Physiology of the Lateral Decubitus Position, Open Chest and One-Lung Ventilation

  • Jens Lohser
  • Seiji Ishikawa


Ventilation and perfusion matching is optimized for gas exchange. Induction of anesthesia, one-lung ventilation (OLV) and opening of the chest progressively uncouple ventilation–perfusion (V/Q) matching. Hypoxic pulmonary vasoconstriction (HPV) improves V/Q matching during OLV, but can be impaired by anesthetic interventions.


Cardiac Output Pulmonary Blood Flow Lateral Decubitus Position Hypoxic Pulmonary Vasoconstriction Shunt Flow 


  1. 1.
    Maloney Jr JV, Schmutzer KJ, Raschke E. Paradoxical respiration and “pendelluft”. J Thorac Cardiovasc Surg. 1961;41:291–8.PubMedGoogle Scholar
  2. 2.
    Benumof JL. Anesthesia for thoracic surgery. 2nd ed. Philadelphia: WB Saunders; 1994.Google Scholar
  3. 3.
    Tacconi F, Pompeo E, Fabbi E, Mineo TC. Awake video-assisted pleural decortication for empyema thoracis. Eur J Cardiothorac Surg. 2010;37(3):594–601.PubMedCrossRefGoogle Scholar
  4. 4.
    Brodsky JB. The evolution of thoracic anesthesia. Thorac Surg Clin. 2005;15(1):1–10.PubMedCrossRefGoogle Scholar
  5. 5.
    West JB. Respiratory physiology: the essentials. 5th ed. Baltimore: Williams and Wilkins; 1995.Google Scholar
  6. 6.
    Hakim TS, Lisbona R, Dean GW. Gravity-independent inequality in pulmonary blood flow in humans. J Appl Physiol. 1987;63(3):1114–21.PubMedGoogle Scholar
  7. 7.
    West JB, Dollery CT, Naimark A. Distribution of blood flow in isolated lung; relation to vascular and alveolar pressures. J Appl Physiol. 1964;19(4):713–24.PubMedGoogle Scholar
  8. 8.
    West JB, Dollery CT, Heard BE. Increased pulmonary vascular resistance in the dependent zone of the isolated dog lung caused by perivascular edema. Circ Res. 1965;17(3):191–206.PubMedGoogle Scholar
  9. 9.
    Chang H, Lai-Fook SJ, Domino KB, et al. Spatial distribution of ventilation and perfusion in anesthetized dogs in lateral postures. J Appl Physiol. 2002;92(2):745–62.PubMedGoogle Scholar
  10.  10.
    Groves BM, Reeves JT, Sutton JR, et al. Operation Everest II: elevated high-altitude pulmonary resistance unresponsive to oxygen. J Appl Physiol. 1987;63(2):521–30.PubMedGoogle Scholar
  11. 11.
    Maseri A, Caldini P, Harward P, Joshi RC, Permutt S, Zierler KL. Determinants of pulmonary vascular volume: recruitment versus distensibility. Circ Res. 1972;31(2):218–28.PubMedGoogle Scholar
  12. 12.
    Weir EK, Lopez-Barneo J, Buckler KJ, Archer SL. Acute oxygen-sensing mechanisms. N Engl J Med. 2005;353(19):2042–55.PubMedCrossRefGoogle Scholar
  13. 13.
    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. 2003;94(4):1543–51.PubMedGoogle Scholar
  14. 14.
    Nagendran J, Stewart K, Hoskinson M, Archer SL. An anesthesiologist’s guide to hypoxic pulmonary vasoconstriction: implications for managing single-lung anesthesia and atelectasis. Curr Opin Anaesthesiol. 2006;19(1):34–43.PubMedCrossRefGoogle Scholar
  15. 15.
    Grichnik KP, Clark JA. Pathophysiology and management of one-lung ventilation. Thorac Surg Clin. 2005;15(1):85–103.PubMedCrossRefGoogle Scholar
  16. 16.
    Talbot NP, Balanos GM, Dorrington KL, Robbins PA. Two temporal components within the human pulmonary vascular response to approximately 2 h of isocapnic hypoxia. J Appl Physiol. 2005;98(3):1125–39.PubMedCrossRefGoogle Scholar
  17. 17.
    Conacher ID. 2000 – time to apply occam’s razor to failure of hypoxic pulmonary vasoconstriction during one-lung ventilation. Br J Anaesth. 2000;84(4):434–6.PubMedGoogle Scholar
  18. 18.
