co 2 injury the balancing act of one-lung ventilation o2o2
TRANSCRIPT
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OptimizingOne-Lung Ventilation
Philip Hartigan, M.D.11/25/11Kuwait
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CO2
Injury
The Balancing Act ofOne-Lung Ventilation
O2
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The essence of efficientgas exchange
is Ventilation –Perfusion
Matching
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West.JB: Resp Physiology
Multiple Inert Gas Elimination Technique
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West.JB: Resp Physiology
Multiple Inert Gas Elimination Technique
HPV
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West.JB: Resp Physiology
Multiple Inert Gas Elimination Technique
HPV
Gravity
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West.JB: Resp Physiology
Multiple Inert Gas Elimination Technique
HPV
Gravity
Anatomy
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MIGET during OLV
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HPV & Gravity
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R/O Obstruction
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CPAP
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PEEPRecruit
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Hypoxia During OLV
FiO2 = 1.0 R/O Obstruction/Malposition Reinflation Recruit/PEEP to Dependent
Lung CPAP to Nondependent Lung PA Crossclamp
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Optimal PEEP ?
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{
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Beyond CPAP & PEEP ?
Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode
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Beyond CPAP & PEEP ?
Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode
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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
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Beyond CPAP & PEEP ?
Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode
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Dose of Volatile Agents and PaO2 during OLV
Schwarzkopf, Anesth Analg, 93:1434, 2001
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Beyond CPAP & PEEP ?
Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode
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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
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PaCO2 (mmHg) 35 + 5 35 + 4 36 + 1
PaO2 (mmHg) 196 + 70† 133 + 58 126 + 57
PvO2 (mmHg) 40 + 5* 37 + 5 36 + 5
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
Schwarzkopf K; J Cardiothoracic Vasc Anesth 2003;17(1):73
TIVA vs Volatile Agents
Prop Desfl Isofl
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Beyond CPAP & PEEP ?
Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode
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iNO and Oxygenation During OLV
Reference n NO PPM PaO2
Hartigan 36 20 No ChangeAnesthesiology 1996
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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
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Beyond CPAP & PEEP ?
Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode
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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)
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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
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Schwarzkopf, Anesth Analg, 93:1434, 2001
Dose of Volatile Agents and PaO2 during OLV
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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
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Advantages of PCV
Decelerating Flow Pattern
Improved Recruitment of Slow Alveoli
More Homogeneous Ventilation
Better V/Q Matching (?)
Lower PIP’s
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Beyond CPAP & PEEP ?
Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode Position Thoracic Epidural Cardiac Output
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Lateral > Prone > Supine
PaO2 during OLV: Effect of Position
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Beyond CPAP & PEEP ?
Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode Position Thoracic Epidural Cardiac Output
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Beyond CPAP & PEEP ?
Choice of Volatile Agent Dose of Volatile Agent TIVA Inhaled Nitric Oxide Ventilator Mode Position Thoracic Epidural Cardiac Output
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Effect of C.O. on PaO2
during OLV
PaO2
Perfusion of Nondependent Lung
P.A. Pressure Counteracts HPV
Mixed Venous O2
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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/Qt
10 x (1 – Qs/Qt)(
)
Shunt
Fick
Combined x·
Levin AI. Anesth Analg 2005; 100:12
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C.O. & CaO2: Effect of Shunt
Levin AI, Anesth Analg 2005; 100:12-14
Qs/Qt=0.2, VO2 = 150.
Qs/Qt = 0.4
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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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THE END