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Raman R, Nair PS, Siddiqui AK, Prabha R, Kohli M, Srivastava VK. Effect of Deferasirox on Shunt Fraction During Thoracic Surgery With One-Lung Ventilation: A Randomized Controlled Study. Cureus 2023; 15:e39071. [PMID: 37323343 PMCID: PMC10267769 DOI: 10.7759/cureus.39071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 06/17/2023] Open
Abstract
Context Deferasirox, an iron chelator, can potentially reduce intraoperative right-to-left shunt and improve oxygenation in patients undergoing thoracic surgery requiring one-lung ventilation (OLV) by potentiating hypoxic pulmonary vasoconstriction (HPV). Aim The aim was to determine the effect of deferasirox on the intraoperative shunt fraction (SF) of patients undergoing thoracic surgery using OLV. Study design and settings This was a prospective, single-blind, randomized, controlled study. The study was conducted at a tertiary-care hospital. Methods Before surgery, 64 patients were allocated to two groups comprising 32 patients each. Group D patients were administered deferasirox, while those in group C were given a placebo. We included patients with the American Society of Anesthesiologists physical status III or IV, aged 18-60 years, undergoing elective thoracic surgery needing OLV. SF was the primary outcome variable. Secondary outcome variables were arterial oxygen tension (PaO2), peripheral oxygen saturation (SpO2), the ratio of PaO2 and inspired oxygen concentration (P/F), and complications such as desaturation episodes, hypotension, and tachycardia. Results Baseline and postoperative values of outcome variables were statistically similar in both groups. Intraoperative values of SF were lower and PaO2, SpO2, and P/F were higher in group D. The incidence of intraoperative desaturation was lower in group D. Conclusion We conclude that pre-treatment with deferasirox reduces intraoperative SF and improves oxygenation during thoracic surgery using OLV.
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Affiliation(s)
- Rajesh Raman
- Department of Anaesthesiology, King George's Medical University, Lucknow, IND
| | - Parvathy S Nair
- Department of Anaesthesiology, King George's Medical University, Lucknow, IND
| | | | - Rati Prabha
- Department of Anaesthesiology, King George's Medical University, Lucknow, IND
| | - Monica Kohli
- Department of Anaesthesiology, King George's Medical University, Lucknow, IND
| | - Vinod K Srivastava
- Department of Anaesthesiology, King George's Medical University, Lucknow, IND
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Schorer R, Dombret AL, Hagerman A, Bédat B, Putzu A. Impact of pharmacological interventions on intrapulmonary shunt during one-lung ventilation in adult thoracic surgery: a systematic review and component network meta-analysis. Br J Anaesth 2023; 130:e92-e105. [PMID: 36939497 DOI: 10.1016/j.bja.2022.08.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 08/05/2022] [Accepted: 08/24/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Intrapulmonary shunt is a major determinant of oxygenation in thoracic surgery under one-lung ventilation. We reviewed the effects of available treatments on shunt, Pao2/FiO2 and haemodynamics through systematic review and network meta-analysis. METHODS Online databases were searched for RCTs comparing pharmacological interventions and intrapulmonary shunt in thoracic surgery under one-lung ventilation up to March 30, 2022. Random-effects (component) network meta-analysis compared 24 treatments and 19 treatment components. The Confidence in Network Meta-Analysis (CINeMA) framework assessed evidence certainty. The primary outcome was intrapulmonary shunt fraction during one-lung ventilation. RESULTS A total of 55 RCTs were eligible for systematic review (2788 participants). The addition of N2O (mean difference [MD]=-15%; 95% confidence interval [CI], -25 to -5; P=0.003) or almitrine (MD=-13%; 95% CI, -20 to -6; P<0.001) to propofol anaesthesia were efficient at decreasing shunt. Combined epidural anaesthesia (MD=3%; 95% CI, 1-5; P=0.005), sevoflurane (MD=5%; 95% CI, 2-8; P<0.001), isoflurane (MD=6%; 95% CI, 4-9; P<0.001), and desflurane (MD=9%; 95% CI, 4-14; P=0.001) increased shunt vs propofol. Almitrine (MD=147 mm Hg; 95% CI, 58-236; P=0.001), dopexamine (MD=88 mm Hg; 95% CI, 4-171; P=0.039), and iloprost (MD=81 mm Hg; 95% CI, 4-158; P=0.038) improved Pao2/FiO2. Certainty of evidence ranged from very low to moderate. CONCLUSIONS Adding N2O or almitrine to propofol anaesthesia reduced intrapulmonary shunt during one-lung ventilation. Halogenated anaesthetics increased shunt in comparison with propofol. The effects of N2O, iloprost, and dexmedetomidine should be investigated in future research. N2O results constitute a research hypothesis currently not backed by any direct evidence. The clinical availability of almitrine is limited. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42022310313.
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Affiliation(s)
- Raoul Schorer
- Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland.
| | - Anna-Luna Dombret
- Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Andres Hagerman
- Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Benoît Bédat
- Division of Thoracic and Endocrine Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Alessandro Putzu
- Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
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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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Shen L, Chen JQ, Yang XL, Hu JC, Gao W, Chai XQ, Wang D. Flurbiprofen used in one-lung ventilation improves intraoperative regional cerebral oxygen saturation and reduces the incidence of postoperative delirium. Front Psychiatry 2022; 13:889637. [PMID: 36117654 PMCID: PMC9470861 DOI: 10.3389/fpsyt.2022.889637] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 08/04/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND We previously demonstrated that flurbiprofen increased arterial oxygen partial pressure and reduced intrapulmonary shunts. The present study aims to investigate whether flurbiprofen improves intraoperative regional cerebral oxygen saturation (rScO2) and reduces the incidence of postoperative delirium (POD) in elderly patients undergoing one-lung ventilation (OLV). METHODS One hundred and twenty patients undergoing thoracoscopic lobectomy were randomly assigned to the flurbiprofen-treated group (n = 60) and the control-treated group (n = 60). Flurbiprofen was intravenously administered 20 minutes before skin incision. The rScO2 and partial pressure of arterial oxygen (PaO2) were recorded during the surgery, and POD was measured by the Confusion Assessment Method (CAM) within 5 days after surgery. The study was registered in the Chinese Clinical Trial Registry with the number ChiCTR1800020032. RESULTS Compared with the control group, treatment with flurbiprofen significantly improved the mean value of intraoperative rScO2 as well as the PaO2 value (P < 0.05, both) and significantly reduced the baseline values of the rScO2 area under threshold (AUT) (P < 0.01) at 15, 30, and 60 min after OLV in the flurbiprofen-treated group. After surgery, the POD incidence in the flurbiprofen-treated group was significantly decreased compared with that in the control group (P < 0.05). CONCLUSION Treatment with flurbiprofen may improve rScO2 and reduce the incidence of POD in elderly patients undergoing thoracoscopic one-lung ventilation surgery for lung cancer. CLINICAL TRIAL REGISTRATION http://www.chictr.org/cn/, identifier ChiCTR1800020032.
