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
Name 4 RELATIVELY LOW reasons for OLV
severe hypoxemia related to unliateral lung disease
anterior approach to thoracic spine
3 different tubes to isolate a lung
endobronchial tube (ie mainstem the ETT)
Double lumen tube
So why/ why not an endobronchial tube over the others?
providers are comfortable with it already
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
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?
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
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.
Difficult to place in pt’s with difficult airway
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
Unclamp tracheal lumen
Check for BBS
Clamp Bronch lumen
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
Very high or very low Mixed Venous oxygen content
NTG / SNP / Beta agonists
Ca Channel blockers
Why do you have decreased blood flow to the dependent lung?
High mean airway pressures
Produces HPV in Vented lung
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?