[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Anaesthesia and ICU](https://durgical.com/en/anaesthesia/) › [By patient and by surgery](https://durgical.com/en/anaesthesia/areas/by-patient/) › Thoracic surgery and one-lung ventilation

# Thoracic surgery and one-lung ventilation

- Patient and surgery

In chest surgery one lung is often deflated so the surgeon can work; the other lung must carry all the breathing safely.

Updated Nov 13, 2026

## Key points

- Lung isolation separates the lungs to protect one from contamination, control ventilation, or give the surgeon a collapsed lung.
- A left double-lumen tube is usually preferred because the right upper lobe bronchus arises close to the carina.
- Confirm tube or blocker position with a flexible bronchoscope, and again after turning the patient.
- Hypoxaemia during one-lung ventilation comes from shunt through the collapsed lung; malposition and secretions are common causes.
- Use lung-protective one-lung ventilation and strong regional analgesia: thoracic epidural or paravertebral block.

On this page

- The basics Key points
- What it is
- What changes in this patient
- Anaesthetic plan (and why)
- Double-lumen tube or bronchial blocker
- Next step
- Memory aid
- Elsewhere in DurgiPedia

- Clinical Risks and complications

- Study Test yourself

- Connections Connections

## What it is

Many thoracic operations, such as lung resection, video-assisted thoracoscopic surgery and oesophageal surgery, need lung isolation: separating the two lungs so that one is ventilated and the other collapses. Isolation is also used to protect a healthy lung from pus or blood in the other, to control ventilation when there is a bronchopleural fistula or large bulla, and for whole-lung lavage. The two main tools are the double-lumen tube, usually a left-sided one because the right upper lobe bronchus arises close to the carina, and the bronchial blocker, passed through or beside a single-lumen tube and useful when the airway is difficult. Position is confirmed with a flexible bronchoscope and rechecked after the patient is turned to the lateral position. During one-lung ventilation the collapsed lung is still perfused, creating a shunt that causes hypoxaemia; hypoxic pulmonary vasoconstriction and gravity reduce it. Ventilation follows lung-protective principles: modest tidal volumes for the single lung, positive end-expiratory pressure, limited airway pressures and tolerance of some hypercapnia. Thoracotomy is among the most painful incisions, so thoracic epidural or paravertebral and other chest-wall blocks are central to the plan.

## What changes in this patient

- Preoperative lung function (spirometry and gas transfer, with predicted postoperative values) estimates whether the patient can tolerate the resection.
- In the lateral position the dependent lung receives more blood flow; ventilating it alone matches ventilation to perfusion best.
- Blood flowing through the non-ventilated lung is a true shunt and lowers arterial oxygen.
- Hypoxic pulmonary vasoconstriction diverts blood away from the collapsed lung; high doses of volatile agents and vasodilators weaken it.
- The single ventilated lung is at risk of injury from high volumes and pressures.
- Pain after thoracotomy is severe and limits coughing and breathing, leading to atelectasis and pneumonia.

## Anaesthetic plan (and why)

- Review lung function and exercise tolerance with the surgeon — they predict whether the patient will cope with less lung.
- Choose a double-lumen tube or a bronchial blocker on the surgery and the airway — blockers suit difficult airways and small patients.
- Confirm position with a flexible bronchoscope after intubation and after turning — tubes move with positioning.
- Start one-lung ventilation with high inspired oxygen, then lower it as tolerated — saturation usually falls during the first minutes.
- Ventilate the single lung protectively: modest volumes, positive end-expiratory pressure, limited pressures — this lowers lung injury.
- If saturation falls: high oxygen, recheck position with the bronchoscope, suction, recruit the ventilated lung — malposition is a common cause.
- Then add continuous positive pressure to the collapsed lung or briefly ventilate both lungs, warning the surgeon — oxygen reaches the shunt.
- Provide thoracic epidural, paravertebral or another chest-wall block — good analgesia allows coughing and deep breaths.
- Re-expand the collapsed lung gently under vision at the end — this checks for air leaks and reduces atelectasis.
- Extubate early when possible and give physiotherapy and early mobilisation — this protects the remaining lung.

## Double-lumen tube or bronchial blocker

| Feature | Double-lumen tube | Bronchial blocker |
| --- | --- | --- |
| Isolation | Reliable and quick to switch sides | Good, but slower lung collapse |
| Suction and access | Both lungs can be suctioned separately | Little access to the isolated lung |
| Difficult airway | Harder to place | Placed through a standard tube, easier |
| After surgery | Needs exchange if ventilation continues | Blocker removed, tube stays |

## Risks and complications

- Hypoxaemia during one-lung ventilation, most often from tube malposition, secretions or high shunt.
- Airway trauma from double-lumen tubes, including bronchial rupture in rare cases.
- Lung injury of the ventilated lung and pulmonary oedema after pneumonectomy, worsened by excess fluid.
- Re-expansion pulmonary oedema of the collapsed lung, and persistent air leak.
- Atrial fibrillation, bleeding and, after pneumonectomy, cardiac herniation or right heart strain.
- Severe pain, atelectasis and pneumonia when analgesia is poor; chronic post-thoracotomy pain.

