Pressure-controlled versus volume-controlled ventilation during one-lung ventilation in elderly patients with poor pulmonary function

Comparisons of Mechanical Power and Respiratory Mechanics in Pressure-Controlled Ventilation and Volume-Controlled Ventilation during Laparoscopic Cholecystectomy in Elderly Patients

We compared the effects of pressure-controlled volume-guaranteed ventilation (PCV) and volume-controlled ventilation (VCV) on respiratory mechanics and mechanical power (MP) in elderly patients undergoing laparoscopy. Fifty patients aged 65-80 years scheduled for laparoscopic cholecystectomy were randomly assigned to either the VCV group (n = 25) or the PCV group (n = 25). The ventilator had the same settings in both modes. The change in MP over time was insignificant between the groups (p = 0.911). MP significantly increased during pneumoperitoneum in both groups compared with anesthesia induction (IND). The increase in MP from IND to 30 min after pneumoperitoneum (PP30) was not different between the VCV and PCV groups. The change in driving pressure (DP) over time were significantly different between the groups during surgery, and the increase in DP from IND to PP30 was significantly higher in the VCV group than in the PCV group (both p = 0.001). Changes in MP during PCV and VCV were similar in elderly patients, and MP increased significantly during pneumoperitoneum in both groups. However, MP did not reach clinical significance (≥12 J/min). In contrast, the PCV group had a significantly lower increase in DP after pneumoperitoneum than the VCV group.

Effect of Pressure-Controlled Ventilation-Volume Guaranteed on One-Lung Ventilation in Elderly Patients Undergoing Thoracotomy

Background

Volume-controlled ventilation (VCV) in one-lung ventilation (OLV) is most commonly used in thoracotomy, but pressure-controlled ventilation-volume guaranteed (PCV-VG) is used in elderly patients to improve arterial oxygenation, reduce inflammatory factors, and decrease acute lung injury (ALI). The purpose of this study was to investigate the effects of these 2 different ventilation modes – VCV versus PCV-VG – during OLV in elderly patients undergoing thoracoscopic lobectomy.

Material/Methods

Sixty patients undergoing thoracoscopic lobectomy from September 2018 to February 2019 at Cangzhou Central Hospital, Hebei, China were randomly assigned to a VCV group or a PCV-VG group. Pulmonary dynamic compliance (Cdyn), peak inspiratory pressure (PIP), arterial blood gas, and inflammatory factors were monitored to assess lung function. The Clinical Trial Registration Identifier number is ChiCTR1800017835.

Results

Compared with the VCV group, PIP in the PCV-VG group was significantly lower (P=0.01) and Cdyn was significantly higher at 30 min after one-lung ventilation (P=0.01). MAP of the PCV-VG group was higher than in the VCV group (P=0.01). MAP of the PCV-VG group was also higher than in the VCV group at 30 min after one-lung ventilation (P=0.01). The concentration of neutrophil elastase (NE) in the PCV-VG group was significantly lower than in the VCV group (P=0.01).

Conclusions

Compared with VCV, PCV-VG mode reduced airway pressure in patients undergoing thoracotomy and also decreased the release of NE and reduced inflammatory response and lung injury. We conclude that PCV-VG mode can protect the lung function of elderly patients undergoing thoracotomy.

Lung ultrasound score-based perioperative assessment of pressure-controlled ventilation-volume guaranteed or volume-controlled ventilation in geriatrics: a prospective randomized controlled trial

Purpose

Recent studies have shown the potential benefits of pressure-controlled ventilation-volume guaranteed (PCV-VG) compared to volume-controlled ventilation (VCV), but the results were not impressive. We assessed the effects of PCV-VG versus VCV in elderly patients by using lung ultrasound score (LUS).

Patients and methods

Elderly patients (aged 65-90 years) scheduled for hip joint surgery were randomly assigned to either the PCV-VG or VCV group during general anesthesia. LUS and mechanical ventilator parameters were evaluated before induction, 30 mins after a semi-lateral position change, during supine repositioning before awakening, and 15 mins after arrival to the post-anesthesia care unit (PACU). Pulmonary function tests were performed before and after surgery. Other recovery indicators were also assessed in the PACU.

