Differential lung ventilation for increased oxygenation during one lung ventilation for video assisted lung surgery

Abstract

Background One lung ventilation (OLV) is the technique used during lung resection surgery in order to facilitate optimal surgical conditions. OLV may result in hypoxemia due to the shunt created. Several techniques are used to overcome the hypoxemia, one of which is continuous positive airway pressure (CPAP) to the non-dependent lung. Another technique is ventilating the non-dependent lung with a minimal volume, thus creating differential lung ventilation (DLV). In this study we compared the efficacy of CPAP to DLV during video assisted thoracoscopic lung resection. Patients and method This is a prospective study of 30 adult patients undergoing elective video assisted thoracoscopic lung lobectomy. Each patient was ventilated in four modes: two lung ventilation, OLV, OLV + CPAP and OLV + DLV. Fifteen patients were ventilated with CPAP first and DLV next, and the other 15 were ventilated with DLV first and then CPAP. Five minutes separated each mode, during which the non-dependent lung was open to room air. We measured the patient’s arterial blood gas during each mode of ventilation. The surgeons, who were blinded to the ventilation technique, were asked to assess the surgical conditions at each stage. Results Oxygenation during OLV+ CPAP was significantly lower that OLV + DLV ( p = 0.018). There were insignificant alterations of pH, PCO2 and HCO3 during the different ventilating modes. The surgeons’ assessments of interference in the field exposure between OLV + CPAP or OLV + DLV was found to be insignificant ( p = 0.073). Conclusions During OLV, DLV is superior to CPAP in improving patient’s oxygenation, and may be used where CPAP failed. Trial registration ClinicalTrials.gov NCT03563612 . Registered 9 June 2018, retrospectively (due to clerical error).

Application of Continuous Positive Airway Pressure During Video-Assisted Thoracoscopic Surgery

“…It is a common conception that CPAP applied to the non-ventilated lung in OLV for VATS is likely to disrupt surgical visualization, to the extent that some experts consider CPAP on the non-ventilated lung contraindicated in VATS [ 29 , 30 ]. This belief may have also influenced the design of some studies that investigated the effectiveness of CPAP in VATS as the study designs avoided an alveolar recruitment maneuver prior to application of CPAP [ 31 , 32 ]. Evidence to support the negative effect of CPAP on surgical visualization is mixed: impediment of surgical exposure has been reported in some studies [ 32 ] and refuted in others [ 25 , 33 ].…”

“…Evidence to support the negative effect of CPAP on surgical visualization is mixed: impediment of surgical exposure has been reported in some studies [ 32 ] and refuted in others [ 25 , 33 ]. As an alternative to CPAP, some authors have reported effective interventions for hypoxemia during VATS, such as apneic oxygen insufflation of the non-ventilated lung [ 34 ], high frequency jet ventilation [ 33 ], differential ventilation of the non-ventilated lung [ 31 ], and selective lobar oxygen insufflation of the non-ventilated lung using the suction/insufflation channel of the fiberoptic bronchoscope [ 35 ]. A summary of selected studies investigating CPAP during OLV in VATS is shown in Table 1 .…”

Intraoperative Anesthetic Management of the Thoracic Patient

“…45 Recently, differential lung ventilation has been described whereby the operative lung is ventilated with minimal tidal volumes (TV). 46 If hypoxemia persists, two-lung ventilation should be restored to allow for fiber-optic assessment of the lung isolation device position and the presence of secretions. As a last resort, during open thoracotomy, the surgeon can clamp the pulmonary artery (PA) to the operative lung to reduce the shunt fraction and improve oxygenation.…”

Effects of bronchial blockers on gas exchange in infants with one-lung ventilation: a single-institutional experience of 22 cases

“…The key to the success of VATS is the maximization of intrathoracic visibility by optimizing the quality of the pulmonary isolation and deflation in a closed thoracic cavity. VATS typically includes lung deflation on the Original Article Effects of bronchial blockers on gas exchange in infants with onelung ventilation: a single-institutional experience of 22 cases surgical side, and one-lung ventilation (OLV) on the nonsurgical side (1)(2)(3)(4).…”