General principles of one lung ventilation
- Martin Ma, MD
Martin Ma, MD
- University of Toronto
- Peter D Slinger, MD, FRCPC
Peter D Slinger, MD, FRCPC
- Section Editor — Thoracic/Vascular Anesthesia
- Professor of Anesthesia
- Toronto General Hospital
In most patients requiring mechanical ventilation, both lungs are inflated and deflated together. One lung ventilation (OLV) refers to mechanical separation of the two lungs to allow ventilation of only one lung, while the other lung is compressed by the surgeon or allowed to passively deflate. OLV is a standard approach to facilitate surgical exposure for pulmonary and other thoracic surgeries, or may be used to isolate a pathologic from a healthy lung to prevent soiling or to allow differential ventilation.
This topic will discuss the general principles and physiology of OLV, its management, and complications. Devices used for OLV, their placement and comparative performance are reviewed separately. (See "Lung isolation techniques".)
INDICATIONS AND CONTRAINDICATIONS
One lung ventilation (OLV) is used either to improve exposure to the surgical field in thoracic surgery, or to anatomically isolate one lung from a pathologic process of the other lung. Contraindications to OLV include dependence on bilateral mechanical ventilation, and intraluminal airway masses that restrict access to the tracheobronchial tree.
Surgical exposure — An immobile, collapsed lung in the vicinity of the surgical field improves access to the thoracic cavity; thus, OLV is used during many thoracic surgical procedures:
●Pulmonary resection, including pneumonectomy, lobectomy, and wedge resection
- Weiss S, Ochroch EA. Thoracic Anesthesia. In: Anesthesiology, Longnecker D, Brown D, Newman M, Zapol W. (Eds), McGraw-Hill, New York 2008. p.1231.
- Karzai W, Schwarzkopf K. Hypoxemia during one-lung ventilation: prediction, prevention, and treatment. Anesthesiology 2009; 110:1402.
- Sylvester JT, Shimoda LA, Aaronson PI, Ward JP. Hypoxic pulmonary vasoconstriction. Physiol Rev 2012; 92:367.
- Lohser J. Evidence-based management of one-lung ventilation. Anesthesiol Clin 2008; 26:241.
- Lohser J, Slinger P. Lung Injury After One-Lung Ventilation: A Review of the Pathophysiologic Mechanisms Affecting the Ventilated and the Collapsed Lung. Anesth Analg 2015; 121:302.
- Licker M, de Perrot M, Spiliopoulos A, et al. Risk factors for acute lung injury after thoracic surgery for lung cancer. Anesth Analg 2003; 97:1558.
- Dulu A, Pastores SM, Park B, et al. Prevalence and mortality of acute lung injury and ARDS after lung resection. Chest 2006; 130:73.
- Alam N, Park BJ, Wilton A, et al. Incidence and risk factors for lung injury after lung cancer resection. Ann Thorac Surg 2007; 84:1085.
- Jeon K, Yoon JW, Suh GY, et al. Risk factors for post-pneumonectomy acute lung injury/acute respiratory distress syndrome in primary lung cancer patients. Anaesth Intensive Care 2009; 37:14.
- Gothard J. Lung injury after thoracic surgery and one-lung ventilation. Curr Opin Anaesthesiol 2006; 19:5.
- Halbertsma FJ, Vaneker M, Scheffer GJ, van der Hoeven JG. Cytokines and biotrauma in ventilator-induced lung injury: a critical review of the literature. Neth J Med 2005; 63:382.
- Gajic O, Dara SI, Mendez JL, et al. Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation. Crit Care Med 2004; 32:1817.
- Determann RM, Royakkers A, Wolthuis EK, et al. Ventilation with lower tidal volumes as compared with conventional tidal volumes for patients without acute lung injury: a preventive randomized controlled trial. Crit Care 2010; 14:R1.
- Michelet P, D'Journo XB, Roch A, et al. Protective ventilation influences systemic inflammation after esophagectomy: a randomized controlled study. Anesthesiology 2006; 105:911.
- Wrigge H, Uhlig U, Zinserling J, et al. The effects of different ventilatory settings on pulmonary and systemic inflammatory responses during major surgery. Anesth Analg 2004; 98:775.
