Top

Published in:

Open Access 01-12-2018 | Research article

Peep titration based on the open lung approach during one lung ventilation in thoracic surgery: a physiological study

Authors: Michela Rauseo, Lucia Mirabella, Salvatore Grasso, Antonella Cotoia, Savino Spadaro, Davide D’Antini, Franca Valentino, Livio Tullo, Domenico Loizzi, Francesco Sollitto, Gilda Cinnella

Published in: BMC Anesthesiology | Issue 1/2018

Abstract

Background

During thoracic surgery in lateral decubitus, one lung ventilation (OLV) may impair respiratory mechanics and gas exchange. We tested a strategy based on an open lung approach (OLA) consisting in lung recruitment immediately followed by a decremental positive-end expiratory pressure (PEEP) titration to the best respiratory system compliance (C_RS) and separately quantified the elastic properties of the lung and the chest wall. Our hypothesis was that this approach would improve gas exchange. Further, we were interested in documenting the impact of the OLA on partitioned respiratory system mechanics.

Methods

In thirteen patients undergoing upper left lobectomy we studied lung and chest wall mechanics, transpulmonary pressure (P_L), respiratory system and transpulmonary driving pressure (ΔP_RS and ΔP_L), gas exchange and hemodynamics at two time-points (a) during OLV at zero end-expiratory pressure (OLV_pre-OLA) and (b) after the application of the open-lung strategy (OLV_post-OLA).

Results

The external PEEP selected through the OLA was 6 ± 0.8 cmH₂O. As compared to OLV_pre-OLA, the PaO₂/FiO₂ ratio went from 205 ± 73 to 313 ± 86 (p = .05) and C_L increased from 56 ± 18 ml/cmH₂O to 71 ± 12 ml/cmH₂O (p = .0013), without changes in C_CW.

Both ΔP_RS and ΔP_L decreased from 9.2 ± 0.4 cmH₂O to 6.8 ± 0.6 cmH₂O and from 8.1 ± 0.5 cmH₂O to 5.7 ± 0.5 cmH₂O, (p = .001 and p = .015 vs OLV_pre-OLA), respectively. Hemodynamic parameters remained stable throughout the study period.

Conclusions

In our patients, the OLA strategy performed during OLV improved oxygenation and increased C_L and had no clinically significant hemodynamic effects. Although our study was not specifically designed to study ΔP_RS and ΔP_L, we observed a parallel reduction of both after the OLA.

Trial registration

TRN: ClinicalTrials.gov, NCT03435523, retrospectively registered, Feb 14 2018.

Park SH, Jeon YT, Hwang JW, Do SH, Kim JH, Park HP. A preemptive alveolar recruitment strategy before one-lung ventilation improves arterial oxygenation in patients undergoing thoracic surgery: a prospective randomised study. Eur J Anaesthesiol. 2011;28(4):298–302.PubMed

Ng A, Swanevelder J. Hypoxaemia associated with one-lung anaesthesia: new discoveries in ventilation and perfusion. Br J Anaesth. 2011;106(6):761–3. https://doi.org/10.1093/bja/aer113.CrossRefPubMed

Lohser J. Evidence-based Management of one-Lung Ventilation. Anesthesiology Clin. 2008;26:241–72. https://doi.org/10.1016/j.anclin.2008.01.011.CrossRef

Hoftman N, Canales C, Leduc M, Mahajan A. Positive end expiratory pressure during one-lung ventilation: selecting ideal patients and ventilator settings with the aim of improving arterial oxygenation. Ann Card Anaesth. 2011;14(3):183–7. https://doi.org/10.4103/0971-9784.83991.CrossRefPubMed

Borges JB, Senturk M, Ahlgren O, Hedenstierna G, Larsson A. Open lung in lateral decubitus with differential selective positive end-expiratory pressure in an experimental model of early acute respiratory distress syndrome. Crit Care Med. 2015;43(10):e404–11. https://doi.org/10.1097/CCM.0000000000001143.CrossRefPubMed

Cinnella G, Grasso S, Natale C, Sollitto F, Cacciapaglia M, Angiolillo M, Pavone G, Mirabella L, Dambrosio M. Physiological effects of a lung-recruiting strategy applied during one-lung ventilation. Acta Anaesthesiol Scand. 2008;52:766–75. https://doi.org/10.1111/j.1399-6576.2008.01652.x.CrossRefPubMed

Gama de Abreu M, Heintz M, Heller A, Széchényi R, Albrecht DM, Koch T. One-lung ventilation with high tidal volumes and zero positive end-expiratory pressure is injurious in the isolated rabbit lung model. Anesth Analg. 2003;96:220–8.CrossRef

Slinger P. Pro: low tidal volume is indicated during one-lung ventilation. Cardiovasc Anesth. 2006;103:2. https://doi.org/10.1213/01.ane.0000223701.24874.c8.CrossRef

Unzueta C, Tusman G, Suarez-Sipmann F, Bohm S, Moral V. Alveolar recruitment improves ventilation during thoracic surgery: a randomized controlled trial. Br J Anaesth. 2006;108(3):517–24. https://doi.org/10.1093/bja/aer415.CrossRef

10.

