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Caljé-van der Klei T, Sun Q, Chase JG, Zhou C, Tawhai MH, Knopp JL, Möller K, Heines SJ, Bergmans DC, Shaw GM. Pulmonary response prediction through personalized basis functions in a virtual patient model. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 244:107988. [PMID: 38171168 DOI: 10.1016/j.cmpb.2023.107988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/16/2023] [Accepted: 12/17/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND AND OBJECTIVE Recruitment maneuvers with subsequent positive-end-expiratory-pressure (PEEP) have proven effective in recruiting lung volume and preventing alveoli collapse. However, determining a safe, effective, and patient-specific PEEP is not standardized, and this more optimal PEEP level evolves with patient condition, requiring personalised monitoring and care approaches to maintain optimal ventilation settings. METHODS This research examines 3 physiologically relevant basis function sets (exponential, parabolic, cumulative) to enable better prediction of elastance evolution for a virtual patient or digital twin model of MV lung mechanics, including novel elements to model and predict distension elastance. Prediction accuracy and robustness are validated against recruitment maneuver data from 18 volume-controlled ventilation (VCV) patients at 7 different baseline PEEP levels (0 to 12 cmH2O) and 14 pressure-controlled ventilation (PCV) patients at 4 different baseline PEEP levels (6 to 12 cmH2O), yielding 623 and 294 prediction cases, respectively. Predictions were made up to 12 cmH2O of added PEEP ahead, covering 6 × 2 cmH2O PEEP steps. RESULTS The 3 basis function sets yield median absolute peak inspiratory pressure (PIP) prediction error of 1.63 cmH2O for VCV patients, and median peak inspiratory volume (PIV) prediction error of 0.028 L for PCV patients. The exponential basis function set yields a better trade-off of overall performance across VCV and PCV prediction than parabolic and cumulative basis function sets from other studies. Comparing predicted and clinically measured distension prediction in VCV demonstrated consistent, robust high accuracy with R2 = 0.90-0.95. CONCLUSIONS The results demonstrate recruitment mechanics are best captured by an exponential basis function across different mechanical ventilation modes, matching physiological expectations, and accurately capture, for the first time, distension mechanics to within 5-10 % accuracy. Enabling the risk of lung injury to be predicted before changing ventilator settings. The overall outcomes significantly extend and more fully validate this digital twin or virtual mechanical ventilation patient model.
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Affiliation(s)
- Trudy Caljé-van der Klei
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand.
| | - Qianhui Sun
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand; University of Liége, Liége, Belgium
| | - J Geoffrey Chase
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand
| | - Cong Zhou
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand
| | - Merryn H Tawhai
- Auckland Bioengineering Institute, The University of Auckland, Auckland, New Zealand
| | - Jennifer L Knopp
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand
| | - Knut Möller
- Institute for Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
| | - Serge J Heines
- Department of Intensive Care, School of Medicine, Maastricht University, Maastricht, Netherlands
| | - Dennis C Bergmans
- Department of Intensive Care, School of Medicine, Maastricht University, Maastricht, Netherlands
| | - Geoffrey M Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch, New Zealand
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Yoo S, Yoon S, Kim BR, Yoo HK, Seo JH, Bahk JH. Positive end-expiratory pressure during one-lung ventilation for preventing atelectasis after video-assisted thoracoscopic surgery: a triple-arm, randomized controlled trial. Minerva Anestesiol 2024; 90:12-21. [PMID: 37987988 DOI: 10.23736/s0375-9393.23.17539-0] [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: 11/22/2023]
Abstract
BACKGROUND There is little evidence regarding the benefits of lung-protective ventilation in patients undergoing one-lung ventilation for thoracic surgery. This study aimed to determine the optimal level of positive end-expiratory pressure (PEEP) during one-lung ventilation for minimizing postoperative atelectasis through lung ultrasonography. METHODS A total of 142 adult patients scheduled for video-assisted thoracoscopic surgery at Seoul National University Hospital between May 2019 and February 2020 were enrolled in this study. Patients were randomly assigned to different groups: 1) PEEP 3 cmH2O group; 2) PEEP 6 cmH2O group; and 3) PEEP 9 cmH2O group during one-lung ventilation. The lung ultrasound score was used to evaluate lung aeration using ultrasonography 1 hour after surgery. RESULTS The 1-hour post-surgery lung ultrasound scores were 8.1±2.5, 6.8±2.6, and 5.9±2.6 in the PEEP 3, 6, and 9 cmH2O groups, respectively (P<0.001). The PEEP 3 cmH2O group showed significantly higher lung ultrasound scores than the PEEP 6 (adjusted P=0.034) and 9 cmH2O groups (adjusted P<0.001). The PaO2/FiO2 ratio measured at 10 minutes after the end of one-lung ventilation was significantly lower in the PEEP 3 cmH2O group (392 [331 to 469]) than the PEEP 6 cmH2O (458 [384 to 530], adjusted P=0.018) or PEEP 9 cmH2O groups (454 [374 to 522], adjusted P=0.016). CONCLUSIONS Although the optimal level of PEEP during one-lung ventilation was not determined, the application of higher PEEP can prevent aeration loss in the ventilated lung after video-assisted thoracoscopic surgery under one-lung ventilation.
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Affiliation(s)
- Seokha Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Susie Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Bo R Kim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Hae K Yoo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jeong-Hwa Seo
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea
| | - Jae-Hyon Bahk
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea -
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Rehman TA, John K, Maslow A. Protective Lung Ventilation: What Do We Know?-"In An Investigation, Details Matter"-Jack Reacher TV Series. J Cardiothorac Vasc Anesth 2023; 37:2572-2576. [PMID: 37423839 PMCID: PMC10264327 DOI: 10.1053/j.jvca.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/11/2023] [Indexed: 07/11/2023]
Affiliation(s)
- T A Rehman
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - K John
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - A Maslow
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI.
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Piccioni F, Langiano N, Bignami E, Guarnieri M, Proto P, D'Andrea R, Mazzoli CA, Riccardi I, Bacuzzi A, Guzzetti L, Rossi I, Scolletta S, Comi D, Benigni A, Pierconti F, Coccia C, Biscari M, Murzilli A, Umari M, Peratoner C, Serra E, Baldinelli F, Accardo R, Diana F, Fasciolo A, Amodio R, Ball L, Greco M, Pelosi P, Della Rocca G. One-Lung Ventilation and Postoperative Pulmonary Complications After Major Lung Resection Surgery. A Multicenter Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2023; 37:2561-2571. [PMID: 37730455 PMCID: PMC10133024 DOI: 10.1053/j.jvca.2023.04.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/14/2023] [Accepted: 04/20/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVES The effect of one-lung ventilation (OLV) strategy based on low tidal volume (TV), application of positive end-expiratory pressure (PEEP), and alveolar recruitment maneuvers (ARM) to reduce postoperative acute respiratory distress syndrome (ARDS) and pulmonary complications (PPCs) compared with higher TV without PEEP and ARM strategy in adult patients undergoing lobectomy or pneumonectomy has not been well established. DESIGN Multicenter, randomized, single-blind, controlled trial. SETTING Sixteen Italian hospitals. PARTICIPANTS A total of 880 patients undergoing elective major lung resection. INTERVENTIONS Patients were randomized to receive lower tidal volume (LTV group: 4 mL/kg predicted body weight, PEEP of 5 cmH2O, and ARMs) or higher tidal volume (HTL group: 6 mL/kg predicted body weight, no PEEP, and no ARMs). After OLV, until extubation, both groups were ventilated using a tidal volume of 8 mL/kg and a PEEP value of 5 cmH2O. The primary outcome was the incidence of in-hospital ARDS. Secondary outcomes were the in-hospital rate of PPCs, major cardiovascular events, unplanned intensive care unit (ICU) admission, in-hospital mortality, ICU length of stay, and in-hospital length of stay. MEASUREMENTS AND MAIN RESULTS ARDS occurred in 3 of 438 patients (0.7%, 95% CI 0.1-2.0) and in 1 of 442 patients (0.2%, 95% CI 0-1.4) in the LTV and HTV group, respectively (Risk ratio: 3.03 95% CI 0.32-29, p = 0.372). Pulmonary complications occurred in 125 of 438 patients (28.5%, 95% CI 24.5-32.9) and in 136 of 442 patients (30.8%, 95% CI 26.6-35.2) in the LTV and HTV group, respectively (risk ratio: 0.93, 95% CI 0.76-1.14, p = 0.507). The incidence of major complications, in-hospital mortality, and unplanned ICU admission, ICU and in-hospital length of stay were comparable in both groups. CONCLUSIONS In conclusion, among adult patients undergoing elective lung resection, an OLV with lower tidal volume, PEEP 5 cmH2O, and ARMs and a higher tidal volume strategy resulted in low ARDS incidence and comparable postoperative complications, in-hospital length of stay, and mortality.
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Affiliation(s)
- Federico Piccioni
- Department of Anesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
| | - Nicola Langiano
- SOC Anesthesia and Intensive Care Medicine Clinic - Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Marcello Guarnieri
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Paolo Proto
- Department of Critical and Supportive Therapy, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Rocco D'Andrea
- Department of Anesthesia, Intensive Care Medicine and Emergency, IRRCS Policlinico di Sant' Orsola, Bologna Academic Hospital, Bologna, Italy
| | - Carlo A Mazzoli
- Department of Anesthesia, Intensive Care Medicine and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Ilaria Riccardi
- SOC Anesthesia and Intensive Care Medicine Clinic - Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | | | - Luca Guzzetti
- ASST Settelaghi Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Irene Rossi
- Cardio-thoracic and vascular Department, UOC Cardio-thoracic and vascular Anesthesia and ICM, Azienda ospedaliero-universitaria Senese, Siena, Italy
| | - Sabino Scolletta
- Cardio-thoracic and vascular Department, UOC Cardio-thoracic and vascular Anesthesia and ICM, Azienda ospedaliero-universitaria Senese, Siena, Italy
| | - Daniela Comi
- Anesthesia and Intensive Care Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Alberto Benigni
- Anesthesia and Intensive Care Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Federico Pierconti
- IRCCS-IFO National Institute of Oncology - Regina Elena, DPT of Oncologic Clinic and Research, UOC Anesthesia and ICM, Rome, Italy
| | - Cecilia Coccia
- IRCCS-IFO National Institute of Oncology - Regina Elena, DPT of Oncologic Clinic and Research, UOC Anesthesia and ICM, Rome, Italy
| | - Matteo Biscari
- Arcispedale Santa Maria Nuova, IRCCS AUSL di Reggio Emilia, Italy
| | - Alice Murzilli
- Arcispedale Santa Maria Nuova, IRCCS AUSL di Reggio Emilia, Italy
| | - Marzia Umari
- SOC Anesthesia and Intensive Care Medicine - Azienda Sanitaria Universitaria Giuliana, Cattinara Hospital, Trieste, Italy
| | - Caterina Peratoner
- SOC Anesthesia and Intensive Care Medicine - Azienda Sanitaria Universitaria Giuliana, Cattinara Hospital, Trieste, Italy
| | - Eugenio Serra
- Anesthesia and Intensive Care Medicine Institute - Azienda Ospedaliera-Università of Padua, Padua, Italy
| | | | - Rosanna Accardo
- Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori Fondazione G. Pascale - IRCCS, Naples, Italy
| | - Fernanda Diana
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera Brotzu - Ospedale Oncologico Businco, Cagliari, Italy
| | | | - Riccardo Amodio
- Department of Anesthesia, Intensive Care and Pain Medicine, IRCCS Centro di Riferimento Oncologico della Basilicata/OECI Clinical Cancer Center - Rionero in Vulture, Potenza, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino-IST, University of Genoa, Genoa, Italy
| | - Massimiliano Greco
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino-IST, University of Genoa, Genoa, Italy
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Wilson MG, Adams CN, Turnbull MD, Falyar CR, Harris EM, Thompson JA, Simmons VC. Improving Certified Registered Nurse Anesthetists' Adherence to a Standardized Intraoperative Lung Protective Ventilation Protocol. J Perianesth Nurs 2023; 38:845-850. [PMID: 37589630 DOI: 10.1016/j.jopan.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/08/2022] [Accepted: 12/11/2022] [Indexed: 08/18/2023]
Abstract
PURPOSE The use of lung protective ventilation (LPV) during general anesthesia is an effective strategy among certified registered nurse anesthetists (CRNAs) to reduce and prevent the incidence of postoperative pulmonary complications. The purpose of this project was to implement a LPV protocol, assess CRNA provider adherence, and investigate differences in ventilation parameters and postoperative oxygen requirements. DESIGN This quality improvement project was conducted using a pre- and postimplementation design. METHODS Sixty patients undergoing robotic laparoscopic abdominal surgery and 35 CRNAs at a community hospital participated. An evidence-based intraoperative LPV protocol was developed, CRNA education was provided, and the protocol was implemented. Pre- and postimplementation, CRNA knowledge, and confidence were assessed. Ventilation data were collected at 1-minute intervals intraoperatively and oxygen requirements were recorded in the postanesthesia care unit (PACU). FINDINGS Use of intraoperative LPV strategies increased 2.4%. Overall CRNA knowledge (P = .588), confidence (P = .031), and practice (P < .001) improved from pre- to postimplementation. Driving pressures decreased from pre- to postimplementation (P < .001). Supplemental oxygen use on admission to the PACU decreased from 93.3% to 70.0%. CONCLUSIONS Educational interventions and implementation of a standardized protocol can improve the use of intraoperative LPV strategies and patient outcomes.
