Impact of intraoperative lung-protective interventions in patients undergoing lung cancer surgery

Marc Licker, John Diaper, Yann Villiger, Anastase Spiliopoulos, Virginie Licker, John Robert, Jean-Marie Tschopp, Marc Licker, John Diaper, Yann Villiger, Anastase Spiliopoulos, Virginie Licker, John Robert, Jean-Marie Tschopp

Abstract

Introduction: In lung cancer surgery, large tidal volume and elevated inspiratory pressure are known risk factors of acute lung (ALI). Mechanical ventilation with low tidal volume has been shown to attenuate lung injuries in critically ill patients. In the current study, we assessed the impact of a protective lung ventilation (PLV) protocol in patients undergoing lung cancer resection.

Methods: We performed a secondary analysis of an observational cohort. Demographic, surgical, clinical and outcome data were prospectively collected over a 10-year period. The PLV protocol consisted of small tidal volume, limiting maximal pressure ventilation and adding end-expiratory positive pressure along with recruitment maneuvers. Multivariate analysis with logistic regression was performed and data were compared before and after implementation of the PLV protocol: from 1998 to 2003 (historical group, n = 533) and from 2003 to 2008 (protocol group, n = 558).

Results: Baseline patient characteristics were similar in the two cohorts, except for a higher cardiovascular risk profile in the intervention group. During one-lung ventilation, protocol-managed patients had lower tidal volume (5.3 +/- 1.1 vs. 7.1 +/- 1.2 ml/kg in historical controls, P = 0.013) and higher dynamic compliance (45 +/- 8 vs. 32 +/- 7 ml/cmH2O, P = 0.011). After implementing PLV, there was a decreased incidence of acute lung injury (from 3.7% to 0.9%, P < 0.01) and atelectasis (from 8.8 to 5.0, P = 0.018), fewer admissions to the intensive care unit (from 9.4% vs. 2.5%, P < 0.001) and shorter hospital stay (from 14.5 +/- 3.3 vs. 11.8 +/- 4.1, P < 0.01). When adjusted for baseline characteristics, implementation of the open-lung protocol was associated with a reduced risk of acute lung injury (adjusted odds ratio of 0.34 with 95% confidence interval of 0.23 to 0.75; P = 0.002).

Conclusions: Implementing an intraoperative PLV protocol in patients undergoing lung cancer resection was associated with improved postoperative respiratory outcomes as evidence by significantly reduced incidences of acute lung injury and atelectasis along with reduced utilization of intensive care unit resources.