Michelet P, Blayac D, Vincent A, D’journo X-B, Perrin G, Badier M, Thomas P, Bregeon F. How do COPD and healthy-lung patients tolerate the reduced volume ventilation strategy during OLV ventilation. Acta Anaesthesiol Scand. 2010;54:1128–36. https://doi.org/10.1111/j.1399-6576.2010.02281.x.CrossRefPubMed

11.

Ferrando C, Mugarra A, Gutierrez A, Carbonell JA, García M, Soro M, Tusman G, Belda FJ. 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.CrossRef

12.

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.CrossRef

13.

Gattinoni L, Caironi P, Cressoni M, Chiumello D, Ranieri VM, Quintel M, Russo S, Patroniti N, Cornejo R, Bugedo G. Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med. 2006; 27;354(17):1775–86.CrossRef

14.

Pepe PE, Hudson LD, Carrico CJ. Early application of positive end-expiratory pressure in patients at risk for the adult respiratory-distress syndrome. N Engl J Med. 1984;311(5):281–6.CrossRef

15.

Cinnella G, Grasso S, Spadaro S, Rauseo M, Mirabella L, Salatto P, De Capraris A, Nappi L, Greco P, Dambrosio M. Effects of Recruitment Maneuver and Positive End-expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery. Anesthesiology. 2013;118:114–22.CrossRef

16.

Garutti I, Martinez G, Cruz P, Piñeiro P, Olmedilla L, de la Gala F. The Impact of Lung Recruitment on Hemodynamics During One-Lung Ventilation. J Cardiothorac Vasc Anesth. 2009;23(4):506–8. https://doi.org/10.1053/j.jvca.2008.12.023.CrossRefPubMed

17.

Benes J, Chytra I, Altmann P, Hluchy M, Kasal E, Svitak R, Pradl R, Stepan M. Intraoperative fluid optimization using stroke volume variation in high risk surgical patients: results of prospective randomized study. Crit Care. 2010;14(3):R118. https://doi.org/10.1186/cc9070.CrossRefPubMedPubMedCentral

18.

Tusman G, Böhm SH, Melkun F, Staltari D, Quinzio C, Nador C, Turchetto E. Alveolar recruitment strategy increases arterial oxygenation during one-lung ventilation. Ann Thorac Surg. 2002;73:1204–9.CrossRef

19.

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.CrossRef

20.

Talmor D, Sarge T, Malhotra A, O'Donnell CR, Ritz R, Lisbon A, Novack V, Loring SH. Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med. 2008;359:2095–104. https://doi.org/10.1056/NEJMoa0708638.CrossRefPubMedPubMedCentral

21.

Akoumianaki E, Maggiore SM, Valenza F, Bellani G, Jubran A, Loring SH, Pelosi P, Talmor D, Grasso S, Chiumello D, Guérin C, Patroniti N, Ranieri VM, Gattinoni L, Nava S, Terragni PP, Pesenti A, Tobin M, Mancebo J, Brochard L. PLeUral pressure working Group (PLUG—Acute Respiratory Failure section of the European Society of Intensive Care Medicine). The application of esophageal pressure measurement in patients with respiratory failure. Am J Respir Crit Care Med. 2014;189:520–31.CrossRef

22.

Chiumello D, Cressoni M, Colombo A, Babini G, Brioni M, Crimella F, Lundin S, Stenqvist O, Gattinoni L. The assessment of transpulmonary pressure in mechanically ventilated ARDS patients. Intensive Care Med. 2014;40(11):1670–8. https://doi.org/10.1007/s00134-014-3415-4.CrossRefPubMed

23.

Chiumello D, Consonni D, Coppola S, Froio S, Crimella F, Colombo A. The occlusion tests and end-expiratory esophageal pressure: measurements and comparison in controlled and assisted ventilation. Ann Intensive Care. 2016;6(1):13.CrossRef

24.

