How to achieve successful lung separation

Recent advances in surgical techniques for thoracic, cardiac, and oesophageal surgery have led to an increased use of lung separation techniques. Currently, double-lumen endotracheal tubes (DLT) and bronchial blockers (an Arndt wire-guided endobronchial blocker, a Cohen Flexitip endobronchial blocker, or the Fuji Uniblocker) are used. 1-3 Achieving successful lung separation relies on knowledge of the anatomical distances of the airway, flexible fibreoptic bronchoscopy techniques, and familiarity with left and right-sided DLTs and bronchial blockers. In general, lung isolation techniques are designed to: facilitate surgical exposure for cases involving the thoracic cavity, to prevent contamination of the contralateral lung in cases where pus or haemorrhage is present, and to establish airway continuity such as in a patient who presents with bronchopleural fistula and requires mechanical ventilation. Specific indications with bronchial blockers include: patients with difficult airways, patients with tracheostomy that require lung separation, selective lobar blockade, or whenever postoperative mechanical ventilation is contemplated. This review focuses on the current methods used to achieve lung separation. The objectives include: selecting the proper size device, intubation issues, optimal positioning with the use of a flexible fibreoptic bronchoscope, potential complications, and the management of lung isolation devices and what to do when they do not work.