One Lung Ventilation
Angela Mordecai and Bailey Freeman, DNP, CRNA
Quick Facts
- One-lung ventilation (OLV) is used for lung isolation during thoracic, esophageal, cardiac, vascular, or spine surgery
- Can be achieved using double-lumen endotracheal tubes (DLT) or bronchial blockers
- Requires careful management to prevent hypoxemia while maintaining surgical exposure
Indications
Optimize surgical access while maintaining ventilation
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- Provide motionless, accessible operative field
- Prevent contralateral lung contamination from hemorrhagic/purulent material
- Enable differential lung ventilation
Procedure
*See sections on “Double Lumen Endotracheal Tubes (DLT)” or “Bronchial Blockers (BB)”
Documentation Requirements
- Ventilation parameters
- FiO2 requirements
- Hypoxic episodes and interventions
- Position changes
- Recruitment maneuvers
- Time spent in OLV
SCOPE GUIDE
Strategies:
Ventilation Management during OLV
- Tidal volume: 4-6ml/kg IBW
- PEEP: Start ~5 cmH2O
- Larger levels of PEEP (8-10 cm H2O) can be counterproductive
- Rate: Adjust for normocapnia
- FiO2: Judicious administration. Titrate to SpO2 88-95%
- Hypoxemia can cause coronary vasoconstriction and absorption atelectasis
Resuming Bilateral Ventilation
- Close cap on lumen to non-ventilated lung and remove clamp on Y connector
- Re-expand collapsed lung by giving manual breaths with recruitment maneuvers
- Return to two lung mechanical ventilation with standard ventilator settings
Clinical Optimization:
Troubleshooting
- Management of Hypoxia during OLV
- Increase FiO2 to 1.0
- Communicate with surgical team as necessary; stop nonurgent surgical procedures if needed
- Verify position of BB, or position & patency of DLT
- Suction DLT if indicated
- Optimize ventilation/minimize atelectasis in ventilated lung (dependent lung in lateral position)
- Recruitment maneuvers
- Add low to moderate levels of PEEP (~5 cmH2O)
- Minimize shunt in the non-ventilated/surgical lung
- Apply CPAP 1-2 L/min O2
- Discuss with surgeon prior to initiating
- Advanced measures for persistent hypoxia
- Notify surgical team
- Consider two-lung ventilation if surgical conditions allow
- Discuss possibility of pulmonary artery clamping with surgeon
- High Airway Pressure Management
- PAW >35cmH2O: check for a mechanical problem, malposition, or obstruction
- Adjust tidal volume to keep PAW <30cmH2O
Pearls:
Risk Factors for Hypoxemia
- Right-sided surgery
- Low FEV1
- Low intraoperative PaO2
- BMI >30 kg/m2
- Previous contralateral lobectomy
Management
- Avoid 100% O2 with bleomycin
- Regular position verification
- Early hypoxia intervention
- Clear team communication
- Monitor surgical field feedback
Quick Resources
References
This work adapts content from FOAMed Medical Education Resources by LITFL (Life in the Fast Lane), licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. The original work can be found at
https://litfl.com
.
Nickson C. Selective Lung Ventilation. Life in the Fast Lane. Published July 5, 2024. Accessed January 28, 2025. https://litfl.com/selective-lung-ventilation/
Life in the Fast Lane. Double-lumen Endotracheal Tube (DLT). Published 2020. Updated 2024. Accessed January 28, 2025. https://litfl.com/double-lumen-endotracheal-tube-dlt/
- Campos JH, Peacher D. Double-Lumen Endotracheal Tubes for One-Lung Ventilation. OpenAnesthesia. Updated 04/25/2023. Accessed 01/25/2025.
- Campos JH. Separation of the lung: Double-lumen endotracheal tubes and endobronchial blocker. In: Cohen E (ed). Cohen’s Comprehensive Thoracic Anesthesia. 1st edition. Philadelphia, PA. Elsevier. 2022: 213-39.
- Campos J. Fiberoptic bronchoscopy for positioning double-lumen tubes and bronchial blockers. In: Slinger P (ed). Principles and Practice of Anesthesia for Thoracic Surgery.