References

    1. Boffa DJ, Allen MS, Grab JD, Gaissert HA, Harpole DH, Wright CD. Data from The Society of Thoracic Surgeons General Thoracic Surgery database: the surgical management of primary lung tumors. J Thorac Cardiovasc Surg. 2008;135:247–254. doi: 10.1016/j.jtcvs.2007.07.060.
    1. Memtsoudis SG, Besculides MC, Zellos L, Patil N, Rogers SO. Trends in lung surgery: United States 1988 to 2002. Chest. 2006;130:1462–1470. doi: 10.1378/chest.130.5.1462.
    1. Goodney PP, Lucas FL, Stukel TA, Birkmeyer JD. Surgeon specialty and operative mortality with lung resection. Ann Surg. 2005;241:179–184.
    1. Alam N, Park BJ, Wilton A, Seshan VE, Bains MS, Downey RJ, Flores RM, Rizk N, Rusch VW, Amar D. Incidence and risk factors for lung injury after lung cancer resection. Ann Thorac Surg. 2007;84:1085–1091. doi: 10.1016/j.athoracsur.2007.05.053.
    1. Licker MJ, Widikker I, Robert J, Frey JG, Spiliopoulos A, Ellenberger C, Schweizer A, Tschopp JM. Operative mortality and respiratory complications after lung resection for cancer: impact of chronic obstructive pulmonary disease and time trends. Ann Thorac Surg. 2006;81:1830–1837. doi: 10.1016/j.athoracsur.2005.11.048.
    1. Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, LeGall JR, Morris A, Spragg R. Report of the American-European consensus conference on ARDS: definitions, mechanisms, relevant outcomes and clinical trial coordination. The Consensus Committee. Intensive Care Med. 1994;20:225–232. doi: 10.1007/BF01704707.
    1. Licker M, Fauconnet P, Villiger Y, Tschopp JM. Acute lung injury and outcomes after thoracic surgery. Curr Opin Anaesthesiol. 2009;22:61–67. doi: 10.1097/ACO.0b013e32831b466c.
    1. Tang SS, Redmond K, Griffiths M, Ladas G, Goldstraw P, Dusmet M. The mortality from acute respiratory distress syndrome after pulmonary resection is reducing: a 10-year single institutional experience. Eur J Cardiothorac Surg. 2008;34:898–902. doi: 10.1016/j.ejcts.2008.06.020.
    1. 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;105:14–18. doi: 10.1097/00000542-200607000-00007.
    1. Licker M, de Perrot M, Spiliopoulos A, Robert J, Diaper J, Chevalley C, Tschopp JM. Risk factors for acute lung injury after thoracic surgery for lung cancer. Anesth Analg. 2003;97:1558–1565. doi: 10.1213/01.ANE.0000087799.85495.8A.
    1. Schultz MJ. Lung-protective mechanical ventilation with lower tidal volumes in patients not suffering from acute lung injury: a review of clinical studies. Med Sci Monit. 2008;14:RA22–RA26.
    1. Petrucci N, Iacovelli W. Lung protective ventilation strategy for the acute respiratory distress syndrome. Cochrane Database Syst Rev. 2007:CD003844.
    1. Vittinghoff EGD, Shibosky SC, McCulloch CE. Regression methods in biostatistics: linear, logistic, survival, and repeated measures of models. Springer New York; 2005. pp. 72–93.
    1. Hedenstierna G, Edmark L. The effects of anesthesia and muscle paralysis on the respiratory system. Intensive Care Med. 2005;31:1327–1335. doi: 10.1007/s00134-005-2761-7.
    1. Kozian A, Schilling T, Freden F, Maripuu E, Rocken C, Strang C, Hachenberg T, Hedenstierna G. One-lung ventilation induces hyperperfusion and alveolar damage in the ventilated lung: an experimental study. Br J Anaesth. 2008;100:549–559. doi: 10.1093/bja/aen021.
    1. Steinberg KP, Kacmarek RM. Respiratory controversies in the critical care setting. Should tidal volume be 6 mL/kg predicted body weight in virtually all patients with acute respiratory failure? Respir Care. 2007;52:556–564.
    1. Yilmaz M, Keegan MT, Iscimen R, Afessa B, Buck CF, Hubmayr RD, Gajic O. Toward the prevention of acute lung injury: protocol-guided limitation of large tidal volume ventilation and inappropriate transfusion. Crit Care Med. 2007;35:1660–1666. doi: 10.1097/01.CCM.0000269037.66955.F0.
    1. Davis JL, Morris A, Kallet RH, Powell K, Chi AS, Bensley M, Luce JM, Huang L. Low tidal volume ventilation is associated with reduced mortality in HIV-infected patients with acute lung injury. Thorax. 2008;63:988–993. doi: 10.1136/thx.2008.095786.
    1. Umoh NJ, Fan E, Mendez-Tellez PA, Sevransky JE, Dennison CR, Shanholtz C, Pronovost PJ, Needham DM. Patient and intensive care unit organizational factors associated with low tidal volume ventilation in acute lung injury. Crit Care Med. 2008;36:1463–1468. doi: 10.1097/CCM.0b013e31816fc3d0.
    1. Kuzkov VV, Suborov EV, Kirov MY, Kuklin VN, Sobhkhez M, Johnsen S, Waerhaug K, Bjertnaes LJ. Extravascular lung water after pneumonectomy and one-lung ventilation in sheep. Crit Care Med. 2007;35:1550–1559. doi: 10.1097/01.CCM.0000265739.51887.2B.
    1. Cheng YJ, Chan KC, Chien CT, Sun WZ, Lin CJ. Oxidative stress during 1-lung ventilation. J Thorac Cardiovasc Surg. 2006;132:513–518. doi: 10.1016/j.jtcvs.2006.03.060.
    1. Meier T, Lange A, Papenberg H, Ziemann M, Fentrop C, Uhlig U, Schmucker P, Uhlig S, Stamme C. Pulmonary cytokine responses during mechanical ventilation of noninjured lungs with and without end-expiratory pressure. Anesth Analg. 2008;107:1265–1275. doi: 10.1213/ane.0b013e3181806212.
    1. Joshi PC, Guidot DM. The alcoholic lung: epidemiology, pathophysiology, and potential therapies. Am J Physiol Lung Cell Mol Physiol. 2007;292:L813–L823. doi: 10.1152/ajplung.00348.2006.
    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. Schilling T, Kozian A, Huth C, Buhling F, Kretzschmar M, Welte T, Hachenberg T. 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. 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. Unzueta MC, Casas JI, Moral MV. Pressure-controlled versus volume-controlled ventilation during one-lung ventilation for thoracic surgery. Anesth Analg. 2007;104:1029–1033. doi: 10.1213/01.ane.0000260313.63893.2f.
    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.
    1. Farias LL, Faffe DS, Xisto DGMC, Lassance R, Prota LF, Amato MB, Morales MM, Zin WA, Rocco PR. Positive end-expiratory pressure prevents lung mechanical stress caused by recruitment/derecruitment. J Appl Physiol. 2005;98:53–61. doi: 10.1152/japplphysiol.00118.2004.
    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. Pavone L, Albert S, DiRocco J, Gatto L, Nieman G. Alveolar instability caused by mechanical ventilation initially damages the nondependent normal lung. Crit Care. 2007;11:R104. doi: 10.1186/cc6122.
    1. Licker M, Tschopp JM, Robert J, Frey JG, Diaper J, Ellenberger C. Aerosolized salbutamol accelerates the resolution of pulmonary edema after lung resection for cancer. Chest. 2008;133:845–852. doi: 10.1378/chest.07-1710.
    1. Phua J, Stewart TE, Ferguson ND. Acute respiratory distress syndrome 40 years later: time to revisit its definition. Crit Care Med. 2008;36:2912–2921. doi: 10.1097/CCM.0b013e31817d20bd.
    1. Monnet X, Anguel N, Osman D, Hamzaoui O, Richard C, Teboul JL. Assessing pulmonary permeability by transpulmonary thermodilution allows differentiation of hydrostatic pulmonary edema from ALI/ARDS. Intensive Care Med. 2007;33:448–453. doi: 10.1007/s00134-006-0498-6.
    1. Karmpaliotis D, Kirtane AJ, Ruisi CP, Polonsky T, Malhotra A, Talmor D, Kosmidou I, Jarolim P, de Lemos JA, Sabatine MS, Gibson CM, Morrow D. Diagnostic and prognostic utility of brain natriuretic peptide in subjects admitted to the ICU with hypoxic respiratory failure due to noncardiogenic and cardiogenic pulmonary edema. Chest. 2007;131:964–971. doi: 10.1378/chest.06-1247.

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