Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress 2023 EHA Congress 2023 ASCO Annual Meeting
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Current Anesthesiology Reports
Published in: Current Anesthesiology Reports 4/2019

01-12-2019 | Thoracic Anesthesia (T Schilling, Section Editor)

Positive End-Expiratory Pressure (PEEP), Tidal Volume, or Alveolar Recruitment: Which One Does Matter in One-Lung Ventilation?

Authors: Taner Abdullah, Mert Şentürk

Published in: Current Anesthesiology Reports | Issue 4/2019

Login to get access

Abstract

Purpose of Review

This review attempts to focus on protective ventilation approaches during one-lung ventilation (OLV) and will summarize recent findings.

Recent Findings

Recent studies have demonstrated the importance of low tidal volume (low TV) and reduced driving pressure during OLV. Along with low TV, correct use of positive end-expiratory pressure (PEEP) seems to have a vital role in terms of protecting the ventilated lung. PEEP decremental trial and the use of electrical impedance tomography are prominent techniques for individualizing the PEEP. The use of alveolar recruitment maneuvers (ARMs) is furthermore recommended. Nevertheless, there are several studies published considering negative effects of ARM.

Summary

Although small tidal volumes are highly recommended during OLV, it is not possible for low TV to be beneficial unless an optimal PEEP is applied. Use of ARM is still under debate. Yet, it seems to be the only way for preventing injurious tidal recruitment, which is known to be harmful to the lungs.
Literature
1.
Fischer GW, Cohen E. An update on anesthesia for thoracoscopic surgery. Curr Opin Anaesthesiol. 2010;23:7–11.PubMed
2.
Katz JA, Laverne RG, Fairley HB, Thomas AN. Pulmonary oxygen exchange during endobronchial anesthesia: effect of tidal volume and PEEP. Anesthesiology. 1982;56:164–71.PubMed
3.
Tarhan S, Lundborg RO. Effects of increased expiratory pressure on blood gas tensions and pulmonary shunting during thoracotomy with the use of the Carlens catheter. Can Anaesth Soc J. 1970;17:4.PubMed
4.
Kozian A, Schilling T, Schütze H, Senturk M, Hachenberg T, Hedenstierna G. Ventilatory protective strategies during thoracic surgery effects of alveolar recruitment maneuver and low-tidal volume ventilation on lung density distribution. Anesthesiology. 2011;114:1025–35.PubMed
5.
Karzai W, Schwarzkopf K. Hypoxemia during one-lung ventilation. Anesthesiology. 2009;110:1402.PubMed
6.
Bae W, Choi S, Lee J, Park Y, Lee CH, Lee SM, et al. Clinical outcomes of acute respiratory distress syndrome after pulmonary resection in lung cancer patients. Am J Respir Crit Care Med. 2014;189:A4479.
7.
• Miskovic A, Lumb AB. Postoperative pulmonary complications. British Journal of Anaesthesia. 2017;118(3):317–34 A rational classification of an important problem. PubMed
8.
Padley SP, Jordan SJ, Goldstraw P, Wells AU, Hansell DM. Asymmetric ARDS following pulmonary resection: CT findings initial observations. Radiology. 2002;223:468–73.PubMed
9.
Kozian A, Schilling T, Rocken C, Breitling C, Hachenberg T, Hedenstierna G. Increased alveolar damage after mechanical ventilation in a porcine model of thoracic surgery. J Cardiothorac Vasc Anesth. 2010;24:617–23.PubMed
10.
Lohser J, Slinger P. Lung injury after one-lung ventilation: a review of the pathophysiologic mechanisms affecting the ventilated and collapsed lung. Anesth Analg. 2015;121(2):302–18.PubMed
11.
Tusman G, Böhm SH, Warner DO, Sprung J. Atelectasis and perioperative pulmonary complications in high-risk patients. Curr Opin Anaesthesiol. 2012;25(1):1–10.PubMed
12.
Gattinoni L, Tonetti T, Cressoni M, Cadringher P, Herrmann P, Moerer O, et al. Ventilator related causes of lung injury: the mechanical power. Intensive Care Med. 2016;42:1567–75.PubMed
13.
Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi-Filho G, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med. 1998;338:347–54.PubMed
