one lung ventilation · 2020. 3. 22. · one lung ventilation zogheib elie md anesthesia and...

ONE LUNG VENTILATION

ZOGHEIB Elie MDAnesthesia and Intensive Care Department

Cardio Thoracic and Vascular Intensive Care Unit

INSERM U1088

CHU Amiens – Picardie, France

[email protected]

Agenda

• Indications

• Hypoxic pulmonary vasoconstriction

• VILI and Protective ventilation

• Hypoxemia and OLV

• Devices for OLV

• OLV and anesthesia

• OLV and simulation

Indications

• Surgical procedures

Thoracic surgeries

• Lung resection procedures:

• Bullectomy

• Pneumonectomy

• Lobectomy

• Wedge resection

• Video-assisted thoracoscopic surgery (VATS)

• Decortication

• Diaphragmatic hernia repair (thoracic approach)

• Single-lung transplant post-operative complications

M.K. Ferguson, W.T. Vigneswaran / European Journal of Cardio-thoracic Surgery 33 (2008) 496—500

Cardiovascular surgery

• Minimally invasive cardiac surgeries:

• Valve repairs/replacements

• Aortic arch surgeries:

• Dissecting aneurysm of aortic arch

• Repair of pericardial window

• Pericardiectomy

Esophageal surgery

• Minimally invasive thoraco-laparoscopic

oesophagectomy.

Indications


• Non-thoracic surgeries

Non-thoracic surgeries

• Anterior fixation of the thoracic spine

Indications


• Non-thoracic surgeries

• Non-surgical indications

Non-surgical indications

• Pulmonary lavage

• Split/differential lung ventilation

• Unilateral lung haemorrhages

• Ventilation in bronchopleural fistulae

• Prevention of spillage from infective to the non-

infective lung

Effect of gravity: V/P

55 45

65

35

The lower lung is the most perfused

Relationship between ventilation and perfusion

Effect of lateral decubitus position

during the spontaneous ventilation

Pleural pressure is less negative on the dependent lung.

The lower lung is on a better part of the lung compliance curve.

of the compliance for both lungs.

The higher lung is on a better part of the lung compliance curve.

Effect of lateral decubitus position

during the mechanical ventilation

OLV

OLV

=

1 lung perfused and not ventilated

=

Shunt flow A-V +++

PaO2 (mmHg)

SaO2 (%)

100

SaO2 = 85 % PaO2 = 65 mmHg

20

40

60

80

100 200 300 400

QS .CvO2 (QS - QS ) .CcO2

QT .CaO2

QS/QT = 50 %

OLV and shunt

PaO2 and OLV

• Preoperative perfusion of the lung (scintigraphy)

PaO2 and OLV

• Preoperative perfusion of the lung

• Gravity

• Hypoxemic vasoconstriction of the non ventilated

lung

• Vascular resistance of the ventilated lung

Hypoxic pulmonary

vasoconstriction (HPV)

HPV reduces blood flow to poorly ventilated lung areas in an attempt to

improve ventilation/perfusion (V/Q) matching

Anesthesiology 2015; 122: 932-46

Figure 1. Homeostatic Oxygen-Sensing System

Specialized tissues that sense the local oxygen level are shown. The carotid body at the carotid-

artery bifurcation increases action-potential frequency in the carotid-sinus nerve in response

to hypoxia, thus stimulating respiration. The small resistance pulmonary and fetoplacental

arteries demonstrate hypoxic vasoconstriction, optimizing oxygen transfer in the lung and

placenta. The ductus arteriosus, by contrast, contracts when oxygen levels rise, redirecting

blood through the newly expanded lungs of the newborn. The neuroepithelial bodies in the

lungs and adrenomedullary cells in the fetus also sense oxygen.

Weir et al. Page 16

N Engl J Med. Author manuscript; available in PMC 2010 January 7.

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Acute Oxygen-Sensing Mechanisms

N Engl J Med. 2005 November 10; 353(19): 2042–2055









Weir et al. Page 16


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Acute Oxygen-Sensing Mechanisms:HYPOXIC PULMONARY VASOCONSTRICTION










Weir et al. Page 16


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Figure 4. Redox Mechanism for Oxygen Sensing in Specialized Tissues

Reactive oxygen species (ROS) from the mitochondria, NADPH oxidase, NADH oxidase, or

redox couples may control potassium-channel gating and membrane potential (E m) and thus

calcium entry. The same redox signaling may control calcium release from the sarcoplasmic

reticulum. The calcium stores in the sarcoplasmic reticulum, in turn, are repleted by calcium

entry through the store-operated channels. Rho kinase augments the response of actin–myosin

at any level of cytosolic calcium (Ca2+i). SOD denotes superoxide dismutase, H2O2 hydrogen

peroxide, GSH glutathione, and GSSG oxidized glutathione.

