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Wu L, Yang L, Yang Y, Wu X, Zhang J. Ultrasound-guided versus conventional lung recruitment manoeuvres in thoracic surgery: a randomised controlled study. J Clin Monit Comput 2024; 38:731-739. [PMID: 38368302 DOI: 10.1007/s10877-024-01134-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 02/02/2024] [Indexed: 02/19/2024]
Abstract
Lung recruitment manoeuvres (RMs) during mechanical ventilation may reduce atelectasis, however, the optimal recruitment strategy for patients undergoing thoracic surgery remains unknown. Our study was designed to investigate whether ultrasound-guided lung RMs is superior to conventional RMs in reducing perioperative atelectasis during thoracic surgery with one-lung ventilation. We conducted a randomised controlled clinical trial from August 2022 to September 2022. Sixty patients scheduled for video-assisted thoracoscopic surgery (VATS) under general anaesthesia were enrolled. Subjects were randomly divided into the ultrasound-guided RMs group (manual inflation guided by lung ultrasound) or conventional RMs group (manual inflation with 30 cmH2O pressure). Lung ultrasound were performed at three predefined time points (1 min after anaesthetic induction; after RMs at the end of surgery; before discharge from postanesthesia care unit [PACU]). The primary outcome was lung ultrasound score before discharge from the PACU after extubation. In the early postoperative period, lung aeration deteriorated in both groups even after lung RMs. However, ultrasound-guided lung RMs had significantly lower lung ultrasound scores when compared with conventional RMs in bilateral lungs (2.0 [0.8-4.0] vs. 8.0 [3.8-10.3], P < 0.01) at the end of surgery, which remained before patients discharged from the PACU. Accordingly, the lower incidence of atelectasis was found in ultrasound-guided RMs group than in conventional RMs group (7% vs. 53%; P < 0.01) at the end of surgery. Ultrasound-guided RMs is superior to conventional RMs in improving lung aeration and reducing the incidence of lung atelectasis at early postoperative period in patients undergoing VATS. The study protocol was approved by the Institutional Review Board of the Fudan University Shanghai Cancer Center (No. 220,825,810; date of approval: August 5, 2022) and registered on Chinese Clinical Trial Registry (registration number: ChiCTR2200062761).
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Affiliation(s)
- Lei Wu
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China
| | - Li Yang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China
| | - Yanyan Yang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China
| | - Xin Wu
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.
| | - Jun Zhang
- Department of Anesthesiology, Fudan University Shanghai Cancer Center, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.
- Department of Oncology, Shanghai Medical College, Fudan University, No. 270, Dong'An Road, Xuhui District, Shanghai, 200032, China.
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Yueyi J, Jing T, Lianbing G. A structured narrative review of clinical and experimental studies of the use of different positive end-expiratory pressure levels during thoracic surgery. THE CLINICAL RESPIRATORY JOURNAL 2022; 16:717-731. [PMID: 36181340 PMCID: PMC9629996 DOI: 10.1111/crj.13545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/03/2022] [Accepted: 09/12/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This study aimed to present a review on the general effects of different positive end-expiratory pressure (PEEP) levels during thoracic surgery by qualitatively categorizing the effects into detrimental, beneficial, and inconclusive. DATA SOURCE Literature search of Pubmed, CNKI, and Wanfang was made to find relative articles about PEEP levels during thoracic surgery. We used the following keywords as one-lung ventilation, PEEP, and thoracic surgery. RESULTS We divide the non-individualized PEEP value into five grades, that is, less than 5, 5, 5-10, 10, and more than 10 cmH2 O, among which 5 cmH2 O is the most commonly used in clinic at present to maintain alveolar dilatation and reduce the shunt fraction and the occurrence of atelectasis, whereas individualized PEEP, adjusted by test titration or imaging method to adapt to patients' personal characteristics, can effectively ameliorate intraoperative oxygenation and obtain optimal pulmonary compliance and better indexes relating to respiratory mechanics. CONCLUSIONS Available data suggest that PEEP might play an important role in one-lung ventilation, the understanding of which will help in exploring a simple and economical method to set the appropriate PEEP level.
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Affiliation(s)
- Jiang Yueyi
- The Affiliated Cancer Hospital of Nanjing Medical UniversityNanjingChina
| | - Tan Jing
- Department of AnesthesiologyJiangsu Cancer HospitalNanjingChina
| | - Gu Lianbing
- The Affiliated Cancer Hospital of Nanjing Medical UniversityNanjingChina,Department of AnesthesiologyJiangsu Cancer HospitalNanjingChina
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The effect of recruitment maneuver on the development of expansion defect and atelectasis after lobectomy: A double-blind randomized controlled trial. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.1001166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Hu MC, Yang YL, Chen TT, Chen JT, Tiong TY, Tam KW. Recruitment maneuvers in patients undergoing thoracic surgery: a meta-analysis. Gen Thorac Cardiovasc Surg 2021; 69:1553-1559. [PMID: 34152550 DOI: 10.1007/s11748-021-01673-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/12/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Pulmonary atelectasis is a common postoperative complication that may lead to intrapulmonary shunt, refractory hypoxemia, and respiratory distress. Recruitment maneuvers may relieve pulmonary atelectasis in patients undergoing thoracic surgery. This meta-analysis of randomized controlled trials (RCTs) is to evaluate the effectiveness and safety of recruitment maneuvers in patients undergoing thoracic surgery. METHODS We performed a literature search on the PubMed, Embase, and Cochrane Library databases and the ClinicalTrials.gov registry for trials published before April 2021. We investigated postoperative pulmonary atelectasis incidence, intrapulmonary shunt fraction, static lung compliance, and mean arterial pressure. RESULTS Six RCTs involving 526 patients were reviewed. Patients receiving a recruitment maneuver exhibited a significant decrease in intrapulmonary shunt fraction [weighted mean difference (WMD) - 0.02, 95% CI - 0.03 to - 0.01], improved static lung compliance (WMD 2.16; 95% CI 1.14-3.18), and PaO2/FIO2 ratio (WMD 31.31; 95% CI 12.11-50.52) without a significant difference in mean arterial pressure (WMD - 0.64; 95% CI - 4.92 to 3.64). The incidence pulmonary atelectasis favored recruitment maneuver group, but was not statistically significant (RR 0.55; 95% CI 0.27-1.12). CONCLUSIONS Recruitment maneuvers may be a viable treatment for reducing intra-pulmonary shunt and improving static lung compliance and PaO2/FIO2 ratio without the disturbance of hemodynamics in patients undergoing thoracic surgery.
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Affiliation(s)
- Ming-Chi Hu
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - You-Lan Yang
- School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Respiratory Therapy, Landseed International Hospital, Taoyuan, Taiwan
| | - Tzu-Tao Chen
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Jui-Tai Chen
- Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tung-Yu Tiong
- Division of Thoracic Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Ka-Wai Tam
- Division of General Surgery, Department of Surgery, Shuang Ho Hospital, Taipei Medical University, 291, Zhongzheng Road, Zhonghe District, New Taipei City, 23561, Taiwan. .,Division of General Surgery, Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan. .,Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.
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Nakahira J, Nakano S, Minami T. Evaluation of alveolar recruitment maneuver on respiratory resistance during general anesthesia: a prospective observational study. BMC Anesthesiol 2020; 20:264. [PMID: 33069208 PMCID: PMC7568405 DOI: 10.1186/s12871-020-01182-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 10/12/2020] [Indexed: 12/02/2022] Open
Abstract
Background Alveolar recruitment maneuvers enable easily reopening nonaerated lung regions via a transient elevation in transpulmonary pressure. To evaluate the effect of these maneuvers on respiratory resistance, we used an oscillatory technique during mechanical ventilation. This study was conducted to assess the effect of the alveolar recruitment maneuvers on respiratory resistance under routine anesthesia. We hypothesized that respiratory resistance at 5 Hz (R5) after the maneuver would be decreased after the lung aeration. Methods After receiving the ethics committee’s approval, we enrolled 33 patients who were classified with an American Society of Anesthesiologists physical status of 1, 2 or 3 and were undergoing general anesthesia for transurethral resection of a bladder tumor within a 12-month period from 2017 to 2018. The recruitment maneuver was performed 30 min after endotracheal intubation. The maneuver consisted of sustained manual inflation of the anesthesia reservoir bag to a peak inspiratory pressure of 40 cmH2O for 15 s, including 5 s of gradually increasing the peak inspiratory pressure. Respiratory resistance was measured using the forced oscillation technique before and after the maneuver, and the mean R5 was calculated during the expiratory phase. The respiratory resistance and ventilator parameter results were analyzed using paired Student’s t-tests, and p < 0.05 was considered statistically significant. Results We analyzed 31 patients (25 men and 6 women). R5 was 7.3 ± 1.6 cmH2O/L/sec before the recruitment maneuver during mechanical ventilation and was significantly decreased to 6.4 ± 1.7 cmH2O/L/sec after the maneuver. Peak inspiratory pressure and plateau pressure were significantly decreased, and pulmonary compliance was increased, although the values were not clinically relevant. Conclusion The recruitment maneuver decreased respiratory resistance and increased lung compliance during mechanical ventilation. Trial registration Name of registry: Japan Medical Association Center for Clinical Trials. Trial registration number: reference JMA-IIA00136. Date of registration: 2 September 2013. URL of trial registry record: https://dbcentre3.jmacct.med.or.jp/JMACTR/App/JMACTRE02_04/JMACTRE02_04.aspx?kbn=3&seqno=3582
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Affiliation(s)
- Junko Nakahira
- Department of Anesthesiology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan.
