Abstract
Ventilatory strategies for one-lung ventilation (OLV) should take into account preventing intraoperative hypoxemia, intraoperative alveolar stress, and postoperative ventilator-induced lung injury (VILI). A lung-protective strategy utilizing low tidal volumes (< 6 mL/kg of predicted body weight) and limited plateau inflation pressures (<25 cm H2O) is clearly indicated for patients at high risk for developing postoperative acute respiratory distress syndrome (ARDS) or acute lung injury (ALI). Based on this recent data, the use of low tidal volumes and inflation pressures during OLV is appropriate as long as high breathing frequencies are not required and permissive hypercapnia is not contraindicated. With appropriate use of pressure and tidal volume alarms, either pressure- or volume-controlled ventilation may be used. Intrinsic positive end-expiratory pressure (PEEP) is common with OLV (utilizing a double-lumen endotracheal tube), and caution is warranted when high respiratory rates (short exhalation times) are utilized.
The addition of external PEEP does not consistently improve oxygenation and has not been shown to reduce the incidence of VILI.
A lung-opening procedure (LOP) utilizing several breaths of high inspiratory and expiratory pressures may improve oxygenation, but the hemodynamic consequences of the maneuver must be considered. While no evidence-based specific recommendations can be made for OLV, the growing body of OLV research does help the anesthesiologist select the best strategy for an individual patient and surgery.
Recognition of Denham S. Ward, MD, author of the first edition chapter and on whose work this edit is based.
Access this chapter
Tax calculation will be finalised at checkout
Purchases are for personal use only
References
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;121:302–18.
Slinger PD. Postpneumonectomy pulmonary edema: good news, bad news. Anesthesiology. 2006;105:2–5.
Zeldin RA, Normandin D, Landtwing D, Peters RM. Postpneumonectomy pulmonary edema. J Thorac Cardiovasc Surg. 1984;87:359–65.
Fernández-Pérez 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.
Gothard J. Lung injury after thoracic surgery and one-lung ventilation. Curr Opin Anaesthesiol. 2006;19:5–10.
Baudouin SV. Lung injury after thoracotomy. Br J Anaesth. 2003;91:132–42.
Williams EA, Evans TW, Goldstraw P. Acute lung injury following lung resection: is one lung anaesthesia to blame? Thorax. 1996;51:114–6.
Gao L, Barnes KC. Recent advances in genetic predisposition to clinical acute lung injury. Am J Physiol Lung Cell Mol Physiol. 2009;296:L713–25.
Licker M, de Perrot M, Spiliopoulos A, et al. Risk factors for acute lung injury after thoracic surgery for lung cancer. Anesth Analg. 2003;97:1558–65.
Jeon K, Yoon JW, Suh GY, et al. Risk factors for post-pneumonectomy acute lung injury/acute respiratory distress syndrome in primary lung cancer patients. Anaesth Intensive Care. 2009;37:14–9.
Liu Z, Liu X, Huang Y, Zhao J. Intraoperative mechanical ventilation strategies in patients undergoing one-lung ventilation: a meta-analysis. Springerplus. 2016;5:1251.
Gulder A, Kiss T, Serpa Neto T, Hemmes SN, Canet j SPM, Rocco PR, Schultz MJ, Pelosi P, Gama de Abreu M. Intraoperative protective mechanical ventilation for prevention of postoperative pulmonary complications: A comprehensive review of the role of tidal volume, positive end-expiratory pressure, and lung recruitment maneuvers. Anesthesiology. 2015;123(3):692–713.
Blank RS, Colquhoun DA, Durieux ME, Kozower BD, McMurray TL, Bender SP, Naik BI. Management of one-lung ventilation: impact of tidal volume on complications after thoracic surgery. Anesthesiology. 2016;124(6):1286–129.
Brassard CL, Lohser J, Donati F, Bussieres JS. Step by step clinical management of one-lung ventilation: continuing professional development. Can J Anaesth. 2014;61:1103–21.
Licker M, Diaper J, Villiger Y, et al. Impact of intraoperative lung-protective interventions in patients undergoing lung cancer surgery. Crit Care. 2009;13:R41.
Lumb AB. Nunn’s applied respiratory physiology. 8th ed. Edinburgh, New York: Elsevier; 2017
Brodsky JB, Lemmens HJ. Left double-lumen tubes: clinical experience with 1,170 patients. J Cardiothorac Vasc Anesth. 2003;17:289–98.
