One lung ventilation

[anbuitachi]

Looking for more advice from anesthesiology experts everywhere!! 🙂 what are your relative contraindications for one lung ventilation in terms of cardiac function? Eg how bad would pHTN have to be for you to not do OLV? What about EF? Tricuspid regurg? RV dysfunction? large pericardial effusion? Thanks!

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[dchz]

Recent threads has made me ask this question: What kind of facility are you at? What kind of mechanical circulatory support do you have?

 

[anbuitachi]

Recent threads has made me ask this question: What kind of facility are you at? What kind of mechanical circulatory support do you have?

I flush the IV to provide mechanical support, that's about it. No bypass/ECMO

 

[Noyac]

We are confronted more often than most with pHTN and I have never had cutoff for OLV. I basically see how it goes. But this topic got me thinking, has anyone used Nitric Oxide in this situation? I haven’t I assume it would prevent hypoxia pulm vasoconstriction and may be useless. I don’t know but this article gives a little info:

Inhaled nitric oxide administration during one-lung ventilation in patients undergoing thoracic surgery - PubMed

Inhaled NO administration neither significantly decreased mean pulmonary arterial pressure in patients with normal pulmonary artery pressure nor improved oxygenation in nonhypoxic patients. Nevertheless, inhaled NO is effective in patients with pulmonary hypertension and hypoxemia during OLV.

www.ncbi.nlm.nih.gov

 

[deleted171991]

We are confronted more often than most with pHTN and I have never had cutoff for OLV. I basically see how it goes. But this topic got me thinking, has anyone used Nitric Oxide in this situation? I haven’t I assume it would prevent hypoxia pulm vasoconstriction and may be useless. I don’t know but this article gives a little info:

Inhaled nitric oxide administration during one-lung ventilation in patients undergoing thoracic surgery - PubMed

Inhaled NO administration neither significantly decreased mean pulmonary arterial pressure in patients with normal pulmonary artery pressure nor improved oxygenation in nonhypoxic patients. Nevertheless, inhaled NO is effective in patients with pulmonary hypertension and hypoxemia during OLV.

www.ncbi.nlm.nih.gov

I didn't read the article, but it makes perfect sense to me. I have used it (and other selective pulmonary vasodilators) during fellowship in severe ARDS patients, and it works.

Why would it prevent hypoxic pulmonary vasoconstriction? It only dilates vessels in the ventilated alveoli.

 

[Noyac]

I didn't read the article, but it makes perfect sense to me. I have used it (and other selective pulmonary vasodilators) during fellowship in severe ARDS patients, and it works.

Why would it prevent hypoxic pulmonary vasoconstriction? It only dilates vessels in the ventilated alveoli.

Yeah the article seemed to support its use.
it shouldn’t alteR HPV since it’s delivered via ventilation but I haven’t used it. I’m now very intrigued. It seems perfect for this.

 

[MoMoGesiologist]

Maybe place a TEE probe during the case or PA cath to monitor closely. Not sure what cutoff would need to be to say you wouldn’t even do a case

 

[deleted171991]

Yeah the article seemed to support its use.
it shouldn’t alteR HPV since it’s delivered via ventilation but I haven’t used it. I’m now very intrigued. It seems perfect for this.

The main issue is that you will need RT to set it up for you in the OR, and I am not sure it's compatible with inhalational anesthesia, hence it may need TIVA.

 

[deleted171991]

Maybe place a TEE probe during the case or PA cath to monitor closely. Not sure what cutoff would need to be to say you wouldn’t even do a case

Usually these are cancers, so the patient probably deserves at least a try. Also, healing after open thoracotomy is no fun, so OLV should be attempted.

What I would do though would be to optimize the patient as much as possible short-term. So, for example, if the patient has a sizable pericardial effusion, that will need to be fixed first. EF is a dynamic thing; the heart can and should be brought as close as possible to baseline, e.g. by diuresis. Etc.

 

[drmwvr]

Usually these are cancers, so the patient probably deserves at least a try. Also, healing after open thoracotomy is no fun, so OLV should be attempted.

You mean VATS? An open thoracotomy requires single lung ventilation.