Weir et al. Page 19


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Acute Oxygen-Sensing Mechanisms:HYPOXIC PULMONARY VASOCONSTRICTION

Time course of HPV during OLV

-Ventilation has returned completely to its initial two-lung value

-Perfusion remains significantly less (*P < 0.01) than its initial two-lung value due to residual HPV.

Br J Anesth 2008; 100: 549-59

Shunt fraction and cardiac output

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

values, CaO2 is reduced because high VO2/Qt ratios

increase the value of the second term in Equation 5. With

increasing cardiac output, this ratio decreases, causing

CaO2 to increase steeply until the VO2/Qt ratio assumes

such small values that the second term in Equation 5

becomes negligible. T heoretically, CaO2 approaches

CcO2 asymptotically at high cardiac outputs. Plot B illus-

trates how the relationship shifts downwards if the shunt

fraction doubles to 0.4. Plot C shows how plot B moves

upwards and to the left if oxygen consumption is halved

but the other criteria used to construct plot B are

unchanged. Plot D demonstrates that, if Hb is reduced

from 15 to 10g/dl, curve A is shifted downwards.

T hese complex relationships are depicted by the three-

dimensional graphs (Fig. 4) that show how, at two differ-

ent hemoglobin concentrations, cardiac output and shunt

fraction both determine CaO2. T he curvilinear surfaces

result from the shape of the oxygen dissociation curve.

In view of the steep arterial –mitochondrial oxygen gra-

dient, an adequate arterial oxygen tension (PaO2) is

needed to maintain intra-mitochondrial oxygen tensions

above the minimum required for aerobic metabolism.

Figure 5 depicts the relationship between cardiac output

and PaO2. ComparingFigs4and 5, it isinteresting tonote

that decreasing Hb (plots A and D) does not (theoreti-

cally) have as great an influence on PaO2 as on CaO2.

T he graphs in Figs 2–5 serve the purpose of illustrating

physiologic theory. In reality, there are combinations of

shunt fraction and cardiac output that would result in

such low values for oxygen content, tension and delivery

that are incompatible with life. Furthermore, the model

assumes that changes in cardiac output do not lead to

changes in shunt fraction. T his assumption is not always

correct and the practical implications thereof will be

addressed.

Unfortunately, there have been few attempts to use a

systematic approach to oxygenation during OL A, and this

30 Thoracic anaesthesia

Figure 5 The influence of cardiac output on PaO2 as predictedby Equation 5

The values used to plot these relationships are at FiO2 of 0.5 and PaCO2

40 mmHg. The curves have similar conditions to those specified in Fig. 4.Construction of this relationship used a lookup table in Excel relatingCaO2 to saturation for a particular Hb and then using an oxygendissociation curve to relate saturation to PaO2.

Figure 4 Two views of a three-dimensional plot of the influence of changing both cardiac output and shunt fraction on arterial oxygencontent (CaO2) at hemoglobin concentrations of 8 and 12 g/ 100 ml blood as predicted by Equation 5

The values used to plot these relationships are at FiO2 of 0.5 and PaCO2 40 mmHg.

HPV affected by variations in cardiac output.

Curr Opin Anaesthesiol 2008 : 21:28–36

ALI and OLV

Anesth Analg 2003;97:1558 -65

Lung protective ventilation

N Engl J Med 2000;342:1301-8.


• In ARDS patients:

• Understanding of the pathophysiology of the ARDS

• Recognition of VILI

• Ventilatory management modification

• Since 2000: ARDSnet:

• 6ml/kg of PBW

• Plateau pressure: < 30cmH2O

• High respiratory rate

N Engl J Med 2000;342:1301-8.



• 6ml/kg of PBW

• Plateau pressure: < 30cmH2O decrease mortality from 39.8 to 31%

Lung protective ventilation - VILI


• Understanding of the pathophysiology of the ARDS

• Recognition of VILI

• Ventilatory management modification

• Since 2000: ARDSnet:

• 6ml/kg of PBW

• Plateau pressure: < 30cmH2O decrease mortality from 39.8 to

31%

Low-Tidal-Volume

VILI

• Low Vt

• High PEEP

• Less VILI

• Better outcome

• During surgery

• In OLV: unknown ??

The impact of tidal volume on pulmonary complications

following minimally invasive esophagectomy: a

randomized and controlled study

• 101 patients: left-lung ventilation during thoracoscopic

esophagectomy.

