When one-lung ventilation goes wrong
Aug 13, 2026
Every one-lung ventilation (OLV) procedure relies on the same core objective: isolating the non-ventilated lung to grant clear surgical access while maintaining safety and adequate gas exchange in the dependent lung. While double-lumen tubes (DLTs) and bronchial blockers (BBs) both deliver single-lung ventilation, the physiological disruption created by a right-to-left transpulmonary shunt means things can quickly go off course. Understanding how to spot early warning signs and systematically troubleshoot allows perianaesthesia nurses to anticipate patient risk and protect the airway.
Lung isolation relies on two distinct approaches. DLTs provide an anatomic seal, making them the ideal choice when absolute lung protection is mandatory—such as in massive hemoptysis, lung abscesses, or high-priority resections like pneumonectomies. Bronchial blockers, inserted through a standard single-lumen tube, provide a functional seal, offering a safer alternative in difficult upper airways, tracheostomies, or when selective lobar blockade is required. While both devices achieve lung isolation, their potential for intraoperative complications differs significantly.
For perianaesthesia nurses, these device- and position-dependent risks shape clinical priorities and immediate crisis response:
Anatomic vs. Functional Sealing: DLTs offer faster insertion and stable, rapid lung collapse but carry higher risks of tracheobronchial injury and sore throat. BBs reduce direct upper airway trauma but present higher rates of intraoperative displacement and slower collapse.
Fiberoptic Verification is Mandatory: Blind insertion yields high rates of malposition. Fiberoptic bronchoscopy (FOB) verification is essential after intubation, following patient positioning into lateral decubitus, and whenever unexpected airway pressure spikes or desaturations occur.
Predicting Hypoxemia Risk: Right-sided surgical procedures (ventilating the smaller left lung) and supine patient positioning increase transpulmonary shunting and elevate the risk of desaturation compared to left-sided cases in lateral decubitus.
Systematic Crisis Protocol: When desaturation (SpO2 < 90%) strikes, the anaesthetists immediate action will likely be to increase FiO2 to 100% and notify the surgeon. They will use FOB to clear secretions or check for tube displacement, apply a gentle recruitment maneuver, and may consider low-level CPAP to the operated lung.
While the choice of device depends on patient anatomy and surgical priority, the core recovery goals remain constant. Protecting the ventilated lung with protective volumes and low PEEP, clearing bronchial secretions, and verifying airway device placement ensure optimal patient safety.
Recognising the early warning signs of OLV failure empowers perianaesthesia nurses to troubleshoot confidently, communicate effectively with the surgical team, and deliver targeted, high-quality care throughout the perioperative journey.
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References
- Cano, P. A., Mora, L. C., Enríquez, I., Reis, M. S., Martínez, E., & Barturen, F. (2023). One-lung ventilation with a bronchial blocker in thoracic patients. BMC Anesthesiology, 23(1), 398.
- Granell, M., Vanpeteghem, C., Mourisse, J., Sentürk, M., Szegedi, L., El Tahan, M., Mukherjee, C., Kawagoe, I., Karzai, W., Hofmeyr, R., Lenartova, K., Martinez Alberici, M., & Marczin, N. (2026). Airway Management in Thoracic Anesthesia: EACTAIC Consensus Document. Journal of Cardiothoracic and Vascular Anesthesia, 40(5), 1276-1287.
- Karzai, W., & Schwarzkopf, K. (2009). Hypoxemia during one-lung ventilation: prediction, prevention, and treatment. Anesthesiology, 110(6), 1402-1411.
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