| | - Shoko Nakano
- Department of Anesthesiology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Toshiaki Minami
- Department of Anesthesiology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
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Peel JK, Funk DJ, Slinger P, Srinathan S, Kidane B. Positive end-expiratory pressure and recruitment maneuvers during one-lung ventilation: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2020; 160:1112-1122.e3. [DOI: 10.1016/j.jtcvs.2020.02.077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 02/13/2020] [Accepted: 02/15/2020] [Indexed: 01/09/2023]
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Carramiñana A, Ferrando C, Unzueta MC, Navarro R, Suárez-Sipmann F, Tusman G, Garutti I, Soro M, Pozo N, Librero J, Gallego L, Ramasco F, Rabanal JM, Rodriguez A, Sastre J, Martinez J, Coves S, García P, Aguirre-Puig P, Yepes J, Lluch A, López-Herrera D, Leal S, Vives M, Bellas S, Socorro T, Trespalacios R, Salazar CJ, Mugarra A, Cinnella G, Spadaro S, Futier E, Ferrer L, Cabrera M, Ribeiro H, Celestino C, Kucur E, Cervantes O, Morocho D, Delphy D, Ramos C, Villar J, Belda J. Rationale and Study Design for an Individualized Perioperative Open Lung Ventilatory Strategy in Patients on One-Lung Ventilation (iPROVE-OLV). J Cardiothorac Vasc Anesth 2019; 33:2492-2502. [DOI: 10.1053/j.jvca.2019.01.056] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/21/2019] [Accepted: 01/24/2019] [Indexed: 11/11/2022]
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Physiologic Evaluation of Ventilation Perfusion Mismatch and Respiratory Mechanics at Different Positive End-expiratory Pressure in Patients Undergoing Protective One-lung Ventilation. Anesthesiology 2019; 128:531-538. [PMID: 29215365 DOI: 10.1097/aln.0000000000002011] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Arterial oxygenation is often impaired during one-lung ventilation, due to both pulmonary shunt and atelectasis. The use of low tidal volume (VT) (5 ml/kg predicted body weight) in the context of a lung-protective approach exacerbates atelectasis. This study sought to determine the combined physiologic effects of positive end-expiratory pressure and low VT during one-lung ventilation. METHODS Data from 41 patients studied during general anesthesia for thoracic surgery were collected and analyzed. Shunt fraction, high V/Q and respiratory mechanics were measured at positive end-expiratory pressure 0 cm H2O during bilateral lung ventilation and one-lung ventilation and, subsequently, during one-lung ventilation at 5 or 10 cm H2O of positive end-expiratory pressure. Shunt fraction and high V/Q were measured using variation of inspired oxygen fraction and measurement of respiratory gas concentration and arterial blood gas. The level of positive end-expiratory pressure was applied in random order and maintained for 15 min before measurements. RESULTS During one-lung ventilation, increasing positive end-expiratory pressure from 0 cm H2O to 5 cm H2O and 10 cm H2O resulted in a shunt fraction decrease of 5% (0 to 11) and 11% (5 to 16), respectively (P < 0.001). The PaO2/FIO2 ratio increased significantly only at a positive end-expiratory pressure of 10 cm H2O (P < 0.001). Driving pressure decreased from 16 ± 3 cm H2O at a positive end-expiratory pressure of 0 cm H2O to 12 ± 3 cm H2O at a positive end-expiratory pressure of 10 cm H2O (P < 0.001). The high V/Q ratio did not change. CONCLUSIONS During low VT one-lung ventilation, high positive end-expiratory pressure levels improve pulmonary function without increasing high V/Q and reduce driving pressure.
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Rauseo M, Mirabella L, Grasso S, Cotoia A, Spadaro S, D'Antini D, Valentino F, Tullo L, Loizzi D, Sollitto F, Cinnella G. Peep titration based on the open lung approach during one lung ventilation in thoracic surgery: a physiological study. BMC Anesthesiol 2018; 18:156. [PMID: 30382819 PMCID: PMC6211445 DOI: 10.1186/s12871-018-0624-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 10/19/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND During thoracic surgery in lateral decubitus, one lung ventilation (OLV) may impair respiratory mechanics and gas exchange. We tested a strategy based on an open lung approach (OLA) consisting in lung recruitment immediately followed by a decremental positive-end expiratory pressure (PEEP) titration to the best respiratory system compliance (CRS) and separately quantified the elastic properties of the lung and the chest wall. Our hypothesis was that this approach would improve gas exchange. Further, we were interested in documenting the impact of the OLA on partitioned respiratory system mechanics. METHODS In thirteen patients undergoing upper left lobectomy we studied lung and chest wall mechanics, transpulmonary pressure (PL), respiratory system and transpulmonary driving pressure (ΔPRS and ΔPL), gas exchange and hemodynamics at two time-points (a) during OLV at zero end-expiratory pressure (OLVpre-OLA) and (b) after the application of the open-lung strategy (OLVpost-OLA). RESULTS The external PEEP selected through the OLA was 6 ± 0.8 cmH2O. As compared to OLVpre-OLA, the PaO2/FiO2 ratio went from 205 ± 73 to 313 ± 86 (p = .05) and CL increased from 56 ± 18 ml/cmH2O to 71 ± 12 ml/cmH2O (p = .0013), without changes in CCW. Both ΔPRS and ΔPL decreased from 9.2 ± 0.4 cmH2O to 6.8 ± 0.6 cmH2O and from 8.1 ± 0.5 cmH2O to 5.7 ± 0.5 cmH2O, (p = .001 and p = .015 vs OLVpre-OLA), respectively. Hemodynamic parameters remained stable throughout the study period. CONCLUSIONS In our patients, the OLA strategy performed during OLV improved oxygenation and increased CL and had no clinically significant hemodynamic effects. Although our study was not specifically designed to study ΔPRS and ΔPL, we observed a parallel reduction of both after the OLA. TRIAL REGISTRATION TRN: ClinicalTrials.gov , NCT03435523 , retrospectively registered, Feb 14 2018.
