Lung isolation techniques for patients with difficult airway

One-lung ventilation in the thoracic surgical patient can be achieved with the use of a double-lumen endotracheal tube or an independent bronchial blocker. A number of patients requiring lung isolation have a potentially difficult airway because of previous radiation to the neck or previous surgery to the tongue and larynx. This review will focus on the management of patients who have a difficult airway and require lung isolation.

Identification of the potentially difficult airway during the preoperative evaluation allows the preplanning and selection of the appropriate lung isolation device. Common devices used to achieve one-lung ventilation in patients with difficult airways include independent bronchial blockers (Arndt, Cohen, and Fuji Uniblocker).

In patients who require one-lung ventilation and who present with a difficult airway, the safest way to establish an airway is by placing a single-lumen endotracheal tube orally or nasotracheally while the patient is awake with the aid of a flexible fiberoptic bronchoscope. Lung isolation in these patients then is achieved by using an independent bronchial blocker; an alternative technique is to use a double-lumen endotracheal tube while using an airway catheter exchange technique. For the patient with a tracheostomy in place, an independent bronchial blocker is recommended.