- Schilling T, Kozian A, Huth C, et al. The pulmonary immune effects of mechanical ventilation in patients undergoing thoracic surgery. Anesth Analg 2005; 101:957.
- Balanos GM, Talbot NP, Dorrington KL, Robbins PA. Human pulmonary vascular response to 4 h of hypercapnia and hypocapnia measured using Doppler echocardiography. J Appl Physiol (1985) 2003; 94:1543.
- Lytle FT, Brown DR. Appropriate ventilatory settings for thoracic surgery: intraoperative and postoperative. Semin Cardiothorac Vasc Anesth 2008; 12:97.
- Sticher J, Müller M, Scholz S, et al. Controlled hypercapnia during one-lung ventilation in patients undergoing pulmonary resection. Acta Anaesthesiol Scand 2001; 45:842.
- Zollinger A, Zaugg M, Weder W, et al. Video-assisted thoracoscopic volume reduction surgery in patients with diffuse pulmonary emphysema: gas exchange and anesthesiological management. Anesth Analg 1997; 84:845.
- Morisaki H, Serita R, Innami Y, et al. Permissive hypercapnia during thoracic anaesthesia. Acta Anaesthesiol Scand 1999; 43:845.
- Grichnik KP, Shaw A. Update on one-lung ventilation: the use of continuous positive airway pressure ventilation and positive end-expiratory pressure ventilation--clinical application. Curr Opin Anaesthesiol 2009; 22:23.
- Végh T, Juhász M, Szatmári S, et al. Effects of different tidal volumes for one-lung ventilation on oxygenation with open chest condition and surgical manipulation: a randomised cross-over trial. Minerva Anestesiol 2013; 79:24.
- Satoh D, Kurosawa S, Kirino W, et al. Impact of changes of positive end-expiratory pressure on functional residual capacity at low tidal volume ventilation during general anesthesia. J Anesth 2012; 26:664.
- Hedenstierna G. Pulmonary perfusion during anesthesia and mechanical ventilation. Minerva Anestesiol 2005; 71:319.
- Leong LM, Chatterjee S, Gao F. The effect of positive end expiratory pressure on the respiratory profile during one-lung ventilation for thoracotomy. Anaesthesia 2007; 62:23.
- Yokota K, Toriumi T, Sari A, et al. Auto-positive end-expiratory pressure during one-lung ventilation using a double-lumen endobronchial tube. Anesth Analg 1996; 82:1007.
- Valenza F, Ronzoni G, Perrone L, et al. Positive end-expiratory pressure applied to the dependent lung during one-lung ventilation improves oxygenation and respiratory mechanics in patients with high FEV1. Eur J Anaesthesiol 2004; 21:938.
- Slinger PD, Kruger M, McRae K, Winton T. Relation of the static compliance curve and positive end-expiratory pressure to oxygenation during one-lung ventilation. Anesthesiology 2001; 95:1096.
- Tuğrul M, Camci E, Karadeniz H, et al. Comparison of volume controlled with pressure controlled ventilation during one-lung anaesthesia. Br J Anaesth 1997; 79:306.
- Sentürk NM, Dilek A, Camci E, et al. Effects of positive end-expiratory pressure on ventilatory and oxygenation parameters during pressure-controlled one-lung ventilation. J Cardiothorac Vasc Anesth 2005; 19:71.
- Nichols D, Haranath S. Pressure control ventilation. Crit Care Clin 2007; 23:183.
- Unzueta MC, Casas JI, Moral MV. Pressure-controlled versus volume-controlled ventilation during one-lung ventilation for thoracic surgery. Anesth Analg 2007; 104:1029.
- Pardos PC, Garutti I, Piñeiro P, et al. Effects of ventilatory mode during one-lung ventilation on intraoperative and postoperative arterial oxygenation in thoracic surgery. J Cardiothorac Vasc Anesth 2009; 23:770.
- van der Werff YD, van der Houwen HK, Heijmans PJ, et al. Postpneumonectomy pulmonary edema. A retrospective analysis of incidence and possible risk factors. Chest 1997; 111:1278.