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Affiliation(s)
- Michela Rauseo
- Department of Anesthesia and Intensive care, University of Foggia, Viale Pinto, 1-71100, Foggia, Italy. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| | - Lucia Mirabella
- Department of Anesthesia and Intensive care, University of Foggia, Viale Pinto, 1-71100, Foggia, Italy
| | - Salvatore Grasso
- Department of Anesthesia and Intensive care, University of Bari, Bari, Italy
| | - Antonella Cotoia
- Department of Anesthesia and Intensive care, University of Foggia, Viale Pinto, 1-71100, Foggia, Italy
| | - Savino Spadaro
- Department of Anesthesia and Intensive care, University of Ferrara, Ferrara, Italy
| | - Davide D'Antini
- Department of Anesthesia and Intensive care, University of Foggia, Viale Pinto, 1-71100, Foggia, Italy
| | - Franca Valentino
- Department of Anesthesia and Intensive care, University of Foggia, Viale Pinto, 1-71100, Foggia, Italy
| | - Livio Tullo
- Department of Anesthesia and Intensive care, University of Foggia, Viale Pinto, 1-71100, Foggia, Italy
| | - Domenico Loizzi
- Department of Thoracic Surgery, University of Foggia, Foggia, Italy
| | | | - Gilda Cinnella
- Department of Anesthesia and Intensive care, University of Foggia, Viale Pinto, 1-71100, Foggia, Italy
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Kidane B, Palma DC, Badner NH, Hamilton M, Leydier L, Fortin D, Inculet RI, Malthaner RA. The Potential Dangers of Recruitment Maneuvers During One Lung Ventilation Surgery. J Surg Res 2018; 234:178-183. [PMID: 30527471 DOI: 10.1016/j.jss.2018.09.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 08/09/2018] [Accepted: 09/11/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Existing evidence regarding lung-protective ventilation (LPV) during one-lung ventilation (OLV) focuses on surrogate outcomes. Our objective was to assess whether an LPV protocol during OLV surgery is associated with reduced respiratory complications. MATERIALS AND METHODS This was a matched control retrospective cohort study of patients undergoing pulmonary resection at a tertiary Canadian hospital. The experimental group (n = 50) was derived from primary data of two crossover RCTs, which utilized protocolized LPV strategies with varying levels of positive end-expiratory pressure and recruitment maneuvers. The control group was drawn from a prospectively maintained database; these patients received conventional nonprotocolized ventilation (2000-2010). Each experimental group patient was matched 1:1 with a control group patient with respect to clinically relevant variables (age, sex, diagnosis, smoking status, cardiovascular disease status, comorbidity, BMI, preoperative forced expiratory volume in 1 s, surgery type). Major respiratory complications were defined as composite of acute respiratory distress syndrome, need for new positive-pressure ventilation, and atelectasis requiring bronchoscopy. Paired and unpaired statistical tests were used. RESULTS Patients appeared well matched. Major respiratory complications occurred in 8% (n = 4) and 2% (n = 1) of patients in experimental and control groups, respectively (P = 0.50). There was a trend toward increased mortality (4 versus 0, P = 0.06) with protocolized LPV. The patients who died had respiratory complications; one had acute respiratory distress syndrome and two had profound hypoxemia. CONCLUSIONS There was a nonsignificant trend toward increased mortality with LPV during OLV. Although limited by a small sample size, our findings identify a potential danger to excessive recruitment maneuvers. Larger studies, with clinically important outcomes are needed to better define the risk/benefit trade-offs for LPV during OLV.
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Affiliation(s)
- Biniam Kidane
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada; Division of Thoracic Surgery, Western University, London, Ontario, Canada.
| | | | - Neal H Badner
- Department of Anesthesiology, Western University, London, Ontario, Canada
| | - Melissa Hamilton
- Division of Thoracic Surgery, Western University, London, Ontario, Canada
| | - Larissa Leydier
- Section of Thoracic Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Dalilah Fortin
- Division of Thoracic Surgery, Western University, London, Ontario, Canada; Division of Critical Care Medicine, Department of Medicine, Western University, London, Ontario, Canada
| | - Richard I Inculet
- Division of Thoracic Surgery, Western University, London, Ontario, Canada
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Choi ES, Oh AY, In CB, Ryu JH, Jeon YT, Kim HG. Effects of recruitment manoeuvre on perioperative pulmonary complications in patients undergoing robotic assisted radical prostatectomy: A randomised single-blinded trial. PLoS One 2017; 12:e0183311. [PMID: 28877238 PMCID: PMC5587235 DOI: 10.1371/journal.pone.0183311] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 07/20/2017] [Indexed: 01/28/2023] Open
Abstract
Robotic-assisted laparoscopic radical prostatectomy (RARP) needs a steep Trendelenburg position and a relatively high CO2 insufflation pressure, and patients undergoing RARP are usually elderly. These factors make intraoperative ventilatory care difficult and increase the risk of perioperative pulmonary complications. The aim was to determine the efficacy of recruitment manoeuvre (RM) on perioperative pulmonary complications in elderly patients undergoing RARP. A total of 60 elderly patients scheduled for elective RARP were randomly allocated to two groups after induction of anaesthesia; positive end expiratory pressure (PEEP) was applied during the operation without RM in the control group (group C) and after RM in the recruitment group (group R). The total number of patients who developed intraoperative desaturation or postoperative atelectasis was significantly higher in group C compared to group R (43.3% vs. 17.8%, P = 0.034). Intraoperative respiratory mechanics, perioperative blood gas analysis, and pulmonary function testing did not show differences between the groups. Adding RM to PEEP compared to PEEP alone significantly reduced perioperative pulmonary complications in elderly patients undergoing RARP.
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Affiliation(s)
- Eun-Su Choi
- Department of Anesthesiology and Pain Medicine, Nowon Eulji Medical Center, Eulji University, Seoul, Republic of Korea
| | - Ah-Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Chi-Bum In
- Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Daejeon, Republic of Korea
| | - Jung-Hee Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Young-Tae Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyoung-Gyun Kim
- Department of Anesthesiology and Pain Medicine, Nowon Eulji Medical Center, Eulji University, Seoul, Republic of Korea
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One-lung Ventilation for Thoracic Surgery: Current Perspectives. TUMORI JOURNAL 2017; 103:495-503. [DOI: 10.5301/tj.5000638] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2017] [Indexed: 11/20/2022]
Abstract
One-lung ventilation (OLV) is an anesthesiological technique that is increasingly being used beyond thoracic surgery. This requires specific skills and knowledge about airway management, maintenance of gas exchange and prevention of acute lung injury. Sometimes maintaining adequate gas exchange and minimizing acute lung injury may be opposing processes. Parameters validated for OLV titration still have not been found, but a multimodal approach based on low tidal volume, end-expiratory pressure application and alveolar recruitment maneuvers is considered the best way to ensure protective ventilation and reduce lung damage. The purpose of this review is to analyze all these factors using the latest scientific evidence and the opinions of the most influential authors.
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Dong C, Yu J, Liu Q, Wu C, Lu Y. Application of CO2 waveform in the alveolar recruitment maneuvers of hypoxemic patients during one-lung ventilation. Medicine (Baltimore) 2016; 95:e3900. [PMID: 27310989 PMCID: PMC4998475 DOI: 10.1097/md.0000000000003900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Deterioration of gas exchange during one-lung ventilation (OLV) is caused by both total collapse of the nondependent lung and partial collapse of the dependent lung. Alveolar recruitment maneuver improves lung function during general anesthesia. The objective of this study was to investigate whether there is an indirect relationship between the changes of CO2 expirogram and the selective lung recruitment. To further improve the oxygenation and gas exchange, we compare adjust setting of ventilated parameters based on CO2 expirogram and a preset setting of ventilated parameters during OLV in patients undergoing right-side thoracic surgery.Thirty patients met the requirements criteria that were studied at 3 time points: during two-lung ventilation (TLV), during OLV with preset ventilation parameters (OLV-PP), and during OLV with adjustable ventilation parameters (OLV-AP) that are in accordance with CO2 expirogram. Adjustable ventilation parameters such as tidal volume (VT), respiratory rate (RR), positive end-expiratory pressure (PEEP), and the ratio of inspiratory to expiratory were adjusted by utilizing the phase III slopes of CO2 expirogram, which together with the relationship between the changes of CO2 expirogram and the selective lung recruitment.During OLV, the phase III slopes of CO2 expirogram in patients with pulse oxymetry (SpO2) decreased less than 93% after the OLV-PP, and were absolutely different from that during TLV. After OLV-AP, the phase III slopes of CO2 expirogram and SpO2 were similar to those during TLV. During OLV, however, parameters of ventilation setting in both OLV-PP and OLV-AP are obviously different.This study indicates that alveolar recruitment by utilizing CO2 expirogram probably improves SpO2 level during one-lung ventilation.
