographic scan measurements of the left main bronchus diameter. Anesth Analg 88:302–305PubMedGoogle Scholar
  11. 11.
    Cinnella G, Grasso S, Natale C et al (2008) Physiological effects of a lung-recruiting strategy applied during one-lung ventilation. Acta Anaesthesiol Scand 52:766–775PubMedCrossRefGoogle Scholar
  12. 12.
    Cohen E (2004) Double-lumen tube position should be confirmed by fiberoptic bronchoscopy. Curr Opin Anaesthesiol 17:1–6PubMedCrossRefGoogle Scholar
  13. 13.
    Daly DJ, Myles PS (2009) Update on the role of paravertebral blocks for thoracic surgery: are they worth it? Curr Opin Anaesthesiol 22:38–43PubMedCrossRefGoogle Scholar
  14. 14.
    De Conno E, Steurer MP, Wittlinger M et al (2009) Anesthetic-induced improvement of the inflammatory response to one-lung ventilation. Anesthesiology 110:1316–1326PubMedCrossRefGoogle Scholar
  15. 15.
    Dumans-Nizard V, Liu N, Laloe PA et al (2009) A comparison of the deflecting-tip bronchial blocker with a wire-guided blocker or left-sided double-lumen tube. J Cardiothorac Vasc Anesth 23:501–505PubMedCrossRefGoogle Scholar
  16. 16.
    Eberle B, Weiler N, Vogel N et al (1999) Computed tomography-based tracheobronchial image reconstruction allows selection of the individually appropriate double-lumen tube size. J Cardiothorac Vasc Anesth 13:532–537PubMedCrossRefGoogle Scholar
  17. 17.
    Fiorelli A, Vicidomini G, Laperuta P et al (2010) Pre-emptive local analgesia in video-assisted thoracic surgery sympathectomy. Eur J Cardiothorac Surg 37: 588–593PubMedCrossRefGoogle Scholar
  18. 18.
    Fischer GW, Cohen E (2010) An update on anesthesia for thoracoscopic surgery. Curr Opin Anaesthesiol 23:7–11PubMedCrossRefGoogle Scholar
  19. 19.
    Fukuoka N, Iida H, Akamatsu S et al (2009) The association between the initial end-tidal carbon ­dioxide difference and the lowest arterial oxygen tension value obtained during one-lung anesthesia with propofol or sevoflurane. J Cardiothorac Vasc Anesth 23:775–779PubMedCrossRefGoogle Scholar
  20. 20.
    Grichnik KP, Shaw A (2009) Update on one-lung ventilation: the use of continuous positive airway pressure ventilation and positive end-expiratory pressure ventilation – clinical application. Curr Opin Anaesthesiol 22:23–30PubMedCrossRefGoogle Scholar
  21. 21.
    Hill SE, Keller RA, Stafford-Smith M et al (2006) Efficacy of single-dose, multilevel paravertebral nerve blockade for analgesia after thoracoscopic procedures. Anesthesiology 104:1047–1053PubMedCrossRefGoogle Scholar
  22. 22.
    Jung SM, Cho CK, Kim YJ et al (2010) The effect of thoracic epidural anesthesia on pulmonary shunt fraction and arterial oxygenation during one-lung ventilation. J Cardiothorac Vasc Anesth 24:456–462PubMedCrossRefGoogle Scholar
  23. 23.
    Karzai W, Schwarzkopf K (2009) Hypoxemia during one-lung ventilation: prediction, prevention, and treatment. Anesthesiology 110:1402–1411PubMedCrossRefGoogle Scholar
  24. 24.
    Ko R, McRae K, Darling G et al (2009) The use of air in the inspired gas mixture during two-lung ventilation delays lung collapse during one-lung ventilation. Anesth Analg 108:1092–1096PubMedCrossRefGoogle Scholar
  25. 25.
    Kotze A, Scally A, Howell S (2009) Efficacy and safety of different techniques of paravertebral block for analgesia after thoracotomy: a systematic review and metaregression. Br J Anaesth 103:626–636PubMedCrossRefGoogle Scholar
  26. 26.
    Ku CM, Slinger P, Waddell TK (2009) A novel method of treating hypoxemia during one-lung ventilation for thoracoscopic surgery. J Cardiothorac Vasc Anesth 23:850–852PubMedCrossRefGoogle Scholar
  27. 27.
    Lytle FT, Brown DR (2008) Appropriate ventilatory settings for thoracic surgery: intraoperative and postoperative. Semin Cardiothorac Vasc Anesth 12:97–108PubMedCrossRefGoogle Scholar
  28. 28.
