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Original Research

Open Access

Hypoxia during one lung ventilation in thoracic surgery


1Department of anesthesia and perioperative intensive therapy, University Medical Centre, Ljubljana, Slovenia

2 University clinic of anesthesia, reanimation and intensive therapy, University Clinical Centre, Skopje, Macedonia

DOI: 10.22514/SV132.112017.8 Vol.13,Issue 2,November 2017 pp.54-62

Published: 06 November 2017

*Corresponding Author(s): GORDANA TALESKA E-mail:


Background. The technique of one lung ventilation (OLV) is used with the pur-pose of achieving isolation of the diseased lung being operated upon, using a double-lumen endobronchial tube. Thoracic surgi-cal procedures which are performed in the lateral decubitus position, nowadays could not be imagined without OLV. In spite of advantages regarding surgical exposure, OLV is associated with serious respiratory impairment. Hypoxemia is considered to be the most important challenge during OLV. The goal of this study was to establish the magnitude of intrapulmonary shunt, as well as the immensity of hypoxia during general anesthesia with OLV.

Materials and Methods. In this prospective interventional clinical study thirty patients were enrolled who underwent elective thoracic surgery with a prolonged period of OLV. The patients received balanced general anesthesia with fentanyl/propofol/rocuronium. A double-lumen endobron-chial tube was inserted in all patients, and mechanical ventilation with 50% oxygen in air was used during the entire study. Arte-rial blood gases were recorded in a lateral decubitus position with two-lung ventila-tion, at the beginning of OLV (OLV 0) and at 10 and 30 min. (OLV 10, OLV 30, respectively) after initiating OLV in all patients. Standard monitoring procedures were used. Arterial oxygenation (PaO2), arterial oxygen saturation (SaO2) and ve-nous admixture percentage - intrapulmo-nary shunt (Qs/Qt %) were measured, as well as mean arterial pressure and heart rate during the same time intervals. For the purpose of this study, the quantitative value of Qs/Qt% was mathematically cal-culated using the blood gas analyser AVL Compact 3. A p value <0.05 was taken to be statistically significant.

Results. When OLV was instituted, arterial oxygenation decreased, whereas Qs/Qt% increased, about 10 min. after commence-ment, with improvement of oxygenation approximately half an hour afterwards. A statistically relevant difference (p<0.05) occurred in PaO2, SaO2 and Qs/Qt at the different time points.

Conclusion. Hypoxia during OLV, with an increase in Qs/Qt, usually occurs after 10 min. of its initiation. After 30 min, the val-ues of the Qs/Qt ratio regularly return to normal levels.


one-lung ventilation, thoracic surgery, venous admixture, intrapulmonary shunt

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1. Alexander Ng, Swanevelder J. Hypoxemia during one-lung anaesthesia. Continuing Education in Anaesthesia, Critical Care & Pain; Volume 10, Number 4, 2010.

2. Karzai W, Schwarzkopf K. Hypoxaemia during one lung ventilation. Anesthesiology 2009; 110: 1402–11.

3. Heimberg C et al. Thorac Cardiovasc Surg 2006; 54: 516—20.

4. Lumb AB, Slinger P. Hypoxic pulmonary vasoconstriction: physiology and anesthetic implications. Anesthesiology. 2015 Apr;122(4):932-46.

5. 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 Feb;19(1):34-43.

6. Naeije R, Brimioulle S. Review: Physiology in medicine: importance of hypoxic pulmonary vasoconstriction in maintaining arterial oxygenation during acute respiratory failure. Critical Care 2001, 5:67–71.

7. Naeije R, Brimioulle S, Gust R, Kozlowski JK, Julien V, Schuster DP. The importance of hypoxic pulmonary vasoconstriction in main-taining arterial oxygenation in acute lung injury. Eur Respir J 2000, 16:365S.

8. Conacher ID: 2000: Time to apply Occam’s razor to failure of hypoxic pulmonary vasoconstriction during one lung ventilation. Br J Anaesth 2000; 84:434–6.

9. Choi YS1, Bang SO, Shim JK, Chung KY, Kwak YL, Hong YW. Effects of headdown tilt on intrapulmonary shunt fraction and oxy-genation during one-lung ventilation in the lateral decubitus position. J Thorac Cardiovasc Surg. 2007 Sep;134(3):613-8.

