Preoperative Preparation - A list of things to have/do prior to the surgery: 1. place 2 large bore IVs or central line. 2. Arterial line recommended. 3. Obtain CBC and ABG for preop values. 4. Have type and cross completed. 5. Place thoracic Epidural for intra-op and post-op pain control. 6. Have bronchoscope and large hemostat or clamp at bedside. 7. Warming - Fluid warmer and Lower body bair hugger. 8. Have a properly sized Left Double Lumen Tube (DLT). Males- Usually 39 or (41 if they're tall). Women - usually 37. Induction - Place DLT with the aid of a glidescope if needed, then ensure placement of the left sided tube with a bronchoscope. Tape very securely before you turn the patient. Turn patient laterally with the affected lung up - (see general lateral positioning implications below). Lung Deflation - The surgeon will notify you when they are ready to deflate the affected lung. Turn off ventilation and clamp the tube. Once you are sure that the lung is deflated restart ventilator at a lower tidal volume (TV). Most will drop the TV by half of the original volume. Using Pressure Control Ventilation (PVC) is also acceptable for one lung ventilation. Keep your Positive Inspiratory Pressure (PIP) below 40 cm H2O. SaO2 drops - If SaO2 drops attempt to add PEEP (usually no more than 7), or hand ventilate until oxygenation is increased. If these methods fail, inform the surgeon and ask if it is feasible to reinflate the affected lung for a short time. Lung Inflation - When surgeon is finished they will let you know to reinflate the lung. Usually it is best to hand ventilate until lung is completely reinflated, then place back on original vent settings. Extubation - Extubating these patients in a head up position is best. Make sure to lower both balloons on the DLT and make sure the airway is not compromised (active bleeding, extreme swelling) before extubation. It is best to extubate awake.
VATS are performed as a minimally invasive procedure, compared to an open chest or thoracotomy. Advantages of VATS include a smaller incision, less postoperative pain, less risk of complications, and shorter hospital stay. A Disadvantage of VATS could include incomplete lymph node removal/dissection due to less surgical space and visualization for the surgeon. Indications for VATS include: lymph node dissection or biopsy, lung decortication for infection or fluid accumulation, lung resection due to cancer or trauma, mediastinal mass resection.