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Affiliation(s)
- Megan G Wilson
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Cara N Adams
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Matthew D Turnbull
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Christian R Falyar
- Middle Tennesee Acute Surgical Pain Management Fellowship, Middle Tennesee School of Anesthesia, Madison, TN
| | - Erica M Harris
- Duke University Anesthesia Department, Duke University Medical Center, Durham, NC
| | - Julie A Thompson
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Virginia C Simmons
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC.
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Campos JH, Sharma A. What is the Ideal Tidal Volume During One-Lung Ventilation? J Cardiothorac Vasc Anesth 2023; 37:1993-1995. [PMID: 37391356 DOI: 10.1053/j.jvca.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/11/2023] [Indexed: 07/02/2023]
Affiliation(s)
- Javier H Campos
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA.
| | - Archit Sharma
- Department of Anesthesia, University of Iowa Carver College of Medicine, Iowa City, IA
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El Tahan MR, Samara E, Marczin N, Landoni G, Pasin L. Impact of Lower Tidal Volumes During One-Lung Ventilation: A 2022 Update of the Meta-analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2023; 37:1983-1992. [PMID: 37225546 DOI: 10.1053/j.jvca.2023.04.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 04/03/2023] [Accepted: 04/14/2023] [Indexed: 05/26/2023]
Abstract
OBJECTIVES To clarify the influence of lower tidal volume (4-7 mL/kg) compared with higher tidal volume (8-15 mL/kg) during one-lung ventilation (OLV) on gas exchange and postoperative clinical outcome. DESIGN Meta-analysis of randomized trials. SETTING Thoracic surgery. PARTICIPANTS Patients receiving OLV. INTERVENTIONS Lower tidal volume during OLV. MEASUREMENTS AND MAIN RESULTS Primary outcome was PaO2-to-the oxygen fraction (PaO2/FIO2) ratio at the end of the surgery, after the reinstitution of two-lung ventilation. Secondary endpoints included perioperative changes in PaO2/FIO2 ratio and carbon dioxide (PaCO2) tension, airway pressure, the incidence of postoperative pulmonary complications, arrhythmia, and length of hospital stay. Seventeen randomized controlled trials (1,463 patients) were selected. Overall analysis showed that the use of low tidal volume during OLV was associated with a significantly higher PaO2/FIO2 ratio 15 minutes after the start of OLV and at the end of surgery (mean difference 33.7 mmHg [p = 0.02] and mean difference 18.59 mmHg [p < 0.001], respectively). The low tidal volume also was associated with higher PaCO2 values 15 minutes and 60 minutes after the start of OLV and with lower airway pressure, which was maintained during two-lung ventilation after surgery. Moreover, the application of lower tidal volume was associated with fewer postoperative pulmonary complications (odds ratio 0.50; p < 0.001) and arrhythmias (odds ratio 0.58; p = 0.009), with no difference in length of hospital stay. CONCLUSIONS The use of lower tidal volume, a component of protective OLV, increases the PaO2/FIO2 ratio, reduces the incidence of postoperative pulmonary complications, and should be considered strongly in daily practice.
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Affiliation(s)
- Mohamed R El Tahan
- Anesthesiology Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Al Khubar, Dammam, Saudi Arabia
| | - Evangelia Samara
- Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece
| | - Nandor Marczin
- The Royal Brompton and Harefield NHS Foundation Trust, London, UK; Section of Anesthesia, Pain Medicine, and Intensive Care, Imperial College London, London, UK; Semmelweis University, Budapest, Hungary
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milano, Italy
| | - Laura Pasin
- Department of Anesthesia and Intensive Care, Azienda Ospedale-Università di Padova, Padua, Italy.
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Shum S, Huang A, Slinger P. Hypoxaemia during one lung ventilation. BJA Educ 2023; 23:328-336. [PMID: 37600211 PMCID: PMC10435364 DOI: 10.1016/j.bjae.2023.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 08/22/2023] Open
Affiliation(s)
- S. Shum
- Toronto General Hospital, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - A. Huang
- Toronto General Hospital, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
| | - P. Slinger
- Toronto General Hospital, Toronto, ON, Canada
- University of Toronto, Toronto, ON, Canada
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Joe YE, Lee CY, Kim N, Lee K, Kang SJ, Oh YJ. Effect of permissive hypercarbia on lung oxygenation during one-lung ventilation and postoperative pulmonary complications in patients undergoing thoracic surgery: A prospective randomised controlled trial. Eur J Anaesthesiol 2023; 40:691-698. [PMID: 37455644 DOI: 10.1097/eja.0000000000001873] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
BACKGROUND The effect of hypercarbia on lung oxygenation during thoracic surgery remains unclear. OBJECTIVE To investigate the effect of hypercarbia on lung oxygenation during one-lung ventilation in patients undergoing thoracic surgery and evaluate the incidence of postoperative pulmonary complications. DESIGN Prospective randomised controlled trial. SETTING A tertiary university hospital in the Republic of Korea from November 2019 to December 2020. PATIENTS Two hundred and ninety-seven patients with American Society of Anaesthesiologists physical status II to III, scheduled to undergo elective lung resection surgery. INTERVENTION Patients were randomly assigned to Group 40, 50, or 60. An autoflow ventilation mode with a lung protective ventilation strategy was applied to all patients. Respiratory rate was adjusted to maintain a partial pressure of arterial carbon dioxide of 40 ± 5 mmHg in Group 40, 50 ± 5 mmHg in Group 50 and 60 ± 5 mmHg in Group 60 during one-lung ventilation and at the end of surgery. MAIN OUTCOME MEASURES The primary outcome was the arterial oxygen partial pressure/fractional inspired oxygen ratio after 60 min of one-lung ventilation. RESULTS Data from 262 patients were analysed. The partial pressure/fractional inspired oxygen ratio was significantly higher in Group 50 and Group 60 than in Group 40 (269.4 vs. 262.9 vs. 214.4; P < 0.001) but was not significantly different between Group 50 and Group 60. The incidence of postoperative pulmonary complications was comparable among the three groups. CONCLUSION Permissive hypercarbia improved lung oxygenation during one-lung ventilation without increasing the risk of postoperative pulmonary complications or the length of hospital stay. TRIAL REGISTRATION NCT04175379.
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Affiliation(s)
- Young-Eun Joe
- From the Department of Anaesthesiology and Pain Medicine, and Anaesthesia and Pain Research Institute (Y-EJ, NK, KL, SJK, YJO) and Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea (CYL)
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Zhang Y, Ding Y, Zhang J, Huang T, Gao J. Tidal volume challenge-induced hemodynamic changes can predict fluid responsiveness during one-lung ventilation: an observational study. Front Med (Lausanne) 2023; 10:1169912. [PMID: 37636561 PMCID: PMC10447224 DOI: 10.3389/fmed.2023.1169912] [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] [Received: 02/20/2023] [Accepted: 07/27/2023] [Indexed: 08/29/2023] Open
Abstract
Background To evaluate the ability of tidal volume challenge (VTC)-induced hemodynamic changes to predict fluid responsiveness in patients during one-lung ventilation (OLV). Methods 80 patients scheduled for elective thoracoscopic surgery with OLV were enrolled. The inclusion criteria were: age ≥ 18 years, American Society of Anesthesiologists physical status I-III, normal right ventricular function, normal left ventricular systolic function (ejection fraction ≥55%), and normal or slightly impaired diastolic function. The study protocol was implemented 15 min after starting OLV. Simultaneous recordings were performed for hemodynamic variables of diameter of left ventricular outflow tract, velocity time integral (VTI) of aortic valve, and stroke volume (SV), and ΔSV-VTC, ΔVTI-VTC, and ΔMAP-VTC were calculated at four time points: with VT 5 mL/kg (T1); after VT increased from 5 mL/kg to 8 mL/kg and maintained at this level for 2 min (T2); after VT was adjusted back to 5 mL/kg for 2 min (T3); and after volume expansion (250 mL of 0.9% saline infused over 10-15 min) (T4). Patients were considered as responders to fluid administration if SV increased by ≥10%. Receiver operating characteristic (ROC) curves for percent decrease in SV, VTI, and MAP by VTC were generated to evaluate their ability to discriminate fluid responders from nonresponders. Results Of the 58 patients analyzed, there were 32 responders (55%) and 26 nonresponders (45%). The basic characteristics were comparable between the two groups (p > 0.05). The area under the curve (AUC) for ΔSV-VTC, ΔVTI-VTC, and ΔMAP-VTC to discriminate responders from nonresponders were 0.81 (95% CI: 0.68-0.90), 0.79 (95% CI: 0.66-0.89), and 0.56 (95% CI: 0.42-0.69). The best threshold for ΔSV-VTC was -16.1% (sensitivity, 78.1%; specificity, 84.6%); the best threshold for ΔVTI-VTC was -14.5% (sensitivity, 78.1%; specificity, 80.8%). Conclusion Tidal volume challenge-induced relative change of stroke volume and velocity time integral can predict fluid responsiveness in patients during one-lung ventilation.Clinical Trial Registration: Chinese Clinical Trial Registry, No: chictr210051310.