    Merli G, Guarino A, Della Rocca G et al (2009) Recommendations for airway control and difficult airway management in thoracic anesthesia and lung separation procedures. Minerva Anestesiol 75:59–78; 79–96PubMedGoogle Scholar
  29. 29.
    Nagahiro I, Andou A, Aoe M et al (2001) Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure. Ann Thorac Surg 72:362–365PubMedCrossRefGoogle Scholar
  30. 30.
    Nagendran J, Stewart K, Hoskinson M et al (2006) An anesthesiologist’s guide to hypoxic pulmonary vasoconstriction: implications for managing single-lung anesthesia and atelectasis. Curr Opin Anaesthesiol 19:34–43PubMedCrossRefGoogle Scholar
  31. 31.
    Neustein SM (2009) The use of bronchial blockers for providing one-lung ventilation. J Cardiothorac Vasc Anesth 23:860–868PubMedCrossRefGoogle Scholar
  32. 32.
    Nicastri DG, Wisnivesky JP, Litle VR et al (2008) Thoracoscopic lobectomy: report on safety, discharge independence, pain, and chemotherapy tolerance. J Thorac Cardiovasc Surg 135:642–647PubMedCrossRefGoogle Scholar
  33. 33.
    Ozcan PE, Senturk M, Sungur Ulke Z et al (2007) Effects of thoracic epidural anaesthesia on pulmonary venous admixture and oxygenation during one-lung ventilation. Acta Anaesthesiol Scand 51:1117–1122PubMedCrossRefGoogle Scholar
  34. 34.
    Pardos PC, Garutti I, Pineiro P et al (2009) Effects of ventilatory mode during one-lung ventilation on intraoperative and postoperative arterial oxygenation in thoracic surgery. J Cardiothorac Vasc Anesth 23:770–774PubMedCrossRefGoogle Scholar
  35. 35.
    Pruszkowski O, Dalibon N, Moutafis M et al (2007) Effects of propofol vs. sevoflurane on arterial oxygenation during one-lung ventilation. Br J Anaesth 98: 539–544PubMedCrossRefGoogle Scholar
  36. 36.
    Schultz MJ (2008) Lung-protective mechanical ventilation with lower tidal volumes in patients not suffering from acute lung injury: a review of clinical studies. Med Sci Monit 14:RA22–RA26PubMedGoogle Scholar
  37. 37.
    Slinger P (2008) Con: the new bronchial blockers are not preferable to double-lumen tubes for lung isolation. J Cardiothorac Vasc Anesth 22:925–929PubMedCrossRefGoogle Scholar
  38. 38.
    Smith GB, Hirsch NP, Ehrenwerth J (1986) Placement of double-lumen endobronchial tubes. Correlation between clinical impressions and bronchoscopic findings. Br J Anaesth 58:1317–1320PubMedCrossRefGoogle Scholar
  39. 39.
    Thomsen RW (2008) Mediastinoscopy and video-assisted thoracoscopic surgery: anesthetic pitfalls and complications. Semin Cardiothorac Vasc Anesth 12: 128–132PubMedCrossRefGoogle Scholar
  40. 40.
    Unzueta MC, Casas JI, Moral MV (2007) Pressure-controlled versus volume-controlled ventilation ­during one-lung ventilation for thoracic surgery. Anesth Analg 104:1029–1033, tables of contentsPubMedCrossRefGoogle Scholar
  41. 41.
    Vogt A, Stieger DS, Theurillat C et al (2005) Single-injection thoracic paravertebral block for postoperative pain treatment after thoracoscopic surgery. Br J Anaesth 95:816–821PubMedCrossRefGoogle Scholar
  42. 42.
    Wolthuis EK, Choi G, Dessing MC et al (2008) Mechanical ventilation with lower tidal volumes and positive end-expiratory pressure prevents pulmonary inflammation in patients without preexisting lung injury. Anesthesiology 108:46–54PubMedCrossRefGoogle Scholar
  43. 43.
    Xu Y, Tan Z, Wang S et al (2010) Effect of thoracic epidural anesthesia with different concentrations of ropivacaine on arterial oxygenation during one-lung ventilation. Anesthesiology 112:1146–1154PubMedCrossRefGoogle Scholar
  44. 44.
    Yoshioka M, Mori T, Kobayashi H et al (2006) The efficacy of epidural analgesia after video-assisted thoracoscopic surgery: a randomized control study. Ann Thorac Cardiovasc Surg 12:313–318PubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  1. 1.Division of General and Thoracic Surgery, University Department of Anaesthesiology and Pain TherapyBerne University Hospital/Inselspital, and University of BernBerneSwitzerland

Personalised recommendations