• Randomisation:

• low VT (5 mL/kg + 5 cm H2O PEEP): preserved

ventilation (PV) group (n = 53)

• conventional VT (8 mL/kg) controlled ventilation (CV)

group (n = 48)

J Thorac Cardiovasc Surg 2013 Nov;146(5):1267-73




After 18h PV CV p

IL-1b (pg/mL) 25.42 ± 31.01 94.96 ± 118.24 <0,05

IL-6 30.86 ± 75.78 92.99 ± 72.90 <0,05

IL-8 258.75 ± 188.24 403.95 ± 151.44 <0,05





After 18h PV CV p

IL-1b (pg/mL) 25.42 ± 31.01 94.96 ± 118.24 <0,05

IL-6 30.86 ± 75.78 92.99 ± 72.90 <0,05

IL-8 258.75 ± 188.24 403.95 ± 151.44 <0,05


-Pulmonary complications were observed in 18 cases:

on the ventilation side (right, 6 cases; and left, 12 cases).




After 18h PV CV p

IL-1b (pg/mL) 25.42 ± 31.01 94.96 ± 118.24 <0,05

IL-6 30.86 ± 75.78 92.99 ± 72.90 <0,05

IL-8 258.75 ± 188.24 403.95 ± 151.44 <0,05


-Pulmonary complications were observed in 18 cases:

on the ventilation side (right, 6 cases; and left, 12 cases).

-The occurrence of pulmonary complications in the PV group was lower than

that in the CV group (9.43% vs 27.08%; P = .021).

Intraoperative Tidal Volume as a Risk Factor for

Respiratory Failure after Pneumonectomy

• 170 eligible study patients.

• Underwent pneumonectomy.

• 30 (18%) postoperative respiratory failure.

Anesthesiology, V 105, No 1, Jul 2006: 14-18

Intraoperative Tidal Volume as a Risk Factor for

Respiratory Failure after Pneumonectomy

Anesthesiology, V 105, No 1, Jul 2006: 14-18

8,3 Vs 6,7 ml/kg OR 1,56 per ml/kg

N Engl J Med 2015;372:747-55.

Impact of Tidal Volume on Complications

after Thoracic Surgery

• Retrospective data collection.

• VT was calculated on the basis of actual body weight(ABW) and predicted body weight (PBW).

• The nonventilated lung can be considered to be at least partially collapsed

• Driving pressure (∆P) and static compliance (Cs) weredefined and calculated as follows:

• ∆P = Pplat − PEEP;

• Cs = VT /(Pplat − PEEP).

ANESTHESIOLOGY 2016; 124:00-00


after Thoracic Surgery



after Thoracic SurgeryPrimary outcome


Impact of Tidal Volume on Complications after

Thoracic SurgeryPrimary outcome


ΔP = VT

/CRS

(CRS

): respiratory-system compliance(VT

): tidal volumes


after Thoracic SurgerySecondary outcome


Impact of Tidal Volume on Complications after

Thoracic SurgerySecondary outcome


Independant risk factor of ALI

• Peak inspiratory pressure > 40 cm H2O

• Plateau pressure > 29 cm H2O

• Excessive perioperative fluid infusion

• Pneumonectomy

• Preoperative alcohol abuse

OLV and hypoxemia

OLV and hypoxemia

Hypoxémia = Sa02 < 95%

OLV and hypoxemia


Failure of lung isolation: mechanism for intraoperative hypoxemia.

OLV and hypoxemia


Failure of lung isolation: mechanism for intraoperative hypoxemia.

-DLT position

-Routine fibreoptic bronchoscopy

-Confirm initial placement of the lung isolation device.

Kinking of a Left-Sided Double-Lumen Tube Within the

TracheaDae-Kee Choi, MD, Jai-Hyun Hwang, MD, Myung-Hee Song, MD, and Kyung-Don Hahm,

MD

Journal of Cardiothoracic and Vascular Anesthesia, Vol 25, No 6 (December), 2011: pp 1119-1120

Hypoxemia and OLV

FiO20.3 0.4 0.5 0.6 0.7 0.8 0.9 1

1 510

1520

25

30

40

50

0.20

50

100

150

200

250

300

350

400

450PaO2

(mm Hg)

Nunn’s Iso-Shunt Curves

FiO2 is efficient if the shunt < 25 / 30%

OLV and per operative hypoxemia

• Inflate the superior

lung intermittently.

• Apply a continuous positive

airway pressure on

the tracheal tube with

PEEP between 3 and 5.

Selective lobar blockade

• Selective one-lobe ventilation

• Maintenance or improvement of arterial

oxygenation in patients who might not tolerate

complete lung collapse.