## Next step

- Call a senior early for persistent hypoxaemia on one lung, a difficult tube placement or a suspected airway injury.
- Check a chest radiograph after surgery for lung expansion, drain position and the mediastinum.
- Keep fluids restrained after lung resection, especially pneumonectomy, to lower the risk of pulmonary oedema.
- Continue regional analgesia after surgery with regular review of pain, breathing and the catheter.
- Arrange physiotherapy, incentive breathing exercises and early mobilisation from the first day.

## Memory aid

Hypoxaemia on one lung: Oxygen up, Look with the scope, Suction, Recruit, then CPAP to the other lung and tell the surgeon.

## Test yourself

Think of the answer, then tap the question to see it.

## What are the main indications for lung isolation?

Protecting a healthy lung from pus or blood, controlling ventilation with a bronchopleural fistula or large bulla, whole-lung lavage, and surgical exposure.

## Why is a left-sided double-lumen tube usually preferred?

The right upper lobe bronchus arises close to the carina, so a right-sided tube can easily block it; the left main bronchus is longer.

## Why does hypoxaemia occur during one-lung ventilation?

Blood still flows through the collapsed, unventilated lung, creating a shunt; hypoxic pulmonary vasoconstriction only partly reduces it.

## What is the first response to falling saturation on one-lung ventilation?

Raise inspired oxygen, recheck tube position with a bronchoscope, suction secretions and recruit the ventilated lung; then consider positive pressure to the collapsed lung.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/anaesthesia/thoracic-surgery-and-one-lung-ventilation/)

## Elsewhere in DurgiPedia

- [Ventilation–perfusion matching and West zones](https://durgical.com/en/physiology/ventilation-perfusion-matching-and-west-zones/)
- [The pulmonary circulation and hypoxic vasoconstriction](https://durgical.com/en/physiology/the-pulmonary-circulation-and-hypoxic-vasoconstriction/)
- [The causes of hypoxemia](https://durgical.com/en/physiology/the-causes-of-hypoxemia/)
- [Lung carcinoma: histologic types](https://durgical.com/en/general-pathology/lung-carcinoma-histologic-types/)

## Connections

## Related 8

- [The patient with lung disease (asthma, COPD, OSA)](https://durgical.com/en/anaesthesia/the-patient-with-lung-disease/)
- [Intraoperative hypoxaemia: a stepwise approach](https://durgical.com/en/anaesthesia/intraoperative-hypoxaemia-a-stepwise-approach/)
- [Tracheal intubation](https://durgical.com/en/anaesthesia/tracheal-intubation/)
- [Epidural anaesthesia and analgesia](https://durgical.com/en/anaesthesia/epidural-anaesthesia-and-analgesia/)
- [Peripheral nerve blocks in principle](https://durgical.com/en/anaesthesia/peripheral-nerve-blocks-in-principle/)
- [Postoperative pain: multimodal analgesia](https://durgical.com/en/anaesthesia/postoperative-pain-multimodal-analgesia/)
- [Ventilating ARDS: low volumes, prone position and more](https://durgical.com/en/anaesthesia/ventilating-ards-low-volumes-prone-position-and-more/)
- [PEEP, plateau pressure and lung protection](https://durgical.com/en/anaesthesia/peep-plateau-pressure-and-lung-protection/)

## Related conditions 5

- [Lung cancer](https://durgical.com/en/conditions/lung-cancer/)
- [Pneumothorax](https://durgical.com/en/conditions/pneumothorax/)
- [Bronchiectasis](https://durgical.com/en/conditions/bronchiectasis/)
- [Lung abscess](https://durgical.com/en/conditions/lung-abscess/)
- [Chronic obstructive pulmonary disease (COPD)](https://durgical.com/en/conditions/chronic-obstructive-pulmonary-disease/)

## In Pharmacology 5

- [Propofol](https://durgical.com/en/pharmacology/propofol/)
- [Sevoflurane](https://durgical.com/en/pharmacology/sevoflurane/)
- [Local anesthetics](https://durgical.com/en/pharmacology/classes/local-anesthetics/)
- [Bupivacaine](https://durgical.com/en/pharmacology/bupivacaine/)
- [Opioids and antagonists](https://durgical.com/en/pharmacology/classes/opioids-and-antagonists/)

[← All of anaesthesia](https://durgical.com/en/anaesthesia/)

Educational content; it does not replace supervised training, your institution's protocols or the anaesthetist's or intensivist's decision. It contains no doses and no ventilator or infusion settings.

Sources: [Lung Isolation and One-Lung Ventilation](https://www.ncbi.nlm.nih.gov/books/NBK555933/) (StatPearls (NCBI Bookshelf), 2024).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/anaesthesia/thoracic-surgery-and-one-lung-ventilation/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/anaesthesia/thoracic-surgery-and-one-lung-ventilation/