    Peinado VI, Santos S, Ramirez J, Roca J, Rodriguez-Roisin R, Barbarà JA. Response to hypoxia of pulmonary arteries in chronic obstructive pulmonary disease: an in vitro study. Eur Respir J. 2002;20(2):332–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Nakos G, Evrenoglou D, Vassilakis N, Lampropoulos S. Haemodynamics and gas exchange in liver cirrhosis: the effect of orally administered almitrine bismesylate. Respir Med. 1993;87(2):93–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Reeves JT, Grover RF. Blockade of acute hypoxic pulmonary hypertension by endotoxin. J Appl Physiol. 1974;36(3):328–32.PubMedGoogle Scholar
  21. 21.
    Moore LG, Reeves JT. Pregnancy blunts pulmonary vascular reactivity in dogs. Am J Physiol. 1980;239(3):H297–301.PubMedGoogle Scholar
  22. 22.
    Wetzel RC, Zacur HA, Sylvester JT. Effect of puberty and estradiol on hypoxic vasomotor response in isolated sheep lungs. J Appl Physiol. 1984;56(5):1199–203.PubMedGoogle Scholar
  23. 23.
    Favret F, Henderson KK, Allen J, Richalet JP, Gonzalez NC. Exercise training improves lung gas exchange and attenuates acute hypoxic pulmonary hypertension but does not prevent pulmonary hypertension of prolonged hypoxia. J Appl Physiol. 2006;100(1):20–5.PubMedCrossRefGoogle Scholar
  24. 24.
    Guazzi MD, Berti M, Doria E, et al. Enhancement of the pulmonary vasoconstriction reaction to alveolar hypoxia in systemic high blood pressure. Clin Sci (Lond). 1989;76(6):589–94.Google Scholar
  25. 25.
    Doekel RC, Weir EK, Looga R, Grover RF, Reeves JT. Potentiation of hypoxic pulmonary vasoconstriction by ethyl alcohol in dogs. J Appl Physiol. 1978;44(1):76–80.PubMedGoogle Scholar
  26. 26.
    Brimioulle S, Lejeune P, Vachiery JL, Leeman M, Melot C, Naeije R. Effects of acidosis and alkalosis on hypoxic pulmonary vasoconstriction in dogs. Am J Physiol. 1990;258(2 Pt 2):H347–53.PubMedGoogle Scholar
  27. 27.
    Benumof JL, Wahrenbrock EA. Dependency of hypoxic pulmonary vasoconstriction on temperature. J Appl Physiol. 1977; 42(1):56–8.PubMedGoogle Scholar
  28. 28.
    Benumof JL, Wahrenbrock EA. Blunted hypoxic pulmonary vasoconstriction by increased lung vascular pressures. J Appl Physiol. 1975;38(5):846–50.PubMedGoogle Scholar
  29. 29.
    Marshall C, Marshall B. Site and sensitivity for stimulation of hypoxic pulmonary vasoconstriction. J Appl Physiol. 1983;55(3):711–6.PubMedGoogle Scholar
  30. 30.
    Choi YS, Bang SO, Shim JK, Chung KY, Kwak YL, Hong YW. Effects of head-down tilt on intrapulmonary shunt fraction and oxygenation during one-lung ventilation in the lateral decubitus position. J Thorac Cardiovasc Surg. 2007;134(3):613–8.PubMedCrossRefGoogle Scholar
  31. 31.
    Bardoczky GI, Szegedi LL, d’Hollander AA, Moures JM, De Francquen P, Yernault JC. Two-lung and one-lung ventilation in patients with chronic obstructive pulmonary disease: the effects of position and FIO2. Anesth Analg. 2000;90(1):35–41.PubMedCrossRefGoogle Scholar
  32. 32.
    Ishikawa S, Nakazawa K, Makita K. Progressive changes in arterial oxygenation during one-lung anaesthesia are related to the response to compression of the nondependent lung. Br J Anaesth. 2003;90(1):21–6.PubMedCrossRefGoogle Scholar
  33. 33.
    Szegedi LL, Van der Linden P, Ducart A, et al. The effects of acute isovolemic hemodilution on oxygenation during one-lung ventilation. Anesth Analg. 2005;100(1):15–20.PubMedCrossRefGoogle Scholar
  34. 34.
    Von Dossow V, Welte M, Zaune U, et al. Thoracic epidural anesthesia combined with general anesthesia: the preferred anesthetic technique for thoracic surgery. Anesth Analg. 2001;92(4):848–54.CrossRefGoogle Scholar
  35. 35.
