Rauseo Michela, Mirabella Lucia, Grasso Salvatore, Cotoia Antonella, Spadaro Savino, D'Antini Davide, Valentino Franca, Tullo Livio, Loizzi Domenico, Sollitto Francesco, Cinnella Gilda
Department of Anesthesia and Intensive care, University of Foggia, Viale Pinto, 1-71100, Foggia, Italy.
Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
BMC Anesthesiol. 2018 Oct 31;18(1):156. doi: 10.1186/s12871-018-0624-3.
During thoracic surgery in lateral decubitus, one lung ventilation (OLV) may impair respiratory mechanics and gas exchange. We tested a strategy based on an open lung approach (OLA) consisting in lung recruitment immediately followed by a decremental positive-end expiratory pressure (PEEP) titration to the best respiratory system compliance (C) and separately quantified the elastic properties of the lung and the chest wall. Our hypothesis was that this approach would improve gas exchange. Further, we were interested in documenting the impact of the OLA on partitioned respiratory system mechanics.
In thirteen patients undergoing upper left lobectomy we studied lung and chest wall mechanics, transpulmonary pressure (P), respiratory system and transpulmonary driving pressure (ΔP and ΔP), gas exchange and hemodynamics at two time-points (a) during OLV at zero end-expiratory pressure (OLV) and (b) after the application of the open-lung strategy (OLV).
The external PEEP selected through the OLA was 6 ± 0.8 cmHO. As compared to OLV, the PaO/FiO ratio went from 205 ± 73 to 313 ± 86 (p = .05) and C increased from 56 ± 18 ml/cmHO to 71 ± 12 ml/cmHO (p = .0013), without changes in C. Both ΔP and ΔP decreased from 9.2 ± 0.4 cmHO to 6.8 ± 0.6 cmHO and from 8.1 ± 0.5 cmHO to 5.7 ± 0.5 cmHO, (p = .001 and p = .015 vs OLV), respectively. Hemodynamic parameters remained stable throughout the study period.
In our patients, the OLA strategy performed during OLV improved oxygenation and increased C and had no clinically significant hemodynamic effects. Although our study was not specifically designed to study ΔP and ΔP, we observed a parallel reduction of both after the OLA.
TRN: ClinicalTrials.gov , NCT03435523 , retrospectively registered, Feb 14 2018.
在侧卧位胸外科手术期间，单肺通气（OLV）可能会损害呼吸力学和气体交换。我们测试了一种基于开放肺策略（OLA）的方法，该方法包括立即进行肺复张，随后将呼气末正压（PEEP）递减滴定至最佳呼吸系统顺应性（C），并分别量化肺和胸壁的弹性特性。我们的假设是这种方法将改善气体交换。此外，我们有兴趣记录OLA对分区呼吸系统力学的影响。
在13例接受左上肺叶切除术的患者中，我们在两个时间点研究了肺和胸壁力学、跨肺压（P）、呼吸系统和跨肺驱动压（ΔP和ΔP）、气体交换和血流动力学：（a）在呼气末压力为零时的OLV期间（OLV），以及（b）应用开放肺策略后（OLV）。
通过OLA选择的外部PEEP为6±0.8 cmH₂O。与OLV相比，PaO₂/FiO₂比值从205±73升至313±86（p = 0.05），C从56±18 ml/cmH₂O增加至71±12 ml/cmH₂O（p = 0.0013），而Cw无变化。ΔP和ΔP分别从9.2±0.4 cmH₂O降至6.8±0.6 cmH₂O以及从8.1±0.5 cmH₂O降至5.7±0.5 cmH₂O（与OLV相比，p = 0.001和p = 0.015）。在整个研究期间，血流动力学参数保持稳定。
在我们的患者中，OLV期间实施的OLA策略改善了氧合，增加了C，并且没有临床显著的血流动力学影响。尽管我们的研究并非专门设计用于研究ΔP和ΔP，但我们观察到OLA后两者均平行降低。
TRN：ClinicalTrials.gov，NCT03435523，回顾性注册，2018年2月14日。
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