Zusammenfassung
Die zunehmend differenzierten und aufwendigen Operationsverfahren für intrathorakale chirurgische Eingriffe erfordern die sichere Seitentrennung der Atemwege und die Möglichkeit der Ein-Lungen-Ventilation. Da jeder Anästhesist im Rahmen der Versorgung von Traumapatienten oder bei akuten pulmonalen Notfällen mit der Notwendigkeit einer Seitentrennung der Atemwege konfrontiert werden kann, werden in dieser Übersichtsarbeit die derzeit gängigen Verfahren zur Lungentrennung und ihre Anwendung vorgestellt. Auf die besonderen Aspekte der Atemwegssicherung bei schwierigen Atemwegen und der Notwendigkeit der Seitentrennung der Atemwege wird eingegangen. Die resultierenden pathophysiologischen Effekte einer Ein-Lungen-Ventilation werden diskutiert und Strategien zur Aufrechterhaltung einer adäquaten Oxygenierung und Vermeidung einer Hypoxie aufgezeigt.
Abstract
The progress in sophisticated and complex operating methods for intrathoracic procedures demands reliable lung separation with the possibility of one-lung ventilation. Patients with thoracic traumas and pulmonary emergencies can confront any anaesthesiologist with the need for lung separating procedures. This review describes the contemporary procedures for lung separation. The special aspects of difficult airway management during one-lung ventilation and the indications for one-lung ventilation are described in detail. The pathophysiological changes during one-lung ventilation and strategies to avoid hypoxemia and to preserve adequate oxygenation are discussed.
Literatur
Abe K, Shimizu T, Takashina M, Shiozaki H, Yoshiya I (1998) The effects of propofol, isoflurane and sevoflurane on oxygenation and shunt fraction during one-lung ventilation. Anesth Analg 87: 1164–1169
Archer S, Michelakis E (2002) The mechanism(s) of hypoxic pulmonary vasoconstriction: potassium channels, redox O2 sensors, and controversies. News Physiol Sci 17: 131–137
Arndt GA, Buchika S, Kranner PW, DeLessio ST (1999) Wire-guided endobronchialblockade in a patient with a limited mouth opening. Can J Anesth 46: 87–89
Arndt GA, DeLessio ST, Kranner PW, Orzepowski W, Ceranski B, Valtysson B (1999) One-lung ventilation when intubation is difficult — presentation of a new endobronchial blocker. Acta Anaesthesiol Scand 43: 356–358
Arndt GA, Kranner PW, Rusy DA, Love R (1999) Single-lung ventilation in a critically ill patient using a fiberoptically directed wire-guided endobronchial blocker. Anesthesiology 90: 1484–1486
Arndt GA, Kranner PW, Valdes-Mura H (2001) Reversal of hypoxemia using insufflation of oxygen during one-lung ventilation with a wire-guided endobronchial blocker. J Cardiothorac Vasc Anesth 15: 144
Bahk JH, Oh YS (1998) A new and simple maneuver to position the left-sided double-lumen tube without the aid of fiberoptic bronchoscopy. Anesth Analg 86(6): 1271–1275
Bahk JH, Lim YJ, Kim CS (2000) Positioning of a double-lumen endobronchial tube without the aid of any instruments: an implication for emergency management. J Trauma 49: 899–902
Bardoczky GI, Yernault JC, Engelman EE, Velghe CE, Cappello M, D’Hollander AA (1996) Intrinsic positive end-expiratory pressure during one-lung ventilation for thoracic surgery — the influence of preoperative pulmonary function. Chest 110: 180–184
Beck DH, Doepfmer UR, Sinemus C, Bloch A, Schenk MR, Kox WJ (2001) Effects of sevoflurane and propofol on pulmonary shunt fraction during one-lung ventilation for thoracic surgery. Br J Anaesth 86: 38–43
Benumof JL (1982) One-lung ventilation: which lung should be peeped? Anesthesiology 56: 161–163
Benumof JL (1985) One-lung ventilation and hypoxic pulmonary vasoconstriction: implications for anesthetic management. Anesth Analg 64: 821–833
Benumof JL (1986) Fiberoptic bronchoscopy and double-lumen tube position. Anesthesiology 65: 117–118
Benumof JL (1986) Isoflurane anesthesia and arterial oxygenation during one-lung ventilation. Anesthesiology 64: 419–422
Benumof JL, Partridge BL, Salvatierra C, Keating J (1987) Margin of safety in positioning modern double-lumen endotracheal tubes. Anesthesiology 67: 729–738
