One lung ventilation

 

Indications for one lung ventilation:

Surgical access

·      Lung

·      Heart

·      Oesophagus

Keep bad lung air-free

·      Damaged airway

·      Bronchopleural fistula

Keep good lung dirt-free

·      Infective material

·      Blood

(one other reason: selective one lung lavage)

 

Ways to achieve lung isolation:

1.       Normal ETT in too far

a.       Useful in paediatrics – no DLETTs available

2.       Normal ETT with bronchial blocker

a.       Useful if difficult intubation

b.       Slow and incomplete collapse

c.       Can’t CPAP

3.       Double lumen ETTs

 

Double lumen ETT:

Device

·      L vs R: designates the location of the bronchial tip

·      Size: 37Fr woman, 39Fr man (N.B. outer, not inner diameter)

·      Depth: 29cm for 175cm; ±1cm per 10cm increment

·      Lumens: blue is for bronchial, white for trachea. Half circles.

·      Cuffs: bronchial 3mL, tracheal not sure
N.B. right bronchial cuff is eccentric to allow RUL ventilation

Insertion (left)

·      Macintosh-shaped blade to see in a straight line

·      Hold with tip pointing anterior, top end pointing right

·      Insert tip a bit past glottis

·      Push and rotate 90° left at the same time

·      Stop at ~29cm

·      Inflate tracheal cuff

Confirmation

1.Capnography (!)

2.Flexible bronchoscope:

·      Go down tracheal lumen

·      Check depth: a) trachealis b) carina c) RUL bronchus (3 holes)

·      Check bronchial cuff position: just inside the left main

·      Inflate bronchial cuff: ~3mL

3.Blind technique:

·      Ventilate both lungs: look + listen

·      Ventilate one lung: look + listen

 

Indications for right DLETT:

Left main bronchus surgery

·      Left pneumonectomy

·      Left lung transplant

·      Left bronchial disruption

·      Left VTS involving airway manipulation

Left main bronchus abnormal

·      Left bronchial cancer

·      Descending thoracic aortic aneurysm

 

Causes of intra-op hypoxia:

See ‘disasters’ section

 

 

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