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Affiliation(s)
| | | | | | | | - Ju Gao
- Department of Anesthesiology, Northern Jiangsu People's Hospital, Yangzhou, China
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Zhang T, Wang G, Li Q, Yan P, Sun J, Jin Y. Relationship between serum Th1/Th2 imbalance and depression in elderly patients with COPD and its clinical implications. Technol Health Care 2023; 31:2047-2058. [PMID: 37694327 PMCID: PMC10741335 DOI: 10.3233/thc-230665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/24/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) causes organic damage as well as anxiety, depression, fear, and other psychological disorders, which seriously affect the quality of life and prognosis of patients and cause a huge economic burden to the family and society. OBJECTIVE The aim of this study was to investigate the correlation between an imbalance of serum Th1/Th2 indicators and psychiatric depression in elderly patients with COPD and analyze its implications for clinical management. METHODS From January 2018 to May 2022, 120 elderly patients with COPD treated at our hospital were categorized into two groups based on the self-rating depression scale (SDS): COPD with depression (SDS score ⩾ 50) and COPD alone (SDS score < 50). Blood gas analysis, pulmonary function, and serum Th1/Th2 index were determined. Receiver operating characteristic (ROC) curves were analyzed to explore the diagnostic value of serum Th1/Th2 ratios for COPD complicated by depression. RESULTS Compared with the group without depression, the partial pressure of carbon dioxide and COPD assessment test scores were significantly higher, and the oxygenation index, forced expiratory volume in one second (FEV1), and percent predicted FEV1 were significantly lower in the COPD with depression group (P< 0.05). Interleukin (IL)-1β, IL-2, IL-6, IL-8, IL-10, and tumor necrosis factor-α (TNF-α) were significantly higher in the COPD with depression group than in the group without depression (P< 0.05). Logistic regression analysis indicated that the imbalance of serum IL-1β, IL-2, IL-6, IL-8, IL-10, and TNF-α was a risk factor for mental depression in elderly patients with COPD. When comparing prognostic indices, the interval before the first onset of clinically noticeable deterioration (CID-C) in the COPD with depression group was noticeably shorter than that in the COPD without depression group; the incidence of CID-C within 6 months was noticeably higher in the COPD with depression group than in the group without depression. CONCLUSION Elderly patients with COPD and depression had reduced pulmonary function and higher serum Th1/Th2 levels, and an imbalance in serum Th1/Th2 indicators was a potential risk factor for depression. Moreover, elderly patients with COPD and depression were at a higher risk of disease progression and had a worse prognosis. Thus, an imbalance in serum Th1/Th2 indicators is a potential prognostic factor for evaluating depression in patients with COPD.
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Affiliation(s)
- Teng Zhang
- Department of Psychiatry, Hangzhou Seventh People’s Hospital, Hangzhou, Zhejiang, China
| | - Guodong Wang
- Department of Geriatrics, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Qiang Li
- Department of Geriatrics, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Pan Yan
- Department of Molecular Laboratory, Hangzhou Seventh People’s Hospital, Hangzhou, Zhejiang, China
| | - Jijun Sun
- Department of Psychiatry, Hangzhou Seventh People’s Hospital, Hangzhou, Zhejiang, China
| | - Yun Jin
- Department of Geriatrics, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
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Walsh SP, Shaz D, Amar D. Ventilation during Lung Resection and Critical Care: Comparative Clinical Outcomes. Anesthesiology 2022; 137:473-483. [PMID: 35993993 PMCID: PMC11210714 DOI: 10.1097/aln.0000000000004325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Recent evidence suggests that outcomes do not meaningfully differ between thoracic surgery patients who are ventilated with a low or higher tidal volume and the effects of low versus higher positive end-expiratory pressure are unclear.
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Affiliation(s)
- Spencer P. Walsh
- Department of Anesthesiology, Weill Cornell Medical College, New York, New York
| | - David Shaz
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina
| | - David Amar
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, and Weill Cornell Medical College, New York, New York
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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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14
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Wang L, Li J, Zhu Y, Zha B. Low tidal volume ventilation alleviates ventilator-induced lung injury by regulating the NLRP3 inflammasome. Exp Lung Res 2022; 48:168-177. [PMID: 35916505 DOI: 10.1080/01902148.2022.2104409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
PURPOSE Low tidal volume ventilation (LTVV) is a well-known ventilation mode which can improve ventilator-induced lung injury (VILI). However, the mechanism of LTVV ameliorating VILI has not yet been elucidated. In this study, we aimed to reveal LTVV protected against VILI by inhibiting the activation of the NLRP3 inflammasome in bronchoalveolar lavage fluid (BALF) from humans and lungs from mice. MATERIALS AND METHODS Twenty-eight patients scheduled for video-assisted thoracoscopic esophagectomy were randomized to receive high-tidal-volume ventilation [Vt = 10 mL/kg without positive end-expiratory pressure (PEEP)] or LTVV (Vt = 5 mL/kg along with 5 cm of H2O PEEP) during one-lung ventilation. BALF was collected before and at the end of surgery. Male C57BL/6 mice received high-tidal-volume ventilation, LTVV or MCC950 (an inhibitor of NLRP3). The activation of the formation of NLRP3 inflammasome in BALF from patients and in lungs from mice were analyzed. RESULTS LTTV decreased the peak airway pressure (Ppeak), plateau airway pressure (Pplat) and driving pressure (ΔP) during one-lung ventilation. Additionally, LTVV not only inhibited pulmonary infiltration and inflammation caused by mechanical ventilation, but also suppressed the NLRP3 inflammasome activation in BALF from humans. In mice, ventilator-induced inflammatory response and pulmonary edema were suppressed by LTVV with an efficacy comparable to that of MCC950 treatment. Furthermore, LTVV, similar to MCC950, clearly decreased ventilator-induced NLRP3 inflammasome activation. CONCLUSION Our study showed that LTVV played a protective role in ventilator-induced lung injury by suppressing the activation of the NLRP3 inflammasome. TRIAL REGISTRATION This study was registered in The Chinese Clinical Trial Registry, ChiCTR1900026190 on 25 September 2019.
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Affiliation(s)
- Lixia Wang
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, People's Republic of China
| | - Jun Li
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, People's Republic of China
| | - Yan Zhu
- Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, People's Republic of China
| | - Binshan Zha
- Department of Vascular and Thyroid Surgery, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, People's Republic of China
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15
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Li X, Xue W, Zhang Q, Zhu Y, Fang Y, Huang J. Effect of Driving Pressure-Oriented Ventilation on Patients Undergoing One-Lung Ventilation During Thoracic Surgery: A Systematic Review and Meta-Analysis. Front Surg 2022; 9:914984. [PMID: 35722525 PMCID: PMC9198650 DOI: 10.3389/fsurg.2022.914984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 05/12/2022] [Indexed: 11/16/2022] Open
Abstract
Background Hypoxemia and fluctuations in respiratory mechanics parameters are common during one-lung ventilation (OLV) in thoracic surgery. Additionally, the incidence of postoperative pulmonary complications (PPCS) in thoracic surgery is higher than that in other surgeries. Previous studies have demonstrated that driving pressure-oriented ventilation can reduce both mortality in patients with acute respiratory distress syndrome (ARDS) and the incidence of PPCS in patients undergoing general anesthesia. Our aim was to determine whether driving pressure-oriented ventilation improves intraoperative physiology and outcomes in patients undergoing thoracic surgery. Methods We searched MEDLINE via PubMed, Embase, Cochrane, Web of Science, and ClinicalTrials.gov and performed a meta-analysis to compare the effects of driving pressure-oriented ventilation with other ventilation strategies on patients undergoing OLV. The primary outcome was the PaO2/FiO2 ratio (P/F ratio) during OLV. The secondary outcomes were the incidence of PPCS during follow-up, compliance of the respiratory system during OLV, and mean arterial pressure during OLV. Results This review included seven studies, with a total of 640 patients. The PaO2/FiO2 ratio was higher during OLV in the driving pressure-oriented ventilation group (mean difference [MD]: 44.96; 95% confidence interval [CI], 24.22–65.70.32; I2: 58%; P < 0.0001). The incidence of PPCS was lower (OR: 0.58; 95% CI, 0.34–0.99; I2: 0%; P = 0.04) and the compliance of the respiratory system was higher (MD: 6.15; 95% CI, 3.97–8.32; I2: 57%; P < 0.00001) in the driving pressure-oriented group during OLV. We did not find a significant difference in the mean arterial pressure between the two groups. Conclusion Driving pressure-oriented ventilation during OLV in patients undergoing thoracic surgery was associated with better perioperative oxygenation, fewer PPCS, and improved compliance of the respiratory system. Systematic Review Registration PROSPERO, identifier: CRD42021297063.
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Affiliation(s)
| | | | | | | | - Yu Fang
- Correspondence: Yu Fang Jie Huang
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Garutti I, Cabañero A, Vicente R, Sánchez D, Granell M, Fraile CA, Real Navacerrada M, Novoa N, Sanchez-Pedrosa G, Congregado M, Gómez A, Miñana E, Piñeiro P, Cruz P, de la Gala F, Quero F, Huerta LJ, Rodríguez M, Jiménez E, Puente-Maestu L, Aragon S, Osorio-Salazar E, Sitges M, Lopez Maldonado MD, Rios FT, Morales JE, Callejas R, Gonzalez-Bardancas S, Botella S, Cortés M, Yepes MJ, Iranzo R, Sayas J. Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:208-241. [PMID: 35585017 DOI: 10.1016/j.redare.2021.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/04/2021] [Indexed: 06/15/2023]
Abstract
In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.
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Affiliation(s)
- I Garutti
- Servicio Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain; Departamento de Farmacología y Toxicología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain.
| | - A Cabañero
- Servicio de Cirugía Torácica, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - R Vicente
- Servicio de Anestesia y Reanimación, Hospital La Fe, Valencia, Spain
| | - D Sánchez
- Servicio de Cirugía Torácica, Hospital Clínic, Barcelona, Spain
| | - M Granell
- Servicio de Anestesia y Reanimación, Hospital General, Valencia, Spain
| | - C A Fraile
- Servicio de Cirugía Torácica, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - M Real Navacerrada
- Servicio de Anestesia y Reanimación, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - N Novoa
- Servicio de Cirugía Torácica, Complejo Asistencial Universitario de Salamanca (CAUS), Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain
| | - G Sanchez-Pedrosa
- Servicio Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - M Congregado
- Servicio de Cirugía Torácica, Hospital Virgen de la Macarena, Sevilla, Spain
| | - A Gómez
- Unitat de Rehabilitació Cardiorespiratòria, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - E Miñana
- Servicio de Anestesia y Reanimación, Hospital de la Ribera, Alzira, Valencia, Spain
| | - P Piñeiro
- Servicio Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - P Cruz
- Servicio Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - F de la Gala
- Servicio Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - F Quero
- Servicio de Cirugía Torácica, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - L J Huerta
- Servicio de Cirugía Torácica, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - M Rodríguez
- Servicio de Cirugía Torácica, Clínica Universidad de Navarra, Madrid, Spain
| | - E Jiménez
- Fisioterapia Respiratoria, Hospital Universitario A Coruña, La Coruña, Spain
| | - L Puente-Maestu
- Servicio de Neumología, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - S Aragon
- Servicio de Anestesia, Reanimación y Tratamiento del Dolor, Hospital Clínico Universitario, Valencia, Spain
| | - E Osorio-Salazar
- Servicio de Anestesia y Reanimación, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - M Sitges
- Bloc Quirúrgic i Esterilització, Hospital del Mar, Parc de Salut Mar, Barcelona, Spain
| | | | - F T Rios
- Servicio de Anestesia y Reanimación, Hospital La Fe, Valencia, Spain
| | - J E Morales
- Servicio de Anestesia y Reanimación, Hospital General, Valencia, Spain
| | - R Callejas
- Servicio de Anestesia, Reanimación y Tratamiento del Dolor, Hospital Clínico Universitario, Valencia, Spain
| | - S Gonzalez-Bardancas
- Servicio de Anestesia y Reanimación, Complejo Hospitalario Universitario A Coruña, La Coruña, Spain
| | - S Botella
- Servicio de Anestesia y Reanimación, Hospital La Fe, Valencia, Spain
| | - M Cortés
- Servicio de Anestesia y Reanimación, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - M J Yepes
- Servicio de Anestesia y Reanimación, Clínica Universidad de Navarra, Navarra, Pamplona, Spain
| | - R Iranzo
- Servicio de Anestesia y Reanimación, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - J Sayas
- Servicio de Neumología, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
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Lagier D, Zeng C, Fernandez-Bustamante A, Melo MFV. Perioperative Pulmonary Atelectasis: Part II. Clinical Implications. Anesthesiology 2022; 136:206-236. [PMID: 34710217 PMCID: PMC9885487 DOI: 10.1097/aln.0000000000004009] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.
