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Traditional One-Lung Ventilation & ALI; Have we been killing our Patients? Philip M. Hartigan, MD Brigham & Women’s Hospital Harvard Medical School. Case Report: 54 y/o male Smoking History COPD Persistent cough. Case Report: . CXR - Large RUL mass Cytology = NSCCA - PowerPoint PPT Presentation
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Traditional One-Lung Ventilation & ALI;Have we been killing our Patients?
Philip M. Hartigan, MDBrigham & Women’s Hospital
Harvard Medical School
Case Report:
• 54 y/o male• Smoking History• COPD• Persistent cough
• CXR - Large RUL mass• Cytology = NSCCA• Metastatic w/u Negative• Scheduled for a Right
Pneumonectomy
Case Report:
CASE REPORT:
General Anesthetic:• Thoracic Epidural• A-Line• TIVA• L-DLT
• VT =10 ml/kg• PEEP = O
CASE REPORT:
Hospital Course – POD # 2:
Dyspnea Hypoxemia Pulmonary Edema
CASE REPORT:
Hospital Course (cont.):
Respiratory Failure Reintubation
PCWP < 16 cmH2O Diuretics Fluid Restriction
ARDS MSOF Death
What Just Happened ?
“Traditional” OLV “Protective” OLVVT = 10 ml/kg VT = 6 ml/kgPEEP = 0 PEEP = 5 cmH2O
Impact: Incidence: 2 - 9%
Mortality: 35 – 72%
“ALI/ARDS is emerging as the most prominent cause of perioperative mortality following pulmonary resection as other complications have become better controlled”
Peter Slinger 2006
Known Causes of ALI / ARDS:
InfectionAspirationBPFCardiac FailurePulmonary Embolic eventsTRALIOther (pancreatitis, trauma, CPB…)
Post-Pneumonectomy Pulmonary Edema
ALI following Pulmonary Resection
Primary ALI following Thoracic Surgery
Idiopathic ALI following Pulm Resection
Nomenclature
Hypothesis:
“Traditional OLV Causes ALI “ Extrapolated Evidence Retrospective Studies Animal Studies Clinical Studies
Extrapolated Evidence:
ARDS Literature:Reduced ARDS Mortality with Protective Ventilation
VILI Literature:VolutraumaAtelectraumaInflammatory Response
AlveolarSystemic
“The finding of small changes in cytokine concentrations is in no way indicative of a causal link with outcome”
Dreyfuss Didier, 2003
Hypothesis:
“Traditional OLV Causes ALI “ Extrapolated Evidence – (Weak) Retrospective Studies Animal Studies Clinical Studies
Retrospective Studies;Factors Associated w/ ALI:
High Perioperative Fluid Balance Extent of Surgery Side of Surgery (R > L) Duration of Surgery Alcoholism / Chemotherapy Increased Vent Pressures/Volumes
Retrospective Studies:
Van der Werff ‘97 190 Pts PIPs > 40 assoc.w/ Pulm Edema
Licker ‘03 879 Pts Ventilatory Hyperpressure
Index
Fernandez - 170 Pts VT assoc with-Perez ‘06 Resp Failure
8.3 vs 6.7 ml/kg
Risk Factors for Primary ALILicker, et al: Anesth Analg 2003;97:1558
Pneumonectomy
Excessive Fluid
Alcoholism
Ventilatory Hyperpressure Index
Risk Factors for Primary ALILicker, et al: Anesth Analg 2003;97:1558
Pneumonectomy
Excessive Fluid
Alcoholism
Ventilatory Hyperpressure Index(P-Plateau > 10 cmH20 x Duration OLV)
Hypothesis:
“Traditional OLV Causes ALI “ Extrapolated Evidence - (weak) Retrospective Studies – (weak) Animal Studies Clinical Studies
Animal Studies:
De Abreu , et al. Anesth Analg 2003
Control – 2LV @ 8 mlPEEP = 2
Protect - OLV @ 4 mlPEEP = 2
Tradit’l – OLV @ 8 mlPEEP = 0
OLV in the Rabbit Lung ModelDe Abreu, et al. Anesth Analg 2003; 96:220
PIP MPAP
TXB2WG