14.
Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342:1301–8.PubMed
15.
Hemmes SN, Serpa Neto A, Schultz MJ. Intraoperative ventilatory strategies to prevent postoperative pulmonary complications: a meta-analysis. Curr Opin Anaesthesiol. 2013;26:126–33.PubMed
16.
Severgnini P, Selmo G, Lanza C, Chiesa A, Frigerio A, Bacuzzi A, et al. Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function. Anesthesiology. 2013;118:1307–21.PubMed
17.
Futier E, Constantin JM, Paugam-Burtz C, Pascal J, Eurin M, Neuschwander A, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med. 2013;369:428–37.PubMed
18.
Serpa Neto A, Hemmes SN, Barbas CS, Beiderlinden M, Biehl M, Binnekade JM, et al. PROVE Network Investigators. Protective versus conventional ventilation for surgery: a systematic review and individual patient data meta-analysis. Anesthesiology. 2015;123(1):66–78.PubMed
19.
Schilling T, Kozian A, Huth C, Bühling F, Kretzschmar M, Welte T, et al. The pulmonary immune effects of mechanical ventilation in patients undergoing thoracic surgery. Anesth Analg. 2005;101:957–65.PubMed
20.
Licker M, Diaper J, Villiger Y, Spiliopoulos A, Licker V, Robert J, et al. Impact of intraoperative lung-protective interventions in patients undergoing lung cancer surgery. Crit Care. 2009;13:R41.PubMedPubMedCentral
21.
Fernandez-Perez ER, Keegan MT, Brown DR, Hubmayr RD, Gajic O. Intraoperative tidal volume as a risk factor for respiratory failure after pneumonectomy. Anesthesiology. 2006;105:14–8.PubMed
22.
Baudouin SV. Lung injury after thoracotomy. Br J Anaesth. 2003;91:132–42.PubMed
23.
Qutub H, El-Tahan MR, Mowafi HA, El Ghoneimy YF, Regal MA, Al Saflan AA. Effect of tidal volume on extravascular lung water content during one-lung ventilation for video-assisted thoracoscopic surgery: a randomised, controlled trial. Eur J Anaesthesiol. 2014;31:466–73.PubMed
24.
•• Blank RS, Colquhoun DA, Durieux ME, Kozower BD, McMurry TL, Bender SP, et al. Management of one-lung ventilation: impact of tidal volume on complications after thoracic surgery. Anesthesiology. 2016;124:1286–95A very well-designed study clearly showing the impact of tidal volume. PubMed
25.
•• El Tahan MR, Pasin L, Marczin N, Landoni G. Impact of low tidal volumes during one-lung ventilation. A meta-analysis of randomized controlled trials. J Cardiothorac Vasc Anesth. 2017;31(5):1767–73 Together with ref #24 (Randall et al), the reader can have a sufficient information about the effects of tidal volume. PubMed
26.
• Tonetti T, Vasques F, Rapetti F, Maiolo G, Collino F, Romitti F, et al. Driving pressure and mechanical power: new targets for VILI prevention. Ann Transl Med. 2017;5(14):286 For anaesthesiologists, this paper should serve as a motivating power. PubMedPubMedCentral
27.
•• Serpa Neto A, Hemmes S, Barbas C, Beiderlinden M, Fernandez-Bustamante A, Futier E, et al. Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: a meta-analysis of individual patient data. Lancet Respir Med. 2016;4(4):272–80 A very strong point of view for an ongoing question: Is PEEP good or evil?
28.
Amar D, Zhang H, Pedoto A, Desiderio DP, Shi W, Tan KS. Protective lung ventilation and morbidity after pulmonary resection: a propensity score–matched analysis. Anesth Analg. 2017;125:190–9.PubMed
29.
Kidane B, Choi S, Fortin D, O’Hare T, Nicolaou G, Badner NH, et al. Use of lung-protective strategies during one-lung ventilation surgery: a multi-institutional survey. Ann Transl Med. 2018;6(13):269.PubMedPubMedCentral
30.
Senturk NM, Dilek A, Camci E, Sentürk E, Orhan M, Tuğrul M, et al. Effects of positive end-expiratory pressure on ventilatory and oxygenation parameters during pressure-controlled one-lung ventilation. J Cardiothorac Vasc Anesth. 2005;19:71–5.PubMed
31.
Capan LM, Turndorf H, Patel C, Ramanathan S, Acinapura A, Chalon J. Optimization of arterial oxygenation during one-lung anesthesia. Anesth Analg. 1980;59:847–51.PubMed
