Posted: May 1st, 2025

RESP 3010: Advanced Mechanical Vent

One Lung Ventilation
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Introduction
❖It is used to isolate one lung during thoracic surgeries.
❖OLV provides excellent exposure to the lung or adjacent areas where the
surgeon will operate (Schorer et al., 2023) .
❖This approach is required for lung resections, esophageal surgeries, and
thoracic aneurysms (Steinack et al., 2023).
❖Anesthesiologists ventilate one lung while deflating the other to treat OLV.
❖OLV requires endotracheal tubes or bronchial blockers to isolate the lungs.
❖This shows that the OLV should be adequately maintained to prevent
significant surgical consequences.
❖OLV is effective if physiology and mechanics are understood.
https://www.sciencedirect.com/science/article/abs/pii/S0889853705702
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Indications for One Lung Ventilation
❖For better surgical access, video-assisted thoracoscopic surgery uses lung
ventilation (Schorer et al., 2023).
❖OLV is used to simplify lung resections, including pneumonectomies and
lobectomies.
❖OLV improves exposure and reduces lung stress during esophageal
procedures (Okahara et al., 2018).
❖OLV improves thoracic aorta repair visualization and reduces morbidity.
❖OLV requires airway surgeries like tracheal or bronchial ones for best
results.
❖Protection of the healthy lung from contralateral illness indicates OLV.
❖One-lung breathing may improve mediastinum and chest wall surgery
exposure.
https://medicaldictionary.thefreedictionary.com/pneumonectomy
Equipment Used in One Lung Ventilation
❖Standard equipment is a double-lumen endotracheal tube for one-lung
ventilation.
❖Left-sided tubes are used more than right-sided tubes due to the anatomy
of the left primary bronchus (Cordioli et al., 2018).
❖Bronchial blockers like Arndt or Cohen can replace lung isolation.
❖Fiberoptic bronchoscopes help install double-lumen tubes and bronchial
blockers correctly (Kaye & Urman, 2021).
❖Non-ventilated lung oxygenation can be improved using CPAP.
❖In OLV, end-tidal CO2 monitors and pulse oximeters offer essential
ventilation and oxygenation data (Cordioli et al., 2018).
❖An arterial line is needed for continuous blood pressure monitoring and
blood gas analysis.
https://www.alamy.com/stock-photo/apparatus-lungventilation.html?sortBy=relevant
Patient Positioning for One Lung
Ventilation
❖ Proper positioning allows for good ventilation and perfusion matching to
reduce the dependent lung’s atelectasis significantly.
❖ Flexion of the table allows for increased space between the ribs on the
operative side (Ashok & Francis, 2018).
❖ Ensure proper padding to avoid nerve injuries from pressure points during
lengthy OLV procedures.
❖ The pillow should adequately support the dependent arm due to the potential
to reduce brachial plexus injury using the measures above (Ashok & Francis,
2018).
❖ The head and neck should be aligned to allow easy access to the airway if
unplanned intervention becomes necessary.
❖ Strapping of the patient should be done accordingly, ensuring that the patient
is always stable during the OLV procedure.
https://www.brainkart.com/article/Anesthesia-for-ThoracicSurgery–The-Lateral-Decubitus-Position_27014/
Physiological changes during an OLV
❖OLV significantly alters respiratory physiology at both ventilation
and oxygenation levels.
❖Ventilation with an OLV decreases the lung volume that functions in
gas exchange (Ashok & Francis, 2018).
❖The non-ventilated lung may collapse, thereby forming shunts and
decreasing oxygenation.
❖Hypoxic pulmonary vasoconstriction reduces blood flow to the non-
ventilated lung (Ashok & Francis, 2018).
❖HPV is a protective process that minimizes the shunt and optimizes
oxygenation during OLV.
❖Anesthesiologists must monitor arterial blood gases and adjust
breathing.
❖More critically, managing OLV patients requires an understanding of
https://en.wikipedia.org/wiki/Pneumothorax
Anesthetic Management During One
Lung Ventilation
❖OLV anesthesia balances sedation, muscle relaxation, and
hemodynamic stability.
❖OLV anesthesia requires proper oxygenation and ventilation.
❖Lung-protective ventilation uses low tidal volumes and high
respiratory rates (Kusumarathna, 2014).
❖Ventilated lung oxygenation can be improved with PEEP.
❖Continuous arterial blood gas monitoring will guide breathing
modifications (Kusumarathna, 2014).
❖Inhaled or intravenous anesthetics can be used for maintenance.
❖Hypoxemia and hypercapnia should be anticipated and monitored by
anesthesiologists.
https://www.netmeds.com/healthlibrary/post/anaesthesia-types-procedure-side-effectsand-risks
Ventilation Strategies for One Lung
Ventilation
❖It applies protective lung ventilation strategies to reduce ventilator-induced
lung injury during Lung Ventilation.
