Step-by-step clinical management of one-lung ventilation: continuing professional development.

PURPOSE: The purpose of this Continuing Professional Development Module is to review the issues pertinent to one-lung ventilation (OLV) and to propose a management strategy for ventilation before, during, and after lung isolation.

PRINCIPAL FINDINGS: The need for optimal lung isolation has increased with the advent of video-assisted thoracoscopic surgery, as surgical exposure is critical for successful surgery. Continuous positive airway pressure applied to the operative lung or intermittent two-lung ventilation should therefore be avoided if possible. Optimal management of OLV should provide adequate oxygenation and also prevent acute lung injury (ALI), the leading cause of death following lung resection. Research conducted in the last decade suggests implementing a protective ventilation strategy during OLV that consists of small tidal volumes based on ideal body weight, routine use of positive end-expiratory pressure, low inspired oxygen fraction, with low peak and plateau airway pressures. High respiratory rates to compensate for low tidal volumes may predispose to significant air trapping during OLV, so permissive hypercapnea is routinely employed. The management of OLV extends into the period of two-lung ventilation, as the period prior to OLV impacts lung collapse, and both the time before and after OLV influence the extent of ALI. Lung re-expansion at the conclusion of OLV is an important component of ensuring adequate ventilation and oxygenation postoperatively but may be harmful to the lung.

CONCLUSIONS: Optimal perioperative care of the thoracic patient includes a protective ventilation strategy from intubation to extubation and into the immediate postoperative period. Anesthetic goals include the prevention of perioperative hypoxemia and postoperative ALI.