Benumof JL, Augustine SD, Gibbons JD (1987) Halothane and isoflurane only slightly impair arterial oxygenation during one-lung ventilation in patients undergoing thoracotomy. Anesthesiology 67: 910–915
Benumof JL (1996) Laryngeal mask airway and the ASA difficult airway algorithm. Anesthesiology 84(3): 686–699
Brodsky JB, Benumof JL, Ehrenwerth J, Ozaki GT (1991) Depth of placement of left double-lumen endobronchial tubes. Anesth Analg 73: 570–572
Brodsky JB, Macario A, Mark JBD (1996) Tracheal diameter predicts double-lumen tube size: a method for selecting left double-lumen tubes. Anesth Analg 82(4): 861–864
Brodsky JB, Fitzmaurice B (2001) Modern anesthetic techniques for thoracic operations. World J Surg 25: 162–166
Brodsky JB, Lemmens HJM (2003) Left double-lumen tubes: clinical experience with 1,170 patients. J Cardiothorac Vasc Anesth 17: 289–298
Brodsky JB (2004) Fiberoptic bronchoscopy need not to be a routine part of double-lumen placement. Curr Opin Anaesthesiol 17: 7–11
Bund M, Henzler D, Walz R, Piepenbrock S, Kuhlen R (2004) Inhalatives und intravenöses Prostazyklin während der Ein-Lungen-Ventilation. Anaesthesist 53: 612–620
Campos JH, Massa FC, Kernstine KH (2000) The incidence of right upper-lobe collapse when comparing a right sided double-lumen tube versus a modified left double-lumen tube for left-sided thoracic surgery. Anesth Analg 90: 535–540
Campos JH, Gomez N (2002) Pro: Right-sided double-lumen endotracheal tubes should be routinely used in thoracic surgery. J Cardiothorac Vasc Anesth 16: 246–248
Campos JH (2002) Current techniques for perioperative lung isolation in adults. Anesthesiology 97: 1295–1301
Campos JH (2003) An update on bronchial blockers during lung separation techniques in adults. Anesth Analg 97: 1266–1274
Chen TL, Ueng TH, Huang CH, Chen CL, Huang FY, Lin CJ (1996) Improvement of arterial oxygenation by selective infusion of prostaglandin E1 to ventilated lung during one-lung ventilation. Acta Anaesthesiol Scand 40: 7–13
Chow MYH, Goh MH, Boey SK, Thirugnaman A, Ip-Yam PC (2003) The effects of remifentanil and thoracic epidural on oxygenation and pulmonary shunt fraction during one-lung ventilation. J Cardiothorac Vasc Anesth 17: 69–72
Cohen E, Eisenkraft JB (1996) Positive end-expiratory pressure during one-lung ventilation improves oxygenation in patients with low arterial oxygen tensions. J Cardiothorac Vasc Anesth 10: 578–582
Cohen E (2002) Methods of lung separation. Anesthesiology 15: 69–78
Cohen E (2002) Con: Right sided double-lumen endotracheal tubes should not be routinely used in thoracic surgery. J Cardiothorac Vasc Anesth 16: 249–252
Cohen E (2004) Double-lumen tube position should be confirmed by fiberoptic bronchoscopy. Curr Opin Anaesthesiol 17: 1–6
Cohen E (2004) Methods of lung separation. Minerva Anesthesiol 70: 313–318
Conacher ID (2000) 2000 — Time to apply Occam’s razor to failure of hypoxic pulmonary vasoconstriction during one lung ventilation. Br J Anaesth 84: 434–436
Dalibon N, Moutafis M, Liu N, Law-Koune JD, Monsel S, Fischler M (2004) Treatment of hypoxemia during one-lung ventilation using intravenous almitrine. Anesth Analg 98: 590–594
Domino KB, Wetstein L, Glassner SA, Lindgren L, Marshall C, Harken A, Marshall BE (1983) Influence of mixed venous oxygen tension (pvO2) on blood flow to atelectatic lung. Anesthesiology 59: 428–434
Domino KB, Borowec L, Alexander CM, Williams JJ, Chen L, Marshall C, Marshall BE (1986) Influence of isoflurane on hypoxic pulmonary vasoconstriction in dogs. Anesthesiology 64: 423–429
Eisenkraft JB (1990) Effects of anaesthetics on the pulmonary circulation. Br J Anaesth 65: 63–78
Garutti I, Quintana B, Olmedilla L, Cruz A, Barranco M, DeLucas EG (1999) Arterial oxygenation during one-lung ventilation: combined versus general anesthesia. Anesth Analg. 88: 494–499
Grichnik KP (2004) Advances in the management of one-lung ventilation. In: Slinger PD (ed) Progress in thoracic anesthesia. Lippincott Williams & Wilkins, Baltimore, pp 47–79
Grocott HP, Darrow TR, Whiteheart DL, Glower DD, Stafford Smith M (2003) Lung isolation during port-access cardiac surgery: Double-lumen endotracheal tube versus single-lumen endotracheal tube with a bronchial blocker. J Cardiothorac Vasc Anesth 17: 725–727