Karzai W, Schwarzkopf K. Hypoxemia during one-lung ventilation: prediction, prevention, and treatment. Anesthesiology. 2009;110:1402–11.
Hedenstierna G, Tokics L, Strandberg A, Lundquist H, Brismar B. Correlation of gas exchange impairment to development of atelectasis during anaesthesia and muscle paralysis. Acta Anaesthesiol Scand. 1986;30:183–91.
Larsson A, Malmkvist G, Werner O. Variations in lung volume and compliance during pulmonary surgery. Br J Anaesth. 1987;59:585–91.
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.
Levin AI, Coetzee JF. Arterial oxygenation during one-lung anesthesia. Anesth Analg. 2005;100:12–4.
Levin AI, Coetzee JF, Coetzee A. Arterial oxygenation and one-lung anesthesia. Curr Opin Anaesthesiol. 2008;21:28–36.
Takala J. Hypoxemia due to increased venous admixture: influence of cardiac output on oxygenation. Intensive Care Med. 2007;33:908–11.
Nagendran J, Stewart K, Hoskinson M, Archer SL. An anesthesiologist’s guide to hypoxic pulmonary vasoconstriction: implications for managing single-lung anesthesia and atelectasis. Curr Opin Anaesthesiol. 2006;19:34–43.
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.
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.
Maeda Y, Fujino Y, Uchiyama A, Matsuura N, Mashimo T, Nishimura M. Effects of peak inspiratory flow on development of ventilator-induced lung injury in rabbits. Anesthesiology. 2004;101:722–8.
Uhlig S. Ventilation-induced lung injury and mechanotransduction: stretching it too far? Am J Physiol Lung Cell Mol Physiol. 2002;282:L892–6.
Prella M, Feihl F, Domenighetti G. Effects of short-term pressure-controlled ventilation on gas exchange, airway pressures, and gas distribution in patients with acute lung injury/ARDS: comparison with volume-controlled ventilation. Chest. 2002;122:1382–8.
Davis K Jr, Branson RD, Campbell RS, Porembka DT. Comparison of volume control and pressure control ventilation: is flow waveform the difference? J Trauma. 1996;41:808–14.
Campbell RS, Davis BR. Pressure-controlled versus volume-controlled ventilation: does it matter? Respir Care. 2002;47:416–24.
Cadi P, Guenoun T, Journois D, Chevallier JM, Diehl JL, Safran D. Pressure-controlled ventilation improves oxygenation during laparoscopic obesity surgery compared with volume-controlled ventilation. Br J Anaesth. 2008;100:709–16.
Balick-Weber CC, Nicolas P, Hedreville-Montout M, Blanchet P, Stéphan F. Respiratory and haemodynamic effects of volume-controlled vs. pressure-controlled ventilation during laparoscopy: a cross-over study with echocardiographic assessment. Br J Anaesth. 2007;99:429–35.
Heimberg C, Winterhalter M, Strüber M, Piepenbrock S, Bund M. Pressure-controlled versus volume-controlled one-lung ventilation for MIDCAB. Thorac Cardiovasc Surg. 2006;54:516–20.
Unzueta MC, Casas JI, Moral MV. Pressure-controlled versus volume-controlled ventilation during one-lung ventilation for thoracic surgery. Anesth Analg. 2007;104:1029–33.
Choi YS, Shim JK, Na S, Hong SB, Hong YW, Oh YJ. Pressure-controlled versus volume-controlled ventilation during one-lung ventilation in the prone position for robot-assisted esophagectomy. Surg Endosc. 2009;23:2286–91.
Tugrul M, Çamci E, Karadeniz H, Sentürk M, Pembeci K, Akpir K. Comparison of volume controlled with pressure controlled ventilation during one-lung anaesthesia. Br J Anaesth. 1997;79:306–10.
Bardoczky GI, d’Hollander AA, Rocmans P, Estenne M, Yernault JC. Respiratory mechanics and gas exchange during one-lung ventilation for thoracic surgery: the effects of end-inspiratory pause in stable COPD patients. J Cardiothorac Vasc Anesth. 1998;12:137–41.
Malhotra A. Low-tidal-volume ventilation in the acute respiratory distress syndrome. N Engl J Med. 2007;357:1113–20.
