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Principles and Practice of Anesthesia for Thoracic Surgery pp 283–309Cite as

Lung Isolation

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Abstract

During the preoperative period, review of the posteroanterior chest radiograph is necessary to measure the tracheal width and also appreciate the pattern of the tracheobronchial anatomy to determine what device and size to use. The left-sided DLT is the most common device used for lung isolation because of its greater margin of safety. The use of bronchial blockers is indicated in patients who present with difficult airways and require lung isolation. Patients with a tracheostomy in place requiring lung isolation are best managed with the use of an independent bronchial blocker and flexible fiberoptic bronchoscopy. Flexible fiberoptic bronchoscopy is the recommended method to achieve optimal position of lung isolation devices, first in supine position, later in lateral decubitus, or whenever a malposition occurs.

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Authors and Affiliations

  1. Department of Anesthesia, University of Iowa Health Care, Roy and Lucille Carver College of Medicine, Iowa City, IA, USA

    Javier Campos

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  1. Javier Campos
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Correspondence to Javier Campos .

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Editors and Affiliations

  1. Department of Anesthesiology, University of Toronto, Toronto, ON, Canada

    Peter Slinger

Clinical Case Discussion

Clinical Case Discussion

Case: A 60-year-old female, weight 61 kg and is 161 cm tall, has a left lower lobe mass and is scheduled for a left lower lobectomy (Fig. 16.17a, b). She is a former smoker and the predicted value of forced expiratory volume in 1 s (FEV1) is 75% of the predicted value. She has no significant known comorbidities and past history otherwise unremarkable (see Fig. 16.20).

Fig. 16.20
figure 20

(a, b) Chest X-ray of a female patient with a carcinoma of the left lower lobe undergoing a lobectomy

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Questions

  • What lung isolation device will be indicated?

  • What side and size of lung isolation device will be indicated?

  • What anatomical structures in the chest radiograph are relevant while planning the use of lung isolation devices?

  • What are the different alternatives for lung isolation devices?

  • What technique should be used to achieve optimal position of lung isolation devices?

  • What are the common problems in the intraoperative period with lung isolation devices?

  • What are the complications associated with lung isolation devices?

Focus on the Patient’s Gender, Size, Height, and Preoperative Chest Radiograph

  • To determine the lung isolation device.

  • Focus on the use of left-sided DLT for routine, uncomplicated cases or a right-sided DLT for selective cases.

  • Focus on the indication of lung isolation.

  • Knowledge of tracheobronchial anatomy and the use of flexible fiberoptic bronchoscopy to confirm device placement are essential for success on lung isolation.

  • Alternative devices for lung isolation such as bronchial blockers should be considered in specific cases.

Choice of Lung Isolation Device

  • If there is nothing in the patient’s history or physical examination to suggest the possibility of difficult airway in a left- or right-sided DLT, depending on the clinician’s preference, would be equivalent first choices to manage this case.

  • The patient’s sex and height suggest that either a 35 or 37 F DLT would be appropriate and the choice can be further refined by measuring the tracheal width on the PA chest X-ray (see Fig. 16.1).

  • In the absence of a difficult airway, the problem of intraoperative displacement with bronchial blockers makes them a second choice for lung isolation in this patient.

  • Correct positioning of the device for lung isolation should be confirmed with fiberoptic bronchoscopy.

Expected Intraoperative Problems During Lung Isolation

  • Malpositions and the potential for tracheobronchial injuries

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Campos, J. (2019). Lung Isolation. In: Slinger, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-00859-8_16

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  • DOI: https://doi.org/10.1007/978-3-030-00859-8_16

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-00858-1

  • Online ISBN: 978-3-030-00859-8

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