Groh J, Kuhnle GEH, Ney L, Sckell A, Goetz AE (1995) Effects of isoflurane on regional pulmonary blood flow during one-lung ventilation. Br J Anaesth 74: 209–216
Hambraeus-Jonzon K, Bindslev L, Mellgard AJ, Hedenstierna G (1997) Hypoxic pulmonary vasoconstriction in human lungs: A stimulus response study. Anesthesiology 86: 308–315
Hedenstierna G, Reber A (1996) Manipulating pulmonary blood flow during one-lung anesthesia. Acta Anaesthesiol Scand 40: 2–4
Henderson JJ, Popat MT, Latto IP, Pearce AC (2004) Difficult airway society guidelines for management of the unanticipated difficult intubation. Anesthesia 59: 675–694
Ishibe Y, Shiokawa Y, Umeda T, Uno H, Nakamura M, Izumi T (1996) The effect of thoracic epidural anesthesia on hypoxic pulmonary vasoconstriction in dogs: an analysis of the pressure-flow curve. Anesth Analg 82: 1049–1055
Ishikawa S, Nakazama K, Makita K (2003) Progressive changes in arterial oxygenation during one-lung anaesthesia are related to the response to compression of the non-dependent lung. Br J Anaesth 90(1): 21–26
Jaggar S, Mofeez A, Haxby E (2002) Double-lumen tube audit. J Cardiothorac Vasc Anesth 16: 790–791
Kabon B, Waltl B, Leitgeb J, Kapral S, Zimpfer M (2001) First experience with a fiberoptical directed wire-guided endobronchial blockade in severe pulmonary bleeding in an emergency setting. Chest 120: 1399–1402
Karzai W, Haberstroh J, Priebe HJ (1998) Effects of desflurane and propofol on arterial oxygenation during one-lung ventilation in the pig. Acta Anaesthesiol Scand 42: 648–652
Katz JA, Laverne RG, Fairley HB, Thomas AN (1982) Pulmonary oxygen exchange during endobronchial anesthesia: effects of tidal volume and peep. Anesthesiology 56: 164–171
Kellow NH, Scott AD, White SA, Feneck RO (1995) Comparison of the effect of propofol and isoflurane anaesthesia on right ventricular function and shunt fraction during thoracic surgery. Br J Anaesth 75: 578–582
Klein U, Karzai W, Bloos F, Wohlfarth M, Gottschall R, Fritz H, Seifert A (1998) Role of fiberoptic bronchoscopy in conjunction with the use of double-lumen tubes for thoracic anesthesia: a prospective study. Anesthesiology 88: 346–350
Kuhlman G, Legros C, Laloe PA, Puyo P, Fischler M (2003) The wire-guided, endobronchial-blocker as a solution to provide one-lung ventilation when a double-lumen endotracheal tube is malpositioned. J Cardiothorac Vasc Anesth 17: 636–637
Lewis JW, Serwin JP, Gabriel FS, Bastanfar M, Jacobson G (1992) The utility of a double-lumen tube for one-lung ventilation in avariety of noncardiac thoracic surgical procedures. J Cardiothorac Vasc Anesth 6: 705–710
Magnusson L, Spahn DR (2003) New concepts of atelectasis during general anesthesia. Br J Anaesth 91(1): 61–72
Malmkvist G, Fletcher R, Nordström L, Werner O (1989) Effects of lung surgery and one-lung ventilation on pulmonary arterial pressure, venous admixture and immediate postoperative lung function. Br J Anaesth 63: 696–701
Max M, Dembinski R (2000) Pulmonaler Gasaustausch in Narkose. Anaesthesist 49: 771–783
Miller FL, Chen L, Malmkvist G, Marshall C, Marshall BE (1989) Mechanical factors do not influence blood flow distribution in atelectasis. Anesthesiology 70: 481–488
Naeije R, Brimioulle S (2001) Physiology in medicine: importance of hypoxic pulmonary vasoconstriction in maintaining arterial oxygenation during acute respiratory failure. Critical Care 5: 67–71
Reid CW, Slinger P, Lennis S (1996) A comparison of the effects of propofol-alfentanil versus isoflurane anesthesia on arterial oxygenation during one-lung ventilation. J Cardiothorac Vasc Anesth 10: 860–863
Rogers SN, Benumof JL (1985) Halothane and isoflurane do not decrease paO2 during one-lung ventilation in intravenously anesthetized patients. Anesth Analg 64: 946–954
Russel WJ, James MF (2000) The effects on increasing cardiac output with adrenaline or isoprenaline on arterial haemoglobin oxygen saturation and shunt during one-lung ventilation. Anaesth Intensive Care 28: 636–641