32.
Mascotto G, Bizzarri M, Messina M, Cerchierini E, Torri G, Carozzo A, et al. Prospective, randomized, controlled evaluation of the preventive effects of positive end-expiratory pressure on patient oxygenation during one-lung ventilation. Eur J Anaesthesiol. 2003;20:704–10.PubMed
33.
Murias G, Blanch L, Lucangelo U. The physiology of ventilation. Resp Care. 2014;59(11):1795–807.
34.
Benumof J. Conventional and differential lung management of one-lung ventilation. In: Benumof J, editor. Anesthesia for thoracic surgery. 2nd ed. WB Saunders Company; 1995. Fig:11-19; 11-20. p.
35.
Slinger PD, Kruger M, McRae K, Winton T. Relation of the static compliance curve and positive end-expiratory pressure to oxygenation during one-lung ventilation. Anesthesiology. 2001;95:1096–102.PubMed
36.
Ferrando C, Mugarra A, Gutierrez A, Carbonell JA, García M, Soro M, et al. Setting individualized positive end-expiratory pressure level with a positive end-expiratory pressure decrement trial after a recruitment maneuver improves oxygenation and lung mechanics during one-lung ventilation. Anesth Analg. 2014;118:657–65.PubMed
37.
• Park M, Ahn HJ, Kim JA, Yang M, Heo BY, Choi JW, et al. Driving pressure during thoracic surgery a randomized clinical trial. Anesthesiology. 2019;130:385–93 Albeit with different (and very low) PEEP’s, this study shows the decisive role of driving pressure. PubMed
38.
•• Kiss T, Wittenstein J, Becker C, Birr K, Cinnella G, Cohen E, et al. Protective ventilation with high versus low positive end-expiratory pressure during one-lung ventilation for thoracic surgery (PROTHOR): study protocol for a randomized controlled trial. Trials. 2019;20(1):213 The biggest multicenter study in one-lung ventilation. PubMedPubMedCentral
39.
Carramiñana A, Ferrando C, Unzueta MC, Navarro R, Suárez-Sipmann F, Tusman G, et al. Rationale and study design for an individualized perioperative open lung ventilatory strategy in patients on one-lung ventilation (iPROVE-OLV). J Cardiothorac Vasc Anesth. 2019.
40.
Spadaro S, Grasso S, Karbing DS, Fogagnolo A, Contoli M, Bollini G, et al. Physiologic evaluation of ventilation perfusion mismatch and respiratory mechanics at different positive end-expiratory pressure in patients undergoing protective one-lung ventilation. Anesthesiology. 2018;128:531–8.PubMed
41.
Gattinoni L, Collino F, Maiolo G, Rapetti F, Romitti F, Tonetti T, et al. Positive end-expiratory pressure: how to set it at the individual level. Ann Transl Med. 2017;5(14):288.PubMedPubMedCentral
42.
Nestler C, Simon P, Petroff D, Hammermüller S, Kamrath D, Wolf S, et al. Individualized positive end-expiratory pressure in obese patients during general anesthesia: a randomized controlled clinical trial using electrical impedance tomography. Br J Anaesth. 2017;119:1194–205.PubMed
43.
Hess DR. Recruitment maneuvers and PEEP titration. Respir Care. 2015;60(11):1688–704.PubMed
44.
Hess DR. Respiratory mechanics in mechanically ventilated patients. Respir Care. 2014;59(11):1773–94.PubMed
45.
Tusman G, Bohm SH, Sipmann FS, Maisch S. Lung recruitment improves the efficiency of ventilation and gas exchange during one-lung ventilation anesthesia. Anesth Analg. 2004;98:1604–9.PubMed
46.
Unzueta C, Tusman G, Suarez-Sipmann F, Böhm S, Moral V. Alveolar recruitment improves ventilation during thoracic surgery: a randomized controlled trial. Br J Anaesth. 2012;108:517–24.PubMed
47.
Kim HJ, Seo JH, Park KU, Kim YT, Park IK, Bahk JH. Effect of combining a recruitment maneuver with protective ventilation on inflammatory responses in video-assisted thoracoscopic lobectomy: a randomized controlled trial. Surg Endosc. 2019;33(5):1403–11.PubMed
48.
Kidane B, Palma DC, Badner NH, Hamilton M, Leydier L, Fortin D, et al. The potential dangers of recruitment maneuvers during one lung ventilation surgery. J Surg Res. 2019;234:178–83.PubMed
49.
Senturk M, Slinger P, Cohen E. Intraoperative mechanical ventilation strategies for one-lung ventilation. Best Pract Res Clin Anesthesiol. 2015;29:357–69.
