Objective: To compare performance of right- versus leftsided
double-lumen tubes (DLTs) among infrequent users by
evaluating the incidence and severity of hypoxemia, hypercapnia,
and high airway pressures.
Design: A retrospective, cohort study.
Setting: A university hospital.
Participants: Ninety-eight patients undergoing left-sided
DLT placement (53.9
21.2 years old) and 98 patients
undergoing right-sided DLT placement (62.3
20.6 years
old). Cases performed by thoracic anesthesia specialists
were excluded.
Interventions: The authors retrospectively reviewed electronic
anesthetic records from a 2-year period to determine
the incidence and severity of hypoxia (SpO2 < 90%), hypercapnia (end-tidal carbon dioxide > 45 mmHg) and high airway
pressures (peak inspiratory pressure >35 cmH2O) during
one-lung ventilation via right and left DLTs.
Measurements and Main Results: Right-sided (n  98)
DLTs were almost exclusively used on the side contralateral
to surgery by infrequent users, whereas left-sided
(n  98) DLTs were used for ipsilateral surgery one third of
the time. Hypoxia lasted longer in left versus right DLTs,
but the frequency of hypoxia was the same for each tube
type among infrequent users. Hypercapnia and high airway
pressures occurred more frequently with left-sided
DLTs.
Conclusions: Left-sided DLTs are perceived to be safer
because they may be less prone to malpositioning during
lung isolation. However, the supposition that left-sided
DLTs are safer than right-sided DLTs when intraoperative
hypoxia, hypercapnia, and high airway pressures are used as
criteria, even when these tubes are used by infrequent users,
is not supported by the data.

Background. Pressure-controlled ventilation (PCV) has been suggested to reduce peak
airway pressure (Ppeak) and intrapulmonary shunt during one-lung ventilation (OLV) when
compared with volume-controlled ventilation (VCV). At the same tidal volume (VT), the
apparent difference in Ppeak is mainly related to the presence of a double-lumen tracheal
tube. We tested the hypothesis that the decrease in Ppeak observed in the breathing
circuit is not necessarily associated with a decrease in the bronchus of the dependent lung.
Methods. This observational study included 15 consecutive subjects who were ventilated
with VCV followed by PCV at constant VT. Airway pressure was measured simultaneously in
the breathing circuit and main bronchus of the dependent lung after 20 min of ventilation.
Results. PCV induced a significant decrease in Ppeak [mean (SD)] measured in the breathing
circuit [36 (4) to 26 (3) cm H20, P,0.0001] and in the bronchus [23 (4) to 22 (3) cm H2O,
P¼0.01]. However, the interaction (ventilatory mode × site of measurement) revealed that
the decrease in Ppeak was significantly higher in the circuit (P,0.0001). Although the mean
percentage decrease in Ppeak was significant at both sites, the decrease was significantly
lower in the bronchus [5 (6)% vs 29 (3)%, P,0.0001].
Conclusions. During PCV for OLV, the decrease in Ppeak is observed mainly in the respiratory
circuit and is probably not clinically relevant in the bronchus of the dependent lung. This
challenges the common clinical perception that PCV offers an advantage over VCV during
OLV by reducing bronchial Ppeak.

Tidal volumes have tremendously decreased over the last decades
from <15 ml kg
1 to w6 mlkg
1 actual body weight. Guidelines, widely agreed and used, exist for patients with acute lung injury or acute respiratory distress syndrome (ARDS). However, it is questionable if data created in patients with acute lung injury or ARDS from ventilation on intensive care units can be transferred to healthy patients undergoing surgery. Consensus criteria regarding this topic are still missing because only a few randomised controlled trials have been performed to date, focussing on the use of the best intra-operative tidal volume. The same problem has been observed regarding the application of positive end-expiratory pressure (PEEP) and intra-operative lung recruitment. This article provides an overviewof the current literature addressing the size of tidal volume, the use of PEEP and the application of the open-lung concept in patients without acute lung injury or ARDS. Pathophysiological aspects of mechanical ventilation are elucidated.

