OptimizingOne-Lung Ventilation

Philip Hartigan, M.D.11/25/11Kuwait

CO2

Injury

The Balancing Act ofOne-Lung Ventilation

O2

The essence of efficientgas exchange

is Ventilation –Perfusion

Matching

West.JB: Resp Physiology

Multiple Inert Gas Elimination Technique

West.JB: Resp Physiology

Multiple Inert Gas Elimination Technique

HPV

West.JB: Resp Physiology

Multiple Inert Gas Elimination Technique

HPV

Gravity

West.JB: Resp Physiology

Multiple Inert Gas Elimination Technique

HPV

Gravity

Anatomy

MIGET during OLV

HPV & Gravity

R/O Obstruction

CPAP

PEEPRecruit

Hypoxia During OLV

FiO2 = 1.0 R/O Obstruction/Malposition Reinflation Recruit/PEEP to Dependent

Lung CPAP to Nondependent Lung PA Crossclamp

Optimal PEEP ?

{

Beyond CPAP & PEEP ?

Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode

Beyond CPAP & PEEP ?

Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode

Choice of Agent & PaO2 during OLV

Pagel ‘98 (humans) Desfl = IsoflSchwarzkopf ‘03 (pigs) Desfl = IsoflWang ‘98 (humans) Isofl = SevoSaito ‘00 (humans) Isofl = SevoShimizu ‘98 (humans) Isofl = SevoAbe ‘98 (humans) Isofl = SevoSlinger ‘95 (humans) Isofl > Enfl

Beyond CPAP & PEEP ?

Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode

Dose of Volatile Agents and PaO2 during OLV

Schwarzkopf, Anesth Analg, 93:1434, 2001

Beyond CPAP & PEEP ?

Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode

TIVA vs Volatile Anesthesia

PaO2 during OLV

Reid ‘96 (30 Pts) Prop/Alf = IsoKarzai ‘98 (10 pigs) Prop > DesAbe ‘98 (20 Pts) Prop > Iso/DesBeck ‘01 (40 Pts) Prop = SevoDossow ‘01 (50 Pts) Prop/Fent > TEA/IsoSchwarzkopf ‘03 (30 pigs) Prop >Des/IsoPruszkowski ‘07 (80 Pts) Prop =SevoSchwarzkopf ‘09 (60 Pts) Prop =Sevo

PaCO2 (mmHg) 35 + 5 35 + 4 36 + 1

PaO2 (mmHg) 196 + 70† 133 + 58 126 + 57

PvO2 (mmHg) 40 + 5* 37 + 5 36 + 5

Qs/Qt (%) 23 + 7 25 + 7 26 + 5

RL Perfusion (%) 19 + 7 20 + 7 18 + 6

CO (L/min) 5.4 + 2§, ‡ 4.4 + 1 5.0 + 2

Schwarzkopf K; J Cardiothoracic Vasc Anesth 2003;17(1):73

TIVA vs Volatile Agents

Prop Desfl Isofl

Beyond CPAP & PEEP ?

Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode

iNO and Oxygenation During OLV

Reference n NO PPM PaO2

Hartigan 36 20 No ChangeAnesthesiology 1996

iNO and Oxygenation During OLV

Reference n NO PPM PaO2

Hartigan 36 20 No ChangeAnesthesiology 1996Wilson 6 40 No ChangeJ. Cardioth Vasc Anesth 1997

Ismail – Zade 12 3-5 No ChangeJ. Cardioth Vasc Anesth 1997Moutafis 20 20 No ChangeAnesth Analg 1997

Fradj 60 20 No ChangeBr J Anaesth 1998Schwarzkopf 152 20 No ChangeAnesth Analg 2001Della Rocca 30 40 No ChangeJ. Cardioth Vasc Anesth 2001

Beyond CPAP & PEEP ?

Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode

PCV vs VCV for OLV

Tugrul ’97 PCV > VCV(n=48, Crossover, VT=10ml/kg)

Heimberg ’06 PCV = VCV(n=50, No Crossover, VT=10ml/kg)

Unzuetta ’07 PCV = VCV(n=57, Crossover, VT=9ml/kg)

Dose of Volatile Agents and PaO2 during OLV

Schwarzkopf, Anesth Analg, 93:1434, 2001

14 Pigs – Anesth / Para, OLV, LLD

Varied Dose of Isofl & Desfl (0.5 – 1.0 – 1.5 MAC)

Measured: Qs/Qt, CO, PvO2, PaO2, % Q-R-Lung

Schwarzkopf, Anesth Analg, 93:1434, 2001

Dose of Volatile Agents and PaO2 during OLV

12 Pigs – Anesth / Para, OLV, LLD Initially Remifent + N2O, then:

Isoflurane 1 MAC Desflurane 1 MAC Propofol - adjusted to equivalent

BP/HR Measurements:

Qs/Qt, PaO2, PVO2, %Q-R-Lung, Hemodyn.

TIVA vs Volatile AgentsSchwarzkopf K; J Cardiothorac Vasc Anesth 17: 73, 2003

Advantages of PCV

Decelerating Flow Pattern

Improved Recruitment of Slow Alveoli

More Homogeneous Ventilation

Better V/Q Matching (?)

Lower PIP’s

Beyond CPAP & PEEP ?

Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode Position Thoracic Epidural Cardiac Output

Lateral > Prone > Supine

PaO2 during OLV: Effect of Position

Beyond CPAP & PEEP ?

Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode Position Thoracic Epidural Cardiac Output

Beyond CPAP & PEEP ?

Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode Position Thoracic Epidural Cardiac Output

Effect of C.O. on PaO2

during OLV

PaO2

Perfusion of Nondependent Lung

P.A. Pressure Counteracts HPV

Mixed Venous O2

Qs/Qt =

Cc´o2 – Cao2

Cc´o2 – Cvo2

Cao2 = Cc´o2 · (1 – Qs/Qt) + (Qs/Qt) · Cvo2

Cvo2 = Cao2 – (Vo2/Qt)

·

Cao2 = Cc´o2 – (Vo2/Qt)

· Qs/Qt

10 x (1 – Qs/Qt)(

)

Shunt

Fick

Combined x·

Levin AI. Anesth Analg 2005; 100:12

C.O. & CaO2: Effect of Shunt

Levin AI, Anesth Analg 2005; 100:12-14

Qs/Qt=0.2, VO2 = 150.

Qs/Qt = 0.4

Optimizing PaO2 during OLV:Beyond CPAP & PEEP ?

Inhaled Nitric Oxide Choice of Volatile Agent Dose of Volatile Agent TIVA Ventilator Mode Position Thoracic Epidural Cardiac Output

THE END