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Affiliation(s)
- David Lagier
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Congli Zeng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Marcos F. Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Over-distension prediction via hysteresis loop analysis and patient-specific basis functions in a virtual patient model. Comput Biol Med 2021; 141:105022. [PMID: 34801244 DOI: 10.1016/j.compbiomed.2021.105022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Recruitment maneuvers (RMs) with subsequent positive-end-expiratory-pressure (PEEP) have proven effective in recruiting lung volume and preventing alveolar collapse. However, a suboptimal PEEP could induce undesired injury in lungs by insufficient or excessive breath support. Thus, a predictive model for patient response under PEEP changes could improve clinical care and lower risks. METHODS This research adds novel elements to a virtual patient model to identify and predict patient-specific lung distension to optimise and personalise care. Model validity and accuracy are validated using data from 18 volume-controlled ventilation (VCV) patients at 7 different baseline PEEP levels (0-12cmH2O), yielding 623 prediction cases. Predictions were made up to ΔPEEP = 12cmH2O ahead covering 6x2cmH2O PEEP steps. RESULTS Using the proposed lung distension model, 90% of absolute peak inspiratory pressure (PIP) prediction errors compared to clinical measurement are within 3.95cmH2O, compared with 4.76cmH2O without this distension term. Comparing model-predicted and clinically measured distension had high correlation increasing to R2 = 0.93-0.95 if maximum ΔPEEP ≤ 6cmH2O. Predicted dynamic functional residual capacity (Vfrc) changes as PEEP rises yield 0.013L median prediction error for both prediction groups and overall R2 of 0.84. CONCLUSIONS Overall results demonstrate nonlinear distension mechanics are accurately captured in virtual lung mechanics patients for mechanical ventilation, for the first time. This result can minimise the risk of lung injury by predicting its potential occurrence of distension before changing ventilator settings. The overall outcomes significantly extend and more fully validate this virtual mechanical ventilation patient model.
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Lei M, Bao Q, Luo H, Huang P, Xie J. Effect of Intraoperative Ventilation Strategies on Postoperative Pulmonary Complications: A Meta-Analysis. Front Surg 2021; 8:728056. [PMID: 34671638 PMCID: PMC8521033 DOI: 10.3389/fsurg.2021.728056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 08/30/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: The role of intraoperative ventilation strategies in subjects undergoing surgery is still contested. This meta-analysis study was performed to assess the relationship between the low tidal volumes strategy and conventional mechanical ventilation in subjects undergoing surgery. Methods: A systematic literature search up to December 2020 was performed in OVID, Embase, Cochrane Library, PubMed, and Google scholar, and 28 studies including 11,846 subjects undergoing surgery at baseline and reporting a total of 2,638 receiving the low tidal volumes strategy and 3,632 receiving conventional mechanical ventilation, were found recording relationships between low tidal volumes strategy and conventional mechanical ventilation in subjects undergoing surgery. Odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CIs) were calculated between the low tidal volumes strategy vs. conventional mechanical ventilation using dichotomous and continuous methods with a random or fixed-effect model. Results: The low tidal volumes strategy during surgery was significantly related to a lower rate of postoperative pulmonary complications (OR, 0.60; 95% CI, 0.44-0.83, p < 0.001), aspiration pneumonitis (OR, 0.63; 95% CI, 0.46-0.86, p < 0.001), and pleural effusion (OR, 0.72; 95% CI, 0.56-0.92, p < 0.001) compared to conventional mechanical ventilation. However, the low tidal volumes strategy during surgery was not significantly correlated with length of hospital stay (MD, -0.48; 95% CI, -0.99-0.02, p = 0.06), short-term mortality (OR, 0.88; 95% CI, 0.70-1.10, p = 0.25), atelectasis (OR, 0.76; 95% CI, 0.57-1.01, p = 0.06), acute respiratory distress (OR, 1.06; 95% CI, 0.67-1.66, p = 0.81), pneumothorax (OR, 1.37; 95% CI, 0.88-2.15, p = 0.17), pulmonary edema (OR, 0.70; 95% CI, 0.38-1.26, p = 0.23), and pulmonary embolism (OR, 0.65; 95% CI, 0.26-1.60, p = 0.35) compared to conventional mechanical ventilation. Conclusions: The low tidal volumes strategy during surgery may have an independent relationship with lower postoperative pulmonary complications, aspiration pneumonitis, and pleural effusion compared to conventional mechanical ventilation. This relationship encouraged us to recommend the low tidal volumes strategy during surgery to avoid any possible complications.
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Affiliation(s)
- Min Lei
- Department of Anesthesiology, Sir Run Run Shaw Hospital of School of Medicine, Zhejiang University, Zhejiang, China
| | - Qi Bao
- Department of Anesthesiology, Sir Run Run Shaw Hospital of School of Medicine, Zhejiang University, Zhejiang, China
| | - Huanyu Luo
- Department of Anesthesiology, Sir Run Run Shaw Hospital of School of Medicine, Zhejiang University, Zhejiang, China
| | - Pengfei Huang
- Department of Anesthesiology, Sir Run Run Shaw Hospital of School of Medicine, Zhejiang University, Zhejiang, China
| | - Junran Xie
- Department of Anesthesiology, Sir Run Run Shaw Hospital of School of Medicine, Zhejiang University, Zhejiang, China
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Li H, Zheng ZN, Zhang NR, Guo J, Wang K, Wang W, Li LG, Jin J, Tang J, Liao YJ, Jin SQ. Intra-operative open-lung ventilatory strategy reduces postoperative complications after laparoscopic colorectal cancer resection: A randomised controlled trial. Eur J Anaesthesiol 2021; 38:1042-1051. [PMID: 34366425 PMCID: PMC8452317 DOI: 10.1097/eja.0000000000001580] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The role of the positive end-expiratory pressure (PEEP) and lung recruitment manoeuvre (LRM) combination (termed open-lung strategy, OLS) during intra-operative mechanical ventilation is not clear. OBJECTIVE To determine whether an open-lung strategy constituting medium PEEP (6-8 cmH2O) and repeated LRMs protects against postoperative complications in at-risk patients undergoing laparoscopic colorectal cancer resection under low-tidal-volume ventilation. DESIGN A prospective, assessor-blinded, randomised controlled trial. SETTING Single university-affiliated hospital, conducted from January 2017 to October 2018. PATIENTS A total of 280 patients at risk of pulmonary complications, scheduled for laparoscopic colorectal cancer resection under general anaesthesia and low-tidal-volume (6-8 ml kg-1 predicted body weight) ventilation. INTERVENTION The patients were randomly assigned (1 : 1) to a PEEP of 6-8 cmH2O with LRMs repeated every 30 min (OLS group) or a zero PEEP without LRMs (non-OLS group). MAIN OUTCOME MEASURES The primary outcome was a composite of major pulmonary and extrapulmonary complications occurring within 7 days after surgery. The secondary outcomes included intra-operative potentially harmful hypotension and the need for vasopressors. RESULTS A total of 130 patients from each group were included in the primary outcome analysis. Primary outcome events occurred in 24 patients (18.5%) in the OLS group and 43 patients (33.1%) in the non-OLS group [relative risk, 0.46; 95% confidence interval (CI), 0.26 to 0.82; P = 0.009). More patients in the OLS group developed potentially harmful hypotension (OLS vs. non-OLS, 15% vs. 4.3%; P = 0.004) and needed vasopressors (25% vs. 8.6%; P < 0.001). CONCLUSION Among at-risk patients undergoing laparoscopic colorectal cancer resection under low-tidal-volume ventilation, an open-lung strategy with a PEEP of 6-8 cmH2O and repeated LRMs reduced postoperative complications compared with a strategy using zero PEEP without LRMs. Of note, LRMs should be used with caution in patients with haemodynamic instability. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT03160144.
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Affiliation(s)
- Hong Li
- From the Department of Anaesthesia, the Sixth Affiliated Hospital, Sun Yat-sen University, No. 26 Yuancun Erheng Road, Tianhe District, Guangzhou, China (HL, Z-NZ, N-RZ, JG, KW, WW, L-GL, JJ, JT, Y-JL, S-QJ)
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Garutti I, Cabañero A, Vicente R, Sánchez D, Granell M, Fraile CA, Real Navacerrada M, Novoa N, Sanchez-Pedrosa G, Congregado M, Gómez A, Miñana E, Piñeiro P, Cruz P, de la Gala F, Quero F, Huerta LJ, Rodríguez M, Jiménez E, Puente-Maestu L, Aragon S, Osorio-Salazar E, Sitges M, Lopez Maldonado MD, Rios FT, Morales JE, Callejas R, Gonzalez-Bardancas S, Botella S, Cortés M, Yepes MJ, Iranzo R, Sayas J. Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 69:S0034-9356(21)00102-X. [PMID: 34294445 DOI: 10.1016/j.redar.2021.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/28/2021] [Accepted: 02/04/2021] [Indexed: 11/24/2022]
Abstract
In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.
