nach oben

Current Anesthesiology Reports

Erschienen in:

24.10.2019 | Thoracic Anesthesia (T Schilling, Section Editor)

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

verfasst von: Taner Abdullah, Mert Şentürk

Erschienen in: Current Anesthesiology Reports | Ausgabe 4/2019

Einloggen, um Zugang zu erhalten

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.

Fischer GW, Cohen E. An update on anesthesia for thoracoscopic surgery. Curr Opin Anaesthesiol. 2010;23:7–11.PubMed

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

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

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

Karzai W, Schwarzkopf K. Hypoxemia during one-lung ventilation. Anesthesiology. 2009;110:1402.PubMed

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.

• Miskovic A, Lumb AB. Postoperative pulmonary complications. British Journal of Anaesthesia. 2017;118(3):317–34 A rational classification of an important problem. PubMed

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

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.

Titel: Positive End-Expiratory Pressure (PEEP), Tidal Volume, or Alveolar Recruitment: Which One Does Matter in One-Lung Ventilation?
verfasst von: Taner Abdullah
Mert Şentürk
Publikationsdatum: 24.10.2019
Verlag: Springer US
Erschienen in: Current Anesthesiology Reports / Ausgabe 4/2019
Elektronische ISSN: 2167-6275
DOI: https://doi.org/10.1007/s40140-019-00350-z

Neu im Fachgebiet AINS

24.04.2024 | DGIM 2024 | Kongressbericht | Nachrichten

Update AINS

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

hier abonnieren

Springer Medizin

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

Abstract

Purpose of Review

Recent Findings

Summary

Neu im Fachgebiet AINS

Magen-Darm-Blutungen werden präklinisch oft falsch eingeschätzt

Sepsis-Verdacht: Eine Stunde, fünf essenzielle Maßnahmen

Hinter dieser Appendizitis steckte ein Erreger

Ärztliche Empathie hilft gegen Rückenschmerzen

Update AINS

Springer Medizin

Abstract

Purpose of Review

Recent Findings

Summary

Bitte loggen Sie sich ein, um Zugang zu diesem Inhalt zu erhalten

Weitere Artikel der Ausgabe 4/2019

Experimental Data on the Pulmonary Effects of Remote Ischemic Preconditioning

The Role of Extracorporeal Life Support in Thoracic Surgery

Transversus Abdominis Plane (TAP) and Rectus Sheath Blocks: a Technical Description and Evidence Review

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

Perioperative Management of Delirium in Geriatric Patients

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

Neu im Fachgebiet AINS

Magen-Darm-Blutungen werden präklinisch oft falsch eingeschätzt

Sepsis-Verdacht: Eine Stunde, fünf essenzielle Maßnahmen

Hinter dieser Appendizitis steckte ein Erreger

Ärztliche Empathie hilft gegen Rückenschmerzen

Update AINS