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Affiliation(s)
- Liang Shen
- Department of Anesthesiology, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, China.,Pain Clinic, Department of Anesthesiology, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, China
| | - Jia-Qi Chen
- Pain Clinic, Department of Anesthesiology, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, China
| | - Xin-Lu Yang
- Pain Clinic, Department of Anesthesiology, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, China
| | - Ji-Cheng Hu
- Pain Clinic, Department of Anesthesiology, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, China
| | - Wei Gao
- Pain Clinic, Department of Anesthesiology, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, China
| | - Xiao-Qing Chai
- Pain Clinic, Department of Anesthesiology, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, China
| | - Di Wang
- Pain Clinic, Department of Anesthesiology, First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, China
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Bergmann A, Schilling T. [Intraoperative Ventilation Approaches to One-lung Ventilation]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:329-341. [PMID: 34038972 DOI: 10.1055/a-1189-8031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The management of thoracic surgery patients is challenging to the anesthetist, since one-lung ventilation (OLV) includes at least two major conditions: sufficient oxygenation and lung protection. The first is mainly because the ventilation of one lung is stopped while perfusion to that lung continues; the latter is related to the fact that the whole ventilation is applied to only a single lung. Recommendations for maintaining the oxygenation and methods of lung protection may contradict each other (e. g. high vs. low inspiratory oxygen fraction (FiO2), high vs. low tidal volume, etc.). Therefore, a high degree of pathophysiological understanding and manual skills are required in the management of these patients.In light of recent clinical studies, this review focuses on a current protective strategy for OLV, which includes a possible decrease in FiO2, lowered VT, the application of positive end-expiratory pressure (PEEP) to the dependent and continuous positive airway pressure (CPAP) to the non-dependent lung and alveolar recruitment manoeuvres as well. Other approaches such as the choice of anaesthetics, remote ischemic preconditioning, fluid management and pain therapy can support the success of ventilatory strategy. The present work describes new developments that may change the classical approach in this respect.
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Ishida Y, Okada T, Kobayashi T, Uchino H. ORi™: a new indicator of oxygenation. J Anesth 2021; 35:734-740. [PMID: 33900455 PMCID: PMC8072303 DOI: 10.1007/s00540-021-02938-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 04/18/2021] [Indexed: 12/14/2022]
Abstract
In the perioperative period, hypoxemia and hyperoxia are crucial factors that require attention, because they greatly affect patient prognoses. The pulse oximeter has been the only noninvasive monitor that can be used as a reference of oxygenation in current anesthetic management; however, in recent years, a new monitoring method that uses the oxygen reserve index (ORi™) has been developed by Masimo Corp. ORi is an index that reflects the state of moderate hyperoxia (partial pressure of arterial oxygen [PaO2] between 100 and 200 mmHg) using a non-unit scale between 0.00 and 1.00. ORi monitoring performed together with percutaneous oxygen saturation (SpO2) measurements may become an important technique in the field of anesthetic management, for measuring oxygenation reserve capacity. By measuring ORi, it is possible to predict hypoxemia and to detect hyperoxia at an early stage. In this review, we summarize the method of ORi, cautions for its use, and suitable cases for its use. In the near future, the monitoring of oxygen concentrations using ORi may become increasingly common for the management of respiratory function before, after, and during surgery.
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Affiliation(s)
- Yusuke Ishida
- Department of Anesthesiology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan.
| | - Toshio Okada
- Department of Anesthesiology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Takayuki Kobayashi
- Department of Anesthesiology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
| | - Hiroyuki Uchino
- Department of Anesthesiology, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo, 160-0023, Japan
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Yoon S, Kim BR, Min SH, Lee J, Bahk JH, Seo JH. Repeated intermittent hypoxic stimuli to operative lung reduce hypoxemia during subsequent one-lung ventilation for thoracoscopic surgery: A randomized controlled trial. PLoS One 2021; 16:e0249880. [PMID: 33857201 PMCID: PMC8049270 DOI: 10.1371/journal.pone.0249880] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 03/23/2021] [Indexed: 11/18/2022] Open
Abstract
Background An intervention to potentiate hypoxic pulmonary vasoconstriction may reduce intrapulmonary shunt and hypoxemia during one-lung ventilation. Previous animal studies reported that repeated intermittent hypoxic stimuli potentiated hypoxic pulmonary vasoconstriction, but no clinical study has examined the effects of this intervention on hypoxemia during one-lung ventilation. We thus performed a single-center, parallel-group, double-blind, randomized controlled trial to investigate whether repeated intermittent hypoxic stimuli to the operative lung reduce hypoxemia during the subsequent one-lung ventilation for thoracoscopic surgery. Methods Patients undergoing one-lung ventilation were randomized into two groups (n = 68 each). Before one-lung ventilation, in the intermittent hypoxia group, the nondependent lung was not ventilated for 2 min and then ventilated for 2 min while the dependent lung was continuously ventilated. This was repeated five times. In the continuous normoxia group, both lungs were ventilated for 20 min. We measured SpO2, PaO2, FiO2, PaCO2, SaO2, and central venous oxygen saturation during one-lung ventilation. The primary outcome was the number of patients with hypoxemia defined as a SpO2 <95% during one-lung ventilation, which was analyzed with a chi-squared test. Results Hypoxemia was less frequent in the intermittent hypoxia group than in the continuous normoxia group during OLV [6/68 (8.8%) vs 17/68 (25.0%), risk ratio (95% CI) 0.35 (0.15–0.84), p = 0.012]. The PaO2 (p = 0.008 for 30 min and 0.007 for 60 min) and PaO2/FiO2 (p = 0.008 for both) were higher 30 and 60 min after starting one-lung ventilation, and the alveolar-arterial pressure gradient (p = 0.010) and shunt index (p = 0.008) were lower 30 min after starting one-lung ventilation in the intermittent hypoxia group than in the continuous normoxia group. Postoperative adverse events did not differ significantly between groups. Conclusions Repeated intermittent hypoxic stimuli to the operative lung seemed to potentiate hypoxic pulmonary vasoconstriction, and thus reduced hypoxemia during the subsequent one-lung ventilation.