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Affiliation(s)
- I Garutti
- Servicio de Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, España; Departamento de Farmacología y Toxicología, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España.
| | - A Cabañero
- Servicio de Cirugía Torácica, Hospital Universitario Ramón y Cajal, Madrid, España
| | - R Vicente
- Servicio de Anestesia y Reanimación, Hospital La Fe, Valencia, España
| | - D Sánchez
- Servicio de Cirugía Torácica, Hospital Clínic, Barcelona, España
| | - M Granell
- Servicio de Anestesia y Reanimación, Hospital General, Valencia, España
| | - C A Fraile
- Servicio de Cirugía Torácica, Hospital Universitari Arnau de Vilanova, Lleida, España
| | - M Real Navacerrada
- Servicio de Anestesia y Reanimación, Hospital Universitario 12 de Octubre, Madrid, España
| | - N Novoa
- Servicio de Cirugía Torácica, Complejo Asistencial Universitario de Salamanca (CAUS), Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, España
| | - G Sanchez-Pedrosa
- Servicio de Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - M Congregado
- Servicio de Cirugía Torácica, Hospital Virgen de la Macarena, Sevilla, España
| | - A Gómez
- Unitat de Rehabilitació Cardiorespiratòria, Hospital Universitari Vall d'Hebron, Barcelona, España
| | - E Miñana
- Servicio de Anestesia y Reanimación, Hospital de La Ribera, Alzira, Valencia, España
| | - P Piñeiro
- Servicio de Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - P Cruz
- Servicio de Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - F de la Gala
- Servicio de Anestesia y Reanimación, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - F Quero
- Servicio de Cirugía Torácica, Hospital Universitario Virgen de las Nieves, Granada, España
| | - L J Huerta
- Servicio de Cirugía Torácica, Hospital General Universitario Gregorio Marañón, Madrid, España
| | - M Rodríguez
- Servicio de Cirugía Torácica, Clínica Universidad de Navarra, Madrid, España
| | - E Jiménez
- Fisioterapia Respiratoria, Hospital Universitario de A Coruña, La Coruña, España
| | - L Puente-Maestu
- Servicio de Neumología, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
| | - S Aragon
- Servicio de Anestesia, Reanimación y Tratamiento del Dolor, Hospital Clínico Universitario, Valencia, España
| | - E Osorio-Salazar
- Servicio de Anestesia y Reanimación, Hospital Universitari Arnau de Vilanova, Lleida, España
| | - M Sitges
- Bloc Quirúrgic i Esterilització, Hospital del Mar, Parc de Salut Mar, Barcelona, España
| | | | - F T Rios
- Servicio de Anestesia y Reanimación, Hospital La Fe, Valencia, España
| | - J E Morales
- Servicio de Anestesia y Reanimación, Hospital General, Valencia, España
| | - R Callejas
- Servicio de Anestesia, Reanimación y Tratamiento del Dolor, Hospital Clínico Universitario, Valencia, España
| | - S Gonzalez-Bardancas
- Servicio de Anestesia y Reanimación, Complejo Hospitalario Universitario A Coruña, La Coruña, España
| | - S Botella
- Servicio de Anestesia y Reanimación, Hospital La Fe, Valencia, España
| | - M Cortés
- Servicio de Anestesia y Reanimación, Hospital Universitario 12 de Octubre, Madrid, España
| | - M J Yepes
- Servicio de Anestesia y Reanimación, Clínica Universidad de Navarra, Navarra, Pamplona, España
| | - R Iranzo
- Servicio de Anestesia y Reanimación, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, España
| | - J Sayas
- Servicio de Neumología, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, España
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Li P, Kang X, Miao M, Zhang J. Individualized positive end-expiratory pressure (PEEP) during one-lung ventilation for prevention of postoperative pulmonary complications in patients undergoing thoracic surgery: A meta-analysis. Medicine (Baltimore) 2021; 100:e26638. [PMID: 34260559 PMCID: PMC8284741 DOI: 10.1097/md.0000000000026638] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 06/24/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Positive end-expiratory pressure (PEEP) is an important part of the lung protection strategies for one-lung ventilation (OLV). However, a fixed PEEP value is not suitable for all patients. Our objective was to determine the prevention of individualized PEEP on postoperative complications in patients undergoing one-lung ventilation. METHOD We searched the PubMed, Embase, and Cochrane and performed a meta-analysis to compare the effect of individual PEEP vs fixed PEEP during single lung ventilation on postoperative pulmonary complications. Our primary outcome was the occurrence of postoperative pulmonary complications during follow-up. Secondary outcomes included the partial pressure of arterial oxygen and oxygenation index during one-lung ventilation. RESULT Eight studies examining 849 patients were included in this review. The rate of postoperative pulmonary complications was reduced in the individualized PEEP group with a risk ratio of 0.52 (95% CI:0.37-0.73; P = .0001). The partial pressure of arterial oxygen during the OLV in the individualized PEEP group was higher with a mean difference 34.20 mm Hg (95% CI: 8.92-59.48; P = .0004). Similarly, the individualized PEEP group had a higher oxygenation index, MD: 49.07mmHg, (95% CI: 27.21-70.92; P < .0001). CONCLUSIONS Individualized PEEP setting during one-lung ventilation in patients undergoing thoracic surgery was associated with fewer postoperative pulmonary complications and better perioperative oxygenation.
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Jiang L, Wu Y, Zhang Y, Lu D, Yan K, Gao J. Effects of intraoperative lung-protective ventilation on clinical outcomes in patients with traumatic brain injury: a randomized controlled trial. BMC Anesthesiol 2021; 21:182. [PMID: 34182951 PMCID: PMC8236740 DOI: 10.1186/s12871-021-01402-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 06/15/2021] [Indexed: 11/11/2022] Open
Abstract
Background Secondary lung injury is the most common non-neurological complication after traumatic brain injury (TBI). Lung-protective ventilation (LPV) has been proven to improve perioperative oxygenation and lung compliance in some critical patients. This study aimed to investigate whether intraoperative LPV could improve respiratory function and prevent postoperative complications in emergency TBI patients. Methods Ninety TBI patients were randomly allocated to three groups (1:1:1): Group A, conventional mechanical ventilation [tidal volume (VT) 10 mL/kg only]; Group B, small VT (8 mL/kg) + positive end-expiratory pressure (PEEP) (5 cmH2O); and Group C, small VT (8 mL/kg) + PEEP (5 cmH2O) + recruitment maneuvers (RMs). The primary outcome was the incidence of total postoperative pulmonary complications; Secondary outcomes were intraoperative respiratory mechanics parameters and serum levels of brain injury markers, and the incidence of each postoperative pulmonary and neurological complication. Results Seventy-nine patients completed the final analysis. The intraoperative PaO2 and dynamic pulmonary compliance of Groups B and C were higher than those of Group A (P = 0.028; P = 0.005), while their airway peak pressure and plateau pressure were lower than those of group A (P = 0.004; P = 0.005). Compared to Group A, Groups B and C had decreased 30-day postoperative incidences of total pulmonary complications, hypoxemia, pulmonary infection, and atelectasis (84.0 % vs. 57.1 % vs. 53.8 %, P = 0.047; 52.0 % vs. 14.3 % vs. 19.2 %, P = 0.005; 84.0 % vs. 50.0 % vs. 42.3 %, P = 0.006; 24.0 % vs. 3.6 % vs. 0.0 %, P = 0.004). Moreover, intraoperative hypotension was more frequent in Group C than in Groups A and B (P = 0.007). At the end of surgery, the serum levels of glial fibrillary acidic protein and ubiquitin carboxyl-terminal hydrolase isozyme L1 in Group B were lower than those in Groups A and C (P = 0.002; P < 0.001). The postoperative incidences of neurological complications among the three groups were comparable. Conclusions Continuous intraoperative administration of small VT + PEEP is beneficial to TBI patients. Additional RMs can be performed with caution to prevent disturbances in the stability of cerebral hemodynamics. Trial registration Chinese Clinical Trial Registry (ChiCTR2000038314), retrospectively registered on September 17, 2020.
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Affiliation(s)
- Lulu Jiang
- Department of Anesthesiology, the Second Xiangya Hospital, Central South University, 139# Renmin Central Road, 410011, Changsha, China.,Department of Anesthesiology, Northern Jiangsu People's Hospital, Clinical Medical School, Yangzhou University, 98# Nantong West Road, 225001, Yangzhou, China
| | - Yujuan Wu
- Department of Anesthesiology, Xiangtan Central Hospital, 120# Heping Road, 411100, Xiangtan, China
| | - Yang Zhang
- Department of Anesthesiology, the Second Xiangya Hospital, Central South University, 139# Renmin Central Road, 410011, Changsha, China.,Department of Anesthesiology, Northern Jiangsu People's Hospital, Clinical Medical School, Yangzhou University, 98# Nantong West Road, 225001, Yangzhou, China
| | - Dahao Lu
- Department of Anesthesiology, Northern Jiangsu People's Hospital, Clinical Medical School, Yangzhou University, 98# Nantong West Road, 225001, Yangzhou, China
| | - Keshi Yan
- Department of Anesthesiology, Northern Jiangsu People's Hospital, Clinical Medical School, Yangzhou University, 98# Nantong West Road, 225001, Yangzhou, China
| | - Ju Gao
- Department of Anesthesiology, Northern Jiangsu People's Hospital, Clinical Medical School, Yangzhou University, 98# Nantong West Road, 225001, Yangzhou, China.
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Neema PK, Malhotra N, Haldar R, Karim HMR. Intraoperative lung-protective ventilation in cardiothoracic surgeries: Paradigm and practices. Indian J Anaesth 2021; 65:S59-S61. [PMID: 34188256 PMCID: PMC8191194 DOI: 10.4103/ija.ija_333_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Revised: 04/24/2021] [Accepted: 04/25/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Praveen K Neema
- Mentor for Paediatric Cardiac Anaesthesia Education and Development, Sri Sathya Sai Sanjeevani Group of Hospitals, Raipur, Chhattisgarh, India
| | - Naveen Malhotra
- In Charge Pain Management Centre, Pt BDS PGIMS, Rohtak, Haryana, India
| | - Rudrashish Haldar
- Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Habib M R Karim
- Department of Anaesthesiology, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
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Abstract
PURPOSE OF REVIEW Although there is clear evidence for benefit of protective ventilation settings [including low tidal volume and higher positive end-expiratory pressure (PEEP)] in patients with acute respiratory distress syndrome (ARDS), it is less clear what the optimal mechanical ventilation settings are for patients with healthy lungs. RECENT FINDINGS Use of low tidal volume during operative ventilation decreases postoperative pulmonary complications (PPC). In the critically ill patients with healthy lungs, use of low tidal volume is as effective as intermediate tidal volume. Use of higher PEEP during operative ventilation does not decrease PPCs, whereas hypotension occurred more often compared with use of lower PEEP. In the critically ill patients with healthy lungs, there are conflicting data regarding the use of a higher PEEP, which may depend on recruitability of lung parts. There are limited data suggesting that higher driving pressures because of higher PEEP contribute to PPCs. Lastly, use of hyperoxia does not consistently decrease postoperative infections, whereas it seems to increase PPCs compared with conservative oxygen strategies. SUMMARY In patients with healthy lungs, data indicate that low tidal volume but not higher PEEP is beneficial. Thereby, ventilation strategies differ from those in ARDS patients.
