Compliance and capnography monitoring during independent lung ventilation: report of two cases

Independent lung ventilation: Implementation strategies and review of literature

Independent lung ventilation, though infrequently used in the critical care setting, has been reported as a rescue strategy for patients in respiratory failure resulting from severe unilateral lung pathology. This involves isolating and ventilating the right and left lung differently, using separate ventilators. Here, we describe our experience with independent lung ventilation in a patient with unilateral diffuse alveolar hemorrhage, who presented with severe hypoxemic respiratory failure despite maximal ventilatory support. Conventional ventilation in this scenario leads to preferential distribution of tidal volume to the non-diseased lung causing over distension and inadvertent volume trauma. Since each lung has a different compliance and respiratory mechanics, instituting separate ventilation strategies to each lung could potentially minimize lung injury. Based on review of literature, we provide a detailed description of indications and procedures for establishing independent lung ventilation, and also provide an algorithm for management and weaning a patient from independent lung ventilation.

Anesthetic Considerations for Thoracic Trauma

The thoracic cavity encompasses three vital organ systems: the lungs with the major airways, the heart with the major blood vessels, and the spinal cord. Therefore, traumatic injury to the thoracic cavity presents a unique clinical challenge to the anesthesiologist. Itstems from the gravity of the patients' situation, the need to rapidly diagnose and treat cardiopulmonary injuries, and to coordinatethese steps with a multidisciplinary trauma team. It is importanttobe well prepared and to review the fundamentals of securing an airway in many different traumatic scenarios. Good communication between team members is the key to a positive outcome. The anesthesiologist, therefore, may play a key role in airway management, diagnosis, respiratory management, and pain management throughout the perioperative continuum of the thoracic trauma patients' care.

Mechanical ventilation strategies in massive chest trauma

Patients in extremis because of trauma-related massive chest injury require expedient evaluation and prompt intervention. The initial pathophysiology relates to the significant intrapulmonary shunting caused by disruption of pulmonary capillaries and extravasation into the alveolar spaces. Disproportionate or unilateral lung involvement needs measures more technical than general supportive care. Independent lung ventilation (mostly with unilateral lung involvement) and other strategies like inhaled nitric oxide, prone positioning, partial liquid ventilation, and extracorporeal membrane oxygenation (ECMO) have had good results. Intensivists confronted with this clinical subset may consider using these strategies as alternative/adjunctive options for optimizing respiratory and hemodynamic status in the supportive management of trauma-related acute lung injury (ALI) and adult respiratory distress syndrome (ARDS).

Advances and New Insights in Monitoring

It cannot be overemphasized that a piece of electrical equipment is not capable of replacing a vigilant, well-trained clinician. As monitoring devices become more sophisticated, the potential for artifact or misinterpretation increases. When applied appropriately, operated properly, and interpreted correctly, however, the monitors afford the patient the best possible outcome.