A nationwide survey of intraoperative management for one-lung ventilation in Taiwan: time to accountable for diversity in protective lung ventilation

Abstract

Background There is a major paradigm shift for intraoperative mechanical ventilator support by the introduction of lung protective ventilation strategies to reduce postoperative pulmonary complications and improve overall clinical outcomes in non-thoracic surgeries. However, there is currently a lack of standardized practice guideline for lung protection during thoracic surgeries that require one-lung ventilation (OLV). This study aimed to collect the expert opinions of the thoracic anesthesiologists in perioperative care for OLV surgery in Taiwan. Methods This prospective cross-sectional study was undertaken in 16 tertiary hospitals in Taiwan from January to February 2019. A structured survey form was distributed across the participating hospitals and the thoracic anesthesiologists were invited to complete the form voluntarily. The survey form consisted of three parts, including the basic information of the institutional anesthesia care standards, ventilatory settings for a proposed patient receiving OLV surgery and expert opinions on OLV. Results A total of 71 thoracic anesthesiologists responded to the survey. Double-lumen tubes are the most commonly used (93.8%) airway devices for OLV. The most commonly recommended ventilator setting during OLV is a tidal volume of 6–7 ml/kg PBW (67.6%) and a PEEP level of 4–6 cmH2O (73.5%). Dual controlled ventilator modes are used by 44.1% of the anesthesiologists. During OLV, high oxygen fraction (FiO2 > 0.8) is more commonly supplemented to achieve an oxygen saturation higher than 94%. The consensus of anesthesiologists on the indices for lung protection in thoracic surgery is considerably low. Large majority of the anesthesiologists (91.5%) highly recommend that an international clinical practice guideline on the protective lung ventilation strategy for thoracic anesthesia should be established. Conclusions This study found that the thoracic anesthesiologists in Taiwan share certain common practices in ventilator support during OLV. However, they are concerned about the lack of fundamental clinical evidences to support the beneficial outcomes of the current lung protective strategies applicable to OLV. Large-scale trials are needed to form an evidence-based clinical practice guideline for thoracic anesthesia.

Awake nasotracheal intubation under bronchoscopic guidance and anesthetic management in a patient undergoing excision of an endotracheal mass

“…Fortunately, the patient underwent the one-lung ventilation uneventfully with clinically acceptable airway pressure (28 cmH 2 O). [18] There are several options and methods reported when intubation fails in patients with a tracheal mass (that we did not experience in our case). Saroa et al [19] reported a case of intraoperative airway maintenance in a patient with a lower tracheal mass using a microlaryngeal surgery tube.…”

“…Because the lower trachea was only 4 cm below the mass, the tip of the endotracheal tube (inner diameter of 6.5 mm) introduced through the lower trachea needed to be placed in the right main bronchus for proper placement of its cuff inside the airway. Fortunately, the patient underwent the one-lung ventilation uneventfully with clinically acceptable airway pressure (28 cmH 2 O) [18] …”

“…Fortunately, the patient underwent the one-lung ventilation uneventfully with clinically acceptable airway pressure (28 cmH 2 O). [ 18 ]…”

Proof-of-principle of a lung sealant based on functionalized polyoxazolines: experiments in an ovine acute aerostasis model

“…A higher BP was observed for the NHS-POx samples, without reaching statistical significance. However, 7/11 (64%) of sealed samples withstood pressures >30 cmH 2 O, which is clinically relevant as most anaesthesiologists attempt to limit ventilatory pressure to a maximum of 30 cmH 2 O [ 22 ]. During lung explantation for ex-situ measurements, blood contact of the control lesions was observed, which may have increased BP, while the manipulations might have damaged the sealants, lowering the BP.…”

Management of Intraoperative Mechanical Ventilation to Prevent Postoperative Complications after General Anesthesia: A Narrative Review

“…Ironically, the last setting discussed in this review is probably the first ventilator parameter changed in clinical practice both during anesthesia induction [ 76 ] and during intraoperative hypoxemia. In a recent nationwide surgery conducted in Taiwan, indeed, high oxygen fraction (FIO2 > 0.8) was the common intervention adopted when oxygen saturation fell below 94% [ 77 ]. Even so, the adequate level of intraoperative FIO 2 is usually neglected when discussing protective ventilation strategies.…”