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 + 1PaO2 (mmHg) 196 + 70† 133 + 58 126 + 57PvO2 (mmHg) 40 + 5* 37 + 5 36 + 5Qs/Qt (%) 23 + 7 25 + 7 26 + 5
RL Perfusion (%) 19 + 7 20 + 7 18 + 6CO (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/Qt10 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
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