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Intra-Operative Ventilation Strategies for Thoracic Surgery

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Principles and Practice of Anesthesia for Thoracic Surgery

Abstract

Ventilatory strategies for one-lung ventilation (OLV) should take into account preventing both intra-operative hypoxemia and postoperative ventilator-induced lung injury (VILI). Although a lung-protective strategy utilizing low tidal volumes (6 mL/kg) and limited inflation pressures (<30 cm H2O) are clearly indicated for patients with acute respiratory distress syndrome, the evidence for the use of low tidal volumes for OLV is not as compelling. However, it seems prudent at this time to limit tidal volumes and inflation pressures during OLV, providing high breathing frequencies or PaCO2 are not required. With appropriate use of pressure and tidal volume alarms, either pressure- or volume-controlled ventilation may be used. Intrinsic positive end-expiratory pressure (PEEP) is common with OLV (utilizing a double-lumen endotracheal tube) and caution is warranted when high respiratory rates (short exhalation times) are utilized. The addition of external PEEP does not consistently improve oxygenation and has not been shown to reduce the incidence of VILI. An “open lung” maneuver utilizing several breaths of high inspiratory and expiratory pressures may improve oxygenation, but the hemodynamic consequences of the maneuver must be considered. No evidence-based specific recommendations can be made for OLV, but available evidence does help the anesthesiologist select the best strategy for an individual patient and surgery.

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References

  1. Slinger PD. Postpneumonectomy pulmonary edema: good news, bad news. Anesthesiology. 2006;105:2–5.

    Article  PubMed  Google Scholar 

  2. Zeldin RA, Normandin D, Landtwing D, Peters RM. Postpneumonectomy pulmonary edema. J Thorac Cardiovasc Surg. 1984;87:359–65.

    PubMed  CAS  Google Scholar 

  3. Fernández-Pérez ER, Keegan MT, Brown DR, Hubmayr RD, Gajic O. Intraoperative tidal volume as a risk factor for respiratory failure after pneumonectomy. Anesthesiology. 2006;105:14–8.

    Article  PubMed  Google Scholar 

  4. Gothard J. Lung injury after thoracic surgery and one-lung ventilation. Curr Opin Anaesthesiol. 2006;19:5–10.

    Article  PubMed  Google Scholar 

  5. Baudouin SV. Lung injury after thoracotomy. Br J Anaesth. 2003;91:132–42.

    Article  PubMed  CAS  Google Scholar 

  6. Williams EA, Evans TW, Goldstraw P. Acute lung injury following lung resection: is one lung anaesthesia to blame? Thorax. 1996;51:114–6.

    Article  PubMed  CAS  Google Scholar 

  7. Gao L, Barnes KC. Recent advances in genetic predisposition to clinical acute lung injury. Am J Physiol Lung Cell Mol Physiol. 2009;296:L713–25.

    Article  PubMed  CAS  Google Scholar 

  8. Licker M, de Perrot M, Spiliopoulos A, et al. Risk factors for acute lung injury after thoracic surgery for lung cancer. Anesth Analg. 2003;97:1558–65.

    Article  PubMed  Google Scholar 

  9. Jeon K, Yoon JW, Suh GY, et al. Risk factors for post-pneumonectomy acute lung injury/acute respiratory distress syndrome in primary lung cancer patients. Anaesth Intensive Care. 2009;37:14–9.

    PubMed  CAS  Google Scholar 

  10. Licker M, Diaper J, Villiger Y, et al. Impact of intraoperative lung-protective interventions in patients undergoing lung cancer surgery. Crit Care. 2009;13:R41.

    Article  PubMed  Google Scholar 

  11. den Hoed PT, Leendertse-Verloop K, Bruining HA, Bonjer HJ. Comparison of one-lung ventilation and high-frequency ventilation in thoracoscopic surgery. Eur J Surg. 1999;165:1031–4.

    Article  Google Scholar 

  12. Lumb AB. Nunn’s applied respiratory physiology. 6th ed. Butterworth Heinemann: Elsevier; 2005.

    Google Scholar 

  13. Brodsky JB, Lemmens HJ. Left double-lumen tubes: clinical experience with 1,170 patients. J Cardiothorac Vasc Anesth. 2003;17:289–98.

    Article  PubMed  Google Scholar 

  14. Karzai W, Schwarzkopf K. Hypoxemia during one-lung ventilation: prediction, prevention, and treatment. Anesthesiology. 2009;110:1402–11.

