Protective Ventilatory Approaches to One-Lung Ventilation: More than Reduction of Tidal Volume

Abstract

The thoracic surgical patient is at special risk for increased postoperative pulmonary complications, such as atelectasis, impaired lung function and pneumonia, as well as acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) with high mortality after lung resections. One-lung ventilation (OLV) induces proinflammatory responses especially in the ventilated lung, based on mechanical stress, persistent hyperperfusion, increased gas content and ventilation to perfusion mismatching. ALI may occur, even in previously healthy lungs. Ventilation management can cause and exacerbate but also attenuate ALI after OLV. Protective ventilatory approaches can improve the outcome by minimizing lung damage. However, ventilation with lower tidal volumes during OLV does not completely abolish alveolar inflammation. The present review addresses the effects of OLV and their role in ventilator-induced lung injury. Lung protective strategies to one-lung ventilation that additionally include reduction of cyclic alveolar recruitment, PEEP ventilation, limitation of inspired oxygen and pharmacological preconditioning by volatile anesthetics are discussed.

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

“…On the other hand, the Italian and Japanese anesthesiologists tend to recommend a low tidal volume (4 to 6 ml/kg PBW) for OLV [1,22]. Nevertheless, opinions from the expert anesthesiologists highlight that protective ventilation in thoracic anesthesia is not simply synonymous of a low tidal volume, but also involves the appropriate application of PEEP, alveolar recruitment and other ventilatory settings during OLV [23,24]. Most recently, a double-blind, [21].…”

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

“…On the other hand, the Italian and Japanese anesthesiologists tend to recommend a low tidal volume (4 to 6 ml/kg PBW) for OLV [1,17]. Nevertheless, opinions from the expert anesthesiologists highlight that protective ventilation in thoracic anesthesia is not simply synonymous of a low tidal volume, but also involves the appropriate application of PEEP, alveolar recruitment and other ventilatory settings during OLV [18,19]. Most recently, a double-blind, randomized controlled trial conducted at the Samsung Medical Center (Seoul, Korea) demonstrated that driving pressure-guided ventilation (median ∆P of 9 cmH 2 O) during OLV significantly reduced the incidence of postoperative pulmonary complications compared with the conventional protective ventilation (tidal volume 6 ml/kg PBW, PEEP 5 cmH 2 O and recruitment) in thoracic surgery [20].…”

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

“…On the other hand, the Italian and Japanese anesthesiologists tend to recommend a lower tidal volume (≤6 ml/kg PBW) for OLV [1,22]. Nevertheless, opinions from the expert anesthesiologists highlight that protective ventilation in thoracic anesthesia is not simply synonymous of a low tidal volume, but also involves the appropriate application of PEEP, alveolar recruitment and other ventilatory settings during OLV [23,24]. Most recently, a double-blind, randomized controlled trial conducted at the Samsung Medical Center (Seoul, Korea) demonstrated that driving pressure-guided ventilation (median ∆P of 9 cmH 2 O) during OLV signi cantly reduced the incidence of postoperative pulmonary complications compared with the conventional protective ventilation (tidal volume 6 ml/kg PBW, PEEP 5 cmH 2 O and recruitment) in thoracic surgery [25].…”