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Affiliation(s)
- Susie Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Bo Rim Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Se-Hee Min
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, Seoul, Republic of Korea
| | - Jaehun Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jae-Hyon Bahk
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jeong-Hwa Seo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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8
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Zhang L, Wang YP, Chen XF, Yan ZR, Zhou M. Effects of bronchial blockers on gas exchange in infants with one-lung ventilation: a single-institutional experience of 22 cases. Transl Pediatr 2020; 9:802-808. [PMID: 33457302 PMCID: PMC7804471 DOI: 10.21037/tp-20-391] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND One-lung ventilation (OLV) in infants is a commonly used airway technique during thoracic surgery. Current research has primarily focused on the operation of the airways and the occurrence of complications. However, there has been minimal data on the pulmonary gas exchange in infants before and after OLV. This study aimed to assess the efficacy of bronchial blockers (BBs) on the pulmonary gas exchange in infants with OLV. METHODS A total of 22 infants requiring OLV from January 2017 to August 2019 were included in this study. OLV was achieved by placing BBs outside the endotracheal tube, and all surgeries were performed by the same experienced anesthesiologist. Numerous clinical features, including the oxygenation index (OI), alveolar-arterial oxygen tension gradient (PA-aO2), pulmonary dynamic compliance (Cdyn), OLV time, pulmonary collapse time, degree of pulmonary collapse at the operative side, operative time, and immediate hemodynamic indexes before and after intubation were assessed. Data from the arterial blood gases and the ventilator's parameters were obtained at three time points: 15 minutes before OLV (pre-OLV), 15 minutes after the initiation of OLV (during OLV), and 15 minutes after the termination of OLV (post-OLV). RESULTS For all patients, the pulmonary gas exchange during OLV was significantly different from both pre-OLV and post-OLV. However, no significant changes of pulmonary function were observed before and after OLV. Extended OLV time was associated with decreased OI and Cdyn, and increased PA-aO2 gradient (P<0.001). In addition, no significant changes of hemodynamic indexes before and after intubation were detected. The degree of lung collapse on the operational side during OLV was optimal. CONCLUSIONS In this study, the efficacy of BBs on the pulmonary gas exchange in infants with OLV was assessed. The results suggested that although each parameter of pulmonary function pre-OLV were similar to those of post-OLV, an extended period of OLV may lead to compromised lung function.
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Affiliation(s)
- Li Zhang
- Department of Anesthesiology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yu-Ping Wang
- Department of Anesthesiology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Xiao-Fen Chen
- Department of Anesthesiology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Zi-Rogn Yan
- Department of Anesthesiology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Min Zhou
- Department of Anesthesiology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
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9
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Weigeldt M, Paul M, Schulz-Drost S, Schmittner MD. [Anesthesia, ventilation and pain treatment in thoracic trauma]. Unfallchirurg 2019; 121:634-641. [PMID: 29907900 DOI: 10.1007/s00113-018-0523-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The management of anesthesia plays a central role in the treatment of thoracic trauma, both in the initial phase when safeguarding the difficult airway and in the intensive care unit. A rapid transfer to a trauma center should be considered in order to recognize and treat organ dysfunction in time. Development of atelectasis, pneumonia and acute lung failure are common pulmonary complications. Non-invasive ventilation combined with physiotherapy and respiratory training can help to minimize these pulmonary complications. If single lung ventilation is necessary as part of the operative patient care, a double-lumen tube, a bronchial blocker and the Univent®-Tubus (Fuji Systems Corporation, Tokyo, Japan) can be used. Special attention should be paid to the hypoxic pulmonary vasoconstriction that occurs in this maneuver. Pain therapy is ideally carried out patient-adapted with epidural anesthesia. In addition, intraoperatively inserted catheters in the sense of a continuous intercostal block or serratus plane block are good alternatives. The aim of these therapies should be early mobilization and transfer of the patient to rehabilitation.
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Affiliation(s)
- M Weigeldt
- Klinik für Anästhesiologie, Intensiv- und Schmerzmedizin, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland. .,Zentrum für Klinische Forschung, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Deutschland.
| | - M Paul
- Klinik für Anästhesiologie, Intensiv- und Schmerzmedizin, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland
| | - S Schulz-Drost
- Klinik für Unfallchirurgie und Orthopädie, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Deutschland
| | - M D Schmittner
- Klinik für Anästhesiologie, Intensiv- und Schmerzmedizin, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Str. 7, 12683, Berlin, Deutschland
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10
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Wang C, Ke H, Xu X, Chen J, Sun D, Ji F. Protective effect of nicorandil on collapse‑induced lung injury in rabbits by inhibiting apoptosis. Int J Mol Med 2019; 44:725-736. [PMID: 31173181 DOI: 10.3892/ijmm.2019.4236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 05/24/2019] [Indexed: 11/06/2022] Open
Abstract
The one‑lung ventilation (OLV) technique is vital in thoracic surgery. However, it can result in severe lung injury, which is difficult to manage. The main solution at present is the use of ventilation strategies, including continuous positive oxygen pressure, low tidal volume and high frequency ventilation, and the administering of drugs, including phenylephrine, dexmedetomidine and morphine. However, the protective effect of these methods on the lungs is not sufficient to improve the prognosis of patients. Therefore, how to develop a novel protective drug remains an open question. Nicorandil, a mitochondrial (mito)KATP‑specific opener, serves an important role in cardioprotection, although its effect on lung injury remains unclear. The present study examined the protective role of nicorandil against collapse‑induced lung injury in rabbits undergoing OLV. Changes in arterial oxygen saturation (SaO2), arterial partial pressure for oxygen (PaO2), wet/dry weight ratio, and the microstructure of tissues and cells were observed. Enzyme‑linked immunosorbent assays were used to determine the concentrations of malondialdehyde (MDA) and tumor necrosis factor (TNF)‑α, and the activity of superoxide dismutase (SOD) in rabbits treated with nicorandil. Terminal deoxynucleotidyl transferase transfer‑mediated dUTP nick end‑labeling was used to detect apoptosis and western blotting was used to analyze the relative proteins involved in apoptosis. Western blotting and reverse transcription‑quantitative polymerase chain reaction analysis were used to examine the expression of hypoxia inducible factor 1α (HIF‑1α), phosphatidylinositol‑3‑kinase (PI3K), protein kinase B (Akt) and nuclear factor (NF)‑κB in the lungs of rabbits treated with nicorandil. The SaO2 and PaO2 in the high‑dose group were significantly higher than those in the control group in the process of OLV. The wet/dry weight ratio, and the concentrations of MDA and TNF‑α in the collapsed lung of the high‑dose group were significantly lower than those in the control group. The activity of SOD in the high‑dose group was significantly higher than that in the control group. The lung had improved microstructure and less apoptosis, which was determined by the Bax/Bcl2 ratio in the high‑dose group. The expression levels of PI3K, phosphorylated Akt and HIF‑1α were upregulated, whereas the expression of NF‑κB was downregulated. In conclusion, nicorandil had a protective effect via inhibiting apoptosis in non‑ventilated lung collapsed and re‑expansion during OLV in the rabbit. It acted on mitoKATP through the PI3K/Akt signaling pathway.
