Open Lung in Lateral Decubitus With Differential Selective Positive End-Expiratory Pressure in an Experimental Model of Early Acute Respiratory Distress Syndrome*

Borges, João Batista; Şentürk, Mert; Ahlgren, Oskar; Hedenstierna, Göran; Larsson, Anders

doi:10.1097/ccm.0000000000001143

Cited by 9 publications

(5 citation statements)

References 53 publications

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“…An increasing amount of data in literature suggests that driving pressure is a predictor of mortality in ARDS patients [ 44 , 45 ], and a key mediator of the effects of various ventilatory interventions [ 5 , 6 , 15 ]. ΔP is the tidal change in static trans-respiratory pressure, measured as P PlatRS -PEEP tot , in response to a volume-controlled breath and expresses the ratio between Vt and respiratory system compliance Vt/C RS [ 45 ].…”

Section: Discussionmentioning

confidence: 99%

“…During one-lung ventilation (OLV) in the lateral decubitus position for thoracic surgery, hypoxemia may occur in almost 10% of patients [ 1 – 3 ], due to the total collapse of the non-dependent lung and, eventually, to atelectasis in the ventilated, dependent lung [ 4 , 5 ]. We recently demonstrated [ 6 ] that a recruitment strategy applied to the dependent lung followed by a moderate PEEP level results in significant alveolar recruitment, increased arterial oxygenation and reduction of the respiratory system elastance (E RS ), without hemodynamic impairment.…”

Section: Introductionmentioning

confidence: 99%

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Peep titration based on the open lung approach during one lung ventilation in thoracic surgery: a physiological study

et al. 2018

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BackgroundDuring thoracic surgery in lateral decubitus, one lung ventilation (OLV) may impair respiratory mechanics and gas exchange. We tested a strategy based on an open lung approach (OLA) consisting in lung recruitment immediately followed by a decremental positive-end expiratory pressure (PEEP) titration to the best respiratory system compliance (CRS) and separately quantified the elastic properties of the lung and the chest wall. Our hypothesis was that this approach would improve gas exchange. Further, we were interested in documenting the impact of the OLA on partitioned respiratory system mechanics.MethodsIn thirteen patients undergoing upper left lobectomy we studied lung and chest wall mechanics, transpulmonary pressure (PL), respiratory system and transpulmonary driving pressure (ΔPRS and ΔPL), gas exchange and hemodynamics at two time-points (a) during OLV at zero end-expiratory pressure (OLVpre-OLA) and (b) after the application of the open-lung strategy (OLVpost-OLA).ResultsThe external PEEP selected through the OLA was 6 ± 0.8 cmH2O. As compared to OLVpre-OLA, the PaO2/FiO2 ratio went from 205 ± 73 to 313 ± 86 (p = .05) and CL increased from 56 ± 18 ml/cmH2O to 71 ± 12 ml/cmH2O (p = .0013), without changes in CCW.Both ΔPRS and ΔPL decreased from 9.2 ± 0.4 cmH2O to 6.8 ± 0.6 cmH2O and from 8.1 ± 0.5 cmH2O to 5.7 ± 0.5 cmH2O, (p = .001 and p = .015 vs OLVpre-OLA), respectively. Hemodynamic parameters remained stable throughout the study period.ConclusionsIn our patients, the OLA strategy performed during OLV improved oxygenation and increased CL and had no clinically significant hemodynamic effects. Although our study was not specifically designed to study ΔPRS and ΔPL, we observed a parallel reduction of both after the OLA.Trial registrationTRN: ClinicalTrials.gov, NCT03435523, retrospectively registered, Feb 14 2018.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Peep titration based on the open lung approach during one lung ventilation in thoracic surgery: a physiological study

et al. 2018

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“…Ventilating independently different parts of the lung with different pressures may help force the air into atalectatic parts, reduce V/Q mismatch and improve oxygenation [14, 15]. This theory is supported by experimental models [7, 12]. Clinical trials showed a similar beneficial effect of DLV in patients in intensive care units [16–18] and during open thoracic surgery [9, 19].…”

Section: Discussionmentioning

confidence: 99%

“…The purpose of this study is to compare ventilation modalities during OLV, which may improve oxygenation with minimal impairment of the surgical field conditions. In this study, the non-dependent lung was ventilated alternately, in crossover fashion, by CPAP and by a portable ventilator with low rate and pressure in a DLV technique [7–9]. We anticipated that a low ventilation rate and pressure would produce the least interference with the surgeon’s exposure and, at the same time, improve oxygenation.…”

Section: Introductionmentioning

confidence: 99%

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

Kremer

Aboud

Haberfeld

et al. 2019

J Cardiothorac Surg

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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).

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“…This is hardly possible in a supine or prone patient but the lateral position may enable separation of upper and lower lung regions since the non-dependent and the dependent lungs can be ventilated separately with a double lumen endobronchial catheter. Considerable improvement of gas exchange and morphology by reducing or eliminating atelectasis with no over-distention of other lung regions has been achieved both in animal experiments and in clinical studies (14,15 In order to limit over-distension of lung regions, a low tidal volume should be applied so that the driving pressure is kept as low as possible. Techniques to apply airway pressures individually in proportion to regional lung mechanical properties would allow more homogeneous aeration and distribution of ventilation and blood flow.…”

Section: Mert şEntürk Editormentioning

confidence: 99%

Optimum PEEP During Anesthesia and in Intensive Care is a Compromise but is Better than Nothing

Hedenstierna¹

2016

Turk J Anaesth Reanim

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Open Lung in Lateral Decubitus With Differential Selective Positive End-Expiratory Pressure in an Experimental Model of Early Acute Respiratory Distress Syndrome*

Cited by 9 publications

References 53 publications

Peep titration based on the open lung approach during one lung ventilation in thoracic surgery: a physiological study

Peep titration based on the open lung approach during one lung ventilation in thoracic surgery: a physiological study

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

Optimum PEEP During Anesthesia and in Intensive Care is a Compromise but is Better than Nothing

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