Intraoperative Anesthetic Management of the Thoracic Patient

Dexmedetomidine improves lung injury after one-lung ventilation in esophageal cancer patients by inhibiting inflammatory response and oxidative stress

Aim

To explore the effect of Dexmedetomidine (DEX) on lung injury in patients undergoing One-lung ventilation (OLV).

Methods

Esophageal cancer patients undergoing general anesthesia with OLV were randomly divided into the DEX group and control group, with 30 cases in each group. Mean arterial pressure (MAP), heart rate (HR), arterial partial pressure of oxygen (PO2), and arterial partial pressure of nitrogen dioxide (PCO2) were recorded at the time points after anesthesia induction and before OLV (T1), OLV 30 min (T2), OLV 60 min (T3), OLV 120 min (T4), OLV end before (T5) and before leaving the room (T6) in both groups. Reverse Transcription-Polymerase Chain Reaction (RT-qPCR) was applied to detect the levels of CC16 mRNA. Enzyme-linked immunosorbent assay (ELISA) was used to detect serum CC16 protein levels. The content of malondialdehyde (MDA) in serum was determined by thio barbituric acid (TBA) method. ELISA was used to measure the concentrations of TNF-α (tumor necrosis factor-alpha)/and IL-6 (interleukin 6).

Results

DEX treatment slowed down HR at time points T1-T6 and increased PO2 and PCO2 at time points T2-T5 compared with the control group. Moreover, at time points T2-T6, DEX treatment reduced the levels of club cell secretory protein-16 (CC16) mRNA and serum CC16 protein levels. Furthermore, DEX treatment caused the reduction of MDA, TNF-α and IL-6 concentrations in serum of patients.

Conclusion

During the OLV process, DEX could reduce serum CC16 protein levels, inhibit inflammatory reactions and oxidative stress, and improve oxygenation index, indicating a protective effect on lung injury during OLV.

Continuous positive airway pressure combined with small-tidal-volume ventilation on arterial oxygenation and pulmonary shunt during one-lung ventilation in patients undergoing video-assisted thoracoscopic lobectomy: A randomized, controlled study

BACKGROUND

One-lung ventilation (OLV) is frequently applied during video-assisted thoracoscopic surgery (VATS) airway management to collapse and isolate the nondependent lung (NL). OLV can give rise to hypoxemia as a result of the pulmonary shunting produced. Our study aimed to assess the influence of continuous positive airway pressure (CPAP) combined with small-tidal-volume ventilation on improving arterial oxygenation and decreasing pulmonary shunt rate (QS/QT) without compromising surgical field exposure during OLV.

METHODS

Forty-eight patients undergoing scheduled VATS lobectomy were enrolled in this research and allocated into three groups at random: C group (conventional ventilation, no NL ventilation intervention was performed), LP group (NL was ventilated with lower CPAP [2 cmH2O] and a 40-60 mL tidal volume [TV]), and HP group (NL was ventilated with higher CPAP [5 cmH2O] and a 60-80 mL TV). Record the blood gas analysis data and calculate the QS/QT at the following time: at the beginning of the OLV (T0), 30 min after OLV (T1), and 60 min after OLV (T2). Surgeons blinded to ventilation techniques were invited to evaluate the surgical fields.

RESULTS

The demography data of the three groups were consistent with the surgical data. At T1, PaO2 in the HP group was substantially higher compared to the C group (P < 0.05), while there was no significant difference in the LP group (P > 0.05). At T1-T2, PaCO2 in the LP and HP groups was significantly less than that in the C group (P < 0.05). At T1, the QS/QT values of groups C, LP, and HP were 29.54 ± 6.89%, 22.66 ± 2.08%, and 19.64 ± 5.76%, respectively, and the QS/QT values in the LP and HP groups markedly reduced (P < 0.01). The surgical field's evaluation by the surgeon among the three groups was not notable (P > 0.05).

CONCLUSION

CPAP combined with small-tidal-volume ventilation effectively improved arterial oxygenation and reduced QS/QT and PaCO2 without compromising surgical field exposure during OLV. Among them, 5 cmH2O CPAP + 60-80 ml TV ventilation had a better effect on improving oxygenation.

Systematic Review and Meta-Analysis of Efficiency and Safety of Double-Lumen Tube and Bronchial Blocker for One-Lung Ventilation

One-lung ventilation is also used in some thoracic or cardiac surgery, vascular surgery and oesophageal procedures. We conducted a search of the literature for relevant studies in PubMed, Web of Science, Embase, Scopus and Cochrane Library. The final literature search was performed on 10 December 2022. Primary outcomes included the quality of lung collapse. Secondary outcome measures included: the success of the first intubation attempt, malposition rate, time for device placement, lung collapse and adverse events occurrence. Twenty-five studies with 1636 patients were included. Excellent lung collapse among DLT and BB groups was 72.4% vs. 73.4%, respectively (OR = 1.20; 95%CI: 0.84 to 1.72; p = 0.31). The malposition rate was 25.3% vs. 31.9%, respectively (OR = 0.66; 95%CI: 0.49 to 0.88; p = 0.004). The use of DLT compared to BB was associated with a higher risk of hypoxemia (13.5% vs. 6.0%, respectively; OR = 2.27; 95%CI: 1.14 to 4.49; p = 0.02), hoarseness (25.2% vs. 13.0%; OR = 2.30; 95%CI: 1.39 to 3.82; p = 0.001), sore throat (40.3% vs. 23.3%; OR = 2.30; 95%CI: 1.68 to 3.14; p < 0.001), and bronchus/carina injuries (23.2% vs. 8.4%; OR = 3.45; 95%CI: 1.43 to 8.31; p = 0.006). The studies conducted so far on comparing DLT and BB are ambiguous. In the DLT compared to the BB group, the malposition rate was statistically significantly lower, and time to tube placement and lung collapse was shorter. However, the use of DLT compared to BB can be associated with a higher risk of hypoxemia, hoarseness, sore throat and bronchus/carina injuries. Multicenter randomized trials on larger groups of patients are needed to draw definitive conclusions regarding the superiority of any of these devices.