BACKGROUND: There is controversy surrounding the value of the predicted postoperative diffusing capacity of lung for carbon monoxide (DLCOppo) in comparison to the forced expired volume in 1 s for prediction of pulmonary complications (PCs) after thoracic surgery.

METHODS: Using a prospective database, we performed an analysis of 956 patients who had resection for lung cancer at a single institution. PC was defined as the occurrence of any of the following: atelectasis, pneumonia, pulmonary embolism, respiratory failure, and need for supplemental oxygen at hospital discharge.

RESULTS: PCs occurred in 121 of 956 patients (12.7%). Preoperative chemotherapy (odds ratio 1.64, 95% confidence interval 1.06–2.55, P = 0.02, point score 2) and a lower DLCOppo (odds ratio per each 5% decrement 1.13, 95% confidence interval 1.06–1.19, P < 0.0001, point score 1 per each 5% decrement of DLCOppo less than 100%) were independent risk factors for PCs. We defined 3 overall risk categories for PCs: low <=10 points, 39 of 448 patients (9%); intermediate 11–13 points, 37 of 256 patients (14%); and high >=14 points, 42 of 159 patients (26%). The median (range) length of hospital stay was significantly greater for patients who developed PCs than for those who did not: 12 (3–113) days vs 6 (2–39) days, P < 0.0001, respectively. Similarly, 30-day mortality was significantly more frequent for patients who developed PCs than for those who did not: 16 of 121 (13.2%) vs 6 of 835 (0.7%), P < 0.0001. CONCLUSIONS: These data show that PCs after thoracic surgery for lung cancer can be predicted with moderate accuracy based on DLCOppo and whether patients had chemotherapy. Forced expired volume in 1 s was not a predictor of PCs.

We used inhaled epoprostenol (with intravenous phenylephrine)
during one-lung ventilation to improve oxygenation
in a patient with severe interstitial lung disease
undergoing video-assisted thoracoscopic surgery. The
pharmacologic manipulation of pulmonary blood flow
remains an underused strategy for the management of
hypoxemia during one-lung ventilation.

Background. The safety of epidural anaesthesia in patients at risk for right ventricular
pressure overload remains controversial. We compared the haemodynamic effects of vascular
and cardiac autonomic nerve block, induced by selective lumbar (LEA) and high thoracic epidural
anaesthesia (TEA), respectively, in an animal model subjected to controlled acute right
ventricular pressure overload.
Methods. Eighteen pigs were instrumented with epidural catheters at the thoracic (T) and
lumbar (L) level and received separate injections at T2 (1 ml) and L3 (4 ml) with saline (s) or
bupivacaine 0.5% (b). Three groups of six animals were studied: (i) a control group (LsþTs), (ii)
LEA group (LbþTs), and (iii) TEA group (LsþTb). Haemodynamic measurements including
biventricular pressure-volumetry were performed. Right ventricular afterload was then
increased by inflating a pulmonary artery (PA) balloon. Measurements were repeated after
30 min of sustained right ventricular afterload increase.
Results. LEA decreased systemic vascular resistance (SVR) and did not affect ventricular function.
TEA had minor effects on SVR but decreased left ventricular contractility while baseline
right ventricular function was not affected. Control and LEA-treated animals responded similarly
to a PA balloon occlusion with an increase in right ventricular contractility and heart rate.
Animals pretreated with a TEA did not show this positive inotropic response and developed
low cardiac output in the presence of right ventricular pressure overload.
Conclusions. In contrast to LEA, TEA reduced the haemodynamic tolerance to PA balloon
occlusion by inhibiting the right ventricular positive inotropic response to acute pressure overload

Placement of the PLMA was achieved by threading a gum elastic bougie (Portex-SIMS; Hythe, Kent, UK) into the drain tube, and, under gentle direct laryngoscopy, its distal end was introduced into the esophagus. Positive-pressure ventilation was instituted and, via the multiport adaptor, the BB was passed into the left mainstem bronchus under bronchoscopic guidance, carefully avoiding the tracheal mass. A gastric drainage tube was gently inserted via the drainage port to drain the stomach. Adequate one-lung ventilation (OLV) was achieved after inflation of the BB cuff in the lateral decubitus position. Throughout the period of OLV, peak inspiratory pressures ranged from 30 to 35 cmH2O on pressure-controlled ventilation with tidal volumes of 400 to 450 mL, a respiratory rate of 12, and end-tidal CO2 of 45 to 48 mmHg. Surgical exposure was good, and surgery proceeded uneventfully. Postprocedure bronchoscopy did not reveal any evidence of aspiration in the larynx or tracheobronchial tree.

