Optimizing One-Lung Ventilation: Moving Beyond Tidal Volume

Abstract

ANESTHESIOLOGISTS INVOLVED in thoracic surgery are striving continuously to optimize one-lung ventilation (OLV). In this issue of the Journal of Cardiothoracic and Vascular Anesthesia, Dr. Ferrando et al. present the results of a Spanish prospective multicenter study using an "open-lung" approach during OLV to decrease the incidence of postoperative pulmonary complications (PPCs) following thoracic surgery. 1 Although there is some variation between studies in the exact definition of PPCs, recent retrospective studies in thoracic surgery suggest that the incidence of PPCs (atelectasis, pneumonia, respiratory failure, reintubation, acute respiratory distress syndrome, etc.) is in the range of 15% to 32%. The intraoperative use of low tidal volumes during OLV, although generally accepted to be lung-protective, has not been shown clearly to be associated with decreased PPCs. 2 With this new study, the authors tried to move beyond a simple consideration of tidal volume and to include a consideration of optimizing positive end-expiratory pressure (PEEP) and driving pressure (the difference between plateau end-inspiratory airway pressure and PEEP) during OLV. The study included 690 patients in 16 centers. During OLV with a fixed tidal volume of 5 to 6 mL/kg predicted body weight and 5 cmH2O PEEP, a 4-step procedure was used to achieve what the authors felt was optimal open-lung ventilation: 1. The patients in this new study mainly had open thoracotomies (v video-assisted thoracic surgery [VATS]). This is unlike the thoracic surgical populations in many centers, where the large majority of standard pulmonary resections are performed by VATS. VATS usually is associated with Contents lists available at ScienceDirect