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Affiliation(s)
- Chunguang Wang
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Honggang Ke
- Department of Cardiothoracic Surgery, The Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Xingguo Xu
- Department of Anesthesiology, The Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Junjie Chen
- Department of Anesthesiology, The Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Dongyun Sun
- Department of Ophthalmic Operating Room, The Affiliated Hospital of Nantong University, Nantong, Jiangsu 226001, P.R. China
| | - Fuhai Ji
- Department of Anesthesiology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
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Effects of Positive End-Expiratory Pressure on Pulmonary Oxygenation and Biventricular Function during One-Lung Ventilation: A Randomized Crossover Study. J Clin Med 2019; 8:jcm8050740. [PMID: 31126111 PMCID: PMC6571862 DOI: 10.3390/jcm8050740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 05/16/2019] [Accepted: 05/21/2019] [Indexed: 12/05/2022] Open
Abstract
Although the application of positive end-expiratory pressure (PEEP) can alter cardiopulmonary physiology during one-lung ventilation (OLV), these changes have not been clearly elucidated. This study assessed the effects of different levels of PEEP on biventricular function, as well as pulmonary oxygenation during OLV. Thirty-six lung cancer patients received one PEEP combination of six sequences, consisting of 0 (PEEP_0), 5 (PEEP_5), and 10 cmH2O (PEEP_10), using a crossover design during OLV. The ratio of arterial oxygen partial pressure to inspired oxygen fraction (P/F ratio), systolic and diastolic echocardiographic parameters were measured at 20 min after the first, second, and third PEEP. P/F ratio at PEEP_5 was significantly higher compared to PEEP_0 (p = 0.014), whereas the P/F ratio at PEEP_10 did not show significant differences compared to PEEP_0 or PEEP_5. Left ventricular ejection fraction (LV EF) and right ventricular fractional area change (RV FAC) at PEEP_10 (EF, p < 0.001; FAC, p = 0.001) were significantly lower compared to PEEP_0 or PEEP_5. RV E/E’ (p = 0.048) and RV myocardial performance index (p < 0.001) at PEEP_10 were significantly higher than those at PEEP_0 or PEEP_5. In conclusion, increasing PEEP to 10 cmH2O decreased biventricular function, especially on RV function, with no further improvement on oxygenation compared to PEEP 5 cmH2O during OLV.
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Abstract
Fifty years after the first description of acute respiratory distress syndrome (ARDS), none of the many positive drug studies in animal models have been confirmed in clinical trials and translated into clinical practice. This bleak outcome of so many animal experiments shows how difficult it is to model ARDS. Lungs from patients are characterized by hyperinflammation, permeability edema, and hypoxemia; accordingly, this is what most models aim to reproduce. However, in animal models it is very easy to cause inflammation in the lungs, but difficult to cause hypoxemia. Often - and not unlike in patients - models with hypoxemia are accompanied by cardiovascular failure that necessitates fluid support and ventilation, raising the question as to the role of intensive care measures in models of ARDS. In our opinion, there are two major arguments in favor of modelling intensive care medicine in models of ARDS: (1) preventing death from shock; and (2) modelling ventilation and other ICU measures as a second hit. The preferable predictive endpoints in any model of ARDS remain unclear. At present, the best recommendation is to use endpoints that can be compared across studies (i.e. PaO2/FiO2 ratio, compliance, wet-to-dry weight ratio) rather than percentage data. Another important and often overlooked issue is the fact that the thermoneutral environmental temperatures for mice and rats are 30℃ and 28℃, respectively; thus, at room temperature (20-22℃) they suffer from cold stress with the associated significant metabolic changes. While, by definition, any model is an abstraction, we suggest that clinically relevant models of ARDS will have to closer recapitulate important properties of the disease while taking into account species-specific confounders.
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Affiliation(s)
- Stefan Uhlig
- 1 Institute of Pharmacology and Toxicology, RWTH Aachen University, Aachen, Germany
| | - Wolfgang M Kuebler
- 2 72126 Institute of Physiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Cruz P, Orozco HD, Garutti Martinez I, Hernández Fernández G. Bloqueio lobar seletivo com um bloqueador Coopdech combinado com um tubo endotraqueal de duplo lúmen para ressecção de metástases pulmonares com laser. Braz J Anesthesiol 2018; 68:200-204. [DOI: 10.1016/j.bjan.2017.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 02/15/2016] [Indexed: 10/19/2022] Open
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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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Naik BI, Colquhoun DA, Shields IA, Davenport RE, Durieux ME, Blank RS. Value of the oxygenation index during 1-lung ventilation for predicting respiratory complications after thoracic surgery. J Crit Care 2017; 37:80-84. [DOI: 10.1016/j.jcrc.2016.09.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/10/2016] [Accepted: 09/01/2016] [Indexed: 01/19/2023]
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Ramasco F, Méndez R, Planas A, Vega L, Gómez A, Santidrián S. Evolution of regional oxygen saturation in the peri-operative of thoracic surgery and its relationship with central venous saturation. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2016; 63:438-443. [PMID: 26633604 DOI: 10.1016/j.redar.2015.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Revised: 07/25/2015] [Accepted: 07/30/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To study the relationship between the values of SvcO2 and SrcO2 in lung resection with one lung ventilation (OLV) and changes in these variables and mean arterial pressure (MAP) and arterial oxygen saturation (SpO2) during the perioperative period. MATERIAL AND METHODS Prospective, observational study of 25 patients in whom pulmonary resection was performed with OLV. The values of MAP, SpO2, SvO2, and SrcO2 were recorded at 6 different times: 1)baseline; 2)double-lung ventilation before the OLV (VBP1); 3)during OLV; 4)after double-lung ventilation (VBP2); 5)30minutes after surgery, and 6)6hours after surgery. RESULTS The SrcO2 showed a significant increase from baseline to starting ventilation (65.72±9.05% vs 70.44±7.24%; P<.01). There were no significant changes in their values at the different intraoperative times. Post-operatively, as in the case of the SvcO2, a significant decrease (P<.001) of its value compared with the previous value was observed. CONCLUSIONS SrcO2 showed a significant increase after induction of anaesthesia and initiation of mechanical ventilation compared to baseline, and a significant decrease at the end of surgery after extubation in the immediate postoperative period. Being a tissue monitoring, non-invasive technique and with continuous values it can alert the clinician of changes in the ratio of oxygen consumption (VO2) to oxygen delivery (DO2) at times of greatest risk, such as OLV, extubation, and the early postoperative period.