- Rothen HU, Sporre B, Engberg G, et al. Influence of gas composition on recurrence of atelectasis after a reexpansion maneuver during general anesthesia. Anesthesiology 1995; 82:832.
- Jordan S, Mitchell JA, Quinlan GJ, et al. The pathogenesis of lung injury following pulmonary resection. Eur Respir J 2000; 15:790.
- Cheng YJ, Chan KC, Chien CT, et al. Oxidative stress during 1-lung ventilation. J Thorac Cardiovasc Surg 2006; 132:513.
- Brodsky JB, Lemmens HJ. Left double-lumen tubes: clinical experience with 1,170 patients. J Cardiothorac Vasc Anesth 2003; 17:289.
- Yang M, Ahn HJ, Kim K, et al. Does a protective ventilation strategy reduce the risk of pulmonary complications after lung cancer surgery?: a randomized controlled trial. Chest 2011; 139:530.
- Licker M, Diaper J, Villiger Y, et al. Impact of intraoperative lung-protective interventions in patients undergoing lung cancer surgery. Crit Care 2009; 13:R41.
- Slinger P, Suissa S, Triolet W. Predicting arterial oxygenation during one-lung anaesthesia. Can J Anaesth 1992; 39:1030.
- Bardoczky GI, Szegedi LL, d'Hollander AA, et al. Two-lung and one-lung ventilation in patients with chronic obstructive pulmonary disease: the effects of position and F(IO)2. Anesth Analg 2000; 90:35.
- Tusman G, Böhm SH, Sipmann FS, Maisch S. Lung recruitment improves the efficiency of ventilation and gas exchange during one-lung ventilation anesthesia. Anesth Analg 2004; 98:1604.
- Cinnella G, Grasso S, Natale C, et al. Physiological effects of a lung-recruiting strategy applied during one-lung ventilation. Acta Anaesthesiol Scand 2008; 52:766.
- Unzueta C, Tusman G, Suarez-Sipmann F, et al. Alveolar recruitment improves ventilation during thoracic surgery: a randomized controlled trial. Br J Anaesth 2012; 108:517.
- Koh WJ, Suh GY, Han J, et al. Recruitment maneuvers attenuate repeated derecruitment-associated lung injury. Crit Care Med 2005; 33:1070.
- Suh GY, Koh Y, Chung MP, et al. Repeated derecruitments accentuate lung injury during mechanical ventilation. Crit Care Med 2002; 30:1848.
- Bardoczky GI, d'Hollander AA, Cappello M, Yernault JC. Interrupted expiratory flow on automatically constructed flow-volume curves may determine the presence of intrinsic positive end-expiratory pressure during one-lung ventilation. Anesth Analg 1998; 86:880.
- Inomata S, Nishikawa T, Saito S, Kihara S. "Best" PEEP during one-lung ventilation. Br J Anaesth 1997; 78:754.
- Fujiwara M, Abe K, Mashimo T. The effect of positive end-expiratory pressure and continuous positive airway pressure on the oxygenation and shunt fraction during one-lung ventilation with propofol anesthesia. J Clin Anesth 2001; 13:473.
- Abe K, Oka J, Takahashi H, et al. Effect of high-frequency jet ventilation on oxygenation during one-lung ventilation in patients undergoing thoracic aneurysm surgery. J Anesth 2006; 20:1.
- Campos JH. Update on selective lobar blockade during pulmonary resections. Curr Opin Anaesthesiol 2009; 22:18.
- Morikawa T, Sugiura H, Kaji M, et al. Availability of lobe-selective bronchial blockade for video-assisted thoracic surgery: an initial experience with three cases. Surg Endosc 2002; 16:327.
- Ishikawa S, Nakazawa K, Makita K. Progressive changes in arterial oxygenation during one-lung anaesthesia are related to the response to compression of the non-dependent lung. Br J Anaesth 2003; 90:21.
- Schwarzkopf K, Klein U, Schreiber T, et al. Oxygenation during one-lung ventilation: the effects of inhaled nitric oxide and increasing levels of inspired fraction of oxygen. Anesth Analg 2001; 92:842.