Petrucci N, Iacovelli W. Lung protective ventilation strategy for the acute respiratory distress syndrome. Cochrane Database Syst Rev. 2007;(2):CD003844.
The Acute Respiratory Distress Syndrome Network. 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.
Putensen C, Theuerkauf N, Zinserling J, Wrigge H, Pelosi P. Meta-analysis: ventilation strategies and outcomes of the acute respiratory distress syndrome and acute lung injury. Ann Intern Med. 2009;151:566–76.
Tobin MJ. Advances in mechanical ventilation. N Engl J Med. 2001;344:1986–96.
Mols G, Priebe HJ, Guttmann J. Alveolar recruitment in acute lung injury. Br J Anaesth. 2006;96:156–66.
Morisaki H, Serita R, Innami Y, Kotake Y, Takeda J. Permissive hypercapnia during thoracic anaesthesia. Acta Anaesthesiol Scand. 1999;43:845–9.
Sticher J, Müller M, Scholz S, Schindler E, Hempelmann G. Controlled hypercapnia during one-lung ventilation in patients undergoing pulmonary resection. Acta Anaesthesiol Scand. 2001;45:842–7.
Broccard AFM. Respiratory acidosis and acute respiratory distress syndrome: time to trade in a bull market? Crit Care Med. 2006;34:229–31.
Vaneker M, Heunks LM, Joosten LA, et al. Mechanical ventilation induces a toll/interleukin-1 receptor domain-containing adapter-inducing interferon beta-dependent inflammatory response in healthy mice. Anesthesiology. 2009;111:836–43.
Curley GF, Kevin LG, Laffey JG. Mechanical ventilation: taking its toll on the lung. Anesthesiology. 2009;111:701–3.
Dos Santos CC, Slutsky AS. Invited review: mechanisms of ventilator-induced lung injury: a perspective. J Appl Physiol. 2000;89:1645–55.
Hager DN, Krishnan JA, Hayden DL, Brower RG. Tidal volume reduction in patients with acute lung injury when plateau pressures are not high. Am J Respir Crit Care Med. 2005;172:1241–5.53.
Hemmes SN, Gamma de Abreu M, Pelosi P, Schultz MJ. High versus low positive end-expiratory pressure during general anesthesia for open abdominal surgery (PROVHILO trial): a multicenter randomized controlled trial. Lancet. 2014;384:495–503.
Ferrando C, Belda FJ. Personalized intraoperative positive end-expiratory pressure: a further step in protective ventilation. Minerva Anestesiol. 2018;84(2):147–9.
Predicted Body Weight Calculator. http://www.ardsnet.org/node/77460. Accessed 18 Dec 2009.
Tandon S, Batchelor A, Bullock R, et al. Peri-operative risk factors for acute lung injury after elective oesophagectomy. Br J Anaesth. 2001;86:633–8.
Kutlu CA, Williams EA, Evans TW, Pastorino U, Goldstraw P. Acute lung injury and acute respiratory distress syndrome after pulmonary resection. Ann Thorac Surg. 2000;69:376–80.
Lytle FT, Brown DR. Appropriate ventilatory settings for thoracic surgery: intraoperative and postoperative. Semin Cardiothorac Vasc Anesth. 2008;12:97–108.
Slinger P. Pro: low tidal volume is indicated during one-lung ventilation. Anesth Analg. 2006;103:268–70.
Gal TJ. Con: low tidal volumes are indicated during one-lung ventilation. Anesth Analg. 2006;103:271–3.
Levin MA, McCormick PJ, Lin HM, Hosseinian L, Fischer GW. Low intraoperative tidal volume ventilation with minimal PEEP is associated with increased mortality. Br J Anaesth. 2014;113(1):97–108.
Duggan M, Kavanagh BP. Pulmonary atelectasis: a pathogenic perioperative entity. Anesthesiology. 2005;102:838–54.
Michelet P, D’Journo XB, Roch A, et al. Protective ventilation influences systemic inflammation after esophagectomy: a randomized controlled study. Anesthesiology. 2006;105:911–9.
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.
Wrigge H, Uhlig U, Zinserling J, et al. The effects of different ventilatory settings on pulmonary and systemic inflammatory responses during major surgery. Anesth Analg. 2004;98:775–81.
Shaw AD, Vaporciyan AA, Wu X, et al. Inflammatory gene polymorphisms influence risk of postoperative morbidity after lung resection. Ann Thorac Surg. 2005;79:1704–10.
