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World J Crit Care Med. Jul 31, 2019; 8(4): 49-58
Published online Jul 31, 2019. doi: 10.5492/wjccm.v8.i4.49
Independent lung ventilation: Implementation strategies and review of literature
Sheri Berg, Edward A Bittner, Lorenzo Berra, Robert M Kacmarek, Abraham Sonny
Sheri Berg, Edward A Bittner, Lorenzo Berra, Abraham Sonny, Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, United States
Robert M Kacmarek, Department of Respiratory Care, Massachusetts General Hospital, Boston, MA 02114, United States
Author contributions: Berg S and Kacmarek RM performed the case and edited the manuscript; Bittner EA and Sonny A wrote and edited the manuscript; Berra L was involved in reviewing and editing the manuscript.
Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Abraham Sonny, MD, Assistant Professor, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit Street, GRB 444, Boston, MA 02114, United States. asonny@mgh.harvard.edu
Telephone: +1-617-7269379
Received: March 14, 2019
Peer-review started: March 15, 2019
First decision: June 6, 2019
Revised: June 21, 2019
Accepted: July 17, 2019
Article in press: July 17, 2019
Published online: July 31, 2019
Abstract

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.

Keywords: Unilateral lung injury, Unilateral pneumonia, Double lumen tube, Differential lung ventilation, Acute lung injury, Ventilator induced lung injury

Core tip: Severe unilateral lung disease presents a unique scenario where the diseased lung has very poor compliance, while the non-diseased lung remains normally compliant. In these patients, conventional positive pressure ventilation causes preferential distribution of tidal volume to the non-diseased lung causing its overdistension and inadvertent volutrauma. Placement of a double lumen endotracheal tube and providing independent lung ventilation, with a ventilator for each lung, can potentially minimize lung injury. This will allow institution of lung protective ventilation strategies to each lung, individualized based on their respective compliances.