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Affiliation(s)
- Chunshan Dong
- Department of Anesthesiology, Third Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, P.R. China
| | - Junma Yu
- Department of Anesthesiology, Third Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, P.R. China
| | - Qi Liu
- Department of Anesthesiology, Third Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, P.R. China
| | - Chao Wu
- Department of Anesthesiology, Third Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, P.R. China
| | - Yao Lu
- Department of Anesthesiology, Third Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, P.R. China
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, P.R. China
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Schlichting N, Flax K, Levine A, DeMaria S, Goldberg A. Thoracic Anesthesia: A Review of Current Topics and Debates. CURRENT ANESTHESIOLOGY REPORTS 2016. [DOI: 10.1007/s40140-016-0159-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Choi YS, Bae MK, Kim SH, Park JE, Kim SY, Oh YJ. Effects of Alveolar Recruitment and Positive End-Expiratory Pressure on Oxygenation during One-Lung Ventilation in the Supine Position. Yonsei Med J 2015; 56:1421-7. [PMID: 26256990 PMCID: PMC4541677 DOI: 10.3349/ymj.2015.56.5.1421] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 11/17/2014] [Accepted: 11/21/2014] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Hypoxemia during one-lung ventilation (OLV) remains a serious problem, particularly in the supine position. We investigated the effects of alveolar recruitment (AR) and positive end-expiratory pressure (PEEP) on oxygenation during OLV in the supine position. MATERIALS AND METHODS Ninety-nine patients were randomly allocated to one of the following three groups: a control group (ventilation with a tidal volume of 8 mL/kg), a PEEP group (the same ventilatory pattern with a PEEP of 8 cm H₂O), or an AR group (an AR maneuver immediately before OLV followed by a PEEP of 8 cm H₂O). The tidal volume was reduced to 6 mL/kg during OLV in all groups. Blood gas analyses, respiratory variables, and hemodynamic variables were recorded 15 min into TLV (TLV(baseline)), 15 and 30 min after OLV (OLV₁₅ and OLV₃₀), and 10 min after re-establishing TLV (TLV(end)). RESULTS Ultimately, 92 patients were analyzed. In the AR group, the arterial oxygen tension was higher at TLV(end), and the physiologic dead space was lower at OLV₁₅ and TLV(end) than in the control group. The mean airway pressure and dynamic lung compliance were higher in the PEEP and AR groups than in the control group at OLV₁₅, OLV₃₀, and TLV(end). No significant differences in hemodynamic variables were found among the three groups throughout the study period. CONCLUSION Recruitment of both lungs with subsequent PEEP before OLV improved arterial oxygenation and ventilatory efficiency during video-assisted thoracic surgery requiring OLV in the supine position.
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Affiliation(s)
- Yong Seon Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Mi Kyung Bae
- Department of Thoracic and Cardiovascular Surgery, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Shin Hyung Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ji-Eun Park
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Soo Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Jun Oh
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Das A, Cole O, Chikhani M, Wang W, Ali T, Haque M, Bates DG, Hardman JG. Evaluation of lung recruitment maneuvers in acute respiratory distress syndrome using computer simulation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:8. [PMID: 25578295 PMCID: PMC4329196 DOI: 10.1186/s13054-014-0723-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 12/16/2014] [Indexed: 02/03/2023]
Abstract
Introduction Direct comparison of the relative efficacy of different recruitment maneuvers (RMs) for patients with acute respiratory distress syndrome (ARDS) via clinical trials is difficult, due to the heterogeneity of patient populations and disease states, as well as a variety of practical issues. There is also significant uncertainty regarding the minimum values of positive end-expiratory pressure (PEEP) required to ensure maintenance of effective lung recruitment using RMs. We used patient-specific computational simulation to analyze how three different RMs act to improve physiological responses, and investigate how different levels of PEEP contribute to maintaining effective lung recruitment. Methods We conducted experiments on five ‘virtual’ ARDS patients using a computational simulator that reproduces static and dynamic features of a multivariable clinical dataset on the responses of individual ARDS patients to a range of ventilator inputs. Three recruitment maneuvers (sustained inflation (SI), maximal recruitment strategy (MRS) followed by a titrated PEEP, and prolonged recruitment maneuver (PRM)) were implemented and evaluated for a range of different pressure settings. Results All maneuvers demonstrated improvements in gas exchange, but the extent and duration of improvement varied significantly, as did the observed mechanism of operation. Maintaining adequate post-RM levels of PEEP was seen to be crucial in avoiding cliff-edge type re-collapse of alveolar units for all maneuvers. For all five patients, the MRS exhibited the most prolonged improvement in oxygenation, and we found that a PEEP setting of 35 cm H2O with a fixed driving pressure of 15 cm H2O (above PEEP) was sufficient to achieve 95% recruitment. Subsequently, we found that PEEP titrated to a value of 16 cm H2O was able to maintain 95% recruitment in all five patients. Conclusions There appears to be significant scope for reducing the peak levels of PEEP originally specified in the MRS and hence to avoid exposing the lung to unnecessarily high pressures. More generally, our study highlights the huge potential of computer simulation to assist in evaluating the efficacy of different recruitment maneuvers, in understanding their modes of operation, in optimizing RMs for individual patients, and in supporting clinicians in the rational design of improved treatment strategies. Electronic supplementary material The online version of this article (doi:10.1186/s13054-014-0723-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anup Das
- School of Engineering, University of Warwick, Library Road, Coventry, CV4 7AL, UK.
| | - Oana Cole
- Anaesthesia & Critical Care Research Group, University of Nottingham, Derby Road, Nottingham, NG7 2UH, UK.
| | - Marc Chikhani
- Anaesthesia & Critical Care Research Group, University of Nottingham, Derby Road, Nottingham, NG7 2UH, UK.
| | - Wenfei Wang
- School of Engineering, University of Warwick, Library Road, Coventry, CV4 7AL, UK.
| | - Tayyba Ali
- Anaesthesia & Critical Care Research Group, University of Nottingham, Derby Road, Nottingham, NG7 2UH, UK.
| | - Mainul Haque
- Anaesthesia & Critical Care Research Group, University of Nottingham, Derby Road, Nottingham, NG7 2UH, UK.
| | - Declan G Bates
- School of Engineering, University of Warwick, Library Road, Coventry, CV4 7AL, UK.
| | - Jonathan G Hardman
- Anaesthesia & Critical Care Research Group, University of Nottingham, Derby Road, Nottingham, NG7 2UH, UK.
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Lee DK, Kim HK, Lee K, Choi YH, Lim SH, Kim H. Optimal Respiratory Rate for Low-Tidal Volume and Two-Lung Ventilation in Thoracoscopic Bleb Resection. J Cardiothorac Vasc Anesth 2014; 29:972-6. [PMID: 25440636 DOI: 10.1053/j.jvca.2014.06.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Indexed: 11/11/2022]
Abstract
OBJECTIVES One-lung ventilation is considered to be mandatory in video-assisted thoracoscopic surgery. However, the authors showed in a previous report that two-lung ventilation with low tidal volume is feasible in thoracoscopic bleb resection (TBR). In this study, they evaluated optimal respiratory rate during TBR under two-lung ventilation with low-tidal volume anesthesia. DESIGN A prospective, randomized, single-blinded intervention study. SETTING An operating room in a teaching hospital. PARTICIPANTS Forty-eight patients who underwent scheduled TBR under general anesthesia. INTERVENTIONS TBR was performed under low-tidal-volume (5 mL/kg), two-lung ventilation. Respiratory rate (RR) varied according to the protocol: 15 (group I), 18 (group II), and 22 cycles/min (group III). Using block randomization method, 16 patients were assigned to each of 3 groups. MEASUREMENTS AND MAIN RESULTS Minute ventilation of group I was lowered significantly compared with the other groups (p<0.001). The results of arterial blood gas analysis were in the physiologic range in all patients. Surgery and anesthetic times and number of endostaples used were not significantly different among the 3 groups. CONCLUSIONS The RR of 15 cycles/min with low-tidal volume (5 mL/kg) and two-lung ventilation did not produce abnormal physiologic changes including arterial pH, partial arterial oxygen pressure, and partial pressure of carbon dioxide and guaranteed an optimal surgical field. Therefore, these setting are considered acceptable for two-lung ventilation during TBR.
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Affiliation(s)
- Dong Kyu Lee
- Departments of *Anesthesiolafogy and Pain Medicine
| | - Hyun Koo Kim
- Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Kanghoon Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Young Ho Choi
- Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sang Ho Lim
- Departments of *Anesthesiolafogy and Pain Medicine
| | - Heezoo Kim
- Departments of *Anesthesiolafogy and Pain Medicine.
