OLV- diana Flashcards
What are 5 ABSOLUTE reasons to use OLV
confine an infection, confine bleeding, bronchopleural fistula, tracheobroncheal disruption, lung cyst
name 4 RELATIVELY HIGH reasons to use OLV
TAA
lung resection
thoracoscopy
lung transplant
Name 4 RELATIVELY LOW reasons for OLV
esophageal surgery
severe hypoxemia related to unliateral lung disease
anterior approach to thoracic spine
bronchoalveolar lavage
3 different tubes to isolate a lung
endobronchial tube (ie mainstem the ETT)
Bronchial blocker
Double lumen tube
So why/ why not an endobronchial tube over the others?
why
it’s inexpensive
smaller diameters
providers are comfortable with it already
why not
no ventilation for operative lung
No CPAP/ PEEP to operative lung
How do you place an ETT for OLV?
DL as per routine
Once confirmation of tracheal intubation fiberoptic for Anatomical location and placement into specific Bronchus
or………
Blindly
Rotate ETT so bevel is on side lung to be isolated
Turn pt’s head contralateral and advance
92% success rate per Miller et al.
Why/ why not use an endobronchial blocker?
Why
Ease of insertion & position vs. DLT
Can be positioned during PPV and in any Position
No need for tube exchange
Can select specific lobe(s)
Can apply CPAP
Why not
Slow Deflation time of operative lung
Slow Re-Inflation time of operative lung
Possibility of mucus / blood blockage in BB lumen
Intraoperative leak of BB
Why/ why not use a double lumen tube (DLT)?
great way to isolate one lung…. makes a lot of the contraindications from the other options obsolete.
Why not
Large Diameter
Difficult to place in pt’s with difficult airway
Easily malpositioned
Potential damage to airway and tracheobronchial tree
If you fiberoptic breaks… How can you assess your DLT?
Inflate tracheal cuff w/ 5-10 cc
Check for BBS
Inflate Bronch. Cuff w/ 1-2 cc
Clamp tracheal lumen
Should have
- Right
+ Left
Unclamp tracheal lumen
Check for BBS
Clamp Bronch lumen
Should have
- Left
+ Right
This is least sensitive method to verify placement
Hypoxemia is an important implication from OLV…. tell me about it… stud
OLV produces a shunt of 20-30%
This is substantial
R/T Dependent lung vs. Non-dependent lung
Initiation of anesthesia
Blunting of HPV
Decreased blood flow to dependent (Ventilated) lung
Atelectasis of operative lung
How does HPV cause blunting of HPV
- Very high or very low PA pressures
- Hypocapnia
- Very high or very low Mixed Venous oxygen content
- NTG / SNP / Beta agonists
- Ca Channel blockers
- Pulmonary infections
- Volatile Agents
Why do you have decreased blood flow to the dependent lung?
High mean airway pressures
High PEEP
Hyperventilation
High PIP
Low FiO2
Produces HPV in Vented lung
Vasopressors
Auto PEEP
Anesthetic management of OLV
similar to normal 2 lung ventilation
RR and tidal volume are often not altered when switching from 2 to 1
FiO2 may need to be increased
Maintain normal PaCO2
ABG after induction and then again post clamp may be necessary
May have to actively collapse lung (low suction to help)
OH SHIT!!! You’re patient is hypoxic…. NOW WHAT?!
- Confirm Tube placement w/ FOB & FiO2 1.0
- Alter ventilation if necessary for an increase in MV
- Add 5 cm H2O CPAP to operative lung
- Add 5 cm H2O PEEP to ventilated lung
- Increase CPAP & PEEP as tolerated
- Manually inflate and ventilate operative lung PRN
- Ligate and/or transect PA of operative lung (if pt is having pneumonectomy)
- If not having pneumonectomy, Crash CPB
How the heck do you emerge these peeps?
- FiO2 100%
- Unclamp Operative lung
- Recruitment maneuvers
- If pt. is to remain intubated, must exchange DLT for Single Lumen
- Tube exchanger through TRACHEAL lumen
- Extubate, then re-intubate over exchanger
- If patient had easy airway, and there is no concern of airway edema, etc. can simply extubate and re-intubate
- Reversal if necessary
- Spontaneous respirations
- Extubate
- Face mask