    Casati A, Mascotto G, Iemi K, Nzepa-Batonga J, De Luca M. Epidural block does not worsen oxygenation during one-lung ventilation for lung resections under isoflurane/nitrous oxide anaesthesia. Eur J Anaesthesiol. 2005;22(5):363–8.PubMedCrossRefGoogle Scholar
  36. 36.
    Özcan 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(8):1117–22.PubMedCrossRefGoogle Scholar
  37. 37.
    Moutafis M, Liu N, Dalibon N, et al. The effects of inhaled nitric oxide and its combination with intravenous almitrine on Pao2 during one-lung ventilation in patients undergoing thoracoscopic procedures. Anesth Analg. 1997;85(5):1130–5.PubMedGoogle Scholar
  38. 38.
    Bindslev L, Cannon D, Sykes MK. Effect of lignocaine and nitrous oxide on hypoxic pulmonary vasoconstriction in the dog constant-flow perfused left lower lobe preparation. Br J Anaesth. 1986;58(3):315–20.PubMedCrossRefGoogle Scholar
  39. 39.
    Kjaeve J, Bjertnaes LJ. Interaction of verapamil and halogenated inhalation anesthetics on hypoxic pulmonary vasoconstriction. Acta Anaesthesiol Scand. 1989;33(3):193–8.PubMedCrossRefGoogle Scholar
  40. 40.
    Carlsson AJ, Hedenstierna G, Bindslev L. Hypoxia-induced vasoconstriction in human lung exposed to enflurane anaesthesia. Acta Anaesthesiol Scand. 1987;31(1):57–62.PubMedCrossRefGoogle Scholar
  41. 41.
    Carlsson AJ, Bindslev L, Hedenstierna G. Hypoxia-induced pulmonary vasoconstriction in the human lung. The effect of isoflurane anesthesia. Anesthesiology. 1987;66(3):312–6.PubMedCrossRefGoogle Scholar
  42. 42.
    Kerbaul F, Guidon C, Stephanazzi J, et al. Sub-MAC concentrations of desflurane do not inhibit hypoxic pulmonary vasoconstriction in anesthetized piglets. Can J Anaesth. 2001;48(8):760–7.PubMedCrossRefGoogle Scholar
  43. 43.
    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(4):539–44.PubMedCrossRefGoogle Scholar
  44. 44.
    Nakayama M, Murray PA. Ketamine preserves and propofol potentiates hypoxic pulmonary vasoconstriction compared with the conscious state in chronically instrumented dogs. Anesthesiology. 1999;91(3):760–71.PubMedCrossRefGoogle Scholar
  45. 45.
    Bjertnaes L, Hauge A, Kriz M. Hypoxia-induced pulmonary vasoconstriction: effects of fentanyl following different routes of administration. Acta Anaesthesiol Scand. 1980;24(1):53–7.PubMedCrossRefGoogle Scholar
  46. 46.
    Clozel JP, Delorme N, Battistella P, Breda JL, Polu JM. Hemodynamic effects of intravenous diltiazem in hypoxic pulmonary hypertension. Chest. 1987;91(2):171–5.PubMedCrossRefGoogle Scholar
  47. 47.
    Thilenius OG, Candiolo BM, Beug JL. Effect of adrenergic blockade on hypoxia-induced pulmonary vasoconstriction in awake dogs. Am J Physiol. 1967;213(4):990–8.PubMedGoogle Scholar
  48. 48.
    Hackett PH, Roach RC, Hartig GS, Greene ER, Levine BD. The effect of vasodilators on pulmonary hemodynamics in high altitude pulmonary edema: a comparison. Int J Sports Med. 1992;13 Suppl 1:S68–71.PubMedCrossRefGoogle Scholar
  49. 49.
    Lübbe N. The effect of clonidine on the intrapulmonary right-to-left shunt in one-lung ventilation in the dog. Anaesthesist. 1991;40(7):391–6.PubMedGoogle Scholar
  50. 50.
    Hales CA, Westphal D. Hypoxemia following the administration of sublingual nitroglycerin. Am J Med. 1978;65(6):911–8.PubMedCrossRefGoogle Scholar
  51. 51.
    Parsons GH, Leventhal JP, Hansen MM, Goldstein JD. Effect of sodium nitroprusside on hypoxic pulmonary vasoconstriction in the dog. J Appl Physiol. 1981;51(2):288–92.PubMedGoogle Scholar
  52. 52.