    Article  PubMed  Google Scholar 

  15. Hedenstierna G, Tokics L, Strandberg A, Lundquist H, Brismar B. Correlation of gas exchange impairment to development of atelectasis during anaesthesia and muscle paralysis. Acta Anaesthesiol Scand. 1986;30:183–91.

    Article  PubMed  CAS  Google Scholar 

  16. Larsson A, Malmkvist G, Werner O. Variations in lung volume and compliance during pulmonary surgery. Br J Anaesth. 1987;59:585–91.

    Article  PubMed  CAS  Google Scholar 

  17. Katz JA, Laverne RG, Fairley HB, Thomas AN. Pulmonary oxygen exchange during endobronchial anesthesia: effect of tidal volume and PEEP. Anesthesiology. 1982;56:164–71.

    Article  PubMed  CAS  Google Scholar 

  18. Levin AI, Coetzee JF. Arterial oxygenation during one-lung anesthesia. Anesth Analg. 2005;100:12–4.

    Article  PubMed  Google Scholar 

  19. Levin AI, Coetzee JF, Coetzee A. Arterial oxygenation and one-lung anesthesia. Curr Opin Anaesthesiol. 2008;21:28–36.

    Article  PubMed  Google Scholar 

  20. Takala J. Hypoxemia due to increased venous admixture: influence of cardiac output on oxygenation. Intensive Care Med. 2007;33:908–11.

    Article  PubMed  CAS  Google Scholar 

  21. Nagendran J, Stewart K, Hoskinson M, Archer SL. An anesthesiologist’s guide to hypoxic pulmonary vasoconstriction: implications for managing single-lung anesthesia and atelectasis. Curr Opin Anaesthesiol. 2006;19:34–43.

    Article  PubMed  Google Scholar 

  22. Capan LM, Turndorf H, Patel C, Ramanathan S, Acinapura A, Chalon J. Optimization of arterial oxygenation during one-lung anesthesia. Anesth Analg. 1980;59:847–51.

    PubMed  CAS  Google Scholar 

  23. Slinger PD, Kruger M, McRae K, Winton T. Relation of the static compliance curve and positive end-expiratory pressure to oxygenation during one-lung ventilation. Anesthesiology. 2001;95:1096–102.

    Article  PubMed  CAS  Google Scholar 

  24. Maeda Y, Fujino Y, Uchiyama A, Matsuura N, Mashimo T, Nishimura M. Effects of peak inspiratory flow on development of ventilator-induced lung injury in rabbits. Anesthesiology. 2004;101:722–8.

    Article  PubMed  Google Scholar 

  25. Uhlig S. Ventilation-induced lung injury and mechanotransduction: stretching it too far? Am J Physiol Lung Cell Mol Physiol. 2002;282:L892–6.

    PubMed  CAS  Google Scholar 

  26. Prella M, Feihl F, Domenighetti G. Effects of short-term pressure-controlled ventilation on gas exchange, airway pressures, and gas distribution in patients with acute lung injury/ARDS: comparison with volume-controlled ventilation. Chest. 2002;122:1382–8.

    Article  PubMed  Google Scholar 

  27. Davis Jr K, Branson RD, Campbell RS, Porembka DT. Comparison of volume control and pressure control ventilation: is flow waveform the difference? J Trauma. 1996;41:808–14.

    Article  PubMed  Google Scholar 

  28. Campbell RS, Davis BR. Pressure-controlled versus volume-controlled ventilation: does it matter? Respir Care. 2002;47:416–24.

    PubMed  Google Scholar 

  29. Cadi P, Guenoun T, Journois D, Chevallier JM, Diehl JL, Safran D. Pressure-controlled ventilation improves oxygenation during laparoscopic obesity surgery compared with volume-controlled ventilation. Br J Anaesth. 2008;100:709–16.

    Article  PubMed  CAS  Google Scholar 

  30. Balick-Weber CC, Nicolas P, Hedreville-Montout M, Blanchet P, Stéphan F. Respiratory and haemodynamic effects of volume-controlled vs. pressure-controlled ventilation during laparoscopy: a cross-over study with echocardiographic assessment. Br J Anaesth. 2007;99:429–35.

    Article  PubMed  Google Scholar 

  31. Heimberg C, Winterhalter M, Strüber M, Piepenbrock S, Bund M. Pressure-controlled versus volume-controlled one-lung ventilation for MIDCAB. Thorac Cardiovasc Surg. 2006;54:516–20.