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A Lower Tidal Volume Regimen during One-lung Ventilation for Lung Resection Surgery Is Not Associated with Reduced Postoperative Pulmonary Complications. Anesthesiology 2021; 134:562-576. [PMID: 33635945 DOI: 10.1097/aln.0000000000003729] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Protective ventilation may improve outcomes after major surgery. However, in the context of one-lung ventilation, such a strategy is incompletely defined. The authors hypothesized that a putative one-lung protective ventilation regimen would be independently associated with decreased odds of pulmonary complications after thoracic surgery. METHODS The authors merged Society of Thoracic Surgeons Database and Multicenter Perioperative Outcomes Group intraoperative data for lung resection procedures using one-lung ventilation across five institutions from 2012 to 2016. They defined one-lung protective ventilation as the combination of both median tidal volume 5 ml/kg or lower predicted body weight and positive end-expiratory pressure 5 cm H2O or greater. The primary outcome was a composite of 30-day major postoperative pulmonary complications. RESULTS A total of 3,232 cases were available for analysis. Tidal volumes decreased modestly during the study period (6.7 to 6.0 ml/kg; P < 0.001), and positive end-expiratory pressure increased from 4 to 5 cm H2O (P < 0.001). Despite increasing adoption of a "protective ventilation" strategy (5.7% in 2012 vs. 17.9% in 2016), the prevalence of pulmonary complications did not change significantly (11.4 to 15.7%; P = 0.147). In a propensity score matched cohort (381 matched pairs), protective ventilation (mean tidal volume 6.4 vs. 4.4 ml/kg) was not associated with a reduction in pulmonary complications (adjusted odds ratio, 0.86; 95% CI, 0.56 to 1.32). In an unmatched cohort, the authors were unable to define a specific alternative combination of positive end-expiratory pressure and tidal volume that was associated with decreased risk of pulmonary complications. CONCLUSIONS In this multicenter retrospective observational analysis of patients undergoing one-lung ventilation during thoracic surgery, the authors did not detect an independent association between a low tidal volume lung-protective ventilation regimen and a composite of postoperative pulmonary complications. EDITOR’S PERSPECTIVE
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Nguyen TK, Mai DH, Le AN, Nguyen QH, Nguyen CT, Vu TA. A review of intraoperative lung-protective mechanical ventilation strategy. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2020.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Berna P, Quesnel C, Assouad J, Bagan P, Etienne H, Fourdrain A, Le Guen M, Leone M, Lorne E, Nguyen YNL, Pages PB, Roz H, Garnier M. Guidelines on enhanced recovery after pulmonary lobectomy. Anaesth Crit Care Pain Med 2021; 40:100791. [PMID: 33451912 DOI: 10.1016/j.accpm.2020.100791] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS). DESIGN A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence. METHODS Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method. RESULTS The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions. CONCLUSIONS A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.
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Affiliation(s)
- Pascal Berna
- Department of Thoracic Surgery, Amiens University Hospital, 80000 Amiens, France
| | - Christophe Quesnel
- Sorbonne Universit,, APHP, DMU DREAM, Service d'Anesth,sie-R,animation et M,decine P,riop,ratoire, H"pital Tenon, 75020 Paris, France
| | - Jalal Assouad
- Department of Thoracic Surgery, Tenon University Hospital, Sorbonne Universit,, 75020 Paris, France
| | - Patrick Bagan
- Department of Thoracic and Vascular Surgery, Victor Dupouy Hospital, 95100 Argenteuil, France
| | - Harry Etienne
- Department of Thoracic Surgery, Tenon University Hospital, Sorbonne Universit,, 75020 Paris, France
| | - Alex Fourdrain
- Department of Thoracic Surgery, Amiens University Hospital, 80000 Amiens, France
| | - Morgan Le Guen
- D,partement d'Anesth,sie, H"pital Foch, Universit, Versailles Saint Quentin, 92150 Suresnes, France; INRA UMR 892 VIM, 78350 Jouy-en-Josas, France
| | - Marc Leone
- Aix Marseille Universit, - Assistance Publique H"pitaux de Marseille - Service d'Anesth,sie et de R,animation - H"pital Nord - 13005 Marseille, France
| | - Emmanuel Lorne
- Departement d'Anesth,sie-R,animation, Clinique du Mill,naire, 34000 Montpellier, France
| | - Y N-Lan Nguyen
- Anaesthesiology and Critical Care Department, APHP Centre, Paris University, 75000 Paris, France
| | - Pierre-Benoit Pages
- Department of Thoracic Surgery, Dijon Burgundy University Hospital, 21000 Dijon, France; INSERM UMR 1231, Dijon Burgundy University Hospital, University of Burgundy, 21000 Dijon, France
| | - Hadrien Roz
- Unit, d'Anesth,sie R,animation Thoracique, H"pital Haut Leveque, CHU de Bordeaux, 33000 Bordeaux, France
| | - Marc Garnier
- Sorbonne Universit,, APHP, DMU DREAM, Service d'Anesth,sie-R,animation et M,decine P,riop,ratoire, H"pital Tenon, 75020 Paris, France.
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Spadaro S, Fogagnolo A. How much positive end expiratory pressure during one lung ventilation? An unresolvable question. Minerva Anestesiol 2021; 87:153-155. [PMID: 33432801 DOI: 10.23736/s0375-9393.20.15428-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Savino Spadaro
- Section of Anesthesia and Intensive Care, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy -
| | - Alberto Fogagnolo
- Section of Anesthesia and Intensive Care, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
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Li XF, Hu JR, Wu Y, Chen Y, Zhang MQ, Yu H. Comparative Effect of Propofol and Volatile Anesthetics on Postoperative Pulmonary Complications After Lung Resection Surgery: A Randomized Clinical Trial. Anesth Analg 2021; 133:949-957. [PMID: 33410611 DOI: 10.1213/ane.0000000000005334] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The effect of general anesthetics (propofol and volatile anesthetics) on pulmonary outcome after lung resection surgery with one-lung ventilation (OLV) is yet undetermined. We evaluated the effect of intravenous anesthesia (propofol) and volatile anesthesia (sevoflurane or desflurane) regimens on postoperative pulmonary complications (PPCs) in patients undergoing lung resection surgery. METHODS This prospective, randomized controlled trial enrolled 555 adult patients scheduled for lung resection surgery with OLV. Participants were randomized to 1 of 3 general anesthetic regimens (propofol, sevoflurane, or desflurane). Standard anesthesia and ventilation protocols were followed in all groups. The primary outcome was a composite of PPCs in the first 7 postoperative days. Secondary outcomes included the severity of PPCs and major postoperative complications classification. Intergroup difference in the primary outcome was assessed for significance using the Pearson χ2 test. RESULTS Of 837 patients who were assessed for eligibility, 555 were randomized and 545 were analyzed. One hundred and seventy-nine patients were assigned to the propofol group, 182 in the sevoflurane group, and 184 in the desflurane group. The incidence of PPCs did not differ between the combined volatile anesthetics (sevoflurane and desflurane) group and the propofol group (21.9% vs 24.0%; odds ratio, 0.89; 95% confidence interval, 0.58-1.35; P = .570). The PPCs grade and Clavien-Dindo scores did not differ significantly across groups. CONCLUSIONS In patients undergoing lung resection surgery with OLV, general anesthesia with volatile anesthetics (sevoflurane or desflurane) did not reduce PPCs compared with propofol. No difference in secondary outcomes was observed.
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Affiliation(s)
- Xue-Fei Li
- From the Department of Anesthesiology, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
| | - Jian-Rong Hu
- Anesthesia Operating Center, West China Hospital, Sichuan University/West China School of Nursing, Chengdu, China
| | - Yan Wu
- From the Department of Anesthesiology, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
| | - Ying Chen
- From the Department of Anesthesiology, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
| | - Meng-Qiu Zhang
- From the Department of Anesthesiology, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
| | - Hai Yu
- From the Department of Anesthesiology, West China Hospital, Sichuan University & The Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, China
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Tidal volume during 1-lung ventilation: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2020; 163:1573-1585.e1. [PMID: 33518385 DOI: 10.1016/j.jtcvs.2020.12.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2020] [Revised: 11/20/2020] [Accepted: 12/07/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The selection of tidal volumes for 1-lung ventilation remains unclear, because there exists a trade-off between oxygenation and risk of lung injury. We conducted a systematic review and meta-analysis to determine how oxygenation, compliance, and clinical outcomes are affected by tidal volume during 1-lung ventilation. METHODS A systematic search of MEDLINE and EMBASE was performed. A systematic review and random-effects meta-analysis was conducted. Pooled mean difference estimated arterial oxygen tension, compliance, and length of stay; pooled odds ratio was calculated for composite postoperative pulmonary complications. Risk of bias was determined using the Cochrane risk of bias and Newcastle-Ottawa tools. RESULTS Eighteen studies were identified, comprising 3693 total patients. Low tidal volumes (5.6 [±0.9] mL/kg) were not associated with significant differences in partial pressure of oxygen (-15.64 [-88.53-57.26] mm Hg; P = .67), arterial oxygen tension to fractional intake of oxygen ratio (14.71 [-7.83-37.24]; P = .20), or compliance (2.03 [-5.22-9.27] mL/cmH2O; P = .58) versus conventional tidal volume ventilation (8.1 [±3.1] mL/kg). Low versus conventional tidal volume ventilation had no significant impact on hospital length of stay (-0.42 [-1.60-0.77] days; P = .49). Low tidal volumes are associated with significantly decreased odds of pulmonary complications (pooled odds ratio, 0.40 [0.29-0.57]; P < .0001). CONCLUSIONS Low tidal volumes during 1-lung ventilation do not worsen oxygenation or compliance. A low tidal volume ventilation strategy during 1-lung ventilation was associated with a significant reduction in postoperative pulmonary complications.
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Battaglini D, Ball L, Wittenstein J, Cohen E, Gama DE Abreu M, Pelosi P. PEEP in thoracic anesthesia: pros and cons. Minerva Anestesiol 2020; 87:223-229. [PMID: 33300325 DOI: 10.23736/s0375-9393.20.14797-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Protective ventilation includes a strategy with low tidal volume, Plateau pressure, driving pressure, positive end-expiratory pressure (PEEP), and recruitment maneuvers on the ventilated lung. The rationale for the application of PEEP during one-lung ventilation (OLV) is that PEEP may contribute to minimize atelectrauma, preventing airway closure and alveolar collapse and improving the ventilation/perfusion to the ventilated lung. However, in case of high partial pressure of oxygen the application of PEEP may cause increased pulmonary vascular resistance, thus diverting blood flow to the non-ventilated lung, and worsening ventilation/perfusion. Further, PEEP may be associated with higher risk of hemodynamic impairment, increased need for fluids and vasoactive drugs. Positive effects on outcome have been reported by titrating PEEP according to driving pressure, targeted to obtain the optimum respiratory as well as pulmonary system compliance. This may vary according to the method employed for titration and should be performed individually for each patient. In summary, the potential for harm combined with the lack of evidence for improved outcome suggest that PEEP must be judiciously used during OLV even when titrated to a safe target, and only as much as necessary to maintain an appropriate gas exchange under low protective tidal volumes and driving pressures.