Mauri T, Yoshida T, Bellani G, Goligher EC, Carteaux G, Rittayamai N, Mojoli F, Chiumello D, Piquilloud L, Grasso S, Jubran A, Laghi F, Magder S, Pesenti A, Loring S, Gattinoni L, Talmor D, Blanch L, Amato M, Chen L, Brochard L, Mancebo J. PLeUral pressure working Group (PLUG—Acute Respiratory Failure section of the European Society of Intensive Care Medicine). Esophageal and transpulmonary pressure in the clinical setting: meaning, usefulness and perspectives. Intensive Care Med. 2016;42(9):1360–73. https://doi.org/10.1007/s00134-016-4400-x.CrossRefPubMed

25.

Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res. 1999;8:135–60.CrossRef

26.

Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986; 8;1(8476):307–10.

27.

Benumof JL. Conventional and differential lung management of one-lung ventilation. In: Benumof JL, editor. Anesthesia for thoracic surgery. Philadelphia: WB Saunders; 1995. p. 406–31.

28.

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.CrossRef

29.

Schilling T, Kozian A, Huth C, et al. The pulmonary immune effects of mechanical ventilation in patients undergoing thoracic surgery. Anesth Analg. 2005;101:957–65.CrossRef

30.

Shen Y, Zhong M, Wu W, Wang H, Feng M, Tan L, Wang Q. The impact of tidal volume on pulmonary complications following minimally invasive esophagectomy: a randomized and controlled study. J Thorac Cardiovasc Surg. 2013;146:1267–73.CrossRef

31.

Wrigge H, Uhlig U, Zinserling J, Behrends-Callsen E, Ottersbach G, Fischer M, Uhlig S, Putensen C. The effects of different ventilatory settings on pulmonary and systemic inflammatory responses during major surgery. Anesth Analg. 2004;98:775–81.CrossRef

32.

Végh T, Juhász M, Szatmári S, Enyedi A, Sessler DI, Szegedi LL, Fülesdi B. Effects of different tidal volumes for one-lung ventilation on oxygenation with open chest condition and surgical manipulation: a randomised cross-over trial. Minerva Anestesiol. 2013;79:24–32.PubMed

33.

Michelet P, D’Journo XB, Roch A, Doddoli C, Marin V, Papazian L, Decamps I, Bregeon F, Thomas P, Auffray JP. Protective ventilation influences systemic inflammation after esophagectomy: a randomized controlled study. Anesthesiology. 2006;105:911–9.CrossRef

34.

Sutherasan Y, D’Antini D, Pelosi P. Advances in ventilator-associated lung injury: prevention is the target. Expert Rev Respir Med. 2014;8(2):233–48. https://doi.org/10.1586/17476348.2014.890519.CrossRefPubMed

35.

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 videoassisted thoracoscopic surgery: a randomised, controlled trial. Eur J Anaesthesiol. 2014;31:466–73.CrossRef

36.

Verhage RJ, Boone J, Rijkers GT, Cromheecke GJ, Kroese AC, Weijs TJ, Borel Rinkes IH, van Hillegersberg R. Reduced local immune response with continuous positive airway pressure during one-lung ventilation for oesophagectomy. Br J Anaesth. 2014;112:920–8.CrossRef

37.

Fujiwara M, Abe K, Mashimo T. The effect of positive endexpiratory pressure and continuous positive airway pressure on the oxygenation and shunt fraction during one-lung ventilation with propofol anesthesia. J Clin Anesthesia. 2001;13:473–7.CrossRef

38.

Lohser J, Slinger P. Lung injury after one-lung ventilation: a review of the pathophysiologic mechanisms affecting the ventilated and the collapsed lung. Anesth Analg. 2015;121(2):302–18. https://doi.org/10.1213/ANE.0000000000000808.CrossRefPubMed

39.

Spadaro S, Grasso S, Karbing DS, Fogagnolo A, Contoli M, Bollini G, Ragazzi R, Cinnella G, Verri M, Cavallesco NG, Rees SE, Volta CA. Physiologic evaluation of ventilation perfusion mismatch and respiratory mechanics at different positive end-expiratory pressure in patients undergoing protective one-lung ventilation. Anesthesiology. 2018 Mar;128(3):531–8. https://doi.org/10.1097/ALN.0000000000002011.CrossRefPubMed

40.

Cinnella G, Grasso S, Raimondo P, D'Antini D, Mirabella L, Rauseo M, Dambrosio M. Physiological effects of the open lung approach in patients with early, mild, diffuse acute respiratory distress syndrome: an electrical impedance tomography study. Anesthesiology. 2015 Nov;123(5):1113–21. https://doi.org/10.1097/ALN.0000000000000862.CrossRefPubMed

41.