Results

A total of 76 patients (40 for PCV-VG and 36 for VCV) were included this study. Demographic data showed no significant difference between the two groups. In both groups, LUSs before induction were significantly lower than those at other time points. LUSs of the VCV group were significantly increased during perioperative periods compared with the PCV-VG group (p=0.049). Visualized LUS modeling suggested an intuitive difference in the two groups and unequal distribution in lung aeration. Higher dynamic compliance and lower inspiratory peak pressure were observed in the PVC-VG group compared to the VCV group (33.54 vs 27.36, p<0.001; 18.93 vs 21.19, p<0.001, respectively). Postoperative forced vital capacity of the VCV group was lower than that of PCV-VG group, but this result was not significant (2.06 vs 1.79, respectively; p=0.091). The other respiratory data are comparable between the two groups.

Conclusion

The PCV-VG group showed better LUS compared with the VCV group. Moreover, LUS modeling in both groups suggests non-homogeneous and positional change in lung aerations during surgery.

Clinical trial registration

This study was registered at the UMIN clinical trials registry (unique trial number: UMIN000029355; registration number: R000033510).

A comparison between two lung ventilation with CO2 artificial pneumothorax and one lung ventilation during thoracic phase of minimally invasive esophagectomy

Background

To investigate the feasibility and safety of two lung ventilation with artificial pneumothorax in minimally invasive esophagectomy (MIE) through a comparison with conventional one lung ventilation.

Methods

Eleven hundred and sixty-six patients with esophageal cancer, who underwent McKeown MIE in our center from February 2006 to December 2016, were studied retrospectively. Seven hundred and five patients who underwent one lung ventilation with double lumen endotracheal tube (DLET) were assigned to DLET group. Other 461 patients who underwent two lung ventilation with single lumen endotracheal tube (SLET) were assigned to SLET group. Clinical characteristics, surgical variables and complications were compared between two groups.

Results

There were comparable patient characteristics in two groups. Surgical variables and complications were discussed between two groups. SLET group seemed to have shorter operative time, shorter postoperative hospital stay, and more harvested recurrent laryngeal nerve (RLN) lymph nodes than DLET group, which might be attributed to experienced surgeons. However, there were no significant differences of complications between two groups. Intraoperative clinical parameters were further studied. Before intubation and artificial pneumothorax, there were no significant differences between two groups, except diastolic blood pressure (DBP). With the application of artificial pneumothorax, patients in SLET group have obviously higher PO₂, PCO₂, and PetCO₂ value, and slightly lower pH value and blood pressure during thoracic phase. After the thoracic phase, the changes induced by artificial pneumothorax in SLET group were gradually reversed and clinical parameters gradually return to normal level.

Conclusions

Two lung ventilation with artificial pneumothorax is a safe and feasible choice during MIE.

Effects of volume-controlled ventilation vs. pressure-controlled ventilation on respiratory function and inflammatory factors in patients undergoing video-assisted thoracoscopic radical resection of pulmonary carcinoma

Background

The best ventilation approach for patients undergoing video-assisted thoracic surgery (ATS) for pulmonary carcinoma remains undefined. This study aimed to assess hemodynamics, airway pressure, arterial blood gas, and inflammatory factors in patients undergoing VATS for pulmonary carcinoma under volume-controlled ventilation (VCV) or pressure-controlled ventilation (PCV).

Methods

This was a prospective study of 60 patients with pulmonary carcinoma treated at a tertiary center in 2015-2016. The subjects were randomized to the VCV or PCV group after anesthesia and total lung ventilation (TLV). Hemodynamics and blood gas parameters were compared between the two groups pre-OLV (one-lung ventilation) (T1) and after 30 (T2), 60 (T3), and 120 (T4) minutes of OLV. Radial artery blood was collected to measure interleukin (IL)-6, IL-10, and tumor necrosis factor (TNF)-α levels.