❖In OLV, tidal volumes are reduced to 4-6 mL/kg ideal body weight.
❖PEEP application in the ventilated lung prevents atelectasis and improves
oxygenation (Ashok & Francis, 2018).
❖Permissive hypercapnia may be tolerated to lower tidal volumes and
reduce airway pressures.
❖The fraction of inspired oxygen is adjusted to ensure adequate oxygenation
while minimizing oxygen toxicity (Steinack et al., 2023).
❖Recruitment maneuvers are periodically done, whenever possible and
needed, to reaerate the ventilated lung’s atelectatic parts.
❖Pressure-controlled ventilation is commonly used instead of volumecontrolled to minimize barotrauma during OLV.
https://www.nature.com/articles/srep07312
Monitoring and Troubleshooting
During One Lung Ventilation
❖Continuous pulse oximetry is fundamental to the early detection of
hypoxemia in the course of one-lung ventilation procedures.
❖Assessment of end-tidal CO2 for the adequacy of ventilation during
OLV and possible complications (Kaye & Urman, 2021).
❖Arterial blood gas analysis provides information on oxygenation,
ventilation, and acid-base status (Kaye & Urman, 2021).
❖Invasive arterial pressure monitoring is performed for beat-to-beat
blood pressure and during OLV procedures.
❖Peak and plateau airway pressures are followed with vigilance for
barotrauma or tube malposition.
❖This may be repeated with fiberoptic bronchoscopy in the operating
room to confirm the proper positioning of the lung isolation device.
❖Cerebral oximetry can also monitor brain oxygenation, particularly in
https://www.periopcpd.com/wp-content/uploads/Arterial-blood-pressuremeasurement-periopCPDa.pdf
Complications Associated with One
Lung Ventilation
❖Hypoxemia is a common complication during OLV and needs
immediate intervention and management.
❖Lung injury due to high airway pressures or volumes can result from
insufficient protective strategies (Kaye & Urman, 2021).
❖Atelectasis in the non-ventilated lung may contribute to decreased
oxygenation and ventilation.
❖Hypercapnia can result from inadequate minute ventilation, leading
to respiratory acidosis.
❖ Incorrect placement of devices for OLV can cause bronchial injury
or trauma (Kaye & Urman, 2021).
❖It can lead to an alteration in intrathoracic pressure and, hence, an
alteration in venous return, leading to hemodynamic instability.

Management of Hypoxemia During
One Lung Ventilation
❖The most common treatment for hypoxemia during OLV is
increasing inspired oxygen fraction.
❖Constant positive airway pressure in the non-ventilated lung may
boost oxygenation (Yoon et al, 2021).
❖Recruitment procedures on the ventilated lung re-expand atelectatic
regions to promote gas exchange.
❖Despite additional efforts, occasional two-lung breathing may be
needed for severe hypoxemia (Yoon et al., 2021).
❖OLV oxygenation can be optimized by adjusting ventilated lung
positive end-expiratory pressure.
❖Nitric oxide or prostaglandins inhaled may enhance ventilationperfusion matching in refractory situations.
https://link.springer.com/article/10.1007/s40140-02100479-w
Pharmacological Interventions During
One Lung Ventilation
❖Usually, sevoflurane or isoflurane are breathed to maintain OLV.
❖Benzodiazepines, propofol, and remifentanil can be utilized for
surgery sedation and analgesia (Kaye & Urman, 2021).
❖Neuromuscular blocking medications relax muscles for effective
surgery (Schorer et al., 2023).
❖Patients receiving OLV may need vasopressors to maintain blood
pressure and hemodynamic stability.
❖To improve ventilated lung airflow, bronchodilators can be given.
❖In extreme hypoxia, inhaled nitric oxide can oxygenate.
❖Drug therapies should match patient needs and surgical demands.
https://www.e-safeanaesthesia.org/sessions/16_05/d/ELFH_Session/587/tab_797.html
Postoperative Care After One Lung
Ventilation
❖OLV surgeries require close postoperative monitoring in a postanesthesia
care facility or intensive care unit.
❖Respiratory complications like atelectasis or pneumonia require rapid
treatment (Okahara et al., 2018).
❖Proactive pulmonary hygiene measures like chest physiotherapy and early
mobilization will reduce postoperative pulmonary problems.
❖Pain management should be optimized to practice deep breathing and
coughing.
❖Postoperative oxygen therapy may be needed after one-lung ventilation.
❖Lung re-expansion and residual pneumothorax can be seen on chest
radiography (Kusumarathna, 2014).
❖ Surgery and OLV can be assessed with pulmonary function tests.
https://www.generalsurgeonbellville.co.za/post
-operative-care
Special Considerations for Pediatric
One Lung Ventilation
❖Pediatric patients need special equipment and strategies for One
Lung Ventilation.
❖Children need a double-lumen tube or bronchial blocker due to their
smaller airways (Kaye & Urman, 2021).
