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Optimal PEEP during one-lung ventilation with capnothorax: An experimental study
Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kirurgiska vetenskaper, Anestesiologi och intensivvård. Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kirurgiska vetenskaper, Hedenstiernalaboratoriet.ORCID-id: 0000-0002-3495-2929
Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kirurgiska vetenskaper, Hedenstiernalaboratoriet. Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kirurgiska vetenskaper, Anestesiologi och intensivvård. Laboratório de Pneumologia LIM–09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kirurgiska vetenskaper, Anestesiologi och intensivvård. Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kirurgiska vetenskaper, Hedenstiernalaboratoriet.ORCID-id: 0000-0001-6100-189X
Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kirurgiska vetenskaper, Anestesiologi och intensivvård.
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2019 (Engelska)Ingår i: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 63, nr 2, s. 222-231Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: One‐lung ventilation (OLV) with induced capnothorax carries the risk of severely impaired ventilation and circulation. Optimal PEEP may mitigate the physiological perturbations during these conditions.

Methods: Right‐sided OLV with capnothorax (16 cm H2O) on the left side was initiated in eight anesthetized, muscle‐relaxed piglets. A recruitment maneuver and a decremental PEEP titration from PEEP 20 cm H2O to zero end‐expiratory pressure (ZEEP) was performed. Regional ventilation and perfusion were studied with electrical impedance tomography and computer tomography of the chest was used. End‐expiratory lung volume and hemodynamics were recorded and.

Results: PaO2 peaked at PEEP 12 cm H2O (49 ± 14 kPa) and decreased to 11 ± 5 kPa at ZEEP (P < 0.001). PaCO2 was 9.5 ± 1.3 kPa at 20 cm H2O PEEP and did not change when PEEP step‐wise was reduced to 12 cm H2O PaCO2. At lower PEEP, PaCO2 increased markedly. The ventilatory driving pressure was lowest at PEEP 14 cm H2O (19.6 ± 5.8 cm H2O) and increased to 38.3 ± 6.1 cm H2O at ZEEP (P < 0.001). When reducing PEEP below 12‐14 cm H2O ventilation shifted from the dependent to the nondependent regions of the ventilated lung (P = 0.003), and perfusion shifted from the ventilated to the nonventilated lung (P = 0.02).

Conclusion: Optimal PEEP was 12‐18 cm H2O and probably relates to capnothorax insufflation pressure. With suboptimal PEEP, ventilation/perfusion mismatch in the ventilated lung and redistribution of blood flow to the nonventilated lung occurred.

Ort, förlag, år, upplaga, sidor
2019. Vol. 63, nr 2, s. 222-231
Nyckelord [en]
anesthesia, capnothorax, cardio-thoracic surgery, one lung ventilation, optimal PEEP, PEEP titration
Nationell ämneskategori
Anestesi och intensivvård
Forskningsämne
Anestesiologi och intensivvård
Identifikatorer
URN: urn:nbn:se:uu:diva-268620DOI: 10.1111/aas.13247ISI: 000454814700012PubMedID: 30132806OAI: oai:DiVA.org:uu-268620DiVA, id: diva2:878190
Forskningsfinansiär
Hjärt-Lungfonden
Anmärkning

Title in thesis list of papers: Optimal PEEP during one lung ventilation with capnothorax. An experimental study

Tillgänglig från: 2015-12-08 Skapad: 2015-12-08 Senast uppdaterad: 2019-01-31Bibliografiskt granskad
Ingår i avhandling
1. Open lung concept in high risk anaesthesia: Optimizing mechanical ventilation in morbidly obese patients and during one lung ventilation with capnothorax
Öppna denna publikation i ny flik eller fönster >>Open lung concept in high risk anaesthesia: Optimizing mechanical ventilation in morbidly obese patients and during one lung ventilation with capnothorax
2016 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

Formation of atelectasis, defined as reversible collapse of aerated lung, often occurs after induction of anaesthesia with mechanical ventilation. As a consequence, there is a risk for hypoxemia, altered hemodynamics and impaired respiratory system mechanics. In certain situations, the risk for atelectasis formation is increased and its consequences may also be more difficult to manage. Anesthesia for bariatric surgery in morbidly obese patients and surgery requiring one-lung ventilation (OLV) with capnothorax are examples of such situations.

In Paper I (30 patients with BMI > 40 kg/m2 scheduled for bariatric surgery) a recruit­ment maneuver followed by positive end-expiratory pressure (PEEP) re­duced the amount of atelectasis and improved oxygenation for a prolonged period of time. PEEP or a recruitment maneuver alone did not reduce the amount of atelectasis.

In paper II we investigated whether it is possible to predict respiratory function impairment in morbidly obese patients without pulmonary disease from a preoperative lung function test. Patients with mild signs of airway obstruction (reduced end-expiratory flow) in the preoperative spirometry developed less atelectasis during anaesthesia.

In paper III we developed an experimental model of sequential OLV with capnothorax using electrical impedance tomography (EIT) that in real-time detected lung separation and dynamic changes in pulmonary ventilation and perfusion distributions. OLV to the left side caused a decrease in cardiac output, arterial oxygenation and mixed venous saturation.

In paper IV we used our model of OLV with capnothorax and applied a CO2-insufflation pressure of 16 cm H2O. We demonstrated that a PEEP level of 12-16 cm H2O is needed for optimal oxygenation and lowest possible driving pressure without compromising hemodynamic variables. Thus, the optimal PEEP was closely related to the level of the capnothorax insufflation pressure. With insufficient PEEP, ventilation/perfusion mismatch in the ventilated lung and redistribution of blood flow to the non-ventilated lung occurred.

Ort, förlag, år, upplaga, sidor
Uppsala: Acta Universitatis Upsaliensis, 2016. s. 77
Serie
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1169
Nyckelord
Anaesthesia, mechanical ventilation, atelectasis, morbidly obese, one-lung ventilation, PEEP, recruitment maneuver, spirometry, EIT
Nationell ämneskategori
Anestesi och intensivvård
Forskningsämne
Anestesiologi och intensivvård
Identifikatorer
urn:nbn:se:uu:diva-268498 (URN)978-91-554-9440-7 (ISBN)
Disputation
2016-02-12, Grönwallssalen, Ing. 70, Akademiska sjukhuset, Uppsala, 13:00 (Svenska)
Opponent
Handledare
Tillgänglig från: 2016-01-22 Skapad: 2015-12-06 Senast uppdaterad: 2018-05-18

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