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Pressure safety range of barotrauma with lung recruitment manoeuvres: a randomised experimental study in a healthy animal model. Eur J Anaesthesiol 2014; 30:567-74. [PMID: 23857081 DOI: 10.1097/eja.0b013e3283607875] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
CONTEXT Recruitment manoeuvres aim at reversing atelectasis during general anaesthesia but are associated with potential risks such as barotrauma. OBJECTIVE To explore the range of pressures that can be used safely to fully recruit the lung without causing barotrauma in an ex-vivo healthy lung rabbit model. DESIGN Prospective, randomised, experimental study. SETTING Experimental Unit, La Paz University Hospital, Madrid, Spain. ANIMALS Fourteen healthy young New Zealand rabbits of 12 weeks of age. INTERVENTIONS Animals were euthanised, the thorax and both pleural spaces were opened and the animals were allocated randomly into one of two groups submitted to two distinct recruitment manoeuvre strategies: PEEP-20 group, in which positive end-expiratory pressure (PEEP) was increased in 5-cmH2O steps from 0 to 20 cmH2O and PEEP-50 group, in which PEEP was increased in 5-cmH2O steps from 0 to 50 cmH2O. In both groups, a driving pressure of 15 cmH2O was maintained until maximal PEEP and its corresponding maximal inspiratory pressures (MIPs) were reached. From there on, driving pressure was progressively increased in 5-cmH2O steps until detectable barotrauma occurred. Two macroscopic conditions were defined: anatomically open lung and barotrauma. MAIN OUTCOME MEASURES We measured open lung and barotrauma MIP, PEEP and driving pressure obtained using each strategy. A pressure safety range, defined as the difference between barotrauma MIP and anatomically open lung MIP, was also determined in both groups. RESULTS Open lung MIP was similar in both groups: 23.6 ± 3.8 and 23.3 ± 4.1 cmH2O in the PEEP-50 and PEEP-20 groups, respectively (P = 0.91). However, barotrauma MIP in the PEEP-50 group was higher (65.7 ± 3.4 cmH2O) than in the PEEP-20 group (56.7 ± 5 0.2 cmH2O) (P = 0.003) resulting in a safety range of pressures of respectively 33.3 ± 8.7 and 42.1 ± 3.9 cmH2O (P = 0.035). CONCLUSION In this ex-vivo model, we found a substantial difference between recruitment and barotrauma pressures using both recruitment strategies. However, a higher margin of safety was obtained when a higher PEEP and lower driving pressure strategy was used for recruiting the lung.
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Jung JD, Kim SH, Yu BS, Kim HJ. Effects of a preemptive alveolar recruitment strategy on arterial oxygenation during one-lung ventilation with different tidal volumes in patients with normal pulmonary function test. Korean J Anesthesiol 2014; 67:96-102. [PMID: 25237445 PMCID: PMC4166395 DOI: 10.4097/kjae.2014.67.2.96] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 03/19/2014] [Accepted: 05/25/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypoxemia during one-lung ventilation (OLV) remains a major concern. The present study compared the effect of alveolar recruitment strategy (ARS) on arterial oxygenation during OLV at varying tidal volumes (Vt) with or without positive end-expiratory pressure (PEEP). METHODS In total, 120 patients undergoing wedge resection by video assisted thoracostomy were randomized into four groups comprising 30 patients each: those administered a 10 ml/kg tidal volume with or without preemptive ARS (Group H and Group H-ARS, respectively) and those administered a 6 ml/kg tidal volume and a 8 cmH2O PEEP with or without preemptive ARS (Group L and Group L-ARS, respectively). ARS was performed using pressure-controlled ventilation with a 40 cmH2O plateau airway pressure and a 15 cmH2O PEEP for at least 10 breaths until OLV began. RESULTS Preemptive ARS significantly improved the PaO2/FiO2 ratio compared to the groups that did not receive ARS (P < 0.05). The H-ARS group showed a highest PaO2/FiO2 ratio during OLV, the L-ARS and H groups showed similarly improved arterial oxygenation, which was significantly higher than in group L (P < 0.05). The plateau airway pressure in group H-ARS was significantly higher than in group L-ARS (P < 0.05). CONCLUSIONS Preemptive ARS can improve arterial oxygenation during OLV. Furthermore, a 6 ml/kg tidal volume combined with 8 cmH2O PEEP after preemptive ARS may reduce the risk of pulmonary injury caused by high tidal volume during one-lung ventilation in patients with normal pulmonary function.
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Affiliation(s)
- Jong Dal Jung
- Department of Anesthesiology and Pain Medicine, Chosun University School of Medicine, Gwangju, Korea. ; Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju, Korea
| | - Sang Hun Kim
- Department of Anesthesiology and Pain Medicine, Chosun University School of Medicine, Gwangju, Korea. ; Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju, Korea
| | - Byung Sik Yu
- Department of Anesthesiology and Pain Medicine, Chosun University School of Medicine, Gwangju, Korea. ; Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju, Korea
| | - Hye Ji Kim
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju, Korea
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Protective Ventilatory Approaches to One-Lung Ventilation: More than Reduction of Tidal Volume. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0057-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Ferrando C, Mugarra A, Gutierrez A, Carbonell JA, García M, Soro M, Tusman G, Belda FJ. Setting Individualized Positive End-Expiratory Pressure Level with a Positive End-Expiratory Pressure Decrement Trial After a Recruitment Maneuver Improves Oxygenation and Lung Mechanics During One-Lung Ventilation. Anesth Analg 2014; 118:657-65. [DOI: 10.1213/ane.0000000000000105] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Alveolar Recruitment Maneuvers for One-Lung Ventilation During Thoracic Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0054-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Hedenstierna G, Rothen HU. Respiratory function during anesthesia: effects on gas exchange. Compr Physiol 2013; 2:69-96. [PMID: 23728971 DOI: 10.1002/cphy.c080111] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Anaesthesia causes a respiratory impairment, whether the patient is breathing spontaneously or is ventilated mechanically. This impairment impedes the matching of alveolar ventilation and perfusion and thus the oxygenation of arterial blood. A triggering factor is loss of muscle tone that causes a fall in the resting lung volume, functional residual capacity. This fall promotes airway closure and gas adsorption, leading eventually to alveolar collapse, that is, atelectasis. The higher the oxygen concentration, the faster will the gas be adsorbed and the aleveoli collapse. Preoxygenation is a major cause of atelectasis and continuing use of high oxygen concentration maintains or increases the lung collapse, that typically is 10% or more of the lung tissue. It can exceed 25% to 40%. Perfusion of the atelectasis causes shunt and cyclic airway closure causes regions with low ventilation/perfusion ratios, that add to impaired oxygenation. Ventilation with positive end-expiratory pressure reduces the atelectasis but oxygenation need not improve, because of shift of blood flow down the lung to any remaining atelectatic tissue. Inflation of the lung to an airway pressure of 40 cmH2O recruits almost all collapsed lung and the lung remains open if ventilation is with moderate oxygen concentration (< 40%) but recollapses within a few minutes if ventilation is with 100% oxygen. Severe obesity increases the lung collapse and obstructive lung disease and one-lung anesthesia increase the mismatch of ventilation and perfusion. CO2 pneumoperitoneum increases atelectasis formation but not shunt, likely explained by enhanced hypoxic pulmonary vasoconstriction by CO2. Atelectasis may persist in the postoperative period and contribute to pneumonia.
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Affiliation(s)
- Göran Hedenstierna
- Department of Medical Sciences, Clinical Physiology, Uppsala University Hospital, Uppsala, Sweden.
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24
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Hung MH, Hsu HH, Chen KC, Chan KC, Cheng YJ, Chen JS. Nonintubated Thoracoscopic Anatomical Segmentectomy for Lung Tumors. Ann Thorac Surg 2013; 96:1209-1215. [DOI: 10.1016/j.athoracsur.2013.05.065] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 05/20/2013] [Accepted: 05/21/2013] [Indexed: 11/16/2022]
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Alveolar recruitment maneuver as an important part of protective one-lung ventilation. J Anesth 2012; 26:794-5. [PMID: 22552387 DOI: 10.1007/s00540-012-1396-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2012] [Accepted: 04/10/2012] [Indexed: 10/28/2022]
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Unzueta C, Tusman G, Suarez-Sipmann F, Böhm S, Moral V. Alveolar recruitment improves ventilation during thoracic surgery: a randomized controlled trial. Br J Anaesth 2012; 108:517-24. [DOI: 10.1093/bja/aer415] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Abstract
PURPOSE OF REVIEW Hypoxemia during one-lung ventilation (OLV) has become less common; however, it may still occur in about 10% of cases. We review recent developments which may affect the incidence and treatment of hypoxemia during OLV. RECENT FINDINGS Changes in surgical techniques are affecting oxygenation during OLV. The increased use of the supine position may adversely affect the prevalence of hypoxemia, whereas the increased application of thoracoscopic techniques is limiting the treatment options. Treatment options such as global or selective recruitment maneuvers and drug effects of dexmedetomidine and epoprostenol on arterial oxygenation during OLV are discussed. Capnometry prior to, or early during OLV, may in fact be able to predict the degree of hypoxemia during OLV. Persistent controversies surrounding the effect of epidural anesthesia, ventilatory modalities and gravity are reviewed. SUMMARY Interesting concepts have emerged from case reports and small studies on the treatment and prediction of hypoxemia during OLV. Definitive studies on the most effective ventilatory mode remain elusive. End-organ effects of OLV are an exciting new concept that may shape clinical practice and research going forward.
