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Correspondence  |   July 2007
Protective Ventilation during One-lung Ventilation
Author Notes
  • (Accepted for publication March 22, 2007.)
    (Accepted for publication March 22, 2007.)×
Article Information
Correspondence
Correspondence   |   July 2007
Protective Ventilation during One-lung Ventilation
Anesthesiology 7 2007, Vol.107, 176-177. doi:10.1097/01.anes.0000268569.01129.d6
Anesthesiology 7 2007, Vol.107, 176-177. doi:10.1097/01.anes.0000268569.01129.d6
To the Editor:—
I read with interest the report by Michelet et al.1  For many years, hypoxemia was considered as the most important—if not the only—problem during one-lung ventilation (OLV). Therefore, the guidelines are primarily aimed at preventing and treating the hypoxemia.2  Since Katz et al.3  found that large tidal volumes produced the highest arterial oxygen tension (Pao2) during OLV, one can find in these guidelines that the tidal volume during OLV should be kept as high as in two-lung ventilation (i.e., 8–10–12 ml/kg).
However, recent studies have shown that the lung injury after thoracotomy is also an important challenge in lung surgery, and the ventilatory setting (especially during OLV) is probably associated with this injury. So, a revision of the classic guidelines has been necessary.4  This article is indeed an important step in this revision after some in vitro5  and in vivo6  studies. However, in contrast to the current study, in the study of Schilling et al.,6  decreased tidal volumes were associated with a (statistically insignificant) decrease in Pao2 levels during OLV. This contrast may be a result of the fact that there was no positive end-expiratory pressure (PEEP) application in the control group in the current study. In several studies, it has been shown that PEEP was associated with an increase in oxygenation compared with zero end-expiratory pressure without any other change in ventilatory setting.7  So, PEEP should be considered as a prevention/treatment strategy both against hypoxemia and against lung injury. Furthermore, information about and comparison of the number of the patients in each group in whom the fraction of inspired oxygen has been increased to treat arterial hypoxemia would also be necessary.
Therefore, I agree with authors that a protective ventilation (lower tidal volumes and PEEP) during OLV can lead to a decrease in lung injury during OLV; however, to argue that this method is also associated with improved oxygenation, a further study comparing low and high tidal volumes (with PEEP in both groups) would be necessary.
Mert Şentürk, M.D. Istanbul University, Istanbul, Turkey. senturkm@istanbul.edu.tr
References
Michelet, P, D'Journo, XB, Roch, A, Doddoli, C, Marin, V, Papazian, L, Decamps, I, Bregeon, F, Thomas, P, Auffray, JP Anesthesiology. (2006). 105 911–9 [Article] [PubMed]
Benumof, JL Benumof, JL Conventional and differential lung management of one-lung ventilation, Anesthesia for Thoracic Surgery.. (1995). Philadelphia WB Saunders 406–31
Katz, JA, Laverne, RG, Fairley, HB, Thomas, AN Pulmonary oxygen exchange during endobronchial anesthesia: Effect of tidal volume and PEEP.. Anesthesiology. (1982). 56 164–71 [Article] [PubMed]
Şentürk, M New concepts of the management of one-lung ventilation.. Curr Opin Anaesthesiol. (2006). 19 1–4 [Article] [PubMed]
Gama de Abreu, M, Heintz, M, Heller, A, Szechenyi, R, Albrecht, DM, 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 [PubMed]
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 [Article] [PubMed]
Şentürk, NM, Dilek, A, Camci, E, Senturk, E, Orhan, M, Tugrul, M, Pembeci, K Effects of positive end-expiratory pressure on ventilatory and oxygenation parameters during pressure-controlled one-lung ventilation.. J Cardiothorac Vasc Anesth. (2005). 19 71–5 [Article] [PubMed]