Tekinbas C, Ulusoy H, Yulug E, et al. One-lung ventilation: for how long? J Thorac Cardiovasc Surg. 2007;134:405–10.
Misthos P, Katsaragakis S, Milingos N, et al. Postresectional pulmonary oxidative stress in lung cancer patients. The role of one-lung ventilation. Eur J Cardiothorac Surg. 2005;27:379–82.
Cheng YJ, Chan KC, Chien CT, Sun WZ, Lin CJ. Oxidative stress during 1-lung ventilation. J Thorac Cardiovasc Surg. 2006;132:513–8.
Gajic O, Dara SI, Mendez JL, et al. Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation. Crit Care Med. 2004;32:1817–24.
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:RA22–6.
Bonetto C, Terragni P, Ranieri VM. Does high tidal volume generate ALI/ARDS in healthy lungs? Intensive Care Med. 2005;31:893–5.
Slinger PD, Hickey DR. The interaction between applied PEEP and auto-PEEP during one-lung ventilation. J Cardiothorac Vasc Anesth. 1998;12:133–6.
Levy MM. PEEP in ARDS – how much is enough? N Engl J Med. 2004;351:389–91.
Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med. 2004;351:327–36.
Meade MO, Cook DJ, Guyatt GH, et al. Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008;299:637–45.
Mercat A, Richard JC, Vielle B, et al. Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial. JAMA. 2008;299:646–55.
Gattinoni L, Caironi P. Refining ventilatory treatment for acute lung injury and acute respiratory distress syndrome. JAMA. 2008;299:691–3.
Ducros L, Moutafis M, Castelain MH, Liu N, Fischler M. Pulmonary air trapping during two-lung and one-lung ventilation. J Cardiothorac Vasc Anesth. 1999;13:35–9.
Yokota K, Toriumi T, Sari A, Endou S, Mihira M. Auto-positive end-expiratory pressure during one-lung ventilation using a double-lumen endobronchial tube. Anesth Analg. 1996;82:1007–10.
Bardoczky GI, Yernault JC, Engelman EE, Velghe CE, Cappello M, Hollander AA. Intrinsic positive end-expiratory pressure during one-lung ventilation for thoracic surgery. The influence of preoperative pulmonary function. Chest. 1996;110:180–4.
Blanch L, Bernabé F, Lucangelo U. Measurement of air trapping, intrinsic positive end-expiratory pressure, and dynamic hyperinflation in mechanically ventilated patients. Respir Care. 2005;50:110–23.
Bardoczky GI, d’Hollander AA, Cappello M, Yernault JC. Interrupted expiratory flow on automatically constructed flow-volume curves may determine the presence of intrinsic positive end-expiratory pressure during one-lung ventilation. Anesth Analg. 1998;86:880–4.
Benumof JL. One-lung ventilation: which lung should be PEEPed? Anesthesiology. 1982;56:161–3.
Mascotto G, Bizzarri M, Messina M, 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.
Leong LM, Chatterjee S, Gao F. The effect of positive end expiratory pressure on the respiratory profile during one-lung ventilation for thoracotomy. Anaesthesia. 2007;62:23–6.
Cohen E, Eisenkraft JB. Positive end-expiratory pressure during one-lung ventilation improves oxygenation in patients with low arterial oxygen tensions. J Cardiothorac Vasc Anesth. 1996;10:578–82.
Valenza F, Ronzoni G, Perrone L, et al. Positive end-expiratory pressure applied to the dependent lung during one-lung ventilation improves oxygenation and respiratory mechanics in patients with high FEV1. Eur J Anaesthesiol. 2004;21:938–43.
Inomata S, Nishikawa T, Saito S, Kihara S. “Best” PEEP during one-lung ventilation. Br J Anaesth. 1997;78:754–6.
Lachmann B. Open up the lung and keep the lung open. Intensive Care Med. 1992;18:319–21.
Lapinsky SE, Mehta S. Bench-to-bedside review: recruitment and recruiting maneuvers. Crit Care. 2005;9:60–5.
Tusman G, Böhm 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.
