One-lung ventilation with intentional closure of the nonventilated lumen in a patient with giant pulmonary bullae undergoing laparoscopic anterior resection: a case report

Background: Anesthetic management of patients with giant pulmonary bullae undergoing nonthoracic laparoscopic surgery is challenging because positive pressure ventilation (PPV) may further distend or rupture the bullous lung, whereas carbon dioxide (CO₂) pneumoperitoneum and Trendelenburg positioning increase ventilatory demand. In conventional one-lung ventilation (OLV) with double-lumen tube (DLT), non-ventilated lumen is usually left open to ambient air. However, this may theoretically promote further bullous distension in closed-chest state. Reports of intentionally keeping the nonventilated lumen closed in this setting are limited.

Case Description: An 86-year-old man with a giant pulmonary bulla in the right lung underwent laparoscopic anterior resection for sigmoid colon cancer. Preoperative computed tomography showed a 17.5-cm bulla occupying the right middle-to-lower lung fields, and pulmonary function testing showed moderate obstructive ventilatory impairment. After induction of general anesthesia, a left-sided DLT was placed. OLV was initiated with ventilation of the left lung only, and the lumen connected to the nonventilated right lung was intentionally clamped and kept closed to ambient air as an initial risk-reduction strategy to reduce both direct positive pressure transmission and possible ambient air entrainment. Low tidal-volume ventilation and low-pressure pneumoperitoneum were used. Oxygenation remained acceptable, but progressive hypercapnia and acidosis developed during prolonged CO₂ pneumoperitoneum, requiring conversion to two-lung ventilation (TLV). The patient was extubated uneventfully without pneumothorax or evidence of bulla rupture.

Conclusions: OLV using a DLT with intentional closure of the nonventilated lumen may be considered a reasonable initial risk-reduction strategy when further inflation of a bullous lung is a major concern. However, prolonged laparoscopic surgery may exceed the ventilatory limits of OLV even when this approach is used. Close monitoring of gas exchange and readiness to convert to TLV are essential.