 

[anbuitachi]

Maybe place a TEE probe during the case or PA cath to monitor closely. Not sure what cutoff would need to be to say you wouldn’t even do a case

Dont have TEE. I dont think we have NO either. 🙂
There are growing number of cases that surgeon books under one lung ventilation. Sympathectomies, sometimes anterior thoracic spines, hiatal hernias etc. the most common i do is of course still for cancer and i find these patients tend to be the 'healthiest'. But i guess lets say the surgeon wants to book a vats in some 70 yr old lady hiatal hernia, and the patient has moderately reduced EF. would you try OLV and see how it goes? Would you always try? Or are there relative contraindications that make you not even try. Or the 70 year old with large pericardial effusion that the surgeon books window under VATS

 

[vector2]

You mean VATS? An open thoracotomy requires single lung ventilation.

Both VATS and open thoracotomy 'require' OLV. The difference is that VATS absolutely requires OLV cause you can barely get a trocar into the chest if the lung is still up. Open thoracotomy OTOH, even if both lungs are up it's still possible to pop them on low tidal volume and isolate sections of lung using retraction, and then get a stapler over a piece that needs resection. It's not ideal for many reasons, but it's still possible (as anyone in a trauma thoracotomy/lung laceration situation can attest).

 

[drmwvr]

It's not ideal for many reasons, but it's still possible (as anyone in a trauma thoracotomy/lung laceration situation can attest).

I thought we were talking about cancer here. And getting a stapler across lacerated lung is hardly the same thing as dividing airways and vessels for a segmentectomy or lobectomy.

 

[Noyac]

Dont have TEE. I dont think we have NO either. 🙂
There are growing number of cases that surgeon books under one lung ventilation. Sympathectomies, sometimes anterior thoracic spines, hiatal hernias etc. the most common i do is of course still for cancer and i find these patients tend to be the 'healthiest'. But i guess lets say the surgeon wants to book a vats in some 70 yr old lady hiatal hernia, and the patient has moderately reduced EF. would you try OLV and see how it goes? Would you always try? Or are there relative contraindications that make you not even try. Or the 70 year old with large pericardial effusion that the surgeon books window under VATS

I would try. I haven’t yet had one that couldn’t tolerate OLV for at least some time. But then again I don’t call doing this on a severely low EF heart either.
Ant spines these days don’t necessarily require it. And it’s actually easier to just pack down the lung than to separate it.

 

[vector2]

I thought we were talking about cancer here. And getting a stapler across lacerated lung is hardly the same thing as dividing airways and vessels for a segmentectomy or lobectomy.

Dude, I get it, the first thing I said is that both kind of cases require it.

 

[Twiggidy]

Dont have TEE. I dont think we have NO either. 🙂
There are growing number of cases that surgeon books under one lung ventilation. Sympathectomies, sometimes anterior thoracic spines, hiatal hernias etc. the most common i do is of course still for cancer and i find these patients tend to be the 'healthiest'. But i guess lets say the surgeon wants to book a vats in some 70 yr old lady hiatal hernia, and the patient has moderately reduced EF. would you try OLV and see how it goes? Would you always try? Or are there relative contraindications that make you not even try. Or the 70 year old with large pericardial effusion that the surgeon books window under VATS

The beauty of a double lumen tube is that if you drop the up lung and the patient starts to decompensate, you can always bring the lung back up.

 

[pgg]

I'm continually surprised by how well people with terrible lungs tolerate OLV. Off pump lung transplants come to mind, at least until the surgeon starts picking up the heart.

 

[sevoflurane]

The main issue is that you will need RT to set it up for you in the OR, and I am not sure it's compatible with inhalational anesthesia, hence it may need TIVA.

You can use it in the OR with Volatiles.

 

[DrZzZz]

You mean VATS? An open thoracotomy requires single lung ventilation.

There's quite a few surgeons doing thoracic surgeries under MAC. I know one of the thoracic surgeons that started at my residency program just as I was graduating started doing it and I thought it was insane. Talked to one of my attendings that's still there and they said it's been great. Surgeon puts in a good intercostal block and it's smooth sailing from there.

There was also a good talk about it at the ASA conference last week.

 

[anbuitachi]

There's quite a few surgeons doing thoracic surgeries under MAC. I know one of the thoracic surgeons that started at my residency program just as I was graduating started doing it and I thought it was insane. Talked to one of my attendings that's still there and they said it's been great. Surgeon puts in a good intercostal block and it's smooth sailing from there.

There was also a good talk about it at the ASA conference last week.

All types of thoracic cases? Or mainly VATS?

 

[DrZzZz]

All types of thoracic cases? Or mainly VATS?

