The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy

Abstract

Patients undergoing lobectomy are at significantly increased risk of lung injury. One-lung ventilation is the most commonly used technique to maintain ventilation and oxygenation during the operation. It is a challenge to choose an appropriate mechanical ventilation strategy to minimize the lung injury and other adverse clinical outcomes. In order to understand the available evidence, a systematic review was conducted including the following topics: (I) protective ventilation (PV); (II) mode of mechanical ventilation [e.g., volume controlled (VCV) versus pressure controlled (PCV)]; (III) use of therapeutic hypercapnia; (IV) use of alveolar recruitment (open-lung) strategy; (V) pre-and post-operative application of positive end expiratory pressure (PEEP); (VI) Inspired Oxygen concentration; (VII) Non-intubated thoracoscopic lobectomy; and (VIII) adjuvant pharmacologic options. The recommendations of class II are non-intubated thoracoscopic lobectomy may be an alternative to conventional one-lung ventilation in selected patients. The recommendations of class IIa are: (I) Therapeutic hypercapnia to maintain a partial pressure of carbon dioxide at 50-70 mmHg is reasonable for patients undergoing pulmonary lobectomy with one-lung ventilation; (II) PV with a tidal volume of 6 mL/kg and PEEP of 5 cmHO are reasonable methods, based on current evidence; (III) alveolar recruitment [open lung ventilation (OLV)] may be beneficial in patients undergoing lobectomy with one-lung ventilation; (IV) PCV is recommended over VCV for patients undergoing lung resection; (V) pre- and post-operative CPAP can improve short-term oxygenation in patients undergoing lobectomy with one-lung ventilation; (VI) controlled mechanical ventilation with I:E ratio of 1:1 is reasonable in patients undergoing one-lung ventilation; (VII) use of lowest inspired oxygen concentration to maintain satisfactory arterial oxygen saturation is reasonable based on physiologic principles; (VIII) Adjuvant drugs such as nebulized budesonide, intravenous sivelestat and ulinastatin are reasonable and can be used to attenuate inflammatory response.

Extrakorporale Membranoxygenierung in der Thoraxchirurgie: die Sicht des Anästhesisten

“…Daher sollte auch für eine ELV eine protektive Beatmung angewandt werden. In einer aktuellen, auf 51 relevanten Arbeiten basierenden Practice Guideline werden folgende Elemente empfohlen [5]:…”

Single lung ventilation in patients undergoing lobectomy

“…Thirty-four patients in this study had complications. Based on the ESTS definitions, 20 patients had major complications, including atrial fibrillation [10], adult respiratory distress syndrome [1], pulmonary embolus [2], prolonged mechanical ventilation [1], pneumonia [3], and atelectasis requiring bronchoscopy [2]. Based on the TM&M system, 24 patients had major complications, including 3 deaths.…”

Mechanical ventilation during lobectomy: is this lung behaving as a “baby”?

“…One of the specific areas in need for standardization of care based on the best available evidence is that of mechanical ventilation. The clinical practice guidelines published in the current issue of the Journal of Thoracic Disease constitute a great attempt to provide this much needed guidance (2).…”

“…Reviewing the recommendations arising from the guidelines one cannot help but notice the similarities between the acute respiratory distress syndrome (ARDS) mechanical ventilation management recommendations and mechanical ventilation management recommendations in lobectomy patients (2,4). Both emphasize the importance of lung-protective ventilation with small tidal volumes as in both instances the portions of the lungs accessible for ventilation are smaller than normal.…”