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Atelectasis in the dependent lung during one-lung ven- and hemodynamic variables were recorded at the end
tilation (OLV) impairs arterial oxygenation and in- of each study period. Arterial oxygenation and dead
creases dead space. We studied the effect of an alveolar space were better during two-lung ventilation com-
recruitment strategy (ARS) on gas exchange and lung pared with OLV. Pao2 increased during OLV after lung
efficiency during OLV by using the single-breath test of recruitment (244 ⫾ 89 mm Hg) when compared with
CO2 (SBT-CO2). Twelve patients undergoing thoracic OLV without recruitment (144 ⫾ 73 mm Hg; P ⬍ 0.001).
surgery were studied at three points in time: (a) during The SBT-CO2 analysis showed a significant decrease in
two-lung ventilation and (b) during OLV before and (c) dead-space variables and an increase in the variables
after an ARS. The ARS was applied selectively to the related to the efficiency of ventilation during OLV after
dependent lung and consisted of an increase in peak an ARS when compared with OLV alone. In conclusion,
inspiratory pressure up to 40 cm H2O combined with a ARS improves gas exchange and ventilation efficiency
peak end-expiratory pressure level of 20 cm H2O for 10 during OLV.
consecutive breaths. The ARS took approximately
3 min. Arterial blood gases, SBT-CO2, and metabolic (Anesth Analg 2004;98:1604 –9)
D
uring one-lung ventilation (OLV) anesthesia in and any deviation from the normal value of 1.0 causes
the lateral position, pulmonary shunt ranges inefficiencies in gas exchange.
from 15% to 40% because of the total collapse of Blood oxygenation evaluates shunt, whereas dead
the nondependent lung (1). In addition, there is clear space (i.e., inefficient ventilation) is related to the
evidence from computerized tomography that zones lung’s CO2 removal. However, shunt has a close
of compression atelectasis are redirected to the depen- relationship to dead space, and vice versa (5), be-
dent lung when patients are changed from the supine cause both are related to gas exchange but use a
to the lateral position (2,3). Both atelectasis and hy- different gas for analysis. Thus, gas exchange and
poventilated zones in the dependent lung contribute ventilation efficiency (4,6,7) during general anesthe-
to a ventilation/perfusion (V̇/Q̇) mismatch and have sia can be evaluated by the analysis of arterial blood
an additive effect to the shunting in the nondependent gases and by the single-breath test of CO2 (SBT-
lung (4). CO2), the most commonly used tool for dead-space
analysis.
The V̇/Q̇ relationship describes the efficiency of gas
We have recently shown that an alveolar recruit-
exchange and ranges from zero (shunt) to infinite
ment strategy (ARS) improves arterial oxygenation
(alveolar dead space; VDalv). Total V̇/Q̇ depends on
during OLV anesthesia after vascular clipping in lo-
the algebraic sum of the V̇/Q̇ ratio in every alveolus,
bectomies (8). We hypothesized that improved V̇/Q̇
matching in the dependent lung was responsible for
the reduced intrapulmonary shunt. The objective of
this study was to evaluate the effect of a recruitment
Accepted for publication March 6, 2003. maneuver on the gas exchange efficiency during OLV
Address correspondence to Gerardo Tusman, MD, Department of
Anesthesiology, University Hospital Hamburg-Eppendorf, Martin- without any kind of pulmonary vascular interruption
istrasse 52, 20246 Hamburg, Germany. Address e-mail to in the nondependent lung. Ventilatory and gas ex-
gtusman@hotmail.com. Reprints will not available from the author. change efficiency was studied by SBT-CO2 and arterial
DOI: 10.1213/01.ANE.0000068484.67655.1A blood gas analysis.
Results
selectively to the dependent lung immediately after Twelve patients—10 men and 2 women—were in-
the measurement at Point 2. First, the ventilator was cluded in this study (Table 2). Only Patient 7 received
switched to pressure-control ventilation, adjusting the inhaled bronchodilators sporadically as needed.
level of pressure to obtain the same Vt as during Pao2 was significantly higher during TLV (379 ⫾
volume-control ventilation. Ventilation was then al- 67 mm Hg) compared with OLVPRE (144 ⫾ 73 mm Hg;
lowed to equilibrate for 3 min. Thereafter, the ARS P ⬍ 0.001) and OLVARS (244 ⫾ 89 mm Hg; P ⬍ 0.001).
was performed as described previously (8,11) on the During OLV, the difference in Pao2 before and after
basis of the concept described by Lachmann (12). The the ARS also reached significance (Fig. 2).
ANESTH ANALG CARDIOVASCULAR ANESTHESIA TUSMAN ET AL. 1607
2004;98:1604 –9 ALVEOLAR RECRUITMENT DURING THORACIC ANESTHESIA
Hemoglobin oxygen saturation was lower at breathing. Arterial oxygenation, however, is an unspe-
OLVPRE (95.5% ⫾ 2.6%) as compared with TLV (98.7% cific variable to evaluate the recruitment effect because
⫾ 0.4%; P ⬍ 0.001) and OLVARS (97.8% ⫾ 0.9%; P ⬍ it depends on the hemodynamic and metabolic status.
