Navigating One-lung Ventilation after Lobectomy: Anesthetic Challenges in Physiological Lung Exclusion

A BSTRACT Management of one-lung ventilation in patients undergoing repeat thoracic surgery presents unique challenges, particularly with an existing bronchopleural fistula and a history of lobectomy. Here we discuss a case of a 46-year-old woman with a history of tuberculosis and previous right upper lobectomy posted for right physiological lung exclusion via midline sternotomy. The patient had a bronchopleural fistula with right hydropneumothorax and significant anatomical alterations demonstrated on imaging. Preoperative assessment revealed sinus tachycardia and compromised respiratory function. Successful anesthetic management was achieved through careful preoperative evaluation, appropriate double-lumen tube selection, placement of a thoracic epidural catheter, and meticulous ventilation strategy. The case demonstrates the practicality of complex thoracic procedures in patients with significant comorbidities and previous thoracic surgery. This case highlights the importance of an individualized approach to airway management in patients with altered pulmonary anatomy and emphasizes that complex thoracic procedures can be safely performed with proper planning and execution.