KEY POINTS

1. Preoperative evaluation. The anesthesiologist should understand the growth of lung cancer in terms of local mass, nodal and distant metastatic effects, and cardiopulmonary physiologic effects.
2. Preoperative preparation. Patients with lung cancer benefit from a preoperative preparation program consisting of discontinuing smoking, dilating the airways, loosening the secretions, removing the secretions, and being motivated to face postoperative rehabilitation procedures.
3. Monitoring. Anesthesiologists must carefully consider the need for direct continuous intra-arterial and central venous access in relation to the operation being performed and the preexisting cardiopulmonary pathophysiology of the patient.
4. Choice of anesthesia. One MAC halogenated drug anesthesia has only a slight negative effect on arterial oxygenation during one-lung ventilation.
5. Physiology of spontaneous ventilation with an open chest. Spontaneous diaphragm descent on the side of an open chest pulls environmental air and the mediastinum into the open hemothorax (mediastinal shift) and causes the lung on that side to collapse during inspiration (paradoxical respiration).
6. Physiology of the lateral decubitus position and the open chest during two-lung ventilation. During two-lung ventilation in an anesthetized paralyzed patient in the lateral decubitus position with an open chest, the nondependent lung has greater ventilation but less perfusion than the dependent lung does.
7. One-lung anesthesia/ventilation. When considering specific anesthetic management choices, it is important to keep in mind that the indications for one-lung ventilation can be absolute (infection, hemorrhage, loss of positive-pressure ventilation seal, lung lavage) or relative (facilitate the performance of surgery).
8. Techniques of lung separation. The techniques of lung separation consist of double-lumen tubes, bronchial blockers, and endobronchial single-lumen tubes. All types should have position confirmed with a fiberoptic bronchoscope.
9. Double-lumen tubes. Left-sided tubes can be used for both right- and left-sided procedures.
10. Bronchial blocker. Independent bronchial blockers can be used in patients with difficult airways, in patients with respiratory failure who are already intubated, after trauma, and in those with tracheotomies.

---

1927

11. Physiology of one-lung ventilation. The primary determinants of pulmonary blood flow during one-lung ventilation are hypoxic pulmonary vasoconstriction in the nonventilated lung and gravitational effects on blood flow to both lungs.
12. Management of one-lung ventilation. Initial ventilation to just one lung should use an FIO₂ of 1.0, a tidal volume of approximately 8 to 10 mL/kg, and a respiratory rate to achieve an end-tidal CO₂ pressure of approximately 40 mm Hg.
13. Differential lung management of one-lung ventilation. Differential lung management of one-lung ventilation includes oxygen insufflation in the nondependent nonventilated lung, CPAP, intermittent positive-pressure ventilation, and dependent lung PEEP.
14. High-frequency ventilation. Management of thoracic surgery with high-frequency ventilation is not recommended for any procedure and is used in only a few specialized centers with specific interest.
15. Early serious complications of thoracic surgery. The early serious complications specifically related to thoracic surgery consist of herniation of the heart, pulmonary torsion, hemorrhage, bronchial disruption, respiratory failure, right heart failure, right-to-left shunting across a patent foramen ovale, and injury to the intrathoracic nerves.
16. Postoperative ventilation. Management of postoperative ventilation after thoracic surgery is similar to that for other types of surgery.
17. Postoperative pain. Management of postoperative pain after thoracotomy is most commonly accomplished with thoracic epidural analgesia; other modalities consist of patient-controlled analgesia, intrapleural analgesia, and cryoanalgesia.
18. Mediastinoscopy. During mediastinoscopy, the anesthesiologist's attention is primarily directed at detecting the complications of mediastinoscopy, namely, hemorrhage, pneumothorax, nerve injury, and compression of the innominate artery.
19. Thoracoscopy. Thoracoscopy under general anesthesia must be performed with one-lung ventilation.
20. Tracheal resection. The level of tracheal resection determines the precise sequence of techniques used to ventilate the lungs.
21. Removal of giant bullous emphysema and air cysts, lung volume reduction surgery, and unilateral bronchopulmonary lavage. The cornerstone of anesthetic management of these conditions is insertion and proper position and function of a double-lumen tube.
22. Mediastinal masses. Anesthesia for patients with mediastinal masses, if possible, should use local anesthesia and, if general anesthesia is necessary, should attempt to first decrease the size of tumor with radiation and chemotherapy, consider awake intubation, and maintain spontaneous ventilation.
23. Massive hemoptysis, bronchopleural fistula, lung abscesses. Anesthesia for massive hemoptysis, bronchopleural fistula, and lung abscesses is an absolute indication for one-lung ventilation.