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Affiliation(s)
- Denise Battaglini
- Department of Anesthesiology and Intensive Care, San Martino Policlinico Hospital, IRCCS Oncology and Neuroscience, Genoa, Italy
| | - Lorenzo Ball
- Department of Anesthesiology and Intensive Care, San Martino Policlinico Hospital, IRCCS Oncology and Neuroscience, Genoa, Italy.,Department of Surgical Science and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Jakob Wittenstein
- Department of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Edmond Cohen
- Department of Anesthesiology and Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marcelo Gama DE Abreu
- Department of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Outcomes Research Consortium, Cleveland, OH, USA
| | - Paolo Pelosi
- Department of Anesthesiology and Intensive Care, San Martino Policlinico Hospital, IRCCS Oncology and Neuroscience, Genoa, Italy - .,Department of Surgical Science and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
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Dai YL, Hsu RJ, Huang HK, Huang TW, Tsai WC, Chang H, Lan CC, Huang KL. Adaptive support ventilation attenuates postpneumonectomy acute lung injury in a porcine model. Interact Cardiovasc Thorac Surg 2020; 31:718-726. [PMID: 33051664 DOI: 10.1093/icvts/ivaa157] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/08/2020] [Accepted: 07/15/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES An optimal ventilation strategy that causes as little mechanical stress and inflammation as possible is critical for patients undergoing pneumonectomy. The aim of this study was to determine whether adaptive support ventilation (ASV) can provide protective ventilation to the remaining lung after pneumonectomy with minimal mechanical stress and less inflammation than volume-control ventilation (VCV). METHODS In this study, 15 pigs were randomly allocated to 3 groups (n = 5 for each group): the control group, the VCV group and the ASV group. After left pneumonectomy, the VCV group was treated with the volume-control set to 20 ml/kg, and the ASV group with the mode set to achieve 60% of the minute ventilation of 2 lungs. RESULTS The ASV group had lower alveolar strain than the VCV group. The ASV group exhibited less lung injury and greater alveolar fluid clearance than the VCV group (13.3% vs -17.8%; P ≤ 0.018). Ventilator-induced lung injury was associated with changes in the cytokine levels in the exhaled breath condensate, differential changes in plasma and changes in the cytokines in the bronchoalveolar lavage fluid. Expression of 3 microRNAs (miR449b-3p, P ≤ 0.001; miR451-5p, P = 0.027; and miR144-5p, P = 0.008) was increased in the VCV group compared with the ASV group. CONCLUSIONS The ASV mode was capable of supporting rapid, shallow breathing patterns to exert lung-protective effects in a porcine postpneumonectomy model. Further investigation of microRNAs as biomarkers of ventilator-induced lung injury is warranted.
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Affiliation(s)
- Yu-Ling Dai
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
- Division of Pulmonary and Critical Care Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ren-Jun Hsu
- Cancer Research Center, Hualien Tzu Chi Hospital, The Buddhist Tzu Chi Medical Foundation, Hualien, Taiwan
| | - Hsu-Kai Huang
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tsai-Wang Huang
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wen-Chiuan Tsai
- Department of Pathology, Tri-Service General Hospital Taipei, National Defense Medical Center, Taipei, Taiwan
| | - Hung Chang
- Department of Physiology, National Defense Medical Center, Taipei, Taiwan
| | - Chou-Chin Lan
- Division of Pulmonary Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
| | - Kun-Lun Huang
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
- Division of Pulmonary and Critical Care Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Friederich P, Fuchsgruber F, Hiebinger A, Angerer H, Bodner J. Ventilator settings and arterial blood gases during video-assisted thoracoscopic surgery including pneumonectomy with pressure support ventilation. Br J Anaesth 2020; 125:e416-e417. [PMID: 32859364 DOI: 10.1016/j.bja.2020.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- Patrick Friederich
- Department of Anaesthesiology, Intensive Care Medicine, Pain Therapy, München Klinik Bogenhausen, Technische Universität München, Munich, Germany.
| | - Florian Fuchsgruber
- Department of Anaesthesiology, Intensive Care Medicine, Pain Therapy, München Klinik Bogenhausen, Technische Universität München, Munich, Germany
| | - Andreas Hiebinger
- Department of Thoracic Surgery, München Klinik Bogenhausen, Technische Universität München, Munich, Germany
| | - Hannes Angerer
- Department of Anaesthesiology, Intensive Care Medicine, Pain Therapy, München Klinik Bogenhausen, Technische Universität München, Munich, Germany
| | - Johannes Bodner
- Department of Thoracic Surgery, München Klinik Bogenhausen, Technische Universität München, Munich, Germany
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Tucci MR, Pereira SM, Costa ELV, Vieira JE. Mechanical ventilation during thoracic surgery: towards individualized medicine. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:842. [PMID: 32793686 DOI: 10.21037/atm-20-2005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Mauro Roberto Tucci
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Sérgio Martins Pereira
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
| | - Eduardo Leite Vieira Costa
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil.,Instituto de Ensino e Pesquisa, Hospital Sírio Libanes, São Paulo, Brazil
| | - Joaquim Edson Vieira
- Disciplina de Anestesiologia, Departamento de Cirurgia, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, Brazil
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Intraoperative mechanical ventilation practice in thoracic surgery patients and its association with postoperative pulmonary complications: results of a multicenter prospective observational study. BMC Anesthesiol 2020; 20:179. [PMID: 32698775 PMCID: PMC7373838 DOI: 10.1186/s12871-020-01098-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/15/2020] [Indexed: 12/02/2022] Open
Abstract
Background Intraoperative mechanical ventilation may influence postoperative pulmonary complications (PPCs). Current practice during thoracic surgery is not well described. Methods This is a post-hoc analysis of the prospective multicenter cross-sectional LAS VEGAS study focusing on patients who underwent thoracic surgery. Consecutive adult patients receiving invasive ventilation during general anesthesia were included in a one-week period in 2013. Baseline characteristics, intraoperative and postoperative data were registered. PPCs were collected as composite endpoint until the 5th postoperative day. Patients were stratified into groups based on the use of one lung ventilation (OLV) or two lung ventilation (TLV), endoscopic vs. non-endoscopic approach and ARISCAT score risk for PPCs. Differences between subgroups were compared using χ2 or Fisher exact tests or Student’s t-test. Kaplan–Meier estimates of the cumulative probability of development of PPC and hospital discharge were performed. Cox-proportional hazard models without adjustment for covariates were used to assess the effect of the subgroups on outcome. Results From 10,520 patients enrolled in the LAS VEGAS study, 302 patients underwent thoracic procedures and were analyzed. There were no differences in patient characteristics between OLV vs. TLV, or endoscopic vs. open surgery. Patients received VT of 7.4 ± 1.6 mL/kg, a PEEP of 3.5 ± 2.4 cmH2O, and driving pressure of 14.4 ± 4.6 cmH2O. Compared with TLV, patients receiving OLV had lower VT and higher peak, plateau and driving pressures, higher PEEP and respiratory rate, and received more recruitment maneuvers. There was no difference in the incidence of PPCs in OLV vs. TLV or in endoscopic vs. open procedures. Patients at high risk had a higher incidence of PPCs compared with patients at low risk (48.1% vs. 28.9%; hazard ratio, 1.95; 95% CI 1.05–3.61; p = 0.033). There was no difference in the incidence of severe PPCs. The in-hospital length of stay (LOS) was longer in patients who developed PPCs. Patients undergoing OLV, endoscopic procedures and at low risk for PPC had shorter LOS. Conclusion PPCs occurred frequently and prolonged hospital LOS following thoracic surgery. Proportionally large tidal volumes and high driving pressure were commonly used in this sub-population. However, large RCTs are needed to confirm these findings. Trial registration This trial was prospectively registered at the Clinical Trial Register (www.clinicaltrials.gov; NCT01601223; registered May 17, 2012.)
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Doan V, Hammond B, Haithcock B, Kolarczyk L. Anesthetic Approach to Postpneumonectomy Syndrome. Semin Cardiothorac Vasc Anesth 2020; 24:205-210. [PMID: 32389098 PMCID: PMC7745610 DOI: 10.1177/1089253220919289] [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] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Postpneumonectomy syndrome is a rare complication in patients who have previously had a pneumonectomy. Over time, the mediastinum may rotate toward the vacant pleural space, which can cause extrinsic airway and esophageal compression. As such, these patients typically present with progressive dyspnea and dysphagia. There is a paucity of reports in the anesthesiology literature regarding the intraoperative anesthetic approach to such rare patients. We present a case of an 18-year-old female found to have postpneumonectomy syndrome requiring thoracotomy with insertion of tissue expanders. Our case report illustrates the complexities involved in the care of these patients with regards to airway management, ventilation concerns, and potential for hemodynamic compromise. This case report underscores the importance of extensive multidisciplinary planning.
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Affiliation(s)
- Vivian Doan
- University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Brandon Hammond
- University of North Carolina Hospitals, Chapel Hill, NC, USA
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Liu J, Huang X, Hu S, Meng Z, He H. Individualized lung protective ventilation vs. conventional ventilation during general anesthesia in laparoscopic total hysterectomy. Exp Ther Med 2020; 19:3051-3059. [PMID: 32256792 PMCID: PMC7086193 DOI: 10.3892/etm.2020.8549] [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] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Accepted: 11/21/2019] [Indexed: 12/15/2022] Open
Abstract
Laparoscopic total hysterectomy is performed by carbon dioxide insufflation, Trendelenburg position and mechanical ventilation of patients under general anesthesia. However, this may induce pulmonary atelectasis and/or hyperdistention of the lungs. Multiple studies have indicated that mechanical ventilation with the use of low tidal volumes, moderate positive end-expiratory pressure (PEEP) and regular alveolar recruitment maneuvers may improve post-operative outcomes. However, the benefits of an individualized level of PEEP have not been clearly established. In the present study, it was hypothesized that a moderate fixed PEEP may not suit all patients and an individually-titrated PEEP during anesthesia may improve the peri-operative pulmonary oxygenation function. The aim of the present study was to compare the pulmonary oxygenation function and post-operative pulmonary complications (PPCs) in patients receiving individualized lung-protective mechanical ventilation (LPV) vs. conventional ventilation (CV) during laparoscopic total hysterectomy. The present study was a randomized double-blinded clinical trial on 87 patients who were randomly divided to receive CV or protective ventilation (PV). An optimal individualized PEEP value was determined using a static pulmonary compliance-directed PEEP titration procedure. Pulmonary oxygenation function, serum inflammatory factors, including interleukin-8 and Clara cell protein 16, the incidence of PPCs and the post-operative length of stay were also determined. Patients in the PV group exhibited improved pulmonary oxygenation function during and after the operation. The total percentage of PPCs during the first 7 days after surgery was significantly lower in the PV group compared with those in the CV group. In conclusion, as compared to CV, intra-operative individualized LPV significantly improved pulmonary oxygenation function and reduced the incidence of PPCs during the first 7 days after laparoscopic total hysterectomy (Clinical trial registration no. ChiCTR1900027738).
