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

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

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 (CRS) 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 (PL), respiratory system and transpulmonary driving pressure (ΔPRS and ΔPL), gas exchange and hemodynamics at two time-points (a) during OLV at zero end-expiratory pressure (OLVpre-OLA) and (b) after the application of the open-lung strategy (OLVpost-OLA).

Results: The external PEEP selected through the OLA was 6 ± 0.8 cmH2O. As compared to OLVpre-OLA, the PaO2/FiO2 ratio went from 205 ± 73 to 313 ± 86 (p = .05) and CL increased from 56 ± 18 ml/cmH2O to 71 ± 12 ml/cmH2O (p = .0013), without changes in CCW. Both ΔPRS and ΔPL 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 OLVpre-OLA), respectively. Hemodynamic parameters remained stable throughout the study period.

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

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

Keywords: One lung ventilation; Open lung approach; Recruitment maneuver; Thoracic surgery.

Conflict of interest statement

Ethics approval and consent to participate

After approval of the local ethics committee (Ethics Review Board: Deni Aldo Procaccini, Maria Rosaria Castrignanò, Michele Monaco, Raffaele De Cesaris, Domenico Paleo, Romano Bucci, Francesco Morreale, Luigia Trabace, Alfonso Francesco Catanzaro, Daniela Pedà, Rosanna Stea, Simona Mastropieri, Agata Danza, Nadia Belgioioso) and written informed consent from each patient, the study was performed in consecutive patients scheduled to undergo elective lung lobectomy or resection through thoracotomy requiring OLV in the right lateral position, from February to November 2012 (Consent for publication

Not applicable.

Competing interests

The authors Savino Spadaro and Gilda Cinnella are Associate Editors for BMC Anesthesiology.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Study protocol
Fig. 2
Fig. 2
CONSORT flow chart

References

    1. 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.
    1. Ng A, Swanevelder J. Hypoxaemia associated with one-lung anaesthesia: new discoveries in ventilation and perfusion. Br J Anaesth. 2011;106(6):761–763. doi: 10.1093/bja/aer113.
    1. Lohser J. Evidence-based Management of one-Lung Ventilation. Anesthesiology Clin. 2008;26:241–272. doi: 10.1016/j.anclin.2008.01.011.
    1. 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):183–187. doi: 10.4103/0971-9784.83991.
    1. 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–e411. doi: 10.1097/CCM.0000000000001143.
    1. 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;52:766–775. doi: 10.1111/j.1399-6576.2008.01652.x.
    1. 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;96:220–228. doi: 10.1213/00000539-200301000-00045.
    1. Slinger P. Pro: low tidal volume is indicated during one-lung ventilation. Cardiovasc Anesth. 2006;103:2. doi: 10.1213/01.ane.0000223701.24874.c8.
    1. 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):517–524. doi: 10.1093/bja/aer415.
    1. 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;54:1128–1136. doi: 10.1111/j.1399-6576.2010.02281.x.
    1. 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;118:657–665. doi: 10.1213/ANE.0000000000000105.
    1. 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;95:1096–1102. doi: 10.1097/00000542-200111000-00012.
    1. Gattinoni Luciano, Caironi Pietro, Cressoni Massimo, Chiumello Davide, Ranieri V. Marco, Quintel Michael, Russo Sebastiano, Patroniti Nicolò, Cornejo Rodrigo, Bugedo Guillermo. Lung Recruitment in Patients with the Acute Respiratory Distress Syndrome. New England Journal of Medicine. 2006;354(17):1775–1786. doi: 10.1056/NEJMoa052052.
    1. 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):281–286. doi: 10.1056/NEJM198408023110502.
    1. 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;118:114–122. doi: 10.1097/ALN.0b013e3182746a10.
    1. 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):506–508. doi: 10.1053/j.jvca.2008.12.023.
    1. 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. doi: 10.1186/cc9070.
    1. 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;73:1204–1209. doi: 10.1016/S0003-4975(01)03624-4.
    1. 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;98:1604–1609. doi: 10.1213/01.ANE.0000068484.67655.1A.
    1. 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;359:2095–2104. doi: 10.1056/NEJMoa0708638.
    1. 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;189:520–531. doi: 10.1164/rccm.201312-2193CI.
    1. 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):1670–1678. doi: 10.1007/s00134-014-3415-4.
    1. 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. doi: 10.1186/s13613-016-0112-1.
    1. 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):1360–1373. doi: 10.1007/s00134-016-4400-x.
    1. Bland JM, Altman DG. Measuring agreement in method comparison studies. Stat Methods Med Res. 1999;8:135–160. doi: 10.1177/096228029900800204.
    1. Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986; 8;1(8476):307–10.
    1. Benumof JL. Conventional and differential lung management of one-lung ventilation. In: Benumof JL, editor. Anesthesia for thoracic surgery. Philadelphia: WB Saunders; 1995. pp. 406–431.
    1. 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;114:1025–1035. doi: 10.1097/ALN.0b013e3182164356.
    1. Schilling T, Kozian A, Huth C, et al. The pulmonary immune effects of mechanical ventilation in patients undergoing thoracic surgery. Anesth Analg. 2005;101:957–965. doi: 10.1213/01.ane.0000172112.02902.77.
    1. 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;146:1267–1273. doi: 10.1016/j.jtcvs.2013.06.043.
    1. 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;98:775–781. doi: 10.1213/.
    1. 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.
    1. 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;105:911–919. doi: 10.1097/00000542-200611000-00011.
    1. Sutherasan Y, D’Antini D, Pelosi P. Advances in ventilator-associated lung injury: prevention is the target. Expert Rev Respir Med. 2014;8(2):233–248. doi: 10.1586/17476348.2014.890519.
    1. 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;31:466–473. doi: 10.1097/EJA.0000000000000072.
    1. 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;112:920–928. doi: 10.1093/bja/aet476.
    1. 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;13:473–477. doi: 10.1016/S0952-8180(01)00310-5.
    1. 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):302–318. doi: 10.1213/ANE.0000000000000808.
    1. 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;128(3):531–538. doi: 10.1097/ALN.0000000000002011.
    1. 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;123(5):1113–1121. doi: 10.1097/ALN.0000000000000862.
    1. 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. doi: 10.1186/s40635-017-0121-x.
    1. 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):753–758. doi: 10.1152/japplphysiol.00697.2005.
    1. 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):716–721. doi: 10.1111/j.1399-6576.1985.tb02287.x.
    1. 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):1007–1015. doi: 10.1016/S2213-2600(14)70228-0.
    1. 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;372:747–755. doi: 10.1056/NEJMsa1410639.
    1. 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. doi: 10.1016/S2213-2600(18)30024-9.

Source: PubMed

Sponsor e collaboratori

Condizioni mediche

Interventi farmacologici

3
Sottoscrivi