Rescue of Refractory Hypoxemia in One-Lung Ventilation Using CPAP via Bronchial Blocker

Overview

This case study describes a novel approach to managing severe hypoxemia during one-lung ventilation (OLV) in a patient with prior contralateral lobectomy. The combined use of a left-sided double-lumen tube (DLT) and a bronchial blocker allowed selective application of continuous positive airway pressure (CPAP) to non-operated lobes, successfully restoring oxygenation without compromising surgical exposure.

Background

One-lung ventilation is essential during thoracic surgery but can lead to hypoxemia, especially in patients with previous contralateral lung resections. Hypoxemia occurs in approximately 4%–6% of OLV cases and poses significant clinical challenges. Selective lobar collapse using bronchial blockers can help maintain oxygenation while preserving surgical access. Combining a double-lumen tube with a bronchial blocker to deliver CPAP selectively is an emerging strategy to address refractory hypoxemia during complex thoracic procedures.

Data Highlights

During OLV, the patient’s oxygen saturation (SpO₂) dropped from 99% to 83% despite maximal ventilatory adjustments including FiO₂ 100%, PEEP increased to 9 cmH₂O, and recruitment maneuvers. Application of CPAP at 5 cmH₂O to the entire operative lung impaired surgical visibility. Placement of a 7-Fr bronchial blocker into the right bronchus intermedius allowed selective CPAP delivery to the right middle and lower lobes, restoring oxygenation without interfering with the surgical field.

Key Findings

• Severe hypoxemia developed during OLV in a patient with prior contralateral lobectomy despite maximal ventilatory support.
• Conventional CPAP applied to the entire operative lung impaired surgical exposure.
• A bronchial blocker placed in the bronchus intermedius enabled selective CPAP to non-operated lobes while maintaining collapse of the operated lobe.
• This selective CPAP approach successfully restored oxygenation without compromising the surgical field.
• The combined use of a left-sided DLT and bronchial blocker is a feasible and safe rescue technique for refractory hypoxemia during complex thoracic surgery.

Clinical Implications

In patients undergoing OLV with prior contralateral lung resections, refractory hypoxemia may be managed by selective lobar CPAP using a bronchial blocker in combination with a double-lumen tube. This technique can improve oxygenation while preserving surgical exposure, offering a valuable rescue strategy when conventional methods fail. Clinicians should consider this approach in complex thoracic cases to optimize intraoperative oxygenation.

Conclusion

The combined use of a double-lumen tube and bronchial blocker to deliver selective CPAP is an effective and safe rescue strategy for refractory hypoxemia during one-lung ventilation in patients with prior contralateral lobectomy. This method preserves surgical access and improves oxygenation, expanding options for managing challenging thoracic surgical cases.

References

1. Lung Cancer Statistics and Advances (2020) -- Global Lung Cancer Mortality and Screening
2. Hypoxemia During One-Lung Ventilation (5) -- Incidence and Management
3. Selective Lobar Collapse and Bronchial Blockers (6-9) -- Techniques in Thoracic Anesthesia