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Flashcards in OLV- diana Deck (15):
1

What are 5 ABSOLUTE reasons to use OLV

confine an infection, confine bleeding, bronchopleural fistula, tracheobroncheal disruption, lung cyst

2

name 4 RELATIVELY HIGH reasons to use OLV

TAA

lung resection

thoracoscopy

lung transplant

3

Name 4 RELATIVELY LOW reasons for OLV

esophageal surgery

severe hypoxemia related to unliateral lung disease

anterior approach to thoracic spine

bronchoalveolar lavage

4

3 different tubes to isolate a lung

endobronchial tube (ie mainstem the ETT)

Bronchial blocker

Double lumen tube

 

5

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

6

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.

7

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 

8

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

9

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

10

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

11

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

12

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

13

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)

14

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

15

How the heck do you emerge these peeps?

  1. FiO2 100%
  2. Unclamp Operative lung
  3. Recruitment maneuvers
  4. If pt. is to remain intubated, must exchange DLT for Single Lumen
  5. Tube exchanger through TRACHEAL lumen
  6. Extubate, then re-intubate over exchanger
  7. If patient had easy airway, and there is no concern of airway edema, etc. can simply extubate and re-intubate
  8. Reversal if necessary
  9. Spontaneous respirations  
  10. Extubate 
  11. Face mask