Nuances of perioperative lung isolation and airway management

Effective lung isolation is fundamental to safe anatomical lung resection. This review examines practical techniques for achieving lung separation with double-lumen tubes (DLTs) and bronchial blockers (BBs), weighing the risks and benefits of each approach, and synthesizes the physiological principles and intraoperative considerations that govern one-lung ventilation (OLV). DLTs offer rapid and reliable lung separation, available suctioning and suction-guided lung collapse, and straightforward conversion between one- and two-lung ventilation, making them well suited to many adult thoracic procedures; however, their larger external diameter and stiffness increase the risk of trauma. BBs permit lung isolation through a single-lumen endotracheal tube, have a smaller airway footprint, facilitate pediatric lung isolation in smaller patients, and allow for postoperative ventilation without tube exchange, but they may provide slower or less complete lung collapse. Device choice should be individualized based on patient anatomy, surgical requirements, airway difficulty, and operator experience. Physiologically, OLV converts a portion of the pulmonary circulation into a shunt and can increase pulmonary vascular resistance; these effects make lung-protective ventilation strategies prudent with low tidal volumes, cautious positive end expiratory pressure (PEEP) to the dependent lung, and limited driving pressures. Intraoperative management prioritizes early confirmation of device position with bronchoscopy, proactive strategies for anticipated hypoxemia, close communication between surgical and anesthesia teams, and readiness to troubleshoot ventilation strategies. Meticulous technique, vigilant monitoring, and collaborative operative planning are essential to minimize complications and optimize both hemodynamic stability and surgical exposure.