10. Napoli, F.; Congedo, E.; Aceto, P.; Damato, I.; De Cosmo, G. One lung ventilation and intrapulmonary shunt: Volume versus pres-sure‐controlled ventilation: 5AP2‐8. European Journal of Anaesthesiology: May/June 2008 - Volume 25 - Issue - p 74.

11. Ferreira HC, Zin WA, Macedo Rocco PR. Review: Physiopathology and clinical management of one-lung ventilation. J Bras Pneumol 2004; 30(5) 566-73.

12. Kellow NH, Scott AD, White SA, Feneck RO. Comparison of the effects of propofol and isoflurane anaesthesia on right ventricular function and shunt fraction during thoracic surgery. Br J Anaesth 1995;75:578–582.J Cardiothorac Vasc Anesth 1996;10:860–863.

13. Aye T, Milne B. Ketamine anesthesia for pericardial window in a patient with pericardial tamponade and severe COPD: [La ketamine utilisee pour l’anesthesie d’une ponction pericardique chez une patiente qui presente une tamponnade et une MPOC severe].Can J Anesth, March 1, 2002; 49(3): 283 - 286.

14. Beck DH, Doepfmer UR, Sinemus C, Bloch A, Schenk MR, Kox WJ. Effects of sevoflurane and propofol on pulmonary shunt fraction during one-lung ventilation for thoracic surgery. Br. J. Anaesth., January 1, 2001; 86(1): 38 - 43.

15. Narayanaswamy M, McRae K, Slinger P et al. Choosing a lung isolation device for thoracic surgery: a randomized trial of three bron-chial blockers versus doublelumen tubes. Anesth Analg 2009; 108: 1097–101.

16. Knoll HK, Ziegeler S, Schreiber JU et al. Airway injuries after one-lung ventilation: a comparison between double-lumen tube and endobronchial blocker. Anesthesiology 2006; 105: 471–7.

17. Operator’s Manual, AVL COMPACT 3, Rev. 2.0, June 1998

18. Essentials of Oxygenation: Implication for clinical practice by Thomas Ahrens, Kim Rutherford Kimberly A. Rutherford Basham,

p. 27-30.

19. Michael Seear, Ignacio Malagon, Henry Hui, John Alexander, Christopher Daoust, Peter Skippen. Evaluation of a mathematical model to predict intrapulmonary shunt non-invasively. Can J Anesth 1999 / 46:5 / pp 483-487.

20. Benumof JL. One-lung ventilation and hypoxic pulmonary vasoconstriction: implications for anesthetic management. Anesth Analg 1985; 64: 821-3.

21. Hurford WE, Kolker AC, Strauss WH. The use of ventilation/perfusion scans to predict oxygenation during one-lung anesthesia. Anesthesiology 1987; 67: 841.

22. Slinger PD, Hickey DR. The interaction between applied PEEP and auto-PEEP during one-lung ventilation. J Cardiothorac Vasc Anesth 1998; 12: 133-136.

23. Katz JA, Laverne RG, Fairley HB, Thomas AN. Pulmonary oxygen exchange during endobronchial anesthesia: effect of tidal volume and PEEP. Anesthesiology 1982; 56: 164-171.

24. Van Keer L, van Aken H, Vandermeersch E, Vermaut G. Propofol does not inhibit HPV in humans. J Clin Anesth 1989; 1: 284-8.

25. Kellow N, Scott AD, White SA, Feneck RO. Comparison of the effects of propofol and isoflurane anesthesia on right ventricular func-tion and shunt fraction during thoracic surgery. Br J Anaesth 1995; 75: 578-82.

26. Steegers PA, Backs PJ. Propofol and alfentanil during one-lung ventilation. J Cardiothorac Anesth 1990; 4: 194-9.

27. Spies C, Zaune U, Pauli G, Martin E. Comparison of enflurane and propofol during thoracic surgery. Anaesthetist 1991; 40: 14-8.

28. Slinger P, Triolet W, Wilson J. Improving arterial oxygenation during one-lung ventilation. Anesthesiology 1988; 68: 291-295.

29. Guenoun T, Journois D, Silleran-Chassany J, Frappier J, D’attellis N, Salem A, Safran D: Prediction of arterial oxygenation during one-lung ventilation: Analysis of preoperative and intraoperative variables. J Cardiothorac Vasc Anesth 2004; 16:199–203.