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Affiliation(s)
- Jing Liu
- Department of Anesthesiology, Huzhou Maternity and Child Healthcare Hospital, Huzhou, Zhejiang 313000, P.R. China
| | - Xinhua Huang
- Department of Anesthesiology, Huzhou Maternity and Child Healthcare Hospital, Huzhou, Zhejiang 313000, P.R. China
| | - Siping Hu
- Department of Anesthesiology, Huzhou Central Hospital, Affiliated Central Hospital of Huzhou University, Huzhou, Zhejiang 313000, P.R. China
| | - Zhipeng Meng
- Department of Anesthesiology, Huzhou Central Hospital, Affiliated Central Hospital of Huzhou University, Huzhou, Zhejiang 313000, P.R. China
| | - Huanzhong He
- Department of Anesthesiology, Huzhou Central Hospital, Affiliated Central Hospital of Huzhou University, Huzhou, Zhejiang 313000, P.R. China
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Park M, Ahn HJ, Kim JA, Yang M, Heo BY, Choi JW, Kim YR, Lee SH, Jeong H, Choi SJ, Song IS. Driving Pressure during Thoracic Surgery: A Randomized Clinical Trial. Anesthesiology 2020; 130:385-393. [PMID: 30664548 DOI: 10.1097/aln.0000000000002600] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC Driving pressure (plateau minus end-expiratory airway pressure) is a target in patients with acute respiratory distress syndrome, and is proposed as a target during general anesthesia for patients with normal lungs. It has not been reported for thoracic anesthesia where isolated, inflated lungs may be especially at risk. WHAT THIS ARTICLE TELLS US THAT IS NEW In a double-blinded, randomized trial (292 patients), minimized driving pressure compared with standard protective ventilation was associated with less postoperative pneumonia or acute respiratory distress syndrome. BACKGROUND Recently, several retrospective studies have suggested that pulmonary complication is related with driving pressure more than any other ventilatory parameter. Thus, the authors compared driving pressure-guided ventilation with conventional protective ventilation in thoracic surgery, where lung protection is of the utmost importance. The authors hypothesized that driving pressure-guided ventilation decreases postoperative pulmonary complications more than conventional protective ventilation. METHODS In this double-blind, randomized, controlled study, 292 patients scheduled for elective thoracic surgery were included in the analysis. The protective ventilation group (n = 147) received conventional protective ventilation during one-lung ventilation: tidal volume 6 ml/kg of ideal body weight, positive end-expiratory pressure (PEEP) 5 cm H2O, and recruitment maneuver. The driving pressure group (n = 145) received the same tidal volume and recruitment, but with individualized PEEP which produces the lowest driving pressure (plateau pressure-PEEP) during one-lung ventilation. The primary outcome was postoperative pulmonary complications based on the Melbourne Group Scale (at least 4) until postoperative day 3. RESULTS Melbourne Group Scale of at least 4 occurred in 8 of 145 patients (5.5%) in the driving pressure group, as compared with 18 of 147 (12.2%) in the protective ventilation group (P = 0.047, odds ratio 0.42; 95% CI, 0.18 to 0.99). The number of patients who developed pneumonia or acute respiratory distress syndrome was less in the driving pressure group than in the protective ventilation group (10/145 [6.9%] vs. 22/147 [15.0%], P = 0.028, odds ratio 0.42; 95% CI, 0.19 to 0.92). CONCLUSIONS Application of driving pressure-guided ventilation during one-lung ventilation was associated with a lower incidence of postoperative pulmonary complications compared with conventional protective ventilation in thoracic surgery.
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Affiliation(s)
- MiHye Park
- From the Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine in Seoul, Korea (M.P., H.J.A., J.A.K., M.Y., B.Y.H., J.W.C., Y.R.K., S.H.L., H.J., S.J.C., I.S.S.) Kangwon National University School of Graduate Medicine in Chuncheon, Korea (M.P.)
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Intraoperative ventilation strategies to prevent postoperative pulmonary complications: a network meta-analysis of randomised controlled trials. Br J Anaesth 2020; 124:324-335. [DOI: 10.1016/j.bja.2019.10.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/24/2019] [Accepted: 10/31/2019] [Indexed: 11/30/2022] Open
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Ahn HJ, Park M, Kim JA, Yang M, Yoon S, Kim BR, Bahk JH, Oh YJ, Lee EH. Driving pressure guided ventilation. Korean J Anesthesiol 2020; 73:194-204. [PMID: 32098009 PMCID: PMC7280884 DOI: 10.4097/kja.20041] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 02/20/2020] [Indexed: 12/16/2022] Open
Abstract
Protective ventilation is a prevailing ventilatory strategy these days and is comprised of small tidal volume, limited inspiratory pressure, and application of positive end-expiratory pressure (PEEP). However, several retrospective studies recently suggested that tidal volume, inspiratory pressure, and PEEP are not related to patient outcomes, or only related when they influence the driving pressure. Therefore, this review introduces the concept of driving pressure and looks into the possibility of driving pressure-guided ventilation as a new ventilatory strategy, especially in thoracic surgery where postoperative pulmonary complications are common, and thus, lung protection is of utmost importance.
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Affiliation(s)
- Hyun Joo Ahn
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, Korea
| | - MiHye Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jie Ae Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mikyung Yang
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Susie Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Bo Rim Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Hyon Bahk
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Jun Oh
- Department of Anesthesiology and Pain Medicine Yonsei University College of Medicine, Seoul, Korea
| | - Eun-Ho Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Abdullah T, Şentürk M. Positive End-Expiratory Pressure (PEEP), Tidal Volume, or
Alveolar Recruitment: Which One Does Matter in One-Lung Ventilation? CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00350-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Driving Pressure-guided Ventilation: Comment. Anesthesiology 2019; 131:1193. [PMID: 31577552 DOI: 10.1097/aln.0000000000002954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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44
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Zhang P, Wu L, Shi X, Zhou H, Liu M, Chen Y, Lv X. Positive End-Expiratory Pressure During Anesthesia for Prevention of Postoperative Pulmonary Complications: A Meta-analysis With Trial Sequential Analysis of Randomized Controlled Trials. Anesth Analg 2019; 130:879-889. [PMID: 31567322 DOI: 10.1213/ane.0000000000004421] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Whether intraoperative positive end-expiratory pressure (PEEP) can reduce the risk of postoperative pulmonary complications remains controversial. We performed a systematic review of currently available literature to investigate whether intraoperative PEEP decreases pulmonary complications in anesthetized patients undergoing surgery. METHODS We searched PubMed, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) that compared intraoperative PEEP versus zero PEEP (ZEEP) for postoperative pulmonary complications in adults. The prespecified primary outcome was postoperative pulmonary atelectasis. RESULTS Fourteen RCTs enrolling 1238 patients met the inclusion criteria. Meta-analysis using a random-effects model showed a decrease in postoperative atelectasis (relative risk [RR], 0.51; 95% confidence interval [CI], 0.35-0.76; trial sequential analyses [TSA]-adjusted CI, 0.10-2.55) and postoperative pneumonia (RR, 0.48; 95% CI, 0.27-0.84; TSA-adjusted CI, 0.05-4.86) in patients receiving PEEP ventilation. However, TSA showed that the cumulative Z-curve of 2 outcomes crossed the conventional boundary but did not cross the trial sequential monitoring boundary, indicating a possible false-positive result. We observed no effect of PEEP versus ZEEP ventilation on postoperative mortality (RR, 1.78; 95% CI, 0.55-5.70). CONCLUSIONS The evidence that intraoperative PEEP reduces postoperative pulmonary complications is suggestive but too unreliable to allow definitive conclusions to be drawn.
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Affiliation(s)
- Pengcheng Zhang
- From the Department of Anesthesiology, The First Hospital of Anhui Medical University, Hefei, China
| | - Lingmin Wu
- From the Department of Anesthesiology, The First Hospital of Anhui Medical University, Hefei, China
| | - Xuan Shi
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Huanping Zhou
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Meiyun Liu
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuanli Chen
- Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xin Lv
- From the Department of Anesthesiology, The First Hospital of Anhui Medical University, Hefei, China.,Department of Anesthesiology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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Liu J, Meng Z, Lv R, Zhang Y, Wang G, Xie J. Effect of intraoperative lung-protective mechanical ventilation on pulmonary oxygenation function and postoperative pulmonary complications after laparoscopic radical gastrectomy. ACTA ACUST UNITED AC 2019; 52:e8523. [PMID: 31166383 PMCID: PMC6556971 DOI: 10.1590/1414-431x20198523] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 03/27/2019] [Indexed: 11/22/2022]
Abstract
This study aimed to observe the effects of lung-protective ventilation (LPV) on oxygenation index (OI) and postoperative pulmonary complications (PPCs) after laparoscopic radical gastrectomy in middle-aged and elderly patients. A total of 120 patients who were scheduled to undergo laparoscopic radical gastrectomy with an expected time of >3 h were randomly divided into conventional ventilation (CV group) with tidal volume (TV) of 10 mL/kg without positive end-expiratory pressure (PEEP), and lung-protective ventilation (PV group) with 7 mL/kg TV and personal level of PEEP with regular recruitment maneuver every 30 min. Measurements of OI, modified clinical pulmonary infection score (mCPIS), and PPCs were assessed during the perioperative period. Fifty-seven patients in the CV group and 58 in the PV group participated in the data analysis. Patients in the PV group showed better pulmonary dynamic compliance, OI, and peripheral capillary oxygen saturation during and after surgery. The mCPIS was significantly lower in the PV group than in the CV group after surgery. The incidence rate of PPCs was lower in the PV group than in the CV group and the difference was significant in patients whose ventilation time was longer than 6 h in both groups. LPV during laparoscopic radical gastrectomy significantly improved pulmonary oxygenation function and reduced postoperative mCPIS and the incidence of PPCs during the early period after surgery of middle-aged and elderly patients, especially patients whose mechanical ventilation time was longer than 6 h.
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Affiliation(s)
- Jing Liu
- Department of Anesthesia, Zhejiang University School of Medicine, Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Zhipeng Meng
- Department of Anesthesia, Huzhou Central Hospital, Huzhou, Zhejiang, China
| | - Ran Lv
- Department of Anesthesia, Zhejiang University School of Medicine, Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Yaping Zhang
- Department of Anesthesia, Zhejiang University School of Medicine, Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Gaojian Wang
- Department of Anesthesia, Zhejiang University School of Medicine, Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Junran Xie
- Department of Anesthesia, Zhejiang University School of Medicine, Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
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Pasin L. Protective intraoperative ventilation during thoracic surgery: definitively yes! J Thorac Dis 2019; 11:S341-S342. [PMID: 30997215 DOI: 10.21037/jtd.2018.12.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Laura Pasin
- Department of Anaesthesia and Intensive Care, Ospedale S. Antonio, Padova, Italy
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Girrbach FF, Pietsch UC, Wrigge H. Optimizing intraoperative ventilation during one-lung ventilation-is individualization the road to success? J Thorac Dis 2019; 11:S343-S346. [PMID: 30997216 DOI: 10.21037/jtd.2018.12.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Felix F Girrbach
- Department of Anesthesiology and Intensive Care, University Hospital of Leipzig, Leipzig, Germany
| | - Uta C Pietsch
- Department of Anesthesiology and Intensive Care, University Hospital of Leipzig, Leipzig, Germany
| | - Hermann Wrigge
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital Halle, Halle, Germany
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48
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Milman S, Ng T. Protective ventilation for lung cancer surgery, the truth likely lies somewhere in the middle. J Thorac Dis 2019; 11:373-375. [PMID: 30962977 DOI: 10.21037/jtd.2018.12.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Steven Milman
- Department of Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Thomas Ng
- Department of Surgery, The Warren Alpert Medical School of Brown University, Providence, RI, USA
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49
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Hu XY, Du B. Lung-protective ventilation during one-lung ventilation: known knowns, and known unknowns. J Thorac Dis 2019; 11:S237-S240. [PMID: 30997186 DOI: 10.21037/jtd.2019.01.45] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Xiao-Yun Hu
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing 100730, China
| | - Bin Du
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing 100730, China
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50
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Petrella F. Indications and timing of conversion to thoracotomy during video-assisted lung resection. J Thorac Dis 2019; 10:S4159-S4161. [PMID: 30631581 DOI: 10.21037/jtd.2018.10.90] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Francesco Petrella
- Department of Thoracic Surgery, IRCCS European Institute of Oncology, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
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