Effect of lung protective ventilation on coronary heart disease patients undergoing lung cancer resection

Positive end-expiratory pressure during one-lung ventilation for preventing atelectasis after video-assisted thoracoscopic surgery: a triple-arm, randomized controlled trial

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.

Identifying biomarkers of ventilator induced lung injury during one-lung ventilation surgery: a scoping review

BACKGROUND

Ventilator-induced lung injury (VILI) can occur as a result of mechanical ventilation to two lungs. Thoracic surgery often requires one-lung ventilation (OLV). The potential for VILI is likely higher in OLV. The impact of OLV on development of post-operative pulmonary complications is not well understood. We aimed to perform a scoping review to determine reliable biomarkers of VILI after OLV.

METHODS

A scoping review was performed using Cochrane Collaboration methodology. We searched Medline, EMBASE and SCOPUS. Gray literature was searched. Studies of adult human or animal models without pre-existing lung damage exposed to OLV, with biomarker responses analyzed were included.

RESULTS

After screening 5,613 eligible papers, 89 papers were chosen for full text review, with 29 meeting inclusion. Approximately half (52%, n=15) of studies were conducted in humans in an intra-operative setting. Bronchoalveolar lavage (BAL) & serum analyses with enzyme-linked immunosorbent assay (ELISA)-based assays were most commonly used. The majority of analytes were investigated by a single study. Of the analytes that were investigated by two or more studies (n=31), only 16 were concordant in their findings. Across all sample types and studies 84% (n=66) of the 79 inflammatory markers and 75% (n=6) of the 8 anti-inflammatory markers tested were found to increase. Half (48%) of all studies showed an increase in TNF-α or IL-6.

CONCLUSIONS

A scoping review of the state of the evidence demonstrated that candidate biomarkers with the most evidence and greatest reliability are general markers of inflammation, such as IL-6 and TNF-α assessed using ELISA assays. Studies were limited in the number of biomarkers measured concurrently, sample size, and studies using human participants. In conclusion these identified markers can potentially serve as outcome measures for studies on OLV.

Effects of dexmedetomide, propofol and remifentanil on perioperative inflammatory response and lung function during lung cancer surgery

OBJECTIVE

To investigate the effects of combined anesthesia with dexmedetomide, propofol and remifentanil on perioperative inflammatory response and pulmonary function in patients with lung cancer.

METHODS

90 patients with lung cancer admitted to our hospital from April 2017 to April 2019 were selected. According to different anesthesia schemes, patients undergoing combined anesthesia with propofol and remifentanil were included in group A (GA), and patients receiving combined anesthesia with dexmedetomidine, propofol and remifentanil were included in group B (GB). The blood gas, pulmonary function index, inflammatory factor level in serum, anesthetic effect and complications were compared between the two groups.

RESULTS

HR indexes at T1 and T2 in GB were significantly lower than those in GA (P<0.001). There was no significant fluctuation in PaCO2 and PaO2 indexes in the two groups at different time points (P>0.05). At T0, T1 and T2, RV/TLC levels in serum increased significantly in the two groups. (MVV-VE)/FEV1 and MVV/FEV levels were significantly decreased (all P<0.05). The fluctuation levels of RV/TLC, (MVV-VE)/FEV1 and MVV/FEV levels in serum of GB were significantly lower than those of GA at T1 and T2 (P<0.05). At T0, T1 and T2, the levels of inflammatory factors in serum were significantly decreased in the two groups (P<0.05), but the levels of inflammatory factors in serum of GB were significantly lower than those of GA at T1 and T2 (P<0.05). The VAS scores of GB were significantly lower than those of GA at 1 hour and 4 hours after operation (P<0.05). Ramsay scores of GB were significantly higher than those of GA at 1 hour and 4 hours after operation (P<0.05). The restlessness score and choking cough score in GB were lower than those in GA (P<0.05). Perioperative complications in GB were better than those in GA (P<0.05).

CONCLUSION

On the basis of propofol and remifentanil anesthesia, the combination of dexmedetomidine for anesthesia induction can achieve satisfactory anesthesia effect. On the basis of propofol and remifentanil anesthesia combined with dexmedetomidine for anesthesia induction, it can significantly inhibit the inflammatory response of lung cancer patients during perioperative period and it can more effectively stabilize the blood gas microcirculation and lung function of patients.

The effects of ventilation on left-to-right shunt and regional cerebral oxygen saturation: a self-controlled trial

BACKGROUND

Increase of pulmonary vascular resistance (PVR) is an efficient method of modulating pulmonary and systemic blood flows (Qp/Qs) for patients with left-to-right (L-R) shunt, and is also closely associated with insufficient oxygen exchange for pulmonary hypoperfusion. So that it might be a preferred regime of maintaining arterial partial pressure of carbon dioxide tension (PaCO₂) within an optimal boundary via ventilation management in congenital heart disease (CHD) patients for the inconvenient measure of the PVR and Qp/Qs. However, the appropriate range of PaCO₂ and patient-specific mechanical ventilation settings remain controversial for CHD children with L-R shunt.

METHODS

Thirty-one pediatric patients with L-R shunt, 1-6 yr of age, were included in this observation study. Patients were ventilated with tidal volume (V_T) of 10, 8 and 6 ml/kg in sequence, and 15 min stabilization period for individual V_T. The velocity time integral (VTI) of L-R shunt, pulmonary artery (PA) and descending aorta (DA) were measured with transesophageal echocardiography (TEE) after an initial 15 min stabilization period for each V_T, with arterial blood gas analysis. Near-infrared spectroscopy sensor were positioned on the surface of the bilateral temporal artery to monitor the change in regional cerebral oxygen saturation (rScO₂).

RESULTS

PaCO₂ was 31.51 ± 0.65 mmHg at V_T 10 ml/kg vs. 37.15 ± 0.75 mmHg at V_T 8 ml/kg (P < 0.03), with 44.24 ± 0.99 mmHg at V_T 6 ml/kg significantly higher than 37.15 ± 0.75 mmHg at V_T 8 ml/kg. However, PaO₂ at a V_T of 6 ml/kg was lower than that at a V_T of 10 ml/kg (P = 0.05). Meanwhile, 72% (22/31) patients had PaCO₂ in the range of 40-50 mmHg at V_T 6 ml/kg. VTI of L-R shunt and PA at V_T 6 ml/kg were lower than that at V_T of 8 and 10 ml/kg (P < 0.05). rScO₂ at a V_T of 6 ml/kg was higher than that at a V_T of 8 and 10 ml/kg (P < 0.05), with a significantly correlation between rScO₂ and PaCO₂ (r = 0.53). VTI of PA in patients with defect diameter > 10 mm was higher that that in patients with defect diameter ≤ 10 mm.

CONCLUSIONS

Maintaining PaCO₂ in the boundary of 40-50 mmHg with V_T 6 ml/kg might be a feasible ventilation regime to achieve better oxygenation for patients with L-R shunt. Continue raising PaCO₂ should be careful.

TRAIL REGISTRATION

Clinical Trial Registry of China (http://www.chictr.org.cn) identifier: ChiCTR-OOC-17011338 , prospectively registered on May 9, 2017.