CPAP and blocker

-To decrease atelectasis

-Recruitment maneuver: carefull

-Risk if emphysema in the lower lung

OLV and per operative hypoxemia

Hypoxemia during one-lung

ventilation

Journal of Cardiothoracic and Vascular Anesthesia, Vol 23, No 6 (December), 2009: pp 850-852

Conf actualisation SFAR 2009

OLV and hypoxemia

• Pulmonary artery clamp

• Two lung ventilation

• Nitric oxide ?

• Almitrine

OLV – hypoxemia - NO

100

200

300

400

500

600

0 10' 20'

TEMPS (min)

VUP (et NO)

DDVBP

DLVBP

PaO2 (mmHg)

30'

NOTémoin

Anesth Analg 1997;85:1130-5

Anesth Analg 2002;94:830 -4

-Almitrine 8µ/kg/min.

Anesth Analg 2004;98:590 -4

18 patients

Almitrine

12 µ/kg/min (10 min)

then 4 µ/kg/min

Hyperinflation

6,14 cm² 9,74 cm²Under mechanical ventilation After ventilator deconnection

How to set up ventilator

• Vt 5-6 ml/kg IBW

• Low plateau pressure

• RR (12-13/min)

• PEP = 5 cm H20 (3-10 cm H2O)

• I/E à 1/3

• I:E ratio to 1:1-2:1 for restrictive lung disease.

• I:E ratio to 1:4-1:6 for obstructive lung disease to avoid intrinsic PEEP.

Positive end expiratory pressure during one-lung

ventilation: Selecting ideal patients and ventilator

settings with the aim of improving arterial oxygenation

Figure 1: PaO2 on OLV during PEEP0, PEEP5, and PEEP10. Average PaO2 values were as follows: PEEP 0 = 149 ± 80 mmHg, PEEP 5 = 144 ± 76 mmHg, PEEP 10 =

146 ± 78 mmHg. (a) PEEP responders (n = 12): increase in PaO2 of at least 20% from baseline. (b) Non-responders (n = 29): no increase in PaO2 of 20%, or a decrease

in PaO2.

Ann Card Anaesth. 2011 Sep-Dec;14(3):183-7. doi: 10.4103/0971-9784.83991.

How to set up ventilator

• Vt 5-6 ml/kg IBW

• Low plateau pressure

• RR (12-13/min)

• PEP = 5 cm H20 (3-10 cm H2O)

• I/E à 1/3

• I:E ratio to 1:1-2:1 for restrictive lung disease.

• I:E ratio to 1:4-1:6 for obstructive lung disease to avoid intrinsic PEEP.

Anatomy

Man 19 ± 6 mm

Woman 15 ± 5 mmMan 49 ± 8 mm

Woman 44 ± 7 mm

Double lumen tube

Fibre-optic view of tracheal and

bronchial carina

DLT size

• Small DLT: • So far threw the bronchius

• Over-inflation of the cuff with risks of bronchial or tracheal ischemia

• Increase of the hyperinflation

• Big size DLT• Proximal intubation: Herniated bronchial cuff in

the trachea

• Bronchial trauma

• Right bronchial trauma

DLT misplacement

Anesthesiology 2009; 110:1402–11

Right side DLT

Current Opinion in Anaesthesiology 2009, 22:4 - 10

Left side DLT


Double-lumen tracheal tubes

Carinal hook Without carinal hook

Right White Robertshaw

Left Carlens Bryce-Smith/

Size: 26 to 41F

DLT size

< 1,60 m 35 F

1,60 - 1,70 m 37 F

> 1,70 m 39 F

< 1,60 m 37 F

1,60 - 1,70 m 39 F

> 1,70 m 41 F

Women Man

Double lumen tube for tracheostomized patient

Tracheopart (Rüsch)

Arndt blocker

Arndt blocker with Cook's multi-port adapter


Arndt blocker

Cohen blocker

Univent blocker

EZ blocker

External Tracheal Manipulation Maneuver (ETMM) to Facilitate

Endobronchial Blocker Placement

Journal of Cardiothoracic and Vascular Anesthesia, Vol ], No ] (Month), 2016

• Easy recognition of anatomy if the tip of a single

tube is above carina.

• Best device for patients with difficult airways

• No cuff damage during intubation

• No need to replace a tube if mechanical ventilation

is needed / already intubated patient.

• Children OLV.

OLV and BlockerAdvantages

• Small channel for suctioning

• Conversion from 1 to 2 then to 1 lung ventilation

• High maintenance device (dislodgement or loss seal

during surgey.