    Zhao L, Mason NA, Morrell NW, et al. Sildenafil inhibits hypoxia-induced pulmonary hypertension. Circulation. 2001;104(4):424–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Marin JL, Orchard C, Chakrabarti MK, Sykes MK. Depression of hypoxic pulmonary vasoconstriction in the dog by dopamine and isoprenaline. Br J Anaesth. 1979;51(4):303–12.PubMedCrossRefGoogle Scholar
  54. 54.
    Silove ED, Grover RF. Effects of alpha adrenergic blockade and tissue catecholamine depletion on pulmonary vascular response to hypoxia. J Clin Invest. 1968;47(2):274–85.PubMedCrossRefGoogle Scholar
  55. 55.
    Doering EB, William Hanson III C, Reily DJ, Marshall C, Marshall BE. Improvement in oxygenation by phenylephrine and nitric oxide in patients with adult respiratory distress syndrome. Anesthesiology. 1997;87(1):18–25.PubMedCrossRefGoogle Scholar
  56. 56.
    Hüter L, Schwarzkopf K, Preussler NP, et al. Effects of arginine vasopressin on oxygenation and haemodynamics during one-lung ventilation in an animal model. Anaesth Intensive Care. 2008;36(2):162–6.PubMedGoogle Scholar
  57. 57.
    Kiely DG, Cargill RI, Lipworth BJ. Acute hypoxic pulmonary vasoconstriction in man is attenuated by type I angiotensin II receptor blockade. Cardiovasc Res. 1995;30(6):875–80.PubMedGoogle Scholar
  58. 58.
    Cargill RI, Lipworth BJ. Lisinopril attenuates acute hypoxic pulmonary vasoconstriction in humans. Chest. 1996;109(2):424–9.PubMedCrossRefGoogle Scholar
  59. 59.
    Leeman M, Lejeune P, Melot C, Deloof T, Naeije R. Pulmonary artery pressure: flow relationships in hyperoxic and in hypoxic dogs. Effects of methylprednisolone. Acta Anaesthesiol Scand. 1988;32(2):147–51.PubMedCrossRefGoogle Scholar
  60. 60.
    Lorente JA, Landin L, de Pablo R, Renes E. The effects of prostacyclin on oxygen transport in adult respiratory distress syndrome. Med Clin (Barc). 1992;98(17):641–5.Google Scholar
  61. 61.
    Weir EK, Reeves JT, Grover RF. Prostaglandin E1 inhibits the pulmonary vascular pressor response to hypoxia and prostaglandin F2alpha. Prostaglandins. 1975;10(4):623–31.PubMedCrossRefGoogle Scholar
  62. 62.
    Pillet O, Manier G, Castaing Y. Anticholinergic versus beta 2-agonist on gas exchange in COPD: a comparative study in 15 patients. Monaldi Arch Chest Dis. 1998;53(1):3–8.PubMedGoogle Scholar
  63. 63.
    Lohser J. Evidence-based management of one-lung ventilation. Anesthesiol Clin. 2008;26(2):241–72.PubMedCrossRefGoogle Scholar
  64. 64.
    Gurney AM, Osipenko ON, MacMillan D, McFarlane KM, Tate RJ, Kempsill FEJ. Two-pore domain K channel, TASK-1, in pulmonary artery smooth muscle cells. Circ Res. 2003;93(10): 957–64.PubMedCrossRefGoogle Scholar
  65. 65.
    Garutti I, Quintana B, Olmedilla L, Cruz A, Cruz A, Barranco M, Garcia de Lucas E. Arterial oxygenation during one-lung ventilation: combined versus general anesthesia. Anesth Analg. 1999;88(3): 494–9.PubMedGoogle Scholar
  66. 66.
    Szegedi LL. Pathophysiology of one-lung ventilation. Anesthesiol Clin North America. 2001;19(3):435–53.PubMedCrossRefGoogle Scholar
  67. 67.
    Levin AI et al. Arterial oxygenation during one-lung anesthesia. Curr Opin Anaesthesiol. 2008;21:28–36.PubMedCrossRefGoogle Scholar
  68. 68.
    Slinger P, Scott WA. Arterial oxygenation during one-lung ventilation. A comparison of enflurane and isoflurane. Anesthesiology. 1995;82(4):940–6.PubMedCrossRefGoogle Scholar
  69. 69.
    Nomoto Y, Kawamura M. Pulmonary gas exchange effects by nitroglycerin, dopamine and dobutamine during one-lung ventilation in man. Can J Anaesth. 1989;36(3 Pt 1):273–7.PubMedCrossRefGoogle Scholar
  70. 70.