Russel WJ, James MF (2004) The effects on arterial haemoglobin oxygen saturation and on shunt of increasing cardiac output with dopamine or dobutamine during one-lung ventilation. Anaesth Intensive Care 32: 644–648
Schwarzkopf K, Klein U, Schreiber T et al. (2001) Oxygenation during one-lung ventilation: the effects of inhaled nitric oxide and increasing levels of inspired fraction of oxygen. Anesth Analg 92: 842–847
Schwarzkopf K, Schreiber T, Preussler NP et al. (2003) Lung perfusion: fraction, and oxygenation during one-lung ventilation in pigs: the effects of desflurane, isoflurane, and propofol. J Cardiothorac Vasc Anesth 17: 73–75
Seymour AH (2003) The relationship between the diameters for the adult cricoid ring and main tracheobronchial tree: a cadaver study to investigate the basis for double-lumen tube selection. J Cardiothorac Vasc Anesth 17: 299–301
Slinger P, Scott WAC (1995) Arterial oxygenation during one-lung ventilation — a comparison of enflurane and isoflurane. Anesthesiology 82: 940–946
Slinger PD, Hickey DR (1998) The interaction between applied peep and auto-peep during one-lung ventilation. J Cardiothorac Vasc Anesth 12: 133–136
Slinger PD, Kruger M, McRae K, Winton T (2001) Relation of the static compliance curve and positive end-expiratory pressure to oxygenation during one-lung ventilation. Anesthesiology 95: 1096–1102
Takita K, Morimoto Y, Kemmotsu O (2003) The height-based formula for prediction of left sided double-lumen tracheal tube depth. J Cardiothorac Vasc Anesth 17: 412–415
Tschernko EM (2004) Anesthesiological considerations for lung volume reduction surgery. In: Progress in Thoracic Anesthesia. Slinger PD (ed) pp 145–162. Lippincott Williams & Wilkins, Baltimore
Visser WA, Liem T, Gielen M (1999) Arterial oxygenation during one-lung ventilation: combined versus general anesthesia — letter to the editor. Anesth Analg. 89: 1332
Von Dossow V, Welte M, Zaune U et al. (2001) Thoracic epidural anesthesia combined with general anesthesia: the preferred anesthetic technique for thoracic surgery. Anesth Analg 92: 848–854
Wang JYY, Russel GN, Page RD, Jackson M, Pennefather SH (1998) Comparison of the effects of sevoflurane and isoflurane on arterial oxygenation during one lung ventilation. Br J Anaesth 81: 850–853
Wang JYY, Russel GN, Page RD, Oo A, Pennefather SH (2000) A comparison of the effects of desflurane and isoflurane on arterial oxygenation during one-lung ventilation. Anaesthesia 55: 167–172
Watanabe S, Noguchi E, Yamada S, Hamada N, Kano T (2000) Sequential changes of arterial oxygen tension in the supine position during one-lung ventilation. Anesth Analg 90: 28–36
Weiskopf RB, Campos JH (2002) Current techniques for perioperative lung isolation in adults. Anesthesiology 97: 1295–1301
Weissmann N, Grimminger F, Olschewski A, Seeger W (2001) Hypoxic pulmonary vasoconstriction: a multifactorial response? Am J Physiol Lung Cell Mol Physiol 281: 314–317
Wiedemann K, Männle C, Layer M, Herth F (2004) Anästhesie in der Thoraxchirurgie. Anästhesiol Intensivmed Notfallmed Schmerzther 39: 616–650
Yokota K, Toriumi T, Sari A, Endou S, Mihira M (1996) Auto-positive end-expiratory pressure during one-lung ventilation using a double-lumen endobronchial tube. Anesth Analg 82: 1007–1010
Yüceyar L, Kaynak K, Cantütk E, Aykac B (2003) Bronchial rupture with a left-sided polyvinylchloride double-lumen tube. Acta Anaesthesiol Scand 47: 622–625
Zollinger A (1999) Anästhesie in der Thoraxchirurgie. Anaesthesist 48: 193–204
Interessenkonflikt:
Der korrespondierende Autor versichert, dass keine Verbindungen mit einer Firma, deren Produkt in dem Artikel genannt ist, oder einer Firma, die ein Konkurrenzprodukt vertreibt, bestehen.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Motsch, J., Wiedemann, K. & Roggenbach, J. Atemwegsmanagement bei der Ein-Lungen-Ventilation. Anaesthesist 54, 601–624 (2005). https://doi.org/10.1007/s00101-005-0866-6
Issue Date:
DOI: https://doi.org/10.1007/s00101-005-0866-6
Schlüsselwörter
- Thoraxanästhesie
- Seitentrennung der Atemwege
- Ein-Lungen-Ventilation
- Pathophysiologie der Ein-Lungen-Ventilation
- Hypoxische pulmonale Vasokonstriktion (HPV)