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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, 177. doi:10.1097/01.anes.0000268572.14940.73
Anesthesiology 7 2007, Vol.107, 177. doi:10.1097/01.anes.0000268572.14940.73
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 VT2  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 VT10  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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