Anesthetic consideration for nonintubated VATS - PMC

In the recent decade, nonintubated-intubated video-assisted thoracoscopic surgery (VATS) has been extensively performed and evaluated. The indicated surgical procedures and suitable patient groups are steadily increasing. Perioperative anesthetic ...

www.ncbi.nlm.nih.gov

 

[vector2]

Anesthetic consideration for nonintubated VATS - PMC

In the recent decade, nonintubated-intubated video-assisted thoracoscopic surgery (VATS) has been extensively performed and evaluated. The indicated surgical procedures and suitable patient groups are steadily increasing. Perioperative anesthetic ...

www.ncbi.nlm.nih.gov

“Hey Steve, I have a great idea. Let’s come up with a VATS anesthetic plan that’s about 50 times more tedious than the standard one and about 100 times more dangerous and then write a paper about it”

 

[nimbus]

Back in residency I did a few spontaneous ventilation VATs with an invasive pulmonologist who trained in France. They were propofol/alfenta infusions and not fun.

 

[deleted162650]

There's quite a few surgeons doing thoracic surgeries under MAC

Just gotta pinch the nostril shut on the operative side.

 

[deleted162650]

Seriously though, at my first gig outta residency we had a thoracic surgeon that decided he wanted to start doing VATS decortication/pleurodesis under MAC. We were all very skeptical and thought it was nuts. Actually turned out to be very well tolerated. Cases went smooth, and it worked great. I usually ran ketofol.

 

[anbuitachi]

Seriously though, at my first gig outta residency we had a thoracic surgeon that decided he wanted to start doing VATS decortication/pleurodesis under MAC. We were all very skeptical and thought it was nuts. Actually turned out to be very well tolerated. Cases went smooth, and it worked great. I usually ran ketofol.

any blocks from your end? thoracic epidural?

i think a lot of ketofol cases are just general with spontaneous breathing, without a tube.

 

[deleted162650]

any blocks from your end? thoracic epidural?

i think a lot of ketofol cases are just general with spontaneous breathing, without a tube.

No blocks. Just local by surgeon and local sprayed into the chest cavity.

 

[Hork Bajir]

We do a number of MAC VATS cases where I am. When they go well, it’s a thing of beauty- makes you wonder why we don’t do them all that way. When they go poorly, it’s a f****** FLOG

My preference is for TEA or PVB; can do it with a rib block by the surgeon too, though not as smooth in my opinion. Injecting the vagus is a must for anything not quick and peripheral, otherwise the patient ends up with a strong cough reflex from the PTX and lung manipulation

 

[dhb]

How is the PTX created? (How do you drop the lung in SV) The surgeon has to put a hole into the lung...

 

[drmwvr]

How is the PTX created? The surgeon has to put a hole into the lung...

The PTX that occurs is from the chest being open and the patient spontaneously breathing.

 

[Noyac]

How is the PTX created? The surgeon has to put a hole into the lung...

Not exactly, pneumothorax is defined as air in the thorax. It can get thee by either means, via lung puncture or chest puncture. Spreading the ribs apart and thorax to ambient air is a pneumothorax. Or they could insuflate during a VATS.

 

[dhb]

Not exactly, pneumothorax is defined as air in the thorax. It can get thee by either means, via lung puncture or chest puncture. Spreading the ribs apart and thorax to ambient air is a pneumothorax. Or they could insuflate during a VATS.

That i knew but if you want full deflation you need to block the air going in (DLT) or make a way out...

 

[drmwvr]

That i knew but if you want full deflation you need to block the air going in (DLT) or make a way out...

There is a way out. The airway is patent and there isn't anything keeping the lung from deflating (or inflating.)

 

[dhb]

There is a way out. The airway is patent and there isn't anything keeping the lung from deflating (or inflating.)

Ok i know that but what i mean is in these cases do you try to drop the lung completly or does the surgeon have to deal with a moving target?

 

[nimbus]

Ok i know that but what i mean is in these cases do you try to drop the lung completly or does the surgeon have to deal with a moving target?

Moving target. The surgeons who ask for these know what they’re getting into and are okay with it.

 

[Mikkel]

I've heard of VATS being done with LMAs.

Makes sense to me, when the surgeon introduces a pneumothorax, the operative side automatically deflates.


MAC VATS make even more sense because you don't get as profound HPV since you're not running any volatile.

