June 2002 / Volume 47 / Number 6 / Page 688
Independent Lung Ventilation in a Patient with Complex Congenital Heart Disease
Independent lung ventilation (ILV) is recognized as a method of treating unilateral lung disease. We report the use of ILV in a 22-year-old woman with acute respiratory failure and complex congenital heart disease with different sources of left and right pulmonary blood flow. She had a palliated single-ventricle circulation with pulsatile pulmonary blood flow from an aorto-pulmonary central shunt to her left lung and nonpulsatile pulmonary blood flow via a classic Glenn shunt (superior vena cava to right pulmonary artery). On admission she was hypoxemic and hypotensive. Her chest radiograph revealed opacification of the left lung and hyperinflation of the right lung, which was more compliant than the left lung. Following placement of a double-lumen endotracheal tube, synchronized ILV was instituted. ILV allowed us to deliver lower ventilator pressure to the right lung, which alleviated the over-distention of the right lung (to which pulmonary blood flow was supplied by the nonpulsatile Glenn shunt) while higher airway pressures were delivered to the diseased left lung, to facilitate re-expansion. There was immediate improvement in gas exchange and blood pressure. After 3 days the double-lumen endotracheal tube was changed to a single-lumen tube. She was extubated on day 6 and discharged on day 13. This case demonstrates the advantage of ILV in a patient with abnormal pulmonary blood flow and different lung mechanics in the left and right lungs.
Key words: independent lung ventilation, ILV, congenital heart disease, Waterston shunt, Glenn shunt, double-lumen endotracheal tube.
[Respir Care 2002;47(6):688–692]
Independent lung ventilation (ILV) is defined as ventilating the left and right lungs selectively. ILV is beneficial in treating unilateral lung disease, when there are substantial differences in lung compliance or pulmonary blood flow to the right and left lungs. The first reported use of ILV was in 1931, for thoracic surgery. Although not widely used in the critical care setting, ILV has proven successful for patients with asymmetric lung disease, particularly in the setting of refractory hypoxemia or a major deterioration in cardiac output from increased intrathoracic pressure secondary to positive-pressure ventilation (PPV) applied to both lungs. This may be especially important for patients with different sources of left and right pulmonary blood flow.
Although outcomes for patients with all types of congenital heart disease have substantially improved over the years, previous palliative surgery or sequelae following corrective surgery may be associated with important physiologic limitations, particularly with regard to pulmonary blood flow. This case report describes an adult with palliated congenital heart disease and different sources of pulmonary blood flow, and in whom ILV enabled successful treatment of acute respiratory failure.