❖Fiberoptic bronchoscopy must verify lung isolation device
implantation in children.
❖The child’s higher metabolic rate and oxygen use require ventilation
adjustments (Kaye & Urman, 2021).
❖Hypoxemia is more likely in children due to less efficient hypoxic
pulmonary vasoconstriction.
❖Preventing ventilated lung pulmonary edema requires careful fluid
control.
❖To maximize healing, postoperative pain management should match
https://www.cambridge.org/core/books/abs/management-of-thedifficult-pediatric-airway/onelungventilation/B9DABCCF8DE533B4F61505549EAF7042
Emerging Technologies
❖Emerging robotic-assisted thoracic surgery may require OLV
management.
❖Emerging therapy VV-ECMO may treat severe OLV hypoxemia.
❖Lung recruitment and OLV issues can be detected using new lung
ultrasonography (Okahara et al., 2018).
❖Electrical impedance tomography, a new technology, can monitor
regional ventilation and guide OLV ventilator adjustment.
❖Based on patient characteristics and intraoperative monitoring data,
OLV research may focus on individualized breathing.
❖AI and machine learning may improve ventilator management and
predict OLV issues (Sadeghi, et al., 2021).
❖Improve lung-protective breathing and OLV results with more research.
https://www.frontiersin.org/journals/surgery/articles/10.3389/fsurg.2022
.1005860/full
Conclusion
❖Thoracic surgery requires lung ventilation for improved surgical
exposure and results.
❖Successful OLV requires knowledge of respiration’s physiology and
expected difficulties (Steinack et al., 2023).
❖One-lung ventilation relies on patient selection, equipment, and posture.
❖OLV operations require constant monitoring and management of
hypoxemia-related consequences (Kaye & Urman, 2021).
❖One-lung ventilation safety and efficiency are constantly improved by
leading research and technology.
❖In OLV, surgeons, anesthesiologists, and intensivists must work together
to improve patient outcomes (Steinack et al., 2023).
❖The final focus is intern education and training in OLV procedures for
improved patient care.
https://www.edhacare.com/treatments/surgicaloncology/thoracic-surgery
References
❖Kusumarathna, K. (2024). Optimizing Patient Outcomes Through Single-lung Ventilation In Thoracic Anesthesia: An Integrative Approach. Uva Clinical
Lab. Ashok, V., & Francis, J. (2018). A Practical Approach To Adult One-lung Ventilation. BJA Education, 18(3), 69-74.
Https://Doi.Org/10.1016/J.Bjae.2017.11.007
❖Cordioli, R. L., Brochard, L., Suppan, L., Lyazidi, A., Templier, F., Khoury, A., Delisle, S., Savary, D., & Richard, J. (2018). How Ventilation Is Delivered
During Cardiopulmonary Resuscitation: An International Survey. Respiratory Care, 63(10), 1293-1301. Https://Doi.Org/10.4187/Respcare.05964
❖Kaye, A., & Urman, R. (2021). Thoracic Anesthesia Procedures. Oxford University Press.Retrieved From Optimizing Patient Outcomes Through Singlelung Ventilation In Thoracic Anesthesia: An Integrative Approach.
❖Okahara, S., Shimizu, K., Suzuki, S., Ishii, K., & Morimatsu, H. (2018). Associations Between Intraoperative Ventilator Settings During One-lung
Ventilation And Postoperative Pulmonary Complications: A Prospective Observational Study. BMC Anesthesiology, 18, 1-7.
❖Sadeghi, A. H., Maat, A. P., Taverne, Y. J., Cornelissen, R., Dingemans, A. M. C., Bogers, A. J., & Mahtab, E. A. (2021). Virtual Reality And Artificial
Intelligence For 3-dimensional Planning Of Lung Segmentectomies. JTCVS Techniques, 7, 309-321.
❖Schorer, R., Dombret, A. L., Hagerman, A., Bedat, B., & Putzu, A. (2023). Impact Of Pharmacological Interventions On Intrapulmonary Shunt During
One-lung Ventilation In Adult Thoracic Surgery: A Systematic Review And Component Network Meta-analysis. British Journal Of Anaesthesia, 130(1),
E92-e105.
❖Steinack, C., Balmer, H., Ulrich, S., Gaisl, T., & Franzen, D. P. (2023). One-lung Ventilation During Rigid Bronchoscopy Using A Single-lumen
Endotracheal Tube: A Descriptive, Retrospective Single-center Study. Journal Of Clinical Medicine, 12(6), 2426.
❖Yoon, S., Kim, B. R., Min, S. H., Lee, J., Bahk, J. H., & Seo, J. H. (2021). Repeated Intermittent Hypoxic Stimuli To Operative Lung Reduce Hypoxemia
During Subsequent One-lung Ventilation For Thoracoscopic Surgery: A Randomized Controlled Trial. Plos One, 16(4), E0249880.