Management of One-lung Ventilation

Abstract

Background The use of lung-protective ventilation (LPV) strategies may minimize iatrogenic lung injury in surgical patients. However, the identification of an ideal LPV strategy, particularly during one-lung ventilation (OLV), remains elusive. This study examines the role of ventilator management during OLV and its impact on clinical outcomes. Methods Data were retrospectively collected from the hospital electronic medical record and the Society of Thoracic Surgery database for subjects undergoing thoracic surgery with OLV between 2012 and 2014. Mean tidal volume (VT) during two-lung ventilation and OLV and ventilator driving pressure (ΔP) (plateau pressure − positive end-expiratory pressure [PEEP]) were analyzed for the 1,019 cases that met the inclusion criteria. Associations between ventilator parameters and clinical outcomes were examined by multivariate linear regression. Results After the initiation of OLV, 73.3, 43.3, 18.8, and 7.2% of patients received VT greater than 5, 6, 7, and 8 ml/kg predicted body weight, respectively. One hundred and eighty-four primary and 288 secondary outcome events were recorded. In multivariate logistic regression modeling, VT was inversely related to the incidence of respiratory complications (odds ratio, 0.837; 95% CI, 0.729 to 0.958), while ΔP predicted the development of major morbidity when modeled with VT (odds ratio, 1.034; 95% CI, 1.001 to 1.068). Conclusions Low VTper se (i.e., in the absence of sufficient PEEP) has not been unambiguously demonstrated to be beneficial. The authors found that a large proportion of patients continue to receive high VT during OLV and that VT was inversely related to the incidence of respiratory complications and major postoperative morbidity. While low (physiologically appropriate) VT is an important component of an LPV strategy for surgical patients during OLV, current evidence suggests that, without adequate PEEP, low VT does not prevent postoperative respiratory complications. Thus, use of physiologic VT may represent a necessary, but not independently sufficient, component of LPV.

Perioperative lung protective ventilation

“…Although use of higher tidal volumes may be influenced by inaccuracies in calculating PBW, it is also likely that a belief may continue among anesthesiologists that lower tidal volumes are harmful 1416. However, high quality data exist to suggest the opposite 9444546474849…”

“…A retrospective study of 170 patients undergoing pneumonectomy found that patients with postoperative respiratory failure were ventilated intraoperatively with higher tidal volumes (median 8.3 (interquartile range 7.6-9.4) mL/kg versus 6.7 (6.1-7.9) mL/kg PBW; P<0.001) and that an increase in tidal volume of one additional mL/kg PBW resulted in a significantly higher likelihood of development of respiratory failure (odds ratio 1.56, 95% confidence interval 1.12 to 2.23; P=0.009) 46. Another retrospective study of 1019 cases of one lung ventilation (OLV) found that tidal volume was inversely proportional to the development of respiratory complications (odds ratio 0.847, 0.739 to 0.96) 47. A single center RCT of 149 patients undergoing cardiac surgery found that ventilating throughout the perioperative period with 6 mL/kg PBW compared with 10 mL/kg at the same PEEP reduced the proportion of patients needing ventilator support at six hours (37.3% v 20.3%; P=0.02) and the incidence of reintubation (1.3% v 9.5%; P=0.03) 48.…”

Improvement Of Surgical Complications Using Single-Lumen Endotracheal Tube Intubation And Artificial Carbon Dioxide Pneumothorax In Esophagectomy: A Meta-analysis

“…Double-lumen intubation with one-lung ventilation to get better surgical eld exposure is a widely used anesthesia strategy, but it increases the rate of acute lung injury and increases pulmonary complications. It is di cult to perform and maintain induction and intubation with this strategy (16). Owing to the di cult manipulation regarding ventilation setting, post-operative pulmonary complications occur frequently in procedures with an extended surgical duration, such as esophagectomy (17).…”

Can Dexmedetomidine Improve Arterial Oxygenation and Intrapulmonary Shunt during One-lung Ventilation in Adults Undergoing Thoracic Surgery? A Meta-analysis of Randomized, Placebo-controlled Trials

“…The Qs/Qt ratio is approximately 2–5% in daily life and up to 10% after general anesthesia and lying on your side, but it can increase to 40–50% after OLV. [26] To date, it is uncertain whether there is well-established prophylaxis, although various preventive and protective measures have been studied, such as lung-protective ventilation strategies (lower tidal volumes and higher positive end-expiratory pressure)[27282930] and reducing the use of inhalation anesthetics. [31]…”