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A preemptive alveolar recruitment strategy before one-lung ventilation improves arterial oxygenation in patients undergoing thoracic surgery: a prospective randomised study. Eur J Anaesthesiol 2011. [DOI: 10.1097/eja.0b013e3283436fdb] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Prevention and reversal of lung collapse during the intra-operative period. Best Pract Res Clin Anaesthesiol 2010; 24:183-97. [PMID: 20608556 DOI: 10.1016/j.bpa.2010.02.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
General anaesthesia induces ventilation/perfusion mismatch by lung collapse. Such lung collapse predisposes patients to preoperative complications since it can persist for several hours or days after surgery. Atelectasis can be partially prevented by using continuous positive airway pressure (CPAP) and/or by lowering FiO2 during anaesthesia induction. However, these manoeuvres are dangerous for patients presenting with challenging airway or ventilator conditions. Lung recruitment manoeuvres (RMs) are ventilatory strategies that aim to restore the aeration of normal lungs. They consist of a brief and controlled increment in airway pressure to open up collapsed areas of the lungs and sufficient positive end-expiratory pressure (PEEP) to keep them open afterward. The application of RMs during anaesthesia normalises lung function along the intraoperative period. There is physiological evidence that patients of all ages and any kind of surgery benefit from such an active intervention. The effect of RMs on patient outcome in the postoperative period is, however, not yet known.
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[Peri-operative atelectasis and alveolar recruitment manoeuvres]. Arch Bronconeumol 2009; 46:317-24. [PMID: 19959274 DOI: 10.1016/j.arbres.2009.10.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Revised: 10/08/2009] [Accepted: 10/10/2009] [Indexed: 10/20/2022]
Abstract
Respiratory complications are a significant cause of post-operative morbidity and mortality. Peri-operative atelectasis, in particular, affects 90% of surgical patients and its effects can be prolonged, due to changes in respiratory mechanics, pulmonary circulation and hypoxaemia. Alveolar collapse is caused by certain predisposing factors, mainly by compression and absorption mechanisms. To prevent or treat these atelectasis several therapeutic strategies have been proposed, such as alveolar recruitment manoeuvres, which has become popular in the last few years. Its application in patients with alveolar collapse, but without a previous significant acute lung lesion, has some special features, therefore its use is not free of uncertainties and complications. This review describes the frequency, pathophysiology, importance and treatment of peri-operative atelectasis. Special attention is paid to treatment with recruitment manoeuvres, with the purpose of providing a basis for the their rational and appropriate use.
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Park SY, Kim DH, Kim JS, Lee SS, Hong YW. Effects of head-up tilt on intrapulmonary shunt fraction and oxygenation during 1-lung ventilation in the lateral decubitus position. J Thorac Cardiovasc Surg 2009; 139:1436-40. [PMID: 19709681 DOI: 10.1016/j.jtcvs.2009.07.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2009] [Revised: 06/16/2009] [Accepted: 07/16/2009] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Hypoxemia is a common problem of 1-lung ventilation. Arterial oxygenation progressively decreases after 1-lung ventilation. The surgical position influences the shunt and arterial oxygenation. Therefore we evaluated the effect of head-up tilt on intrapulmonary shunt and oxygenation during 1-lung ventilation in the lateral decubitus position. METHODS Twenty patients requiring 1-lung ventilation were included in this study. During 1-lung ventilation, hemodynamic and respiratory variables were measured 15 minutes after horizontal positioning in the lateral decubitus position (baseline), 5 and 10 minutes after a 10-degree head-up tilt (T5 and T10, respectively), and 10 minutes after the patient was returned to a horizontal position (T20). Arterial and mixed venous blood analyses were performed at the same time points. RESULTS Arterial oxygenation was increased, and shunt was decreased significantly during head-up tilt position in 1-lung ventilation. These changes were accompanied by decreases in the mean arterial pressure and cardiac filling pressures without significant changes in cardiac index. CONCLUSIONS Head-up tilt during 1-lung ventilation in the lateral decubitus position caused a significant decrease in shunt and an increase in arterial oxygenation that persisted after the patient was returned to the horizontal lateral decubitus position.
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Affiliation(s)
- Sung Yong Park
- Department of Anesthesiology and Pain Medicine, Ajou University of College of Medicine, Suwon, Korea
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Garutti I, Martinez G, Cruz P, Piñeiro P, Olmedilla L, de la Gala F. The Impact of Lung Recruitment on Hemodynamics During One-Lung Ventilation. J Cardiothorac Vasc Anesth 2009; 23:506-8. [DOI: 10.1053/j.jvca.2008.12.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2008] [Indexed: 11/11/2022]
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Effects of early vital capacity maneuver on respiratory variables during multivessel off-pump coronary artery bypass graft surgery. Crit Care Med 2009; 37:539-44. [PMID: 19114907 DOI: 10.1097/ccm.0b013e3181954403] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Despite avoiding cardiopulmonary bypass, similar degrees of pulmonary impairment compared with on-pump coronary artery bypass surgery have been demonstrated in patients undergoing off-pump coronary artery bypass graft surgery (OPCAB) compared with on-pump coronary artery bypass surgery. To investigate the effects of an early vital capacity maneuver (VCM) on intrapulmonary shunt (Qs/Qt), oxygenation, and pulmonary outcome in OPCAB. DESIGN Prospective, randomized, controlled, double-blind clinical trial. SETTING Cardiothoracic operating room and intensive care unit (ICU) of a university hospital. PATIENTS Fifty patients scheduled for OPCAB were randomized to treatment with VCM or none. INTERVENTIONS After sternotomy, VCM was performed by inflating the lungs to 40 cm H2O and holding this pressure for 10 seconds. MEASUREMENTS AND MAIN RESULTS Qs/Qt, Pao2/Fio2 (P/F) ratio, and dynamic and static pulmonary compliances were measured before induction of anesthesia (T0), 15 minutes after tracheal intubation (T1), during Y-graft construction (T2), 15 minutes after completion of grafting (T3), 15 minutes after sternal closure (T4), and 3 hours after arrival at the ICU (T5). Qs/Qt was lower and P/F ratio was higher in the VCM group at T2 through T5. Pulmonary compliances were also higher in the VCM group at T4 and T5. Patients in the VCM group were extubated earlier. CONCLUSIONS The beneficial effects of an early VCM on Qs/Qt persisted into the period of ICU care, with an improvement in P/F ratio and preserved pulmonary compliances, leading to a shorter time to extubation.
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Martínez G, Cruz P. [Atelectasis in general anesthesia and alveolar recruitment strategies]. ACTA ACUST UNITED AC 2009; 55:493-503. [PMID: 18982787 DOI: 10.1016/s0034-9356(08)70633-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Atelectasis occurs in most patients during general anesthesia and is the main cause of hypoxemia. The objective of this review is to examine the causes and diagnosis of atelectasis and the different strategies for reducing or preventing this complication and improving oxygenation. Pulmonary atelectasis is mainly caused by 3 factors: compression, gas absorption, and lack of surfactant. Compression and gas absorption are, however, the 2 most commonly implicated factors. Lung collapse is accentuated if pure oxygen is inhaled during induction or if the patient is morbidly obese. Laparoscopic, thoracic, and upper abdominal interventions also carry risk of lung collapse. Various techniques may be used to prevent atelectasis or to reopen collapsed lung tissue. These include using positive end-expiratory pressure or a high tidal volume-thus providing a higher airway pressure (vital capacity maneuver)-or both in combination. Alveolar recruitment strategies have been tried in bariatric surgery, single-lung ventilation, laparoscopy, and adult respiratory distress syndrome. Their application has reduced or prevented atelectasis, thereby reducing postoperative pulmonary complications.
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Affiliation(s)
- G Martínez
- Servicio de Anestesiología y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid.