OLV and BlockerDisadvantages

A Comparison of the Efficacy and Adverse Effects of Double-Lumen

Endobronchial Tubes and Bronchial Blockers in Thoracic Surgery:

A Systematic Review and Meta-analysis of Randomized Controlled Trials

• Malposition

JournalofCardiothoracicandVascularAnesthesia, Vol29,No4(August),2015:pp955–966




• Time to positionning





• Lung collapse


Video-Capable Double-Lumen Endotracheal

Tubes in Thoracic Surgery

Journal of Cardiothoracic and Vascular Anesthesia, Volume 28, Issue 4, 2014, 870–872

DOUBLE-LUMEN TUBE VIVASIGHT-DL

(DLT-ETVIEW)

Journal of Cardiothoracic and Vascular Anesthesia, Vol 29, No 6 (December), 2015: pp 1544–1549

DOUBLE-LUMEN TUBE VIVASIGHT-DL

(DLT-ETVIEW)

• Continuous visualization of the carina is a major improvement for patient.

• Intraoperative displacement is diagnosed immediatelyand corrected before any clinical effects.

• When FOB is not a routine procedure

• During robotic lobectomies because the anesthesiologist is placed far from the patient’s headand a continuous visualization of correct tube

Journal of Cardiothoracic and Vascular Anesthesia, Vol 29, No 6 (December), 2015: pp 1544–1549

Characteristics of Double-Lumen Tubes

Determine Bronchial Airway Pressure

Characteristics of Double-Lumen Tubes Determine Bronchial Airway Pressure. Journal of Cardiothoracic and Vascular Anesthesia, http://dx.doi.org/10.1053/j.jvca.2016.03.126

Evaluation of pH in removed double-lumen

tracheal tubes after general anesthesia:

A prospective observational study5

Journal of Cardiothoracic and Vascular Anesthesia, http://dx.doi.org/10.1053/j.jvca.2016.03.142

Evaluation of pH in removed double-lumen

tracheal tubes after general anesthesia:

A prospective observational study

5

-Low incidence of regurgitation of gastric fluid for well-prepared elective lung

surgery patient.

-No evidence of regurgitation in the stand care of patients using DLT for lung

isolation in the lateral position.

Journal of Cardiothoracic and Vascular Anesthesia, http://dx.doi.org/10.1053/j.jvca.2016.03.142

Relationship between V/P ventilation with surgical pneumothorax

Spontaneous inspiration Exhalation phase

Paradoxical ventilation and mediastinal shift

Ann Transl Med 2015;3(8):106

Spontaneous inspiration

Exhalation phase



-Excluded and not ventilated lung continues to be perfused.

-Right-left intrapulmonary shunt, condition that involves an

increased risk of intraoperative hypoxemia.

-HPV: pulmonary arteries of hypoxic alveoli constrict and

divert the blood flow to the arteries of well oxygenated alveoli.

-Simple oxygen administration through a Venturi mask can

easily correct a decrease in arterial oxygenation in an awake

patient undergoing surgical pneumothorax.

-Dependent lung has been shown to be able to compensate for

decrease in oxygenation


Spontaneous inspiration

Exhalation phase



-Air enters the pleural space through the surgical access on

the chest wall, and transmitted atmospheric pressure

determines the non-dependent lung collapse allowing an

adequate surgical access.

-Increase in the ratio between airways size and lung

volume, increases the expiratory flow and the speed of

pulmonary emptying.


Tracheal injury

Ann Fr Anesth Reanim 13:127-9, 1994

Traumatic rupture of the right bronchus

Effect of inhalation anesthesia vs Propofol

• General anesthesia during mechanical ventilation

can mediate several immune effects which may

affect postoperative outcomes.

Propofol Volatile anesthesia

Attenuate lung inflammations Immunomodulator in the patients

undergoing OLV

Protective effect on pulmonary

functionality

Reduction of inflammatory cytokines

Br J Anaesth 2007 ; 98 : 539-544



J Anesth (2015) 29:570–579

PropofolVolatile

OLV and Simulation

High-Fidelity Simulation of Lung Isolation With

Double-Lumen Endotracheal Tubes and Bronchial

Blockers in Anesthesiology Resident Training

Journal of Cardiothoracic and Vascular Anesthesia, Vol 28, No 4 (August), 2014: pp 865–869





Confidence Self-Rating by Anesthesiology Residents





Scores for Resident Performance During the Second Session

[email protected]

KFARDEBIAN

LEBANON

one lung ventilation · 2020. 3. 22. · one lung ventilation zogheib elie md anesthesia and...

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