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Traditional One-Lung Ventilation & ALI; Have we been killing our Patients? Philip M. Hartigan, MD PowerPoint Presentation
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Traditional One-Lung Ventilation & ALI; Have we been killing our Patients? Philip M. Hartigan, MD Brigham & Women’s Hospital Harvard Medical School. Case Report: 54 y/o male Smoking History COPD Persistent cough. Case Report: . CXR - Large RUL mass Cytology = NSCCA

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slide1

Traditional One-Lung Ventilation & ALI;

Have we been killing our Patients?

Philip M. Hartigan, MD

Brigham & Women’s Hospital

Harvard Medical School

slide2

Case Report:

  • 54 y/o male
  • Smoking History
  • COPD
  • Persistent cough
slide3

Case Report:

  • CXR - Large RUL mass
  • Cytology = NSCCA
  • Metastatic w/u Negative
  • Scheduled for a Right
  • Pneumonectomy
slide4

CASE REPORT:

  • General Anesthetic:
    • Thoracic Epidural
    • A-Line
    • TIVA
    • L-DLT
      • VT =10 ml/kg
      • PEEP = O
slide5

CASE REPORT:

  • Hospital Course – POD # 2:
        • Dyspnea
        • Hypoxemia
        • Pulmonary Edema
slide7

CASE REPORT:

  • Hospital Course (cont.):
        • Respiratory Failure
        • Reintubation
          • PCWP < 16 cmH2O
          • Diuretics
          • Fluid Restriction
        • ARDS
        • MSOF
        • Death
slide9

“Traditional” OLV“Protective” OLV

VT = 10 ml/kg VT = 6 ml/kg

PEEP = 0 PEEP = 5 cmH2O

slide10

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

slide11

Known Causes of ALI / ARDS:

Infection

Aspiration

BPF

Cardiac Failure

Pulmonary Embolic events

TRALI

Other (pancreatitis, trauma, CPB…)

slide12

Nomenclature

Post-Pneumonectomy Pulmonary Edema

ALI following Pulmonary Resection

Primary ALI following Thoracic Surgery

Idiopathic ALI following Pulm Resection

slide13

Hypothesis:

  • “Traditional OLV Causes ALI “
  • Extrapolated Evidence
  • Retrospective Studies
  • Animal Studies
  • Clinical Studies
slide14

Extrapolated Evidence:

ARDS Literature:

Reduced ARDS Mortality

with Protective Ventilation

VILI Literature:

Volutrauma

Atelectrauma

Inflammatory Response

Alveolar

Systemic

slide16

“The finding of small changes in cytokine

concentrations is in no way indicative of a

causal link with outcome”

Dreyfuss Didier, 2003

slide17

Hypothesis:

  • “Traditional OLV Causes ALI “
  • Extrapolated Evidence – (Weak)
  • Retrospective Studies
  • Animal Studies
  • Clinical Studies
slide18

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
slide19

Retrospective Studies:

Van der Werff ‘97 190 Pts PIPs > 40 assoc.

w/ Pulm Edema

Licker ‘03 879 PtsVentilatory

Hyperpressure

Index

Fernandez - 170 Pts VT assoc with

-Perez ‘06 Resp Failure

8.3 vs 6.7 ml/kg

slide21

Risk Factors for Primary ALI

  • Licker, et al: AnesthAnalg 2003;97:1558
  • Pneumonectomy
  • Excessive Fluid
  • Alcoholism
  • VentilatoryHyperpressure Index
slide22

Risk Factors for Primary ALI

  • Licker, et al: AnesthAnalg 2003;97:1558
  • Pneumonectomy
  • Excessive Fluid
  • Alcoholism
  • VentilatoryHyperpressure Index
  • (P-Plateau > 10 cmH20 x Duration OLV)
slide23

Hypothesis:

  • “Traditional OLV Causes ALI “
  • Extrapolated Evidence - (weak)
  • Retrospective Studies – (weak)
  • Animal Studies
  • Clinical Studies
slide24

Animal Studies:

De Abreu , et al. AnesthAnalg 2003

Control – 2LV @ 8 ml

PEEP = 2

Protect - OLV @ 4 ml

PEEP = 2

Tradit’l – OLV @ 8 ml

PEEP = 0

slide25

OLV in the Rabbit Lung Model

De Abreu, et al. AnesthAnalg 2003; 96:220

PIP

MPAP

WG

TXB2

2-LV (CTRL)

