(1146) Novel Use of Independent Lung Ventilation After Intrapleural Wound Vac Placement

Introduction: Independent lung ventilation (ILV) is a rarely applied technique of rescue ventilation for patients with severe, unilateral lung pathology. In this patient population, marked contrast in the physiology of each lung necessitates an individualized ventilatory approach. Once ILV is achieved, dual ventilators can be utilized to individualize the ventilatory strategy for each lung.

Description: We present a 74-year-old female with squamous cell carcinoma of the right lung who suffered an intraoperative hemorrhage during an attempted video assisted thoracoscopic approach to lobectomy. She required conversion to open thoracotomy, subsequent cardiopulmonary bypass for aortic repair, and wound vac placement into the right pleural space. The right lung was injured in the process, with an air leak present. The patient returned to the surgical ICU hypotensive, acidotic, hypercarbic, and hypoxic on maximal ventilatory support. The patient had an ABG showing 7.11/80/76/24 with a P/F ratio of 76 and a lactate of 4.0. Attempts at optimizing her ventilator were severely limited due to massive air leak into her intrapleural wound vac, which impaired her ventilatory volumes. We then utilized her existing double lumen endotracheal tube (placed for her index operation) and placed the patient on ILV. Dual ventilators were connected for individual lung support. Her right lung ventilator had settings of: AC/VC+, RR 8, TV 200, PEEP 8, IT 1s, 100% FiO2. Her left lung ventilator had settings of: AC/VC+, RR 24, TV 300, PEEP 10, IT 1s, 100% FiO2. Two hours following initiation of ILV the patient’s ABG was 7.32/51/304/25 with a P/F ratio of 304. The patient remained on ILV for 48 hours prior to returning to the OR for definitive management of the chest injury and completion lobectomy.

Discussion: ILV is an option for rescue ventilation in a patient with massive unilateral air leak to prevent loss of tidal volumes, normalize pH, and optimize both oxygenation and ventilation. This is a good alternative to extracorporeal support and may be helpful in unstable patients who otherwise have a surgically correctable problem.