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Cinnella G, Grasso S, Natale C, Sollitto F, Cacciapaglia M, Angiolillo M, Pavone G, Mirabella L, Dambrosio M. Physiological effects of a lung-recruiting strategy applied during one-lung ventilation. Acta Anaesthesiol Scand 2008; 52:766-75. [PMID: 18582305 DOI: 10.1111/j.1399-6576.2008.01652.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND One-lung ventilation (OLV) affects respiratory mechanics and ventilation/perfusion matching, reducing functional residual capacity of the ventilated lung. While the application of a lung-recruiting manoeuvre (RM) on the ventilated lung has been shown to improve oxygenation, data regarding the impact of RM on respiratory mechanics are not available. METHODS Thirteen patients undergoing lung resection in lateral decubitus were studied. During OLV, a lung-recruiting strategy consisting in a RM lasting 1 min followed by the application of positive end-expiratory pressure 5 cmH(2)O was applied to the ventilated lung. Haemodynamics, gas exchange and respiratory mechanics parameters were recorded on two-lung ventilation (TLV(baseline)), OLV before and 20 min after the RM (OLV(pre-RM), OLV(post-RM), respectively) and TLV(end). Haemodynamics parameters were also recorded during the RM. RESULTS The PaO(2)/FiO(2) ratio was 358+/-126 on TLV(baseline); it decreased to 235+/-113 on OLV(pre-RM) (P<0.01) increased to 351+/-120 on OLV(post-RM) (P<0.01 vs. OLV(pre-RM)), and remain stable thereafter. During the RM, CI decreased from 3.04+/-0.7 l/m(2) OLV(pre-RM) to 2.4+/-0.6 l/m(2) (P<0.05), and returned to baseline on OLV(post-RM) (3.1+/-0.7 l/m(2), NS vs. OLV(pre-RM)). The RM resulted in alveolar recruitment and caused a significant decrease in static elastance of the dependent lung (16.6+/-8.9 cmH(2)O/ml OLV(post-RM) vs. 22.3+/-8.1 cmH(2)O/ml OLV(pre-RM)) (P<0.01). CONCLUSIONS During OLV in lateral decubitus for thoracic surgery, application to the dependent lung a recruiting strategy significantly recruits the dependent lung, improving arterial oxygenation and respiratory mechanics until the end of surgery. However, the transient haemodynamic derangement occurring during the RM should be taken into account.
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Affiliation(s)
- G Cinnella
- Dipartimento di Scienze Chirurgiche, Sezione di Anestesiologia e Rianimazione, Università degli Studi di Foggia, Policlinico Riuniti, Foggia, Italy.
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Lytle FT, Brown DR. Appropriate Ventilatory Settings for Thoracic Surgery: Intraoperative and Postoperative. Semin Cardiothorac Vasc Anesth 2008; 12:97-108. [DOI: 10.1177/1089253208319869] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Mechanical ventilation of patients undergoing thoracic surgery is often challenging. These patients frequently have significant underlying comorbidities, including cardiopulmonary disease, and often must undergo 1-lung ventilation. Perioperative respiratory complications are common and are multifactorial in etiology. Increasing evidence suggests that mechanical ventilation is associated with, and may even cause, lung damage in both sick and healthy patients. Gas exchange to provide acceptable end-organ oxygenation remains a primary goal but so too is minimization of risks for acute lung injury. Every ventilator strategy is associated with potential beneficial and adverse side effects. Understanding the impact of various ventilation strategies allows clinicians to provide optimal care for patients.
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Affiliation(s)
| | - Daniel R. Brown
- Department of Anesthesia, Division of Critical Care, Mayo Clinic, Rochester, Minnesota,
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Abstract
PURPOSE OF REVIEW In the presence of the obligatory shunt during one-lung ventilation, arterial oxygenation is determined by the magnitude of the shunt in addition to the oxygen content of the mixed venous blood coursing through that shunt. The present discussion aims to heighten awareness of factors determining arterial oxygenation during one-lung anesthesia, other than the magnitude of the shunt and dependent lung low-ventilation perfusion units. RECENT FINDINGS A convenient way to increase mixed venous and thereby arterial oxygenation is to raise cardiac output. While this approach has achieved some success when increasing cardiac output from low levels, other studies have highlighted limitations of this approach when cardiac output attains very high levels. The effect of anesthesia techniques on the relationship between oxygen consumption and cardiac output could also explain unanswered questions regarding the pathophysiology of arterial oxygenation during one-lung anesthesia. SUMMARY The effects of anesthesia techniques on oxygen consumption, cardiac output and therefore mixed venous oxygenation can significantly affect arterial oxygenation during one-lung anesthesia. While pursuing increases in cardiac output may, under limited circumstances, benefit arterial oxygenation during one-lung ventilation, this approach is not a panacea and does not obviate the necessity to optimize dependent lung volume.
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Maisch S, Reissmann H, Fuellekrug B, Weismann D, Rutkowski T, Tusman G, Bohm SH. Compliance and Dead Space Fraction Indicate an Optimal Level of Positive End-Expiratory Pressure After Recruitment in Anesthetized Patients. Anesth Analg 2008; 106:175-81, table of contents. [DOI: 10.1213/01.ane.0000287684.74505.49] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Thoracic trauma, most often associated with other serious injuries, is the main cause of death in the first 45 years of life. The percentage of chest injuries in multiple trauma, mainly from blunt impact, has remained relatively constant at 80% during the last 30 years. Isolated thoracic injuries comprise only 25% of all trauma cases, 90% of chest injuries are due to blunt impact, while penetrating injuries make up 5-10%. Since 25% of deaths from trauma are attributable to chest injuries, they determine the survival rate in multiple trauma to a significant extent. The pattern of chest injuries is variable, frequently in different combinations comprising rib cage and diaphragm, lung parenchyma, airway and mediastinal organs. This article details the immediate simultaneous diagnostic and therapeutic procedures in the prehospital phase, management in the emergency room, the relative importance of computed tomography, ultrasound examination and endoscopy in the primary diagnostic evaluation and the principles of anaesthetic management of thoracic trauma.
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Affiliation(s)
- U Klein
- Klinik für Anaesthesie und operative Intensivtherapie, Südharz-Krankenhaus, Dr. Robert Koch-Strasse 39, 99734 Nordhausen.
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Abstract
PURPOSE OF REVIEW Hypoxemia is considered to be the most important challenge during one-lung ventilation. Recent studies, however, have shown that one-lung ventilation can involve some lung damage and can therefore be per se a cause of hypoxemia. RECENT FINDINGS It has been shown that some parameters of one-lung ventilation are associated with an increased probability of lung injury. High tidal volumes can trigger an increase in some inflammatory mediators in both experimental and clinical settings. High inspiratory pressures and/or a collapse of alveoli in every respiratory cycle would lead not only to an impairment of oxygenation, but also to a further incidence of 'postpneumonectomy pulmonary edema', the earlier definition of lung injury associated with one-lung ventilation. SUMMARY Hypoxemia should always be considered as the most important challenge during one-lung ventilation. One should also keep in mind, however, that some ventilatory strategies can even be harmful.
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Affiliation(s)
- Mert Sentürk
- Department of Anesthesiology, Istanbul University, Istanbul Medical Faculty, Turkey.
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Hinz J, Moerer O, Quintel M. Rekrutierungsmanöver bei Patienten mit Lungenversagen. Anaesthesist 2005; 54:1111-9. [PMID: 16075254 DOI: 10.1007/s00101-005-0906-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Recruitment maneuvers have been proposed as an adjunct to mechanical ventilation to re-expand collapsed lung regions. Although, in most patients recruitment maneuvers improve gas exchange a controversial discussion on recruitment maneuvers remains. This article reviews the physiological and patho-physiological backgrounds of recruitment maneuvers. The different recruitment maneuvers and possible monitoring are discussed as well as the influence of recruitment on other organs. Furthermore, we discuss whether recruitment maneuvers are useful if patients with acute lung injury or acute respiratory distress syndrome are ventilated with a lung-protective strategy.
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Affiliation(s)
- J Hinz
- Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin, Georg-August-Universität, Göttingen.