2-LV (CTRL) Protect OLV Traditional OLV
Hypothesis:
“Traditional OLV Causes ALI “ Extrapolated Evidence – (weak) Retrospective Studies – (weak) Animal Studies – (suggestive) Clinical Studies
Clinical Studies:
• Schilling, et al 2005• Schilling, et al 2007• Schilling, et al 2011
Traditional vs Protective OLV:
Proinflammatory CytokinesInhalational Agents are protective
Schilling T, et al. Anesth Analg 2005;101:957Protective OLV and Inflammatory Mediators
Design:32 Pts for thoracotomyOLV @ 5 vs 10 ml/kgPEEP = 0 BAL at 3 time points
Findings:Traditional OLV was associated with:
Proinflammatory cytokinesAntiinflammatory cytokines
I
IL-8 TNF-a
sICAM IL-10
VT = 10 ml/kg VT = 5 ml/kg Schilling ‘05
Schilling T, et al. Anesthesiology 2011;115:65
Effect of Volatile Anesthetics on Systemic and Alveolar Inflammatory Response
Design:63 Pts for thoracotomy
21 – Propofol (4mg/kg/hr)21 – Desflurane (1 MAC)21 – Sevoflurane (1 MAC)
OLV @ 7 ml/kgPEEP = 5 BAL before & after OLV
Findings:Desfl & Sevo attenuate proinflammatory changes evenwith protective OLV compared to Propofol.
III
Hypothesis:
“Traditional OLV Causes ALI “ Extrapolated Evidence – (weak) Retrospective Studies – (weak) Animal Studies – (suggestive) Clinical Studies – (suggestive)
Death
OLV
InflammatoryResponse
ALI / ARDS
Death
Unbalance DrainageChemo / XRTExtent of SurgeryDuration of SurgAlcoholismGeneticUnrecognized:InfectionAspirationEmboliTRALICardiac
PneumonectomyImpaired LymphaticsExcessive Fluids
OLV
InflammatoryResponse
ALI / ARDS
Death
Unbalance DrainageChemo / XRTExtent of SurgeryDuration of SurgAlcoholismGeneticUnrecognized:InfectionAspirationEmboliTRALICardiac
PneumonectomyImpaired LymphaticsExcessive Fluids
Low VTPEEPSevofluraneDesflurane
Low FiO2
OLV
InflammatoryResponse
ALI / ARDS
CO2
Injury
The Balancing Act of OLV
O2
Schilling T, et al. Br J Anaesth 2007;99:368
OLV & Inflammatory Mediators:Propofol vs Desflurane
Design:30 Pts for thoracotomy
15 – Propofol (4mg/kg/hr)15 – Desflurane (1 MAC)
OLV @ 10 ml/kgPEEP = 0 BAL at 3 time points
Findings:Desflurane attenuates the proinflammatory changesof non-protective OLV
II
TNF-aIL-8
IL-10 sICAM-1
Propofol Desflurane Schilling ‘07
Postulated Causes
VILI from “Traditional” OLV Oxygen Toxicity Hyperperfusion Stress Injury Inflammatory Response to Surgery Postoperative Hyperexpansion Unrecognized, Known Etiologies
Known Causes of ALI / ARDS:
InfectionAspirationBPFCardiac FailurePulmonary Embolic eventsTRALIVILIOther (pancreatitis, trauma, CPB…)
Factors Associated with ALI High Perioperative Fluid Balance Extent of Surgery Side of Surgery (R > L) Duration of Surgery Alcoholism / Chemotherapy
Idiopathic ALI following Pulm Resection
2-9% following pneumonectomy
35 – 50% Mortality
Clinical / Histology resembles ALI/ARDS
Low PCWP, high alveolar protein
Diagnosis of Exclusion
Acute Lung Injury• Bilateral Pulmonary Infiltrates• PCWP < 18 mmHg• PaO2/FiO2 < 300 mmHg
ARDS• PaO2/FiO2 < 200 mmHg
Definitions: ALI & ARDS
Hypothesis:
“Traditional OLV Causes ALI “ Extrapolated Evidence Retrospective Studies Animal Studies Clinical Studies
OLV
Mech StressInjury
ALI
ARDS
DEATH
InflammMediators
Perspective
Does Traditional OLV Cause ALI ?
Potential contributing factorTheoretical riskNot currently strongly supported by evidence
Recommendations:
Initial VT = 5-6 ml/kgPEEP = 5