Protect OLV

Traditional OLV

slide26

Hypothesis:

  • “Traditional OLV Causes ALI “
  • Extrapolated Evidence – (weak)
  • Retrospective Studies – (weak)
  • Animal Studies – (suggestive)
  • Clinical Studies
slide27

Clinical Studies:

  • Schilling, et al 2005
  • Schilling, et al 2007
  • Schilling, et al 2011
  • Traditional vs Protective OLV:
  • ProinflammatoryCytokines
  • Inhalational Agents are protective
slide28

I

Protective OLV and Inflammatory Mediators

Schilling T, et al. AnesthAnalg 2005;101:957

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

slide29

IL-8

TNF-a

IL-10

sICAM

VT = 10 ml/kg

VT = 5 ml/kg

Schilling ‘05

slide30

III

Effect of Volatile Anesthetics on Systemic

and Alveolar Inflammatory Response

Schilling T, et al. Anesthesiology 2011;115:65

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.

slide32

Hypothesis:

  • “Traditional OLV Causes ALI “
  • Extrapolated Evidence – (weak)
  • Retrospective Studies – (weak)
  • Animal Studies – (suggestive)
  • Clinical Studies – (suggestive)
slide33

OLV

Inflammatory

Response

ALI / ARDS

Death

slide34

OLV

  • Unbalance Drainage
  • Chemo / XRT
  • Extent of Surgery
  • Duration of Surg
  • Alcoholism
  • Genetic
  • Unrecognized:
  • Infection
  • Aspiration
  • Emboli
  • TRALI
  • Cardiac
  • Pneumonectomy
  • Impaired Lymphatics
  • Excessive Fluids

Inflammatory

Response

ALI / ARDS

Death

slide35

Low VT

PEEP

Sevoflurane

Desflurane

OLV

  • Unbalance Drainage
  • Chemo / XRT
  • Extent of Surgery
  • Duration of Surg
  • Alcoholism
  • Genetic
  • Unrecognized:
  • Infection
  • Aspiration
  • Emboli
  • TRALI
  • Cardiac
  • Pneumonectomy
  • Impaired Lymphatics
  • Excessive Fluids

Inflammatory

Response

Low FiO2

ALI / ARDS

Death

slide38

II

OLV & Inflammatory Mediators:

PropofolvsDesflurane

Schilling T, et al. Br J Anaesth 2007;99:368

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

slide39

TNF-a

IL-8

IL-10

sICAM-1

Propofol

Desflurane

Schilling ‘07

slide42

Postulated Causes

  • VILI from “Traditional” OLV
  • Oxygen Toxicity
  • Hyperperfusion Stress Injury
  • Inflammatory Response to Surgery
  • Postoperative Hyperexpansion
  • Unrecognized, Known Etiologies
slide43

Known Causes of ALI / ARDS:

Infection

Aspiration

BPF

Cardiac Failure

Pulmonary Embolic events

TRALI

VILI

Other (pancreatitis, trauma, CPB…)

slide48

Factors Associated with ALI

  • High Perioperative Fluid Balance
  • Extent of Surgery
  • Side of Surgery (R > L)
  • Duration of Surgery
  • Alcoholism / Chemotherapy
slide50

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
slide51

Definitions: ALI & ARDS

  • Acute Lung Injury
    • Bilateral Pulmonary Infiltrates
    • PCWP < 18 mmHg
    • PaO2/FiO2 < 300 mmHg
  • ARDS
    • PaO2/FiO2 < 200 mmHg
slide52

Hypothesis:

  • “Traditional OLV Causes ALI “
  • Extrapolated Evidence
  • Retrospective Studies
  • Animal Studies
  • Clinical Studies
slide53

OLV

Inflamm

Mediators

MechStress

Injury

ALI

ARDS

DEATH

slide55

Perspective

Does Traditional OLV Cause ALI ?

Potential contributing factor

Theoretical risk

Not currently strongly supported by evidence

slide56

Recommendations:

Initial VT = 5-6 ml/kg

PEEP = 5