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Affiliation(s)
- F Ramasco
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario de La Princesa, Madrid, España
| | - R Méndez
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario de La Princesa, Madrid, España.
| | - A Planas
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario de La Princesa, Madrid, España
| | - L Vega
- Unidad de Apoyo Metodológico, Hospital Universitario de La Princesa, Madrid, España
| | - A Gómez
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario de La Princesa, Madrid, España
| | - S Santidrián
- Servicio de Anestesiología, Reanimación y Terapia del Dolor, Hospital Universitario de La Princesa, Madrid, España
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Kim KN, Kim DW, Jeong MA, Sin YH, Lee SK. Comparison of pressure-controlled ventilation with volume-controlled ventilation during one-lung ventilation: a systematic review and meta-analysis. BMC Anesthesiol 2016; 16:72. [PMID: 27581657 PMCID: PMC5007729 DOI: 10.1186/s12871-016-0238-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2015] [Accepted: 08/23/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Not only arterial hypoxemia but acute lung injury also has become the major concerns of one-lung ventilation (OLV). The use of pressure-controlled ventilation (PCV) for OLV offers the potential advantages of lower airway pressure and intrapulmonary shunt, which result in a reduced risk of barotrauma and improved oxygenation, respectively. METHODS We searched Medline, Embase, the Cochrane central register of controlled trials and KoreaMedto find publications comparing the effects of PCV with those of volume-controlled ventilation (VCV) during intraoperative OLV in adults. A meta-analysis of randomized controlled trials was performed using the Cochrane Review Methods. RESULTS Six studies (259 participants) were included. The PaO2/FiO2 ratio in PCV was higher than in VCV [weighted mean difference (WMD) = 11.04 mmHg, 95 % confidence interval (CI) = 0.30 to 21.77, P = 0.04, I(2) = 3 %] and peak inspiratory pressure was significantly lower in PCV (WMD = -4.91 cm H2O, 95 % CI = -7.30 to -2.53, P < 0.0001, I (2) = 91 %). No differences in PaCO2, tidal volume, heart rate and blood pressure were observed. There were also no differences incompliance, plateau and mean airway pressure. CONCLUSIONS Our meta-analysis provided the evidence of improved oxygenation in PCV. However, it is difficult to draw any definitive conclusions due to the fact that the duration of ventilation in the studies reviewed was insufficient to reveal clinically relevant benefits or disadvantages of PCV. Significantly lower peak inspiratory pressure is the advantage of PCV.
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Affiliation(s)
- Kyu Nam Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, 222, Wangsimni-ro, Seongdonggu, Seoul, 133-792, Republic of Korea
| | - Dong Won Kim
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, 222, Wangsimni-ro, Seongdonggu, Seoul, 133-792, Republic of Korea.
| | - Mi Ae Jeong
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, 222, Wangsimni-ro, Seongdonggu, Seoul, 133-792, Republic of Korea
| | - Yeong Hun Sin
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, 222, Wangsimni-ro, Seongdonggu, Seoul, 133-792, Republic of Korea
| | - Soo Kyung Lee
- Department of Anesthesiology and Pain Medicine, Hanyang University Hospital, 222, Wangsimni-ro, Seongdonggu, Seoul, 133-792, Republic of Korea
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Feng Y, Wang J, Zhang Y, Wang S. One-Lung Ventilation with Additional Ipsilateral Ventilation of Low Tidal Volume and High Frequency in Lung Lobectomy. Med Sci Monit 2016; 22:1589-92. [PMID: 27166086 PMCID: PMC4913818 DOI: 10.12659/msm.895294] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND To investigate the protective effects of additional ipsilateral ventilation of low tidal volume and high frequency on lung functions in the patients receiving lobectomy. MATERIAL AND METHODS Sixty patients receiving lung lobectomy were randomized into the conventional one-lung ventilation (CV) group (n=30) and the ipsilateral low tidal volume high frequency ventilation (LV) group (n=30). In the CV group, patients received only contralateral OLV. In the LV group, patients received contralateral ventilation and additional ipsilateral ventilation of low tidal volume of 1-2 ml/kg and high frequency of 40 times/min. Normal lung tissues were biopsied for the analysis of lung injury. Lung injury was scored by evaluating interstitial edema, alveolar edema, neutrophil infiltration, and alveolar congestion. RESULTS At 30 min and 60 min after the initiation of one-lung ventilation and after surgery, patients in the LV group showed significantly higher ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen than those in the CV group (P<0.001). Lung injury was significantly less severe (2.7±0.7) in the LV group than in the CV group (3.1±0.7) (P=0.006). CONCLUSIONS Additional ipsilateral ventilation of low tidal volume and high frequency can decrease the risk of hypoxemia and alleviate lung injury in patients receiving lobectomy.
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Affiliation(s)
- Yong Feng
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China (mainland)
| | - Jianyue Wang
- Department of Anesthesiology, Binzhou City People's Hospital, Binzhou, Shandong, China (mainland)
| | - Yang Zhang
- Department of Anesthesiology, Binzhou City People's Hospital, Binzhou, Shandong, China (mainland)
| | - Shiduan Wang
- Department of Anesthesiology, Affiliated Hospital of Qingdao University, Qingdao, Shandong, China (mainland)
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Intraoperative mechanical ventilation strategies for one-lung ventilation. Best Pract Res Clin Anaesthesiol 2015; 29:357-69. [DOI: 10.1016/j.bpa.2015.08.001] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 08/04/2015] [Accepted: 08/12/2015] [Indexed: 02/05/2023]
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Abstract
PURPOSE OF REVIEW Describe the importance of monitoring dead space during thoracic surgery, specifically during one-lung ventilation. RECENT FINDINGS The concept of dead space has gained renewed interest among anesthesiologists ever since breath-by-breath measurement by volumetric capnography became available. Monitoring dead space during thoracic surgery assesses the ventilatory deficiencies related to increases in instrumental, airway and/or alveolar dead space, when ventilating patients with positive pressure and double-lumen tubes. Another interesting use of such monitoring is to detect ventilator-induced lung injury due to tidal overdistension. This type of injury threatens the fragile lungs especially during one-lung ventilation and can clinically be recognized as an increase in airway and alveolar dead space above normal values. To date, lung protective ventilation is based on the use of low tidal volumes and airway pressures to decrease overdistension. It has been shown to reduce the incidence of postoperative pulmonary complications after thoracic surgeries. However, such a ventilatory strategy impairs ventilation and induces hypercapnia due to increases in dead space. Therefore, continuous assessment of dead space is helpful in guiding ventilation and avoiding overdistension while maintaining the elimination of CO(2) during thoracic surgery sufficiently high. SUMMARY Monitoring dead space helps anesthesiologists monitor the status of the lung and find appropriate ventilatory settings during thoracic surgeries.
