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Optimizing One-Lung Ventilation Philip Hartigan , M.D. 11/25/11 Kuwait

Optimizing One-Lung Ventilation Philip Hartigan , M.D. 11/25/11 Kuwait. The Balancing Act of One-Lung Ventilation. O 2. CO 2. Injury. The essence of efficient g as exchange i s Ventilation –Perfusion Matching. Multiple Inert Gas Elimination Technique. West.JB: Resp Physiology.

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Optimizing One-Lung Ventilation Philip Hartigan , M.D. 11/25/11 Kuwait

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  1. Optimizing One-Lung Ventilation Philip Hartigan, M.D. 11/25/11 Kuwait

  2. The Balancing Act of One-Lung Ventilation O2 CO2 Injury

  3. The essence of efficient gas exchange is Ventilation –Perfusion Matching

  4. Multiple Inert Gas Elimination Technique West.JB: Resp Physiology

  5. Multiple Inert Gas Elimination Technique HPV West.JB: Resp Physiology

  6. Multiple Inert Gas Elimination Technique HPV Gravity West.JB: Resp Physiology

  7. Multiple Inert Gas Elimination Technique HPV Gravity Anatomy West.JB: Resp Physiology

  8. MIGET during OLV

  9. HPV & Gravity

  10. R/O Obstruction

  11. CPAP

  12. PEEP Recruit

  13. Hypoxia During OLV • FiO2 = 1.0 • R/O Obstruction/Malposition • Reinflation • Recruit/PEEP to Dependent Lung • CPAP to Nondependent Lung • PA Crossclamp

  14. Optimal PEEP ?

  15. Beyond CPAP & PEEP ? • Choice of Volatile Agent • Dose of Volatile Agent • TIVA • Inhaled Nitric Oxide • Ventilator Mode

  16. Beyond CPAP & PEEP ? • Choice of Volatile Agent • Dose of Volatile Agent • TIVA • Inhaled Nitric Oxide • Ventilator Mode

  17. Choice of Agent & PaO2 during OLV Pagel‘98(humans) Desfl= Isofl Schwarzkopf ‘03 (pigs) Desfl = Isofl Wang ‘98 (humans) Isofl= Sevo Saito ‘00 (humans) Isofl= Sevo Shimizu ‘98 (humans) Isofl = Sevo Abe ‘98 (humans) Isofl= Sevo Slinger ‘95 (humans) Isofl > Enfl

  18. Beyond CPAP & PEEP ? • Choice of Volatile Agent • Dose of Volatile Agent • TIVA • Inhaled Nitric Oxide • Ventilator Mode

  19. Dose of Volatile Agents and PaO2 during OLV Schwarzkopf, Anesth Analg, 93:1434, 2001

  20. Beyond CPAP & PEEP ? • Choice of Volatile Agent • Dose of Volatile Agent • TIVA • Inhaled Nitric Oxide • Ventilator Mode

  21. TIVA vs Volatile AnesthesiaPaO2 during OLV Reid ‘96 (30 Pts) Prop/Alf = Iso Karzai ‘98 (10 pigs) Prop > Des Abe ‘98 (20 Pts) Prop > Iso/Des Beck ‘01 (40 Pts) Prop = Sevo Dossow‘01 (50 Pts) Prop/Fent > TEA/Iso Schwarzkopf ‘03 (30 pigs) Prop > Des/Iso Pruszkowski‘07 (80 Pts) Prop = Sevo Schwarzkopf ‘09 (60 Pts) Prop = Sevo

  22. TIVA vsVolatile Agents Schwarzkopf K; J Cardiothoracic Vasc Anesth2003;17(1):73 PropDesflIsofl PaCO ( mmHg) 35 + 5 35 + 4 36 + 1 2 PaO ( mmHg) 196 + 70† 133 + 58 126 + 57 2 PvO ( mmHg) 40 + 5* 37 + 5 36 + 5 2 Qs/Qt (%) 23 + 7 25 + 7 26 + 5 RL Perfusion (%) 19 + 7 20 + 7 18 + 6 CO (L/min) 5.4 + 2§, ‡ 4.4 + 1 5.0 + 2

  23. Beyond CPAP & PEEP ? • Choice of Volatile Agent • Dose of Volatile Agent • TIVA • Inhaled Nitric Oxide • Ventilator Mode

  24. iNO and Oxygenation During OLV ReferencenNO PPMPaO2 Hartigan 36 20 No Change Anesthesiology 1996

  25. iNO and Oxygenation During OLV ReferencenNO PPMPaO2 Hartigan 36 20 No Change Anesthesiology 1996 Wilson 6 40 No Change J. CardiothVascAnesth 1997 Ismail – Zade 12 3-5 No Change J. Cardioth Vasc Anesth 1997 Moutafis 20 20 No Change Anesth Analg 1997 Fradj 60 20 NoChange Br J Anaesth 1998 Schwarzkopf 152 20 No Change Anesth Analg 2001 Della Rocca 30 40 No Change J. Cardioth Vasc Anesth 2001

  26. Beyond CPAP & PEEP ? • Choice of Volatile Agent • Dose of Volatile Agent • TIVA • Inhaled Nitric Oxide • Ventilator Mode

  27. 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)

  28. Dose of Volatile Agents and PaO2 during OLV Schwarzkopf, AnesthAnalg, 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

  29. Dose of Volatile Agents and PaO2 during OLV Schwarzkopf, Anesth Analg, 93:1434, 2001

  30. 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 vsVolatile AgentsSchwarzkopf K; J CardiothoracVascAnesth 17: 73, 2003

  31. Advantages of PCV • Decelerating Flow Pattern • Improved Recruitment of Slow Alveoli • More Homogeneous Ventilation • Better V/Q Matching (?) • Lower PIP’s

  32. Beyond CPAP & PEEP ? • Choice of Volatile Agent • Dose of Volatile Agent • TIVA • Inhaled Nitric Oxide • Ventilator Mode • Position • Thoracic Epidural • Cardiac Output

  33. PaO2 during OLV: Effect of Position Lateral > Prone > Supine

  34. Beyond CPAP & PEEP ? • Choice of Volatile Agent • Dose of Volatile Agent • TIVA • Inhaled Nitric Oxide • Ventilator Mode • Position • Thoracic Epidural • Cardiac Output

  35. Beyond CPAP & PEEP ? • Choice of Volatile Agent • Dose of Volatile Agent • TIVA • Inhaled Nitric Oxide • Ventilator Mode • Position • Thoracic Epidural • Cardiac Output

  36. PaO2 Perfusion of Nondependent Lung P.A. Pressure Counteracts HPV Mixed Venous O2 Effect of C.O. on PaO2during OLV

  37. · Cvo2= Cao2 – (Vo2/Qt) Cc´o2 – Cao2 Shunt Qs/Qt = Cc´o2 – Cvo2 Cao2= Cc´o2 · (1 – Qs/Qt) + (Qs/Qt) · Cvo2 Fick ( ) Qs/Qt · · x Combined Cao2= Cc´o2 – (Vo2/Qt) 10 x (1 – Qs/Qt) Levin AI. Anesth Analg 2005; 100:12

  38. . Qs/Qt=0.2, VO2 = 150 C.O. & CaO2: Effect of Shunt Qs/Qt = 0.4 Levin AI, Anesth Analg 2005; 100:12-14

  39. 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

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