Cinnella G, Grasso S, Natale C, et al. Physiological effects of a lung-recruiting strategy applied during one-lung ventilation. Acta Anaesthesiol Scand. 2008;52:766–75.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Clinical Case Discussion
Clinical Case Discussion
A 72-year-old woman, with weight = 98 kg, height = 168 cm (BMI = 34.7, PBW = 60.3 kg), and a 43 pack-year smoking history (stopped smoking 2 weeks ago), presents for left upper lobectomy for small cell carcinoma via a left VATS. Past medical history includes hypertension, type 2 DM, and obstructive sleep apnea (CPAP at 10 cm H2O nightly).
Preoperative pulmonary function testing showed:
-
FVC = 2.82 L (57% predicted).
-
FEV1 = 1.58 (42% predicted).
-
FEV1/FVC = 56%.
-
DLCO = 23.9 mL/min/mmHg (79% predicted).
A left 37 French DLT was placed without difficulty, and its correct position was confirmed via fiber-optic bronchoscopy. Two-lung ventilation was initiated, while the patient was supine with VCV incorporating a 10% end-inspiratory pause with a tidal volume of 550 mL and a rate of 10 breaths/min. Peak airway pressures were 22 cm H2O and the PETCO2 was 45 mmHg. SpO2 = 98% on 100% oxygen.
-
(a)
What mode of ventilation and inspiratory gas concentration would you use for initiating OLV? What tidal volume would you use?
Either PCV or VCV would be acceptable. Initial tidal volume should be set based on the PBW, typically at 4–6 mL/kg. 6 mL/kg × 60.3 kg PBW = 361 mL, so initial tidal volume should be reduced and the OLV peak and plateau pressures noted.
-
(b)
After setting the tidal volume to 361 mL with a rate of 14 and 0 end-expiratory pressure (ZEEP), the peak inspiratory pressure is 28 cm H2O, and the PETCO2 is 49 mmHg. Is any further adjustment of the ventilator required? Would other clinical measurements be useful?
With the peak inspiratory pressure less than 30 mmHg (presumable if VCV is being used, the plateau pressure, which is more reflective of the alveolar distending pressure, will be less than the peak) and the end-tidal CO2 at an acceptable level, no further adjustments are needed. Initially observing the end-tidal CO2 (PETCO2) can guide the respiratory rate setting, but a blood gas would be helpful because the increased alveolar dead space associated with this patient’s COPD may result in a significant arterial to end-tidal gradient.
-
(c)
What would your recommendation for PEEP be after making these adjustments?
At low tidal volumes and in patients with ALI, PEEP may help reduce the opening and closing of atelectatic regions of the lung, improving oxygenation and possibly prevent further lung injury. However, a high PEEP may also reduce oxygenation during OLV by forcing more blood flow to the unventilated lung. PEEP up to 5 cm H2O may be used but higher levels should be instituted cautiously.
-
(d)
Thirty minutes after the start of OLV, SpO2 falls to 88%. What maneuvers could be employed to stabilize the SpO2?
Whenever there is an acute decrease in the SpO2, after increasing the FiO2, the position of the DLT must be carefully checked with a fiber-optic bronchoscopy. In this case entry of the left bronchial lumen into the left lower lobe orifice could result in the tracheal opening of the DLT to abut the carina and result in a decrease in right lung ventilation.
A lung opening procedure (LOP) with a few breaths of high PEEP and inspiratory pressure may also be of benefit, but caution must be exercised if there is any indication of hemodynamic instability.
If hypoxemia still persists after optimal positioning of the DLT and a LOP, then CPAP to the unventilated lung is the most reliable way of decreasing the venous admixture; however, this is unlikely to provide acceptable operating conditions for a VATS. Switching to PCV or increasing the end-inspiratory pause with VCV may be useful. With a large DLT and a respiratory rate of only 14, significant intrinsic PEEP is unlikely, but a reduction in the inspiratory rate (with perhaps an increase in the tidal volume) can be tried.
A blood gas should be obtained and the surgeon notified that it may be necessary to return to two-lung ventilation intermittently if the saturation falls any lower. Since a low cardiac output will cause hypoxemia during OLV, interventions to increase the cardiac output may be of value.
Rights and permissions
Copyright information
© 2019 Springer Nature Switzerland AG
About this chapter
Cite this chapter
Macpherson, J.A. (2019). Intraoperative Ventilation Strategies for Thoracic Surgery. In: Slinger, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-00859-8_22
Download citation
DOI: https://doi.org/10.1007/978-3-030-00859-8_22
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-030-00858-1
Online ISBN: 978-3-030-00859-8
eBook Packages: MedicineMedicine (R0)