Results

Hemodynamic and blood gas parameters were similar between the two groups (all P>0.05). During OLV, airway resistance (RAW) was significantly lower in the PCV group compared with the VCV group at T2 (26.0±3.8 vs. 29.9±7.3 cmH₂O/L/s), T3 (26.0±3.7 vs. 30.2±7.7 cmH₂O/L/s), and T4 (25.8±4.1 vs. 29.6±6.7 cmH₂O/L/s). Similar trends were found for peak pressure (Ppeak) and plateau pressure (Pplat). Mean pressure (Pmean) was similar between the two groups. Compared with the PCV group, TNF-α and IL-6 levels in the VCV group were significantly increased (all P<0.05). The levels of the anti-inflammatory mediator IL-10 were higher in the PCV group compared with the VCV group.

Conclusions

PCV for OLV during radical resection of pulmonary carcinoma by VATS could reduce Ppeak and downregulate pro-inflammatory factors, likely decreasing airway injury.

The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy

Patients undergoing lobectomy are at significantly increased risk of lung injury. One-lung ventilation is the most commonly used technique to maintain ventilation and oxygenation during the operation. It is a challenge to choose an appropriate mechanical ventilation strategy to minimize the lung injury and other adverse clinical outcomes. In order to understand the available evidence, a systematic review was conducted including the following topics: (I) protective ventilation (PV); (II) mode of mechanical ventilation [e.g., volume controlled (VCV) versus pressure controlled (PCV)]; (III) use of therapeutic hypercapnia; (IV) use of alveolar recruitment (open-lung) strategy; (V) pre-and post-operative application of positive end expiratory pressure (PEEP); (VI) Inspired Oxygen concentration; (VII) Non-intubated thoracoscopic lobectomy; and (VIII) adjuvant pharmacologic options. The recommendations of class II are non-intubated thoracoscopic lobectomy may be an alternative to conventional one-lung ventilation in selected patients. The recommendations of class IIa are: (I) Therapeutic hypercapnia to maintain a partial pressure of carbon dioxide at 50-70 mmHg is reasonable for patients undergoing pulmonary lobectomy with one-lung ventilation; (II) PV with a tidal volume of 6 mL/kg and PEEP of 5 cmH₂O are reasonable methods, based on current evidence; (III) alveolar recruitment [open lung ventilation (OLV)] may be beneficial in patients undergoing lobectomy with one-lung ventilation; (IV) PCV is recommended over VCV for patients undergoing lung resection; (V) pre- and post-operative CPAP can improve short-term oxygenation in patients undergoing lobectomy with one-lung ventilation; (VI) controlled mechanical ventilation with I:E ratio of 1:1 is reasonable in patients undergoing one-lung ventilation; (VII) use of lowest inspired oxygen concentration to maintain satisfactory arterial oxygen saturation is reasonable based on physiologic principles; (VIII) Adjuvant drugs such as nebulized budesonide, intravenous sivelestat and ulinastatin are reasonable and can be used to attenuate inflammatory response.

Comparison of three ventilatory modes during one-lung ventilation in elderly patients

OBJECTIVE

The purpose of this study was to explore the effects of three different ventilatory modes: volume controlled ventilation (VCV), pressure controlled ventilation (PCV) and pressure controlled ventilation-volume guaranteed (PCV-VG) on arterial oxygenation and airway pressure during one-lung ventilation (OLV) in elderly patients.

METHODS

We enrolled 66 patients who underwent thoracic surgery requiring at least 1 hour of OLV and aged above 65 years into the study. Patients were classified into VCV, PCV and PCV-VG groups according to a controlled, randomized design. Patients were ventilated to obtain a tidal volume (TV) of 8 mL/kg with three different ventilatory modes during OLV. The Hemodynamic and respiratory data had been recorded during intraoperation and arterial blood gases were obtained at baseline, 20, 40, 60 minutes after OLV, end of surgery.

RESULTS

Compared with VCV group, Ppeak was significantly lower in PCV and PCV-VG group (P<0.05), and the difference was not found between the PCV and PCV-VG group. PaO2 in PCV and PCV-VG group were higher than VCV group after the point of OLV+40 (P<0.05). Comparison of PCV group, PaO2 in PCV-VG group was higher, but did not show a significantly improved during OLV (P>0.05).

CONCLUSIONS

Compared with VCV, the use of PCV and PCV-VG have a significant advantage in intraoperative oxygenation and airway pressure for eldly patients undergoing OLV.