50.
Hedensiterna G, Edmar L. Effects of anesthesia on the respiratory system. Best Pract Res Clin Anesthesiol. 2015;29(3):273–84.
51.
Bernasconi F, Piccioni F. One lung ventilation for thoracic surgery: current perspectives. Tumori. 2017;103(6):495–503.PubMed
52.
Marret E, Cinotti R, Berard L, Piriou V, Jobard J, Barrucand B, et al. Protective ventilation during anaesthesia reduces major postoperative complications after lung cancer surgery: a double-blind randomised controlled trial. Eur J Anaesthesiol. 2018;35(10):727–35.PubMed
53.
Yang M, Ahn HJ, Kim K, Kim JA, Yi CA, Kim MJ, et al. Does a protective ventilation strategy reduce the risk of pulmonary complications after lung cancer surgery? A randomized controlled trial. Chest. 2011;139(3):530–7.PubMed
54.
Michelet P, D'Journo XB, Roch A, Doddoli C, Marin V, Papazian L, et al. Protective ventilation influences systemic inflammation after esophagectomy: a randomized controlled study. Anesthesiology. 2006;105(5):911–9.PubMed
55.
Zhao Z, Wang W, Zhang Z, Xu M, Frerichs I, Wu J, et al. Influence of tidal volume and positive endexpiratory pressure on ventilation distribution and oxygenation during one-lung ventilation. Physiol Meas. 2018;39(3):034003.PubMed
56.
•• Belda J, Ferrando C, Garutti I, iPROVE Network investigators. The effects of an open-lung approach during one-lung ventilation on postoperative pulmonary complications and driving pressure: a descriptive, multicenter national study. J Cardiothorac Vasc Anesth. 2018;32(6):2665–72 The previous study of the same group has shown the effects of individual PEEP on oxygenation; this study shows the effects on postoperative complications. PubMed
57.
Verbeek GL, Myles PS, Westall GP, Lin E, Hastings SL, Marasco SF, et al. Intra-operative protective mechanical ventilation in lung transplantation: a randomised, controlled trial. Anaesthesia. 2017;72:993–1004.PubMed
58.
Hemmes SN, Gama de Abreu M, Pelosi P, Schultz MJ, PROVE Network Investigators for the Clinical Trial Network of the European Society of Anaesthesiology. High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial. Lancet. 2014;384(9942):495–503.PubMed
59.
Bluth T, Serpa Neto A, Schultz MJ, Pelosi P, Gama de Abreu M, Writing Committee for the PROBESE Collaborative Group of the PROtective VEntilation Network (PROVEnet) for the Clinical Trial Network of the European Society of Anaesthesiology. Effect of intraoperative high positive end-expiratory pressure (PEEP) with recruitment maneuvers vs low PEEP on postoperative pulmonary complications in obese patients: a randomized clinical trial. JAMA. 2019. https://​doi.​org/​10.​1001/​jama.​2019.​7505.
Metadata
Title
Positive End-Expiratory Pressure (PEEP), Tidal Volume, or Alveolar Recruitment: Which One Does Matter in One-Lung Ventilation?
Authors
Taner Abdullah
Mert Şentürk
Publication date
01-12-2019
Publisher
Springer US
Published in
Current Anesthesiology Reports / Issue 4/2019
Electronic ISSN: 2167-6275
DOI
https://doi.org/10.1007/s40140-019-00350-z

Other articles of this Issue 4/2019

Current Anesthesiology Reports 4/2019 Go to the issue

Regional Anesthesia (P Kukreja, Section Editor)

Infiltration Between the Popliteal Artery and Capsule of the Knee (iPACK): Essential Anatomy, Technique, and Literature Review

Geriatric Anesthesia (S Akhtar, Section Editor)

Emergency General Surgery in Older Patients: Where Are We Now?

Thoracic Anesthesia (T Schilling, Section Editor)

Experimental Data on the Pulmonary Effects of Remote Ischemic Preconditioning

Thoracic Anesthesia (T Schilling, Section Editor)

Hypoxemia During One-Lung Ventilation: Does it Really Matter?

Thoracic Anesthesia (T Schilling, Section Editor)

Which Anesthesia Regimen Should Be Used for Lung Surgery?

Thoracic Anesthesia (T Schilling, Section Editor)

Serratus Plane Block in the Management of Post-operative Thoracotomy Pain