Nieman GF, Satalin J, Andrews P, Aiash H, Habashi NM, Gatto LA. Personalizing mechanical ventilation according to physiologic parameters to stabilize alveoli and minimize ventilator induced lung injury (VILI). Intensive Care Med Exp. 2017;5(1):8. https://doi.org/10.1186/s40635-017-0121-x.CrossRefPubMedPubMedCentral

42.

Washko GR, O'Donnell CR, Loring SHJ. Volume-related and volume-independent effects of posture on esophageal and transpulmonary pressures in healthy subjects. Appl Physiol (1985). 2006;100(3):753–8.CrossRef

43.

Klingstedt C, Baehrendtz S, Bindslev L, Hedenstierna G. Lung and chest wall mechanics during differential ventilation with selective PEEP. Acta Anaesthesiol Scand. 1985;29(7):716–21.CrossRef

44.

Serpa Neto A, Hemmes SN, Barbas CS, Beiderlinden M, Fernandez-Bustamante A, Futier E, Hollmann MW, Jaber S, Kozian A, Licker M, Lin WQ, Moine P, Scavonetto F, Schilling T, Selmo G, Severgnini P, Sprung J, Treschan T, Unzueta C, Weingarten TN, Wolthuis EK, Wrigge H, Gama de Abreu M, Pelosi P, Schultz MJ. PROVE Network investigators. Incidence of mortality and morbidity related to postoperative lung injury in patients who have undergone abdominal or thoracic surgery: a systematic review and meta-analysis. Lancet Respir Med. 2014;2(12):1007–15. https://doi.org/10.1016/S2213-2600(14)70228-0.CrossRefPubMed

45.

Amato MB, Meade MO, Slutsky AS, Brochard L, Costa EL, Schoenfeld DA, Stewart TE, Briel M, Talmor D, Mercat A, Richard JC, Carvalho CR, Brower RG. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372:747–55. https://doi.org/10.1056/NEJMsa1410639.CrossRefPubMed

46.

Ferrando C, Soro M, Unzueta C, Suarez-Sipmann F, Canet J, Librero J, Pozo N, Peiró S, Llombart A, León I, India I, Aldecoa C, Díaz-Cambronero O, Pestaña D, Redondo FJ, Garutti I, Balust J, García JI, Ibáñez M, Granell M, Rodríguez A, Gallego L, de la Matta M, Gonzalez R, Brunelli A, García J, Rovira L, Barrios F, Torres V, Hernández S, Gracia E, Giné M, García M, García N, Miguel L, Sánchez S, Piñeiro P, Pujol R, García-Del-Valle S, Valdivia J, Hernández MJ, Padrón O, Colás A, Puig J, Azparren G, Tusman G, Villar J, Belda J. Individualized PeRioperative Open-lung VEntilation (iPROVE) Network. Individualised perioperative open-lung approach versus standard protective ventilation in abdominal surgery (iPROVE): a randomised controlled trial. Lancet Respir Med. 2018;6(3):193–203. https://doi.org/10.1016/S2213-2600(18)30024-9 Epub 2018 Jan 19.CrossRefPubMed

Title: Peep titration based on the open lung approach during one lung ventilation in thoracic surgery: a physiological study
Authors: Michela Rauseo
Lucia Mirabella
Salvatore Grasso
Antonella Cotoia
Savino Spadaro
Davide D’Antini
Franca Valentino
Livio Tullo
Domenico Loizzi
Francesco Sollitto
Gilda Cinnella
Publication date: 01-12-2018
Publisher: BioMed Central
Published in: BMC Anesthesiology / Issue 1/2018
Electronic ISSN: 1471-2253
DOI: https://doi.org/10.1186/s12871-018-0624-3

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Peep titration based on the open lung approach during one lung ventilation in thoracic surgery: a physiological study

Abstract

Background

Methods

Results

Conclusions

Trial registration

Keynote webinar | Spotlight on sleep in brain health

Springer Medicine

Abstract

Background

Methods

Results

Conclusions

Trial registration

Please log in to get access to this content

Other articles of this Issue 1/2018

Effects of patient-controlled analgesia with hydromorphone or sufentanil on postoperative pulmonary complications in patients undergoing thoracic surgery: a quasi-experimental study

Prospective investigation of intravenous patient-controlled analgesia with hydromorphone or sufentanil: impact on mood, opioid adverse effects, and recovery

Pre-anesthetic assessment with three core questions for the detection of obstructive sleep apnea in childhood: An observational study

Impedance cardiography as tool for continuous hemodynamic monitoring during cesarean section: randomized, prospective double blind study

Ultrasound-guided phrenic nerve block for intraoperative persistent hiccups: a case report

Ultrasound-guided versus low dose computed tomography scanning guidance for lumbar facet joint injections: same accuracy and efficiency