    Article  PubMed  CAS  Google Scholar 

  32. Unzueta MC, Casas JI, Moral MV. Pressure-controlled versus volume-controlled ventilation during one-lung ventilation for thoracic surgery. Anesth Analg. 2007;104:1029–33.

    Article  PubMed  Google Scholar 

  33. Choi YS, Shim JK, Na S, Hong SB, Hong YW, Oh YJ. Pressure-controlled versus volume-controlled ventilation during one-lung ventilation in the prone position for robot-assisted esophagectomy. Surg Endosc. 2009;23:2286–91.

    Article  PubMed  Google Scholar 

  34. Tugrul M, Çamci E, Karadeniz H, Sentürk M, Pembeci K, Akpir K. Comparison of volume controlled with pressure controlled ventilation during one-lung anaesthesia. Br J Anaesth. 1997;79:306–10.

    PubMed  CAS  Google Scholar 

  35. Bardoczky GI, d’Hollander AA, Rocmans P, Estenne M, Yernault JC. Respiratory mechanics and gas exchange during one-lung ventilation for thoracic surgery: the effects of end-inspiratory pause in stable COPD patients. J Cardiothorac Vasc Anesth. 1998;12:137–41.

    Article  PubMed  CAS  Google Scholar 

  36. Malhotra A. Low-tidal-volume ventilation in the acute respiratory distress syndrome. N Engl J Med. 2007;357:1113–20.

    Article  PubMed  CAS  Google Scholar 

  37. Petrucci N, Iacovelli W. Lung protective ventilation strategy for the acute respiratory distress syndrome. Cochrane Database Syst Rev. 2007;CD003844.

    Google Scholar 

  38. The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342:1301–8.

    Article  Google Scholar 

  39. Putensen C, Theuerkauf N, Zinserling J, Wrigge H, Pelosi P. Meta-analysis: ventilation strategies and outcomes of the acute respiratory distress syndrome and acute lung injury. Ann Intern Med. 2009;151:566–76.

    PubMed  Google Scholar 

  40. Tobin MJ. Advances in mechanical ventilation. N Engl J Med. 2001;344:1986–96.

    Article  PubMed  CAS  Google Scholar 

  41. Mols G, Priebe HJ, Guttmann J. Alveolar recruitment in acute lung injury. Br J Anaesth. 2006;96:156–66.

    Article  PubMed  CAS  Google Scholar 

  42. Morisaki H, Serita R, Innami Y, Kotake Y, Takeda J. Permissive hypercapnia during thoracic anaesthesia. Acta Anaesthesiol Scand. 1999;43:845–9.

    Article  PubMed  CAS  Google Scholar 

  43. Sticher J, Müller M, Scholz S, Schindler E, Hempelmann G. Controlled hypercapnia during one-lung ventilation in patients undergoing pulmonary resection. Acta Anaesthesiol Scand. 2001;45:842–7.

    Article  PubMed  CAS  Google Scholar 

  44. Broccard AFM. Respiratory acidosis and acute respiratory distress syndrome: time to trade in a bull market? Crit Care Med. 2006;34:229–31.

    Article  PubMed  Google Scholar 

  45. Vaneker M, Heunks LM, Joosten LA, et al. Mechanical ventilation induces a toll/interleukin-1 receptor domain-containing adapter-inducing interferon beta-dependent inflammatory response in healthy mice. Anesthesiology. 2009;111:836–43.

    Article  PubMed  CAS  Google Scholar 

  46. Curley GF, Kevin LG, Laffey JG. Mechanical ventilation: taking its toll on the lung. Anesthesiology. 2009;111:701–3.

    Article  PubMed  Google Scholar 

  47. Dos Santos CC, Slutsky AS. Invited review: mechanisms of ventilator-induced lung injury: a perspective. J Appl Physiol. 2000;89:1645–55.

    PubMed  Google Scholar 

  48. Hager DN, Krishnan JA, Hayden DL, Brower RG. Tidal volume reduction in patients with acute lung injury when plateau pressures are not high. Am J Respir Crit Care Med. 2005;172:1241–5.

    Article  PubMed  Google Scholar 

  49. Predicted Body Weight Calculator. http://www.ardsnet.org/node/77460. Accessed 18 Dec 2009.

  50. Tandon S, Batchelor A, Bullock R, et al. Peri-operative risk factors for acute lung injury after elective oesophagectomy. Br J Anaesth. 2001;86:633–8.