The patient had a friable tracheal mass close to the vocal cords that precluded the placement of an endotracheal tube and had the potential for tumor trauma. We used a supraglottic airway to mitigate this and chose the PLMA in view of the patient’s aspiration risk, taking advantage of the probable added protection of a gastric drainage tube. Although a reduction in aspiration risk with the PLMA (compared with the CLMA) has not been shown, the drainage tube successfully vented regurgitated fluid and protected against aspiration. 2 In more than 2,000 PLMA placements, there were 12 cases of clinically apparent regurgitation with no clinical or bronchoscopic evidence of aspiration. 2

The measured peak airway pressures of 30 to 35 cmH2O were high probably because of reduced lung compliance. These pressures are within the appropriate “lung-protective ventilation” strategy of limiting the peak inspiratory pressure to <35 cmH2O during OLV. 3 The reported improved seal of the PLMA as compared with the CLMA was to our advantage. Median seal pressures with PLMA are reported to be approximately 30 cmH2O, 4 with pressures exceeding 40 cmH2O in 20% of cases. 5 The airway seal with CLMA is reported to exceed 30 cmH2O in only 4% of cases. 5 Our approach was an effective strategy in the management of this uncommon yet challenging scenario. We suggest that it be considered as part of the armamentarium for such cases requiring lung separation.

HYPOXEMIA DURING one-lung ventilation (OLV) for video-assisted thoracoscopic surgery (VATS) is a difficult problem for the anesthesiologist to manage. The standard therapy recommended for this problem is the application of continuous positive airway pressure (CPAP) to the nonventilated lung. However, CPAP interferes with surgical exposure in the hemithorax. A novel technique to treat hypoxemia in this context using fiberoptic bronchoscopic segmental oxygen insufflation and recruitment that does not impede surgery is described.

Objective: The aim of this study was to identify predictors
of delayed endotracheal extubation defined as the need for
postoperative ventilatory support after open thoracotomy
for lung resection.
Design: An observational cohort investigation.
Setting: A tertiary referral center.
Participants: The study population consisted of 2,068 patients
who had open thoracotomy for pneumonectomy, lobectomy,
or segmental lung resection between January
1996 and December 2005.
Interventions: Not applicable.
Measurements and Main Results: Preoperative and intraoperative
variables were collected concurrently with the patient’s
care. Risk factors were identified using logistic regression
with stepwise variable selection procedure on 1,000
bootstrap resamples, and a bagging algorithm was used to
summarize the results. Intraoperative red blood cell transfusion,
higher preoperative serum creatinine level, absence of a
thoracic epidural catheter, more extensive surgical resection,
and lower preoperative FEV1 were associated with an increased
risk of delayed extubation after lung resection.
Conclusion: Most predictors of delayed postoperative extubation
(ie, red blood cell transfusion, higher preoperative serum
creatinine, lower preoperative FEV1, and more extensive
lung resection) are difficult to modify in the perioperative period
and probably represent greater severity of underlying lung
disease and more advanced comorbid conditions. However,
thoracic epidural anesthesia and analgesia is a modifiable factor
that was associated with reduced odds for postoperative
ventilatory support. Thus, the use of epidural analgesia may
reduce the need for post-thoracotomy mechanical ventilation

We present a 15-yr-old-girl who underwent interventional lung assist via Novalung® (Novalung GmbH, Lotzenaecker, Heckingen, Germany) insertion as a bridge to bilateral lung transplantation for pulmonary veno-occlusive disease. This is the first pediatric and smallest patient to receive the device. Central cannulation was chosen to optimize blood flow through the device by enabling larger-sized cannulae in a patient with high pulmonary artery pressure. Novalung provided circulatory support with oxygenation obviating the need for extracorporeal membrane oxygenation while waiting for lung transplantation.