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Alarming hypoxemia during one-lung ventilation in a patient with respiratory bronchiolitis-associated interstitial lung disease

[Hypoxémie inquiétante pendant la ventilation unilatérale chez une patiente souffrant de pneumopathie interstitielle respiratoire associée à une bronchiolite]

From the Department of Anesthesiology, American University of Beirut-Medical Center, Beirut, Lebanon.

Address correspondence to: Dr. Anis Baraka, American University of Beirut, Department of Anesthesiology, P.O. Box 11 0236, Beirut, Lebanon. Phone: 961-1-350000; Fax: 961-1-744464; E-mail: abaraka{at}aub.edu.lb

Purpose: To report a patient with respiratory bronchiolitis-associated interstitial lung disease (RB-ILD) who developed severe hypoxemia during one-lung ventilation (OLV).

Clinical features: A 27-yr-old female, ex-smoker presented with productive cough and dyspnea of 18-month duration. The chest x-ray revealed diffuse abnormalities involving both lungs consisting of interstitial emphysema with irregular shadowing. Preoperative PaO₂ was 88 mmHg and pulmonary function tests showed moderate obstructive disease. The patient underwent right open lung biopsy. After induction of anesthesia, a left double lumen tube was inserted and its position verified with auscultation and fibreoptic bronchoscopy. Upon initiation of OLV, the patient developed severe hypoxemia and the PaO₂ dropped from 500 mmHg during two-lung ventilation (TLV) to 50 mmHg. Hypoxemia was readily corrected by resuming TLV.

Conclusion: The severe hypoxemia during OLV in this patient with RB-ILD may be attributed to impaired hypoxic pulmonary vasoconstriction. Other causes were not excluded. Caution is warranted when initiating OLV in these patients.