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Fu Q, Duan M, Zhao F, Mi W. Evaluation of stroke volume variation and pulse pressure variation as predictors of fluid responsiveness in patients undergoing protective one-lung ventilation. Drug Discov Ther 2015; 9:296-302. [PMID: 26370528 DOI: 10.5582/ddt.2015.01046] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In order to investigate whether the hemodynamic indices, including stroke volume variation (SVV) and pulse pressure variation (PPV) could predict fluid responsiveness in patients undergoing protective one-lung ventilation. 60 patients scheduled for a combined thoracoscopic and laparoscopic esophagectomy were enrolled and randomized into two groups. The patients in the protective group (Group P) were ventilated with a tidal volume of 6 mL/kg, an inspired oxygen fraction (FiO2) of 80%, and a positive end expiratory pressure (PEEP) of 5 cm H2O. Patients in the conventional group (Group C) were ventilated with a tidal volume of 8 mL/kg and a FiO2 of 100%. Dynamic variables were collected before and after fluid loading (7 mL/kg hydroxyethyl starch 6%, 0.4 mL/kg/min). Patients whose stroke volume index (SVI) increased by more than 15% were defined as responders. Data collected from 45 patients were finally analyzed. Twelve of 24 patients in Group P and 10 of 21 patients in Group C were responders. SVV and PPV significantly changed after the fluid loading. The receive operating characteristic (ROC) analysis showed that the thresholds for SVV and PPV to discriminate responders were 8.5% for each, with a sensitivity of 66.7% (SVV) and 75% (PPV) and a specificity of 50% (SVV) and 83.3% (PPV) in Group P. However, the thresholds for SVV and PPV were 8.5% and 7.5% with a sensitivity of 80% (SVV) and 90% (PPV) and a specificity of 70% (SVV) and 80% (PPV) in Group C. We found SVV and PPV could predict fluid responsiveness in protective one-lung ventilation, but the accuracy and ability of SVV and PPV were weak compared with the role they played in a conventional ventilation strategy.
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Affiliation(s)
- Qiang Fu
- Department of Anesthesiology, General Hospital of People's Liberation Army
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Navarro-Martínez J, Gálvez C, Rivera-Cogollos MJ, Galiana-Ivars M, Bolufer S, Martínez-Adsuar F. Intraoperative crisis resource management during a non-intubated video-assisted thoracoscopic surgery. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:111. [PMID: 26046052 DOI: 10.3978/j.issn.2305-5839.2015.04.14] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 04/19/2015] [Indexed: 11/14/2022]
Abstract
The management of surgical and medical intraoperative emergencies are included in the group of high acuity (high potential severity of an event and the patient impact) and low opportunity (the frequency in which the team is required to manage the event). This combination places the patient into a situation where medical errors could happen more frequently. Although medical error are ubiquitous and inevitable we should try to establish the necessary knowledge, skills and attitudes needed for effective team performance and to guide the development of a critical event. This strategy would probably reduce the incidence of error and improve decision-making. The way to apply it comes from the application of the management of critical events in the airline industry. Its use in a surgical environment is through the crisis resource management (CRM) principles. The CRM tries to develop all the non-technical skills necessary in a critical situation, but not only that, also includes all the tools needed to prevent them. The purpose of this special issue is to appraise and summarize the design, implementation, and efficacy of simulation-based CRM training programs for a specific surgery such as the non-intubated video-assisted thoracoscopic surgery.
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Affiliation(s)
- Jose Navarro-Martínez
- 1 Anesthesiology and Surgical Critical Care Department, 2 Thoracic Surgery Department, Hospital General Universitario de Alicante, Alicante, Spain
| | - Carlos Gálvez
- 1 Anesthesiology and Surgical Critical Care Department, 2 Thoracic Surgery Department, Hospital General Universitario de Alicante, Alicante, Spain
| | - María Jesus Rivera-Cogollos
- 1 Anesthesiology and Surgical Critical Care Department, 2 Thoracic Surgery Department, Hospital General Universitario de Alicante, Alicante, Spain
| | - María Galiana-Ivars
- 1 Anesthesiology and Surgical Critical Care Department, 2 Thoracic Surgery Department, Hospital General Universitario de Alicante, Alicante, Spain
| | - Sergio Bolufer
- 1 Anesthesiology and Surgical Critical Care Department, 2 Thoracic Surgery Department, Hospital General Universitario de Alicante, Alicante, Spain
| | - Francisco Martínez-Adsuar
- 1 Anesthesiology and Surgical Critical Care Department, 2 Thoracic Surgery Department, Hospital General Universitario de Alicante, Alicante, Spain
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Lin F, Pan LH, Ruan L, Qian W, Liang R, Ge WY, Huang B. Differential expression of HIF-1α, AQP-1, and VEGF under acute hypoxic conditions in the non-ventilated lung of a one-lung ventilation rat model. Life Sci 2015; 124:50-5. [PMID: 25592135 DOI: 10.1016/j.lfs.2014.12.020] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 12/19/2014] [Accepted: 12/27/2014] [Indexed: 10/24/2022]
Abstract
AIMS One-lung ventilation (OLV) is a standard practice in thoracic surgery. However, OLV can give rise to arterial hypoxemia. Hypoxia-inducible transcription factor-1 alpha (HIF-1α), vascular endothelial growth factor (VEGF) and aquaporin-1 (AQP-1) may be involved in arterial hypoxemia and contribute to cellular injury. Therefore, in the present study, these moieties were investigated in an OLV rat model. MAIN METHODS Forty Sprague-Dawley (S-D) rats were randomly divided into four groups: right lung mechanical ventilation for 0.5 h (Group A); 1 h (Group B); 2 h (Group C) and mechanical ventilation of both lungs (control group). Rat lung tissue was examined using electron microscopy. Serum and lung tissue levels of VEGF were measured by ELISA, Western blot analyses were used to detect the protein expression of HIF-1α and immunohistochemical staining and real-time polymerase chain reaction (PCR) were performed to examine protein expression and gene levels, respectively, of VEGF and AQP-1 after hypoxia. KEY FINDINGS Electron microscopy revealed that increased duration of OLV was correlated with greater destruction of the non-ventilated lung. The protein expression of HIF-1α was significantly increased in the non-ventilated lungs of the experimental hypoxia groups (A-C) compared to the control group, whereas VEGF and AQP-1 protein expression and gene levels were decreased in the non-ventilated lungs of the hypoxia groups (A-C) compared to the control group. SIGNIFICANCE The OLV caused hypoxia in the non-ventilated lung and subsequent injury. The altered expression of HIF-1α, VEGF, and AQP-1 may be involved in the pathological process of lung injury caused by hypoxia.