    Article  PubMed  CAS  Google Scholar 

  51. Kutlu CA, Williams EA, Evans TW, Pastorino U, Goldstraw P. Acute lung injury and acute respiratory distress syndrome after pulmonary resection. Ann Thorac Surg. 2000;69:376–80.

    Article  PubMed  CAS  Google Scholar 

  52. Lytle FT, Brown DR. Appropriate ventilatory settings for thoracic surgery: intraoperative and postoperative. Semin Cardiothorac Vasc Anesth. 2008;12:97–108.

    Article  PubMed  Google Scholar 

  53. Slinger P. Pro: low tidal volume is indicated during one-lung ventilation. Anesth Analg. 2006;103:268–70.

    Article  PubMed  Google Scholar 

  54. Gal TJ. Con: low tidal volumes are indicated during one-lung ventilation. Anesth Analg. 2006;103:271–3.

    Article  PubMed  Google Scholar 

  55. Duggan M, Kavanagh BP. Pulmonary atelectasis: a pathogenic perioperative entity. Anesthesiology. 2005;102:838–54.

    Article  PubMed  Google Scholar 

  56. Michelet P, D’Journo XB, Roch A, et al. Protective ventilation influences systemic inflammation after esophagectomy: a randomized controlled study. Anesthesiology. 2006;105:911–9.

    Article  PubMed  Google Scholar 

  57. Schilling T, Kozian A, Huth C, et al. The pulmonary immune effects of mechanical ventilation in patients undergoing thoracic surgery. Anesth Analg. 2005;101:957–65.

    Article  PubMed  Google Scholar 

  58. Wrigge H, Uhlig U, Zinserling J, et al. The effects of different ­ventilatory settings on pulmonary and systemic inflammatory responses during major surgery. Anesth Analg. 2004;98:775–81.

    Article  PubMed  Google Scholar 

  59. Shaw AD, Vaporciyan AA, Wu X, et al. Inflammatory gene polymorphisms influence risk of postoperative morbidity after lung resection. Ann Thorac Surg. 2005;79:1704–10.

    Article  PubMed  Google Scholar 

  60. Tekinbas C, Ulusoy H, Yulug E, et al. One-lung ventilation: for how long? J Thorac Cardiovasc Surg. 2007;134:405–10.

    Article  PubMed  Google Scholar 

  61. Misthos P, Katsaragakis S, Milingos N, et al. Postresectional pulmonary oxidative stress in lung cancer patients. The role of one-lung ventilation. Eur J Cardiothorac Surg. 2005;27:379–82.

    Article  PubMed  CAS  Google Scholar 

  62. Cheng YJ, Chan KC, Chien CT, Sun WZ, Lin CJ. Oxidative stress during 1-lung ventilation. J Thorac Cardiovasc Surg. 2006;132:513–8.

    Article  PubMed  Google Scholar 

  63. Gajic O, Dara SI, Mendez JL, et al. Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation. Crit Care Med. 2004;32:1817–24.

    Article  PubMed  Google Scholar 

  64. Schultz MJ. Lung-protective mechanical ventilation with lower tidal volumes in patients not suffering from acute lung injury: a review of clinical studies. Med Sci Monit. 2008;14: RA22–6.

    PubMed  Google Scholar 

  65. Bonetto C, Terragni P, Ranieri VM. Does high tidal volume generate ALI/ARDS in healthy lungs? Intensive Care Med. 2005;31:893–5.

    Article  PubMed  Google Scholar 

  66. Slinger PD, Hickey DR. The interaction between applied PEEP and auto-PEEP during one-lung ventilation. J Cardiothorac Vasc Anesth. 1998;12:133–6.

    Article  PubMed  CAS  Google Scholar 

  67. Levy MM. PEEP in ARDS – how much is enough? N Engl J Med. 2004;351:389–91.

    Article  PubMed  CAS  Google Scholar 

  68. Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med. 2004;351:327–36.

    Article  PubMed  Google Scholar 

  69. Meade MO, Cook DJ, Guyatt GH, et al. Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008;299:637–45.

    Article  PubMed  CAS  Google Scholar 

  70. Mercat A, Richard JC, Vielle B, et al. Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008;299:646–55.

    Article  PubMed  CAS  Google Scholar 

  71. Gattinoni L, Caironi P. Refining ventilatory treatment for acute lung injury and acute respiratory distress syndrome. JAMA. 2008;299:691–3.