0.01). Only Patient 8 needed four cycles of intermittent Because these two conditions remained stable
ventilation during OLV before the ARS (Spo2 ⬍90%). throughout the study period, a true recruitment effect
Blood gases were taken after the fourth cycle of inter- is the most likely explanation for the increases seen in
mittent TLV immediately before the recruitment ma- Pao2.
neuver. In this patient, the ARS relieved the arterial During TLV, a mean Pao2 of 379 ⫾ 67 mm Hg
hypoxemia instantaneously (Spo2 from 88% to 98%), indicated some extent of lung collapse, a common
and no more episodes of hemoglobin desaturation finding during general anesthesia (Fig. 2). Oxygen-
occurred. ation was further impaired during OLVPRE but in-
Paco2 was 43 ⫾ 6 mm Hg during OLVARS but was creased after the dependent lung was recruited.
not significantly different from the other conditions. The nomogram of Benatar et al. (17) was used to
However, Paco2 was higher during OLVPRE (46 ⫾ calculate the approximate shunt in our patients: at
6 mm Hg) compared with TLV (38 ⫾ 4 mm Hg; P ⬍ TLV, shunt values ranged from 8% to 22% (mean,
0.05). ETco2 and the mean partial pressure of CO2 in 16%), values typically seen in general anesthesia. Dur-
alveolar air (Paeco2) were stable during the protocol, ing OLV, they ranged from 18% to 45% (mean, 28%),
without any significant differences among the meas- and during OLVARS they ranged from 12% to 27%
urement points. The Pa-ETco2 difference was signifi- (mean, 21%). After lung recruitment, oxygenation was
cantly higher during OLVPRE (14.2 ⫾ 4.8 mm Hg) sufficient to maintain hemoglobin saturation ⬎95%.
compared with TLV (8.8 ⫾ 3.2 mm Hg) and OLVARS Paco2 increased during OLV at the same ETco2 and
(11.6 ⫾ 4.6 mm Hg). The arterial pH remained in the Paeco2 values as those observed during TLV. In-
normal range throughout the study period. creases in dead space during OLV can explain this
All dead-space variables (Table 1) decreased during decrease in the efficiency of CO2 removal. Because
OLVARS compared with OLVPRE, but differences arterial oxygenation is only one of the variables de-
showed statistical significance only for the dead-space scribing the effects of recruitment in the protocol, we
gas volume/Vt ratio, Vol I, II, III/Vt, and Phase III included the dead-space analysis, a well known tool
slope. Vts were higher during TLV (506 ⫾ 83 mL) for evaluating the lung’s efficiency of gas exchange.
compared with OLVPRE (377 ⫾ 45 mL) and OLVARS During TLV, the values of dead space-derived vari-
(382 ⫾ 42 mL). Minute ventilation was similar be- ables are larger than normal (18) because of the DLT,
tween OLVPRE (5.9 L/min) and OLVARS (5.8 L/min), lung collapse, open-chest condition, and the use of
but both values were significantly smaller than during positive-pressure ventilation.
TLV (7 L/min). PIP values were higher during Surprisingly, VDalv did not change during OLV de-
OLVPRE (25.3 ⫾ 1.7 cm H2O) compared with TLV (20.6 spite a significant increase in shunt. We cannot explain
⫾ 1.7 cm H2O; P ⬍ 0.001) and OLVARS (23.2 ⫾ 2 cm the absence of an increase in VDalv despite a marked
H2O; P ⬍ 0.05), with no differences between the last shunt effect (apparent dead space) during OLV com-
two. pared with TLV. We believe that during TLV, a de-
Hemodynamic variables, minute CO2 elimination, crease in the perfusion of the nondependent lung can
oxygen consumption, and RQ were similar at all time increase VDalv (real VDalv) despite a lower shunt
points. The total time of OLV ranged from 50 to (6,19).
105 min. No hemodynamic or ventilatory side effects Large tidal values during TLV result also in abso-
related to the recruitment maneuver were detected. lute large values for VDaw, alveolar tidal volume
(Vtalv), and physiological dead space than the ones
observed during OLV, thus making their direct com-
parison questionable. Nevertheless, when these vari-
Discussion ables are adjusted to account for differences in Vt, this
The results of this study indicate an improved effi- comparison may become useful.
ciency in gas exchange after a lung recruitment ma- The variables that represent efficiency of ventilation
neuver during OLV. This finding agrees with our and CO2 exchange (Vtco2,br, dead-space gas
previous results (8) and can be explained by a recruit- volume/Vt ratio, Pa-ETco2, Vtalv, and VDalv/Vtalv)
ment effect on both shunt and dead space, taking into were higher during TLV compared with OLV. During
account that hemodynamic, metabolic, and ventilatory OLV, all variables improved only after the recruitment
conditions were stable along the protocol. maneuver.
Arterial oxygenation is a common measurement Even more interesting was the behavior of the vari-
used to describe the extent of lung collapse. Different ables that show the distribution of Vt throughout the
authors (15,16) propose that a Pao2 ⬎450 mm Hg SBT-CO2 phases. Distribution of volume was most
defines an “open lung” condition during pure oxygen efficient during OLV after the ARS, as indicated by a
1608 CARDIOVASCULAR ANESTHESIA TUSMAN ET AL. ANESTH ANALG
ALVEOLAR RECRUITMENT DURING THORACIC ANESTHESIA 2004;98:1604 –9