30. 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 F(iO)2. Anesth Analg 2000; 90:35–41.

31. Pfitzner J, Pfitzner L: The theoretical basis for using apnoeic oxygenation via the nonventilated lung during one-lung ventilation to delay the onset of arterial hypoxaemia. Anaesth Intensive Care 2005; 33:794–800.

32. Ng A, Russell W. High frequency jet ventilation. CPD Anaesth 2004; 6:68–72.

33. Inoue S, Nishimine N, Kitaguchi K, Furuya H, Taniguchi S: Double lumen tube location predicts tube malposition and hypoxaemia during one lung ventilation. Br J Anaesth 2004; 92:195–201.

34. Tusman G, Bohm SH, Sipmann FS, Maisch S: Lung recruitment improves the efficiency of ventilation and gas exchange during one-lung ventilation anesthesia. Anesth Analg 2004; 98:1604–9.

35. Cinnella G, Grasso S, Natale C, Sollitto F, Cacciapaglia M, Angiolillo M, Pavone G, Mirabella L, Dambrosio M: Physiological effects of a lung-recruiting strategy applied during one-lung ventilation. Acta Anaesthesiol Scand 2008; 52:766–75.

36. Slinger P: Pro: Low tidal volume is indicated during one-lung ventilation. Anesth Analg 2006; 103:268–70.

37. Lohser J: One-lung ventilation calls for one-lung recruitment. Anesth Analg 2007; 104:220.

38. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory dis-tress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000; 342:1301–8.

39. Senturk NM, Dilek A, Camci E, Senturk E, Orhan M, Tugrul M, Pembeci K: Effects of positive end-expiratory pressure on ventilatory and oxygenation parameters during pressure-controlled one-lung ventilation. J Cardiothorac Vasc Anesth 2005; 19:71–5.

40. Leong LM, Chatterjee S, Gao F: The effect of positive end expiratory pressure on the respiratory profile during one-lung ventilation for thoracotomy. Anaesthesia 2007; 62:23–6.

41. Valenza F, Ronzoni G, Perrone L, Valsecchi M, Sibilla S, Nosotti M, Santambrogio L, Cesana BM, Gattinoni L: Positive end-expiratory pressure applied to the dependent lung during one-lung ventilation improves oxygenation and respiratory mechanics in patients with high FEV1. Eur J Anaesthesiol 2004; 21: 938–43.

42. Slinger PD, Kruger M, McRae K, Winton T: Relation of the static compliance curve and positive end-expiratory pressure to oxygena-tion during one-lung ventilation. Anesthesiology 2001; 95:1096–102.

43. Misthos P, Katsaragakis S, Milingos N, Kakaris S, Sepsas E, Athanassiadi K, Theodorou D, Skottis I: Postresectional pulmonary oxida-tive stress in lung cancer patients: The role of one-lung ventilation. Eur J Cardiothorac Surg 2005; 27:379– 82.

44. Pfitzner J, Pfitzner L: The theoretical basis for using apnoeic oxygenation via the nonventilated lung during one-lung ventilation to delay the onset of arterial hypoxaemia. Anaesth Intensive Care 2005; 33:794–800.

45. Baraka A, Lteif A, Nawfal M, Taha S, Maroun M, Khoury S, Jalbout M: Ambient pressure oxygenation via the nonventilated lung during video-assisted thoracoscopy. Anaesthesia 2000; 55:602–3.

46. Rocca GD, Passariello M, Coccia C, Costa MG, Di Marco P, Venuta F, Rendina EA, Pietropaoli P: Inhaled nitric oxide administration during one-lung ventilation in patients undergoing thoracic surgery. J Cardiothorac Vasc Anesth 2001; 15:218–23.

47. Moutafis M, Dalibon N, Liu N, Kuhlman G, Fischler M: The effects of intravenous almitrine on oxygenation and hemodynamics during one-lung ventilation. Anesth Analg 2002; 94:830–4.

48. Silva-Costa-Gomes T, Gallart L, Valles J, Trillo L, Minguella J, Puig MM: Low versus high-dose almitrine combined with nitric oxide to prevent hypoxia during open-chest one-lung ventilation. Br J Anaesth 2005; 95:410–6.

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