Management of a difficult Airway in Lung Isolation

A variety of thoracic surgical procedures, such as lobectomy, pneumonectomy, esophago-gastrectomy, pleural decortication, bullectomy and bronchopulmonary lavage are commonly performed. Customarily they are classified either as absolute or as relative. THE ABSOLUTE INDICATIONS include life-threatening complications, such as massive bleeding, sepsis and pus, where the non diseased contra lateral lung, must be protected from contamination. Broncho-pleural and broncho-cutaneous fistulae are absolute indications since they offer a low resistance pathway for the delivered tidal volume during positive pressure ventilation. Giant unilateral bullae may rupture under positive pressure and ventilatory exclusion is mandatory. Finally, during bronchopulmonary lavage for alveolar proteinosis or cystic fibrosis, prevention of the contra lateral lung from drowning is necessary. Video assisted thoracoscopy (VAT) brought to the practice of surgery for diagnostic and therapeutic procedures required a well collapse lung and should be included in the absolute indication for OLV category. RELATIVE INDICATIONS which includes lobectomies (particularly right upper), pneumonectomy, and thoracic aortic aneurysm repair, are primarily for surgical exposure. Lower or middle lobectomy and esophageal resection are of lower priority. In practice, the majority of the procedures where DLT is used, are in essence relative indication, and only a small fraction are absolute. The use of OLV for relative indications rely on the surgeon-anesthesiologist practice and preference.