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Affiliation(s)
- Fei Lin
- Department of Anesthesiology, Affiliated Cancer Hospital, Guangxi Medical University, Nanning, China
| | - Ling-Hui Pan
- Department of Anesthesiology, Affiliated Cancer Hospital, Guangxi Medical University, Nanning, China.
| | - Lin Ruan
- Department of Anesthesiology, Affiliated Cancer Hospital, Guangxi Medical University, Nanning, China
| | - Wei Qian
- Department of Anesthesiology, Affiliated Cancer Hospital, Guangxi Medical University, Nanning, China
| | - Rui Liang
- Department of Anesthesiology, Affiliated Cancer Hospital, Guangxi Medical University, Nanning, China
| | - Wan-Yun Ge
- Department of Anesthesiology, Affiliated Cancer Hospital, Guangxi Medical University, Nanning, China
| | - Bin Huang
- Department of Anesthesiology, Affiliated Cancer Hospital, Guangxi Medical University, Nanning, China
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Bilbao Ares A, Castañeda Pascual M. [Reply to authors]. ACTA ACUST UNITED AC 2014; 62:172-3. [PMID: 25127555 DOI: 10.1016/j.redar.2014.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2014] [Accepted: 06/19/2014] [Indexed: 10/24/2022]
Affiliation(s)
- A Bilbao Ares
- Servicio Anestesia y Reanimación, Complejo Hospitalario de Navarra, Pamplona, Navarra, España.
| | - M Castañeda Pascual
- Servicio Anestesia y Reanimación, Complejo Hospitalario de Navarra, Pamplona, Navarra, España
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Bermejo S, Gallart L, Silva-Costa-Gomes T, Vallès J, Aguiló R, Puig MM. Almitrine Fails to Improve Oxygenation During One-Lung Ventilation With Sevoflurane Anesthesia. J Cardiothorac Vasc Anesth 2014; 28:919-24. [DOI: 10.1053/j.jvca.2013.03.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Indexed: 11/11/2022]
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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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Sharifian Attar A, Tabari M, Rahnamazadeh M, Salehi M. A comparison of effects of propofol and isoflurane on arterial oxygenation pressure, mean arterial pressure and heart rate variations following one-lung ventilation in thoracic surgeries. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 16:e15809. [PMID: 24719749 PMCID: PMC3965882 DOI: 10.5812/ircmj.15809] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Revised: 12/16/2013] [Accepted: 01/20/2014] [Indexed: 11/16/2022]
Abstract
Background: Hypoxia occurs during one-lung ventilation (OLV) due to the arteriovenous shunt of unsaturated pulmonary venous blood. Hypoxic pulmonary vasoconstriction (HPV) acts as a defense mechanism against shunting. In thoracic surgery, anesthetics with minimal inhibitory effect on HPV and minimal hemodynamic changes are preferred. Objectives: The present study aimed to evaluate the effects of propofol and isoflurane on patients’ arterial oxygen pressure following one-lung ventilation during thoracic surgeries. Materials and Methods: In this randomized clinical trial study which was conducted in Iran, sixty patients with ASA (The American Society of Anesthesiologists) class I & II who were candidates for right elective thoracotomy were divided in two groups. Induction of anesthesia in the two groups was conducted using the same method, and left double-lumen endotracheal tube was inserted. In the first group propofol was used for the maintenance of anesthesia, and isoflurane for the second group. During two-lung ventilation and at minutes 5 and 10 after OLV, ABG (arterial blood gas) (for detecting the mean pressure of arterial oxygen), mean arterial pressure and heart rate were recorded. Results: Sixty patients (mean age = 4124.18 ± 18.63 years) were divided into two groups. The age and gender of the subjects were not statistically different between the two groups. In the propofol group, the arterial oxygen pressure during two-lung ventilation and at 5th and 10th minutes after OLV was 263.14 ± 136.19, 217.40 ± 133.99 and 182.34 ± 122.39; in the isoflurane group, it was reported as 206.29 ± 135.59, 164.78 ± 118.90 and 155.35 ± 109.21 mmHg, respectively. In the propofol group, mean arterial pressure during two-lung ventilation, and 5th and 10th minutes after OLV, was 84.01 ± 20.67, 88.15 ± 20.23 and 86.10 ± 19.13, respectively; regarding the isoflurane group, it was reported as 79.66 ± 17.04, 84.78 ± 20.19 and 86.50 ± 17.07 mmHg, respectively. In the propofol group, heart rate during two-lung ventilation, and 5th and 10th minutes after OLV was 92.77 ± 17.20, 94.0 ± 18.34 and 94.33 ± 21.03, respectively; In the isoflurane group, it was reported as 92.87 ± 16.96, 91.8 ± 18.75 and 91.05 ± 17.20 min, respectively. These values were statistically similar in the two study groups. Conclusions: The effects of propofol on hemodynamics and arterial oxygen pressure during one- or two-lung ventilation were not different from those of isoflurane.
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Affiliation(s)
- Alireza Sharifian Attar
- Department of Anesthesiology, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Masoomeh Tabari
- Department of Anesthesiology, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
- Corresponding Author: Masoomeh Tabari, Department of Anesthesiology, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran. Tel: +98-5118012612, Fax: +98-5118417402, E-mail:
| | - Mohammadreza Rahnamazadeh
- Department of Anesthesiology, Ghaem Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
| | - Maryam Salehi
- Department of Community Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, IR Iran
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Chen KC, Cheng YJ, Hung MH, Tseng YD, Chen JS. Nonintubated thoracoscopic surgery using regional anesthesia and vagal block and targeted sedation. J Thorac Dis 2014; 6:31-6. [PMID: 24455173 DOI: 10.3978/j.issn.2072-1439.2014.01.01] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2013] [Accepted: 12/29/2013] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Thoracoscopic surgery without endotracheal intubation is a novel technique for diagnosis and treatment of thoracic diseases. This study reported the experience of nonintubated thoracoscopic surgery in a tertiary medical center in Taiwan. METHODS From August 2009 through August 2013, 446 consecutive patients with lung or pleural diseases were treated by nonintubated thoracoscopic surgery. Regional anesthesia was achieved by thoracic epidural anesthesia or internal intercostal blockade. Targeted sedation was performed with propofol infusion to achieve a bispectral index value between 40 and 60. The demographic data and clinical outcomes were evaluated by retrospective chart review. RESULTS Thoracic epidural anesthesia was used in 290 patients (65.0%) while internal intercostal blockade was used in 156 patients (35.0%). The final diagnosis were primary lung cancer in 263 patients (59.0%), metastatic lung cancer in 38 (8.5%), benign lung tumor in 140 (31.4%), and pneumothorax in 5 (1.1%). The median anesthetic induction time was 30 minutes by thoracic epidural anesthesia and was 10 minutes by internal intercostal blockade. The operative procedures included lobectomy in 189 patients (42.4%), wedge resection in 229 (51.3%), and segmentectomy in 28 (6.3%). Sixteen patients (3.6%) required conversion to tracheal intubation because of significant mediastinal movement (seven patients), persistent hypoxemia (two patients), dense pleural adhesions (two patients), ineffective epidural anesthesia (two patients), bleeding (two patients), and tachypnea (one patient). One patient (0.4%) was converted to thoracotomy because of bleeding. No mortality was noted in our patients. CONCLUSIONS Nonintubated thoracoscopic surgery is technically feasible and safe and can be a less invasive alternative for diagnosis and treatment of thoracic diseases.
