Intraoperative Anesthetic Management of the Thoracic Patient

Abstract

Serious complications from one-lung ventilation include arterial hypoxemia, injury to the nonoperative lung, and right ventricular dysfunction. Understanding the effects of anesthetic agents on hypoxic pulmonary vasoconstriction is important for optimizing oxygenation during thoracic surgery. Individualized one-lung ventilation management strategies, influenced by the patient's risk for developing hypoxemia, the surgical approach, and the airway device selected, can improve postoperative outcomes. Goal-directed fluid therapy and perioperative pain management strategies can reduce morbidity after thoracic surgery.

A comparison between bronchial blockers and double-lumen tubes for patients undergoing lung resection: A propensity score-matched cohort study

“…It has been reported by a previous meta-analysis that both of the two techniques show a similar quality of lung collapse for patients with normal stature 5 . Otherwise, between the two techniques, DLT is the more frequently used device, and can be easy to place only via laryngoscope and auscultation 21 - 25 . However, DLT is more rigid and has a larger diameter, which proves to be difficult or even impossible in patients with airway abnormalities and increases the incidences of airway injuries, postoperative sore throat and even vocal paralysis under an oversized selecting size 21 , 26 - 27 .…”

“…A growing body of literature has proven that BB is more advantageous than DLT for difficult airways and significantly reduces the incidences of airway injuries and sore throat 8 , 23 . However, confirmation of the BB's position in a bronchus needs the guidance of fiberoptic bronchoscope, which takes more time than DLT and puts forward the higher requirements for the anesthesiologists 24 , 25 . Moreover, the incidence of malposition for BB is much higher particularly in patients accepting the right side-BB intubation 21 , 26 , 28 and it should also be noted that BB insertion has a risk of bronchial rupture if misapplied 29 , or being included in the surgical staple line 30 .…”

Updates to Thoracic Procedures: Perioperative Care and Anesthetic Considerations

“…OLV in its most basic form allows the anesthesiologist to control ventilation to each lung, deflating the operative (nondependent) lung and preferentially ventilating the non-operative (dependent) lung. OLV facilitates good surgical exposure of the collapsed lung in the thoracic patient, while ensuring adequate gas exchange of the ventilated lung and protecting it from contamination with surgical debris, pus, or secretions from the operative lung [26,27]. OLV is not an all-or-nothing phenomenon, as the extent of lung deflation differentiates lung separation (adequate deflation) from lung isolation (complete deflation) [27].…”

“…OLV facilitates good surgical exposure of the collapsed lung in the thoracic patient, while ensuring adequate gas exchange of the ventilated lung and protecting it from contamination with surgical debris, pus, or secretions from the operative lung [26,27]. OLV is not an all-or-nothing phenomenon, as the extent of lung deflation differentiates lung separation (adequate deflation) from lung isolation (complete deflation) [27]. Common indications include pulmonary resection, video-assisted thoracoscopic surgeries, biopsies of the lungs or lymph nodes, thoracic aortic surgery, esophageal surgery, mediastinal surgery, among many others.…”

“…Single-lumen endobronchial tubes (SLTs) are another alternative, possessing a single lumen with a distal bronchial cuff and a proximal tracheal cuff. Both lungs can be ventilated when the proximal cuff is inflated and the tip of the SLT remains within the trachea, or the SLT can be advanced into one of the mainstem bronchi and OLV achieved with inflation of the distal cuff (proximal cuff remains deflated) [27]. These have fallen out of favor for reasons such as inability to aspirate secretions from the operative lung.…”