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Reis Miranda D, Struijs A, Koetsier P, van Thiel R, Schepp R, Hop W, Klein J, Lachmann B, Bogers AJJC, Gommers D. Open lung ventilation improves functional residual capacity after extubation in cardiac surgery*. Crit Care Med 2005; 33:2253-8. [PMID: 16215379 DOI: 10.1097/01.ccm.0000181674.71237.3b] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE After cardiac surgery, functional residual capacity (FRC) after extubation is reduced significantly. We hypothesized that ventilation according to the open lung concept (OLC) attenuates FRC reduction after extubation. DESIGN A prospective, single-center, randomized, controlled clinical study. SETTING Cardiothoracic operating room and intensive care unit of a university hospital. PATIENTS Sixty-nine patients scheduled for elective coronary artery bypass graft and/or valve surgery with cardiopulmonary bypass. INTERVENTIONS Before surgery, patients were randomly assigned to three groups: (1) conventional ventilation (CV); (2) OLC, started after arrival in the intensive care unit (late open lung); and (3) OLC, started directly after intubation (early open lung). In both OLC groups, recruitment maneuvers were applied until Pao2/Fio2 was >375 Torr (50 kPa). No recruitment maneuvers were applied in the CV group. MEASUREMENTS AND MAIN RESULTS FRC was measured preoperatively and 1, 3, and 5 days after extubation. Peripheral hemoglobin saturation (Spo2) was measured daily till the third day after extubation while the patient was breathing room air. Hypoxemia was defined by an Spo2 value < or =90%. Averaged over the 5 postoperative days, FRC was significantly higher in the early open lung group and tended to be higher in the late open lung group, in comparison with the CV group (mean +/- sem: CV, 1.8 +/- 0.1; late open lung,1.9 +/- 0.1; and early open lung, 2.2 +/- 0.1l). In the CV group, 37% of the patients were hypoxic on the third day after extubation, compared with none of the patients in both OLC groups. CONCLUSIONS After cardiac surgery, earlier application of OLC resulted in a significantly higher FRC and fewer episodes of hypoxemia than with CV after extubation.
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Affiliation(s)
- Dinis Reis Miranda
- Department of Cardio-Thoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
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Abstract
The ability to manage OLV effectively in patients with significant pulmonary disease is increasing. Knowledge of pulmonary ventilation and perfusion physiology, improvements in the ability to prevent and treat hypoxia, and a thorough grasp of traditional and novel ventilatory techniques may promote improved perioperative outcomes.
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Affiliation(s)
- Katherine P Grichnik
- Department of Anesthesiology, Duke University Medical Center, Box 3094, Duke University Health Care Systems, Durham, NC 27710, USA.
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Abstract
PURPOSE OF REVIEW Increased awareness of widespread atelectasis and deoxygenation after cardiac surgery, and in the ventilated lung during one-lung anaesthesia, has prompted many studies on recruitment of collapsed tissue and other methods to treat hypoxia in the perioperative period. It is therefore time to summarize what benefits might come from such manoeuvres. RECENT FINDINGS Major findings are that recruitment by different, often vigorous inflation of the lungs improves oxygenation and that this can also be seen when a recruitment manoeuvre is done of the ventilated lung in one-lung anaesthesia. The inspired oxygen fraction seems to be an important determinant of how long the recruitment persists. SUMMARY Recruitment manoeuvres are highly efficient in improving oxygenation but often for a limited period. So they have to be repeated. To what extent they may affect hospital stay and other variables of outcome, remains to be shown.
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Affiliation(s)
- Göran Hedenstierna
- Department of Medical Sciences, Clinical Physiology, Uppsala University, Sweden.
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Abstract
A ventilação seletiva consiste em ventilar um pulmão mecanicamente enquanto o outro é ocluído ou exposto ao ar ambiente. Essa técnica permite visualizar as estruturas intratorácicas e, assim, fornecer excelentes condições cirúrgicas. Todo o volume corrente é administrado apenas para um único pulmão. Entretanto, este procedimento está associado à redução da pressão parcial arterial de oxigênio, principalmente em pacientes com comprometimento pulmonar prévio, por diminuição na superfície da área de troca gasosa e perda da auto-regulação pulmonar normal. Sendo assim, a manutenção da oxigenação e a eliminação de gás carbônico adequadas representam o maior desafio durante o manejo da ventilação seletiva. Preconiza-se que o pulmão dependente seja ventilado com um volume corrente similar àquele utilizado para ventilar ambos os pulmões na ventilação mecânica convencional, além de altas frações inspiradas de oxigênio. Entretanto, vários outros métodos vêm sendo propostos a fim de minimizar a hipoxemia durante a ventilação seletiva: conferir o correto posicionamento do tubo de duplo-lúmen, uso de pressão positiva ao final da expiração, pressão contínua nas vias aéreas, uso de óxido nítrico, ventilação de alta freqüência e recrutamento alveolar. O manejo da ventilação seletiva continua sendo um desafio à prática clínica.
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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; 98:1604-1609. [PMID: 15155312 DOI: 10.1213/01.ane.0000068484.67655.1a] [Citation(s) in RCA: 130] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
UNLABELLED Atelectasis in the dependent lung during one-lung ventilation (OLV) impairs arterial oxygenation and increases dead space. We studied the effect of an alveolar recruitment strategy (ARS) on gas exchange and lung efficiency during OLV by using the single-breath test of CO(2) (SBT-CO(2)). Twelve patients undergoing thoracic surgery were studied at three points in time: (a) during two-lung ventilation and (b) during OLV before and (c) after an ARS. The ARS was applied selectively to the dependent lung and consisted of an increase in peak inspiratory pressure up to 40 cm H(2)O combined with a peak end-expiratory pressure level of 20 cm H(2)O for 10 consecutive breaths. The ARS took approximately 3 min. Arterial blood gases, SBT-CO(2), and metabolic and hemodynamic variables were recorded at the end of each study period. Arterial oxygenation and dead space were better during two-lung ventilation compared with OLV. PaO(2) increased during OLV after lung recruitment (244 +/- 89 mm Hg) when compared with OLV without recruitment (144 +/- 73 mm Hg; P < 0.001). The SBT-CO(2) analysis showed a significant decrease in dead-space variables and an increase in the variables related to the efficiency of ventilation during OLV after an ARS when compared with OLV alone. In conclusion, ARS improves gas exchange and ventilation efficiency during OLV. IMPLICATIONS In this article, we showed how a pulmonary ventilatory maneuver performed in the dependent lung during one-lung ventilation anesthesia improved arterial oxygenation and dead space.
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Affiliation(s)
- Gerardo Tusman
- *Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina; †Department of Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany; and ‡Department of Critical Care Medicine, Fundación Jimenez Diaz, Madrid, Spain
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Piacentini E, Villagrá A, López-Aguilar J, Blanch L. Clinical review: the implications of experimental and clinical studies of recruitment maneuvers in acute lung injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2003; 8:115-21. [PMID: 15025772 PMCID: PMC420020 DOI: 10.1186/cc2364] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Mechanical ventilation can cause and perpetuate lung injury if alveolar overdistension, cyclic collapse, and reopening of alveolar units occur. The use of low tidal volume and limited airway pressure has improved survival in patients with acute lung injury or acute respiratory distress syndrome. The use of recruitment maneuvers has been proposed as an adjunct to mechanical ventilation to re-expand collapsed lung tissue. Many investigators have studied the benefits of recruitment maneuvers in healthy anesthetized patients and in patients ventilated with low positive end-expiratory pressure. However, it is unclear whether recruitment maneuvers are useful when patients with acute lung injury or acute respiratory distress syndrome are ventilated with high positive end-expiratory pressure, and in the presence of lung fibrosis or a stiff chest wall. Moreover, it is unclear whether the use of high airway pressures during recruitment maneuvers can cause bacterial translocation. This article reviews the intrinsic mechanisms of mechanical stress, the controversy regarding clinical use of recruitment maneuvers, and the interactions between lung infection and application of high intrathoracic pressures.
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Affiliation(s)
- Enrique Piacentini
- Research Fellow, Critical Care Centre, Hospital de Sabadell, Institut Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Ana Villagrá
- Research Fellow, Critical Care Centre, Hospital de Sabadell, Institut Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Josefina López-Aguilar
- Researcher, Critical Care Centre, Hospital de Sabadell, Institut Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Lluis Blanch
- Executive Director, Critical Care Centre, Hospital de Sabadell, Institut Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
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Affiliation(s)
- L Magnusson
- Department of Anaesthesiology, University Hospital, CHUV, CH-1011 Lausanne, Switzerland.
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Tusman G, Melkun F, Staltari D, Quinzio C, Nador C, Turchetto E, Böhm SH. Alveolar recruitment during one-lung ventilation—really “one” lung?: Reply. Ann Thorac Surg 2003. [DOI: 10.1016/s0003-4975(02)04273-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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