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Affiliation(s)
- Ke-Cheng Chen
- Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan ; ; Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ya-Jung Cheng
- Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ming-Hui Hung
- Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yu-Ding Tseng
- Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
| | - Jin-Shing Chen
- Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan ; ; Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Alveolar recruitment during mechanical ventilation – Where are we in 2013? TRENDS IN ANAESTHESIA AND CRITICAL CARE 2013. [DOI: 10.1016/j.tacc.2013.06.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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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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Abstract
PURPOSE OF REVIEW This review will analyze the risk factors of acute lung injury (ALI) in patients undergoing thoracic surgery. Evidence for the occurrence of lung injury following mechanical ventilation and one-lung ventilation (OLV) and the strategies to avoid it will also be discussed. RECENT FINDINGS Post-thoracotomy ALI has become one of the leading causes of operative death. The pathogenesis of ALI implicates a multiple-hit sequence of various triggering factors (e.g. preoperative conditions, surgery-induced inflammation, ventilator-induced injury, fluid overload, and transfusion). Conventional ventilation during OLV is performed with high tidal volumes equal to those being used in two-lung ventilation, high FiO(2), and without positive end-expiratory pressure. This practice was originally recommended to improve oxygenation and decrease shunt fraction during OLV. However, a number of recent studies using experimental models or human patients have shown low tidal volumes to be associated with a decrease in inflammatory mediators and a reduction in pulmonary postoperative complications. However, the application of such protective strategies could be harmful if not still properly used. SUMMARY The goal of ventilation is to minimize lung trauma by avoiding overdistension and repetitive alveolar collapse, while providing adequate oxygenation. Protective ventilation is not simply synonymous of low tidal volume ventilation, but it also involves positive end-expiratory pressure, lower FiO(2), recruitment maneuvers, and lower ventilatory pressures.
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Abstract
An ever-increasing number of thoracic procedures are being performed through minimally invasive techniques. Although the incidence of hypoxemia during one-lung ventilation (OLV) has decreased over the years, it remains an issue in roughly 10% of cases. Algorithms for the management of OLV hypoxemia have to be adapted to the thoracoscopic approach, in particular the need for optimal surgical exposure. With appropriate planning and caution, most of the treatment modalities for OLV hypoxemia can be applied to the thoracoscopy setting, with some modifications.
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Affiliation(s)
- Jens Lohser
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia.
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Kim SH, Choi YS, Lee JG, Park IH, Oh YJ. Effects of a 1:1 inspiratory to expiratory ratio on respiratory mechanics and oxygenation during one-lung ventilation in the lateral decubitus position. Anaesth Intensive Care 2012. [PMID: 23194211 DOI: 10.1177/0310057x1204000613] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Prolonged inspiratory to expiratory (I:E) ratio ventilation may have both positive and negative effects on respiratory mechanics and oxygenation during one-lung ventilation (OLV), but definitive information is currently lacking. We therefore compared the effects of volume-controlled ventilation with I:E ratios of 1:1 and 1:2 on respiratory mechanics and oxygenation during OLV. Fifty-six patients undergoing thoracoscopic lobectomy were randomly assigned volume-controlled ventilation with an I:E ratio of 1:1 (group 1:1, n=28) or 1:2 (group 1:2, n=28) during OLV. Arterial and central venous blood gas analyses and respiratory variables were recorded 15 minutes into two-lung ventilation, at 30 and 60 minutes during OLV, and 15 minutes after two-lung ventilation was re-initiated. Peak and plateau airway pressures in cmH2O [standard deviation] during OLV were significantly lower in group 1:1 than in group 1:2 (P <0.01) (19 [3] and 23 [4]; 16 [3] and 19 [5], respectively). The arterial to end-tidal carbon dioxide tension difference was significantly lower in group 1:1 than in group 1:2 (P <0.01), (0.5 [0.3] and 1.1 [0.5]). There were no significant differences in PaO2 during OLV between the two groups (OLV30, P=0.856; OLV60, P=0.473). In summary, volume-controlled ventilation with an I:E ratio of 1:1 reduced peak and plateau airway pressures improved dynamic compliance and efficiency of alveolar ventilation, but it did not improve arterial oxygenation in a substantial manner. Furthermore, the associated increase in mean airway pressure might have reduced cardiac output, resulting in a lower central venous oxygen saturation.
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Affiliation(s)
- S H Kim
- Department of Anaesthesiology and Pain Medicine, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Sanchez-Lorente D, Iglesias M, Rodríguez A, Jungebluth P, Macchiarini P. The pumpless extracorporeal lung membrane provides complete respiratory support during complex airway reconstructions without inducing cellular trauma or a coagulatory and inflammatory response. J Thorac Cardiovasc Surg 2012; 144:425-30. [DOI: 10.1016/j.jtcvs.2012.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2011] [Revised: 03/09/2012] [Accepted: 04/03/2012] [Indexed: 10/28/2022]
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Ferreira HC, Mazzoli-Rocha F, Momesso DP, Garcia CSNB, Carvalho GMC, Lassance-Soares RM, Prota LFM, Morales MM, Faffe DS, Carvalho AR, Rocco PRM, Zin WA. On the crucial ventilatory setting adjustment from two- to one-lung ventilation. Respir Physiol Neurobiol 2011; 179:198-204. [PMID: 21871975 DOI: 10.1016/j.resp.2011.08.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Revised: 08/10/2011] [Accepted: 08/12/2011] [Indexed: 11/28/2022]
Abstract
Lung mechanics, histology, oxygenation and type-III procollagen (PCIII) mRNA were studied aiming to evaluate the need to readjust ventilatory pattern when going from two- to one-lung ventilation (OLV). Wistar rats were assigned to three groups: the left lung was not ventilated while the right lung received: (1) tidal volume (V(T))=5 ml/kg and positive end-expiratory pressure (PEEP)=2 cm H(2)O (V5P2), (2) V(T)=10 ml/kg and PEEP=2 cm H(2)O (V10P2), and (3) V(T)=5 ml/kg and PEEP=5 cm H(2)O (V5P5). At 1-h ventilation, V5P2 showed hypoxemia, alveolar collapse and impaired lung function. Higher PEEP minimized these changes and prevented hypoxemia. Although high V(T) prevented hypoxemia and maintained a higher specific compliance than V5P2, a morphologically inhomogeneous parenchyma and higher PCIII expression resulted. In conclusion, the association of low V(T) and an adequate PEEP level could be useful to maintain arterial oxygenation without inducing a possible inflammatory/remodeling response.
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Affiliation(s)
- Halina C Ferreira
- Laboratory of Respiration Physiology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, RJ, Brazil.
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Ishikawa S. Arterial oxygenation during one-lung ventilation may not improve within 30 min. J Clin Monit Comput 2011; 25:143-4. [DOI: 10.1007/s10877-011-9272-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2011] [Accepted: 02/01/2011] [Indexed: 10/18/2022]
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