    Mathru M, Dries DJ, Kanuri D, Blakeman B, Rao T. Effect of cardiac output on gas exchange in one-lung atelectasis. Chest. 1990;97(5):1121–4.PubMedCrossRefGoogle Scholar
  71. 71.
    Russell WJ, James MF. The effects on arterial haemoglobin oxygen saturation and on shunt of increasing cardiac output with dopamine or dobutamine during one-lung ventilation. Anaesth Intensive Care. 2004;32(5):644–8.PubMedGoogle Scholar
  72. 72.
    Russell WJ, James MF. The effects on increasing cardiac output with adrenaline or isoprenaline on arterial haemoglobin oxygen saturation and shunt during one-lung ventilation. Anaesth Intensive Care. 2000;28(6):636–41.PubMedGoogle Scholar
  73. 73.
    Malmkvist G, Fletcher R, Nordström L, Werner O. Effects of lung surgery and one-lung ventilation on pulmonary arterial pressure, venous admixture and immediate postoperative lung function. Br J Anaesth. 1989;63(6):696–701.PubMedCrossRefGoogle Scholar
  74. 74.
    McFarlane PA, Mortimer AJ, Ryder WA, et al. Effects of dopamine and dobutamine on the distribution of pulmonary blood flow during lobar ventilation hypoxia and lobar collapse in dogs. Eur J Clin Invest. 1985;15(2):53–9.PubMedCrossRefGoogle Scholar
  75. 75.
    Benumof JL. Respiratory physiology and respiratory function during anesthesia. In: Miller RD, editor. Anesthesia. 2nd ed. New York: Churchill Livingstone; 1983.Google Scholar
  76. 76.
    Hoppin Jr FG, Green ID, Mead J. Distribution of pleural surface pressure in dogs. J Appl Physiol. 1969;27(6):863–73.PubMedGoogle Scholar
  77. 77.
    Milic-Emili J, Henderson JA, Dolovich MB, Trop D, Kaneko K. Regional distribution of inspired gas in the lung. J Appl Physiol. 1966;21(3):749–59.PubMedGoogle Scholar
  78. 78.
    West JB. Regional differences in gas exchange in the lung of erect man. J Appl Physiol. 1962;17(6):893–8.PubMedGoogle Scholar
  79. 79.
    Wulff KE, Aulin I. The regional lung function in the lateral decubitus position during anesthesia and operation. Acta Anaesthesiol Scand. 1972;16(4):195–205.PubMedCrossRefGoogle Scholar
  80. 80.
    Rehder K, Hatch DJ, Sessler AD, Fowler WS. The function of each lung of anesthetized and paralyzed man during mechanical ventilation. Anesthesiology. 1972;37(1):16–26.PubMedCrossRefGoogle Scholar
  81. 81.
    Rehder K, Wenthe FM, Sessler AD. Function of each lung during mechanical ventilation with ZEEP and with PEEP in man anesthetized with thiopental-meperidine. Anesthesiology. 1973;39(6):597–606.PubMedCrossRefGoogle Scholar
  82. 82.
    Conlan AA, Moyes DG, Schutz J, Scoccianti M, Abramor E, Levy H. Pulmonary resection in the prone position for suppurative lung disease in children. J Thorac Cardiovasc Surg. 1986;92(5):890–3.PubMedGoogle Scholar
  83. 83.
    Fabian T, Martin J, Katigbak M, McKelvey AA, Federico JA. Thoracoscopic esophageal mobilization during minimally invasive esophagectomy: a head-to-head comparison of prone versus decubitus positions. Surg Endosc. 2008;22(11):2485–91.PubMedCrossRefGoogle Scholar
  84. 84.
    Turner MW, Buchanan CC, Brown SW. Paediatric one lung ventilation in the prone position. Paediatr Anaesth. 1997;7(5):427–9.PubMedCrossRefGoogle Scholar
  85. 85.
    Albert RK. Prone ventilation. Clin Chest Med. 2000;21(3):427–9.CrossRefGoogle Scholar
  86. 86.
    Pelosi P, Croci M, Calappi E, et al. The prone position during general anesthesia minimally affects respiratory mechanics while improving functional residual capacity and increasing oxygen tension. Anesth Analg. 1995;80(5):955–60.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • Jens Lohser
    • 1
  • Seiji Ishikawa
    • 2
  1. 1.Department of Anesthesiology, Pharmacology, and TherapeuticsUniversity of British Columbia, Vancouver General HospitalVancouverCanada
  2. 2.Department of AnesthesiologyTokyo Medical and Dental University, Graduate School of Medical and Dental SciencesTokyoJapan

Personalised recommendations