    Article  PubMed  CAS  Google Scholar 

  72. Yokota K, Toriumi T, Sari A, Endou S, Mihira M. Auto-positive end-expiratory pressure during one-lung ventilation using a double-lumen endobronchial tube. Anesth Analg. 1996;82:1007–10.

    PubMed  CAS  Google Scholar 

  73. Bardoczky GI, Yernault JC, Engelman EE, Velghe CE, Cappello M, Hollander AA. ntrinsic positive end-expiratory pressure during one-lung ventilation for thoracic surgery. The influence of preoperative pulmonary function. Chest. 1996;110:180–4.

    Article  PubMed  CAS  Google Scholar 

  74. Ducros L, Moutafis M, Castelain MH, Liu N, Fischler M. Pulmonary air trapping during two-lung and one-lung ventilation. J Cardiothorac Vasc Anesth. 1999;13:35–9.

    Article  PubMed  CAS  Google Scholar 

  75. Blanch L, Bernabé F, Lucangelo U. Measurement of air trapping, intrinsic positive end-expiratory pressure, and dynamic hyperinflation in mechanically ventilated patients. Respir Care. 2005;50:110–23.

    PubMed  Google Scholar 

  76. Bardoczky GI, d’Hollander AA, Cappello M, Yernault JC. Interrupted expiratory flow on automatically constructed flow-volume curves may determine the presence of intrinsic positive end-expiratory pressure during one-lung ventilation. Anesth Analg. 1998;86:880–4.

    PubMed  CAS  Google Scholar 

  77. Benumof JL. One-lung ventilation: which lung should be PEEPed? Anesthesiology. 1982;56:161–3.

    Article  PubMed  CAS  Google Scholar 

  78. Mascotto G, Bizzarri M, Messina M, et al. Prospective, randomized, controlled evaluation of the preventive effects of positive end-expiratory pressure on patient oxygenation during one-lung ventilation. Eur J Anaesthesiol. 2003;20:704–10.

    Article  PubMed  CAS  Google Scholar 

  79. Leong LM, Chatterjee S, Gao F. The effect of positive end expiratory pressure on the respiratory profile during one-lung ventilation for thoracotomy. Anaesthesia. 2007;62:23–6.

    Article  PubMed  CAS  Google Scholar 

  80. Cohen E, Eisenkraft JB. Positive end-expiratory pressure during one-lung ventilation improves oxygenation in patients with low arterial oxygen tensions. J Cardiothorac Vasc Anesth. 1996;10:578–82.

    Article  PubMed  CAS  Google Scholar 

  81. Valenza F, Ronzoni G, Perrone L, et al. Positive end-expiratory pressure applied to the dependent lung during one-lung ventilation improves oxygenation and respiratory mechanics in patients with high FEV1. Eur J Anaesthesiol. 2004;21:938–43.

    PubMed  CAS  Google Scholar 

  82. Inomata S, Nishikawa T, Saito S, Kihara S. “Best” PEEP during one-lung ventilation. Br J Anaesth. 1997;78:754–6.

    PubMed  CAS  Google Scholar 

  83. Lachmann B. Open up the lung and keep the lung open. Intensive Care Med. 1992;18:319–21.

    Article  PubMed  CAS  Google Scholar 

  84. Lapinsky SE, Mehta S. Bench-to-bedside review: recruitment and recruiting maneuvers. Crit Care. 2005;9:60–5.

    Article  PubMed  Google Scholar 

  85. Tusman G, Böhm SH, Sipmann FS, Maisch S. Lung recruitment improves the efficiency of ventilation and gas exchange during one-lung ventilation anesthesia. Anesth Analg. 2004;98:1604–9.

    Article  PubMed  Google Scholar 

  86. Cinnella G, Grasso S, Natale C, et al. Physiological effects of a lung-recruiting strategy applied during one-lung ventilation. Acta Anaesthesiol Scand. 2008;52:766–75.

    Article  PubMed  CAS  Google Scholar 

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  1. Department of Anesthesiology, University of Rochester, Rochester, NY, USA

    Denham S. Ward MD, PhD

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  1. University of Toronto, Staff Anesthesiologist, Professor of Anesthesia, Toronto, M5G 2C4, Ontario, Canada

    Peter Slinger, MD, FRCPC

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Ward, D.S. (2011). Intra-Operative Ventilation Strategies for Thoracic Surgery. In: Slinger, MD, FRCPC, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, New York, NY. https://doi.org/10.1007/978-1-4419-0184-2_21

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