Traditional One-Lung Ventilation & ALI; Have we been killing
our Patients? Philip M. Hartigan, MD Brigham & Womens Hospital
Harvard Medical School Slide 2 Case Report: 54 y/o male Smoking
History COPD Persistent cough Slide 3 CXR - Large RUL mass Cytology
= NSCCA Metastatic w/u Negative Scheduled for a Right Pneumonectomy
Case Report: Slide 4 CASE REPORT: General Anesthetic: Thoracic
Epidural A-Line TIVA L-DLT VT =10 ml/kg PEEP = O Slide 5 CASE
REPORT: Hospital Course POD # 2: Dyspnea Hypoxemia Pulmonary Edema
Slide 6 Slide 7 CASE REPORT: Hospital Course (cont.): Respiratory
Failure Reintubation PCWP < 16 cmH 2 O Diuretics Fluid
Restriction ARDS MSOF Death Slide 8 What Just Happened ? Slide 9
Traditional OLVProtective OLV VT = 10 ml/kgVT = 6 ml/kg PEEP =
0PEEP = 5 cmH 2 O Slide 10 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
Slide 11 Known Causes of ALI / ARDS: Infection Aspiration BPF
Cardiac Failure Pulmonary Embolic events TRALI Other (pancreatitis,
trauma, CPB) Slide 12 Post-Pneumonectomy Pulmonary Edema ALI
following Pulmonary Resection Primary ALI following Thoracic
Surgery Idiopathic ALI following Pulm Resection Nomenclature Slide
13 Hypothesis: Traditional OLV Causes ALI Extrapolated Evidence
Retrospective Studies Animal Studies Clinical Studies Slide 14
Extrapolated Evidence: ARDS Literature: Reduced ARDS Mortality with
Protective Ventilation VILI Literature: Volutrauma Atelectrauma
Inflammatory Response Alveolar Systemic Slide 15 Slide 16 The
finding of small changes in cytokine concentrations is in no way
indicative of a causal link with outcome Dreyfuss Didier, 2003
Slide 17 Hypothesis: Traditional OLV Causes ALI Extrapolated
Evidence (Weak) Retrospective Studies Animal Studies Clinical
Studies Slide 18 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 Slide 19 Retrospective Studies: Van der
Werff 97 190 Pts PIPs > 40 assoc. w/ Pulm Edema Licker 03879 Pts
Ventilatory Hyperpressure Index Fernandez -170 Pts VT assoc with
-Perez 06Resp Failure 8.3 vs 6.7 ml/kg Slide 20 Slide 21 Risk
Factors for Primary ALI Licker, et al: Anesth Analg 2003;97:1558
Pneumonectomy Excessive Fluid Alcoholism Ventilatory Hyperpressure
Index Slide 22 Risk Factors for Primary ALI Licker, et al: Anesth
Analg 2003;97:1558 Pneumonectomy Excessive Fluid Alcoholism
Ventilatory Hyperpressure Index (P-Plateau > 10 cmH 2 0 x
Duration OLV) Slide 23 Hypothesis: Traditional OLV Causes ALI
Extrapolated Evidence - (weak) Retrospective Studies (weak) Animal
Studies Clinical Studies Slide 24 Animal Studies: De Abreu, et al.
Anesth Analg 2003 Control 2LV @ 8 ml PEEP = 2 Protect - OLV @ 4 ml
PEEP = 2 Traditl OLV @ 8 ml PEEP = 0 Slide 25 OLV in the Rabbit
Lung Model De Abreu, et al. Anesth Analg 2003; 96:220 PIP MPAP TXB2
WG 2-LV (CTRL)Protect OLVTraditional OLV Slide 26 Hypothesis:
Traditional OLV Causes ALI Extrapolated Evidence (weak)
Retrospective Studies (weak) Animal Studies (suggestive) Clinical
Studies Slide 27 Clinical Studies: Schilling, et al 2005 Schilling,
et al 2007 Schilling, et al 2011 Traditional vs Protective OLV:
Proinflammatory Cytokines Inhalational Agents are protective Slide
28 Schilling T, et al. Anesth Analg 2005;101:957 Protective OLV and
Inflammatory Mediators Design: 32 Pts for thoracotomy OLV @ 5 vs 10
ml/kg PEEP = 0 BAL at 3 time points Findings: Traditional OLV was
associated with: Proinflammatory cytokines Antiinflammatory
cytokines I Slide 29 IL-8TNF-a sICAM IL-10 VT = 10 ml/kgVT = 5
ml/kg Schilling 05 Slide 30 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/kg PEEP = 5 BAL before & after OLV Findings: Desfl &
Sevo attenuate proinflammatory changes even with protective OLV
compared to Propofol. III Slide 31 Slide 32 Hypothesis: Traditional
OLV Causes ALI Extrapolated Evidence (weak) Retrospective Studies
(weak) Animal Studies (suggestive) Clinical Studies (suggestive)
Slide 33 Death OLV Inflammatory Response ALI / ARDS Slide 34 Death
Unbalance Drainage Chemo / XRT Extent of Surgery Duration of Surg
Alcoholism Genetic Unrecognized: Infection Aspiration Emboli TRALI
Cardiac Pneumonectomy Impaired Lymphatics Excessive Fluids OLV
Inflammatory Response ALI / ARDS Slide 35 Death Unbalance Drainage
Chemo / XRT Extent of Surgery Duration of Surg Alcoholism Genetic
Unrecognized: Infection Aspiration Emboli TRALI Cardiac
Pneumonectomy Impaired Lymphatics Excessive Fluids Low VT PEEP
Sevoflurane Desflurane Low FiO2 OLV Inflammatory Response ALI /
ARDS Slide 36 CO 2 Injury The Balancing Act of OLV O2O2 Slide 37
Slide 38 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/kg PEEP = 0 BAL at 3 time points Findings: Desflurane attenuates
the proinflammatory changes of non-protective OLV II Slide 39 TNF-a
IL-8 IL-10 sICAM-1 PropofolDesflurane Schilling 07 Slide 40 Slide
41 Slide 42 Postulated Causes VILI from Traditional OLV Oxygen
Toxicity Hyperperfusion Stress Injury Inflammatory Response to
Surgery Postoperative Hyperexpansion Unrecognized, Known Etiologies
Slide 43 Known Causes of ALI / ARDS: Infection Aspiration BPF
Cardiac Failure Pulmonary Embolic events TRALI VILI Other
(pancreatitis, trauma, CPB) Slide 44 Slide 45 Slide 46 Slide 47
Slide 48 Factors Associated with ALI High Perioperative Fluid
Balance Extent of Surgery Side of Surgery (R > L) Duration of
Surgery Alcoholism / Chemotherapy Slide 49 Slide 50 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 Slide 51 Acute Lung Injury
Bilateral Pulmonary Infiltrates PCWP < 18 mmHg PaO 2 /FiO 2 <
300 mmHg ARDS PaO 2 /FiO 2 < 200 mmHg Definitions: ALI &
ARDS Slide 52 Hypothesis: Traditional OLV Causes ALI Extrapolated
Evidence Retrospective Studies Animal Studies Clinical Studies
Slide 53 OLV Mech Stress Injury ALI ARDS DEATH Inflamm Mediators
Slide 54 Slide 55 Perspective Does Traditional OLV Cause ALI ?
Potential contributing factor Theoretical risk Not currently
strongly supported by evidence Slide 56 Recommendations: Initial VT
= 5-6 ml/kg PEEP = 5
