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Anesthesiology:
doi: 10.1097/01.anes.0000268572.14940.73
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Protective Ventilation during One-lung Ventilation

Michelet, Pierre M.D.

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In Reply:—

I read with a great interest the comments formed by Dr. Şentürk about our article.1 As suggested by Dr. Şentürk, the occurrence of lung injury represents undoubtedly a second major of concern in association with the induced hypoxemia after thoracotomy and one-lung ventilation. Regarding one-lung ventilation–related hypoxemia, the approach retaining the same tidal volume (VT) as during two-lung ventilation was due to pulmonary derecruitment with lower VT 2 and overinflation after the adjunction of positive end-expiratory pressure (PEEP).3 In accord with recent studies,4,5 I believe that a protective ventilatory strategy during one-lung ventilation (reduced VT and moderate level of PEEP) could prevent overinflation (and related lung injury) and preserve alveolar recruitment in settings characterized by reduced lung volume (i.e., one-lung ventilation). Dr. Şentürk questions the interest of performing a further study comparing low versus high VT with PEEP in both groups. In regard to this issue, the debatable point is not the influence of VT alone but the interaction between PEEP and VT with the determination of their optimal combination. Indeed, studies of acute lung injury have clearly demonstrated that respective effects are interdependent with a progressive derecruitment with reduced VT counteracted by the adjunction of PEEP which ensures the best oxygenation.6,7 Moreover, if the most important factor in the development of ventilator-induced lung injury is the end-inspiratory lung volume,8,9 both high VT 10 and a high level of PEEP11 could be associated with oxygenation impairment related to a redistribution of pulmonary blood flow from overdistended lung units to the excluded lung or areas with low ventilation/perfusion ratio. Choi et al.4 recently reported the lack of difference between reduced VT (6 ml/kg) associated with a high level of PEEP (10 cm H2O) and a high level of VT alone (no PEEP) on oxygenation. This contrasts with the results of our study previously published using a protective ventilation strategy with similar VT (5 ml/kg) and lower PEEP level (5 cm H2O).1 One can argue whether this last combination is close to the best between these settings.
Pierre Michelet, M.D.
Hôpital Sainte Marguerite, Marseille, France. pierre.michelet@ap-hm.fr
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References

1. Michelet P, D'Journo X, Roch A, Doddoli C, Marin V, Papazian L, Decamps I, Bregeon F, Thomas P, Auffray J: Protective ventilation influences systemic inflammation after esophagectomy: A randomized controlled study. Anesthesiology 2006; 105:911–9

2. Schilling T, Kozian A, Huth C, Buhling F, Kretzschmar M, Welte T, Hachenberg T: The pulmonary immune effects of mechanical ventilation in patients undergoing thoracic surgery. Anesth Analg 2005; 101:957–65

3. Capan L, Turndorf H, Patel C, Ramanathan S, Acinapura A, Chalon J: Optimization of arterial oxygenation during one-lung anesthesia. Anesth Analg 1980; 59:847–51

4. Choi G, Wolthuis E, Bresser P, Levi M, van der Poll T, Dzoljic M, Vroom M, Schultz M: Mechanical ventilation with lower tidal volumes and positive end-expiratory pressure prevents alveolar coagulation in patients without lung injury. Anesthesiology 2006; 105:689–95

5. Gama de Abreu M, Heintz M, Heller A, Széchenyi R, Albrecht D, Koch T: One-lung ventilation with high tidal volumes and zero positive end-expiratory pressure is injurious in the isolated rabbit lung model. Anesth Analg 2003; 96:220–8

6. Ranieri V, Mascia L, Fiore T, Bruno F, Brienza A, Giuliani R: Cardiorespiratory effects of positive end-expiratory pressure during progressive tidal volume reduction (permissive hypercapnia) in patients with acute respiratory distress syndrome. Anesthesiology 1995; 83:710–20

7. Richard J, Brochard L, Vandelet P, Breton L, Maggiore S, Jonson B, Clabault K, Leroy J, Bonmarchand G: Respective effects of end-expiratory and end-inspiratory pressures on alveolar recruitment in acute lung injury. Crit Care Med 2003; 31:89–92

8. The Acute Respiratory Distress Syndrome Network: Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and acute respiratory distress syndrome N Engl J Med 2000; 342:1301–8

9. Dreyfuss D, Soler P, Basset G, Saumon G: High inflation pressure pulmonary edema: Respective effect of high airway pressure, high tidal volume and positive end-expiratory pressure. Am Rev Respir Dis 1988; 137:1159–64

10. Flacke J, Thompson D, Read R: Influence of tidal volume and pulmonary artery occlusion on arterial oxygenation during endobronchial anesthesia. South Med J 1976; 69:619–26

11. Michelet P, Roch A, Brousse D, D'Journo X, Bregeon F, Lambert D, Perrin G, Papazian L, Thomas P, Carpentier J, Auffray J: Effects of PEEP on oxygenation and respiratory mechanics during one-lung ventilation. Br J Anaesth 2005; 95:267–73

Cited By:

This article has been cited 2 time(s).

Journal of Cardiothoracic and Vascular Anesthesia
Effects of Ventilatory Mode During One-Lung Ventilation on Intraoperative and Postoperative Arterial Oxygenation in Thoracic Surgery
Pardos, PC; Garutti, I; Pineiro, P; Olmedilla, L; de la Gala, F
Journal of Cardiothoracic and Vascular Anesthesia, 23(6): 770-774.
10.1053/j.jvca.2009.06.002
CrossRef
Current Opinion in Anesthesiology
Update on one-lung ventilation: the use of continuous positive airway pressure ventilation and positive end-expiratory pressure ventilation – clinical application
Grichnik, KP; Shaw, A
Current Opinion in Anesthesiology, 22(1): 23-30.
10.1097/ACO.0b013e32831d7b41
PDF (171) | CrossRef
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