- Rocca GD, Passariello M, Coccia C, et al. Inhaled nitric oxide administration during one-lung ventilation in patients undergoing thoracic surgery. J Cardiothorac Vasc Anesth 2001; 15:218.
- Wilson WC, Kapelanski DP, Benumof JL, et al. Inhaled nitric oxide (40 ppm) during one-lung ventilation, in the lateral decubitus position, does not decrease pulmonary vascular resistance or improve oxygenation in normal patients. J Cardiothorac Vasc Anesth 1997; 11:172.
- Casati A, Mascotto G, Iemi K, et al. Epidural block does not worsen oxygenation during one-lung ventilation for lung resections under isoflurane/nitrous oxide anaesthesia. Eur J Anaesthesiol 2005; 22:363.
- Ozcan PE, Sentürk M, Sungur Ulke Z, et al. Effects of thoracic epidural anaesthesia on pulmonary venous admixture and oxygenation during one-lung ventilation. Acta Anaesthesiol Scand 2007; 51:1117.
- Garutti I, Quintana B, Olmedilla L, et al. Arterial oxygenation during one-lung ventilation: combined versus general anesthesia. Anesth Analg 1999; 88:494.
- Xu Y, Tan Z, Wang S, et al. Effect of thoracic epidural anesthesia with different concentrations of ropivacaine on arterial oxygenation during one-lung ventilation. Anesthesiology 2010; 112:1146.
- Módolo NS, Módolo MP, Marton MA, et al. Intravenous versus inhalation anaesthesia for one-lung ventilation. Cochrane Database Syst Rev 2013; :CD006313.
- Rogers SN, Benumof JL. Halothane and isoflurane do not decrease PaO2 during one-lung ventilation in intravenously anesthetized patients. Anesth Analg 1985; 64:946.
- Beck DH, Doepfmer UR, Sinemus C, et al. Effects of sevoflurane and propofol on pulmonary shunt fraction during one-lung ventilation for thoracic surgery. Br J Anaesth 2001; 86:38.
- Pruszkowski O, Dalibon N, Moutafis M, et al. Effects of propofol vs sevoflurane on arterial oxygenation during one-lung ventilation. Br J Anaesth 2007; 98:539.
- Reid CW, Slinger PD, Lenis S. A comparison of the effects of propofol-alfentanil versus isoflurane anesthesia on arterial oxygenation during one-lung ventilation. J Cardiothorac Vasc Anesth 1996; 10:860.
- Abe K, Shimizu T, Takashina M, et al. The effects of propofol, isoflurane, and sevoflurane on oxygenation and shunt fraction during one-lung ventilation. Anesth Analg 1998; 87:1164.
- Schilling T, Kozian A, Senturk M, et al. Effects of volatile and intravenous anesthesia on the alveolar and systemic inflammatory response in thoracic surgical patients. Anesthesiology 2011; 115:65.
- De Conno E, Steurer MP, Wittlinger M, et al. Anesthetic-induced improvement of the inflammatory response to one-lung ventilation. Anesthesiology 2009; 110:1316.
- Sugasawa Y, Yamaguchi K, Kumakura S, et al. Effects of sevoflurane and propofol on pulmonary inflammatory responses during lung resection. J Anesth 2012; 26:62.
- Hu XL, Tang HH, Zhou ZG, et al. [The effect of sevoflurane inhalation anesthesia only and propofol total intravenous anesthesia on perioperative cytokine balance in lung cancer patients]. Xi Bao Yu Fen Zi Mian Yi Xue Za Zhi 2011; 27:659.
- INDICATIONS AND CONTRAINDICATIONS
- - Surgical exposure
- - Lung isolation
- VENTILATION STRATEGIES
- Low tidal volume
- Permissive hypercapnia
- Positive end-expiratory pressure
- - Auto PEEP in obstructive disease
- Low airway pressures
- Oxygen concentration
- Protective ventilation
- MANAGEMENT OF HYPOXEMIA
- Predicting hypoxemia during OLV
- Treatment of hypoxemia
- ANESTHETIC CHOICE
- Intravenous versus inhalation anesthetics
- General versus combined thoracic epidural/general anesthesia
- REEXPANSION OF THE NONVENTILATED LUNG
- SUMMARY AND RECOMMENDATIONS