 

[Maverikk]

To answer the original question: usually your thoracic surgeon has a grip on sick patients has weighed the risk/benefit, for all the sick people they're bringing they're turning down a lot more (hopefully). I've done some dicey OLV but usually when there where problems it wasn't the OLV. And yes NO works with inhalationals, but it's really only added on if the heart poops out coming off bypass, I could see adding it if there's an intracardiac event in someone with pHTN.

 

[epidural man]

Seriously though, at my first gig outta residency we had a thoracic surgeon that decided he wanted to start doing VATS decortication/pleurodesis under MAC. We were all very skeptical and thought it was nuts. Actually turned out to be very well tolerated. Cases went smooth, and it worked great. I usually ran ketofol.

So room air general.

 

[deleted697535]

Looking for more advice from anesthesiology experts everywhere!! 🙂 what are your relative contraindications for one lung ventilation in terms of cardiac function? Eg how bad would pHTN have to be for you to not do OLV? What about EF? Tricuspid regurg? RV dysfunction? large pericardial effusion? Thanks!

I would say it's a multiD picture with lots of tests!

Isn't it all based on your 3 legged stool? Ppo's etc
Vo2max <10 is a hard no obvi.
Abg on air.

Pulm htn itself isn't a contraindication if they can walk> 2 flights of stairs.

I've seen lots of echos reporting high rvsps in the 80s and 90s but the patient was quite active...

 

[anbuitachi]

I would say it's a multiD picture with lots of tests!

Isn't it all based on your 3 legged stool? Ppo's etc
Vo2max <10 is a hard no obvi.
Abg on air.

Pulm htn itself isn't a contraindication if they can walk> 2 flights of stairs.

I've seen lots of echos reporting high rvsps in the 80s and 90s but the patient was quite active...

what are you using to estimate your vo2max <10..? do you use this to cancel cases??

 

[coffeebythelake]

Any of you guys ever just mainstem a single lumen tube?

 

[nimbus]

Any of you guys ever just mainstem a single lumen tube?

No. Our surgeons are spoiled. They request a lot of up down up down. And some patients need CPAP or what I call “microbreaths” (hand ventilating the down lung with an ambu bag while watching the surgical field) on the down lung. I prefer the control offered by a DLT.

 

[Maverikk]

Any of you guys ever just mainstem a single lumen tube?

Yes, this works but is just more inconvenient, for people that have had tracheal operations that putting in a DLT could cause more damage I've done it when training, some part of it was for resident benefit 🙂. No real difference between this and a bronchial blocker, you have to bronch more often to make sure the tubes in the right place and when you're re-insufflating, plus you can't provide CPAP or suction

 

[deleted697535]

Any of you guys ever just mainstem a single lumen tube?

Basically never. Or only in absolute extremist. Absolutely not for someone with bad pulm htn.

For testing we have full cpex suite which this person with bad pulm htn would definitely get. In general tho a 6 min walk test is well correlated so the books say. I've never seen it done here for us tho

 

[Ronin786]

If you cant get a DLT/BB/main stem tube in, you can always just use intermittent apnea. It sucks for everybody involved, but sometimes it's the only option when your BB gets dislodged in somebody who's already lateral and open, has a terrible airway and you cant mainstem (speaking from experience).

 

[Noyac]

Any of you guys ever just mainstem a single lumen tube?

not on purpose

 

[deleted697535]

If you cant get a DLT/BB/main stem tube in, you can always just use intermittent apnea. It sucks for everybody involved, but sometimes it's the only option when your BB gets dislodged in somebody who's already lateral and open, has a terrible airway and you cant mainstem (speaking from experience).

What?
Intermittent apnea in an open thoracotomy in the lateral position in someone with a terrible airway and proceed with the case?

 

[anes121508]

We are confronted more often than most with pHTN and I have never had cutoff for OLV. I basically see how it goes. But this topic got me thinking, has anyone used Nitric Oxide in this situation? I haven’t I assume it would prevent hypoxia pulm vasoconstriction and may be useless. I don’t know but this article gives a little info:

Inhaled nitric oxide administration during one-lung ventilation in patients undergoing thoracic surgery - PubMed

Inhaled NO administration neither significantly decreased mean pulmonary arterial pressure in patients with normal pulmonary artery pressure nor improved oxygenation in nonhypoxic patients. Nevertheless, inhaled NO is effective in patients with pulmonary hypertension and hypoxemia during OLV.

www.ncbi.nlm.nih.gov

Saw this topic on oral bords.