Differential Lung Ventilation Research Articles

Continuous Positive Airway Pressure versus Differential Lung Ventilation during One Lung Ventilation for Thoracic Surgery.

One lung ventilation (OLV) is a technique used during lung resection surgery to facilitate optimal surgical conditions. However, this may result in severe hypoxemia due to the right-to-left shunt created in the collapsed lung. Several techniques are used to overcome hypoxemia, one of which is continuous positive airway pressure (CPAP) to the non-dependent lung. Another technique is ventilating the non-dependent lung with a minimal volume, thus creating differential lung ventilation (DLV) or split lung ventilation (SLV). In this study, we compared the efficacy of CPAP to DLV during video-assisted thoracoscopic (VATS) lung resection. In this single-center randomized controlled, cross-over study, each patient acted as his control as well as the study. Patients crossed over from SLV to CPAP (or vice versa) with an interval period during which only OLV was used (control period). The primary objective of the study was to observe the changes in oxygenation, ventilation, and the surgeons' perception of the surgical field using CPAP or SLV to the non-ventilated lung during the period of OLV in patients undergoing thoracic surgery. The study revealed that oxygenation was significantly better when using SLV to the non-ventilated lung during the period of OLV (P = 0.03). However, the surgeon found a significantly better surgical field when applying CPAP to the surgical field. The study showed that using SLV to the non-ventilated lung during the period of OLV was superior in terms of oxygenation, although it interfered more with the surgical field.

Endoscopically assisted transaxillary release of the scalene muscles for thoracic outlet syndromes: a comparison with or without first rib resection.

There are several surgical techniques for thoracic outlet syndrome (TOS). However, there have been no reports of endoscopically assisted transaxillary release of the anterior and middle scalene muscles (EATRS), leaving the first rib intact for TOS. We hypothesized that EATRS would achieve a good Quick Disability of the Arm, Shoulder and Hand score. This study aims to present our experience with a new technique for TOS using endoscopy. We chose two surgeries depending on the patient's TOS condition. If the costoclavicular space was under 12mm, we selected endoscopically assisted transaxillary first rib resection (EAFRR). If the costoclavicular space was over 12mm, we selected EATRS. Between January 2021 and December 2022, 31 consecutive surgeries for TOS were performed in our institution. Twenty-five patients underwent EAFRR, and six (19%) underwent EATRS. Since July 2022, EAFRR has been performed under differential lung ventilation. Complete and almost complete relief was achieved in 24 patients (77%), and partial relief was conducted in seven patients (23%) at a mean of 19.7months after surgery. The symptoms improved in all cases. Intraoperative pneumothorax did not occur, and no other complications were observed. Both EAFRR and EATRS were effective and safe surgeries for TOS. Operative time was significantly shorter in EATRS than in EAFRR. We first report EATRS surgery for TOS. EATRS is indicated for patients whose costoclavicular space is preserved before surgery. Good surgical results were obtained after surgery for this indication.

Simultaneous transmediastinal esophagectomy and thoracoscopic lobectomy for synchronous double cancers of the esophagus and lung: a case report

Abstract Background Simultaneous surgery for synchronous double cancers of the esophagus and lung is so invasive that minimally invasive surgical procedures are preferred. For left lung cancer, there are few reports on simultaneous surgery due to the difficulty of performing radical esophagectomy only via the left thoracic approach and the high invasiveness of bilateral thoracotomy. Case presentation A 65-year-old man who was diagnosed with synchronous double cancer of the esophagus and left lung underwent transmediastinal esophagectomy (TME) and thoracoscopic lobectomy (TSL) simultaneously. This procedure is advantageous because radical esophagectomy can be completed regardless of the side affected by the lung cancer, and respiratory function can be preserved by shortening the duration of differential lung ventilation and avoiding thoracotomy. Conclusion This surgery could be a good treatment option for synchronous double cancers of the esophagus and lung in a highly proficient hospital.

Extubation by supraglottic airway after lobectomy prevents cough-associated air leaks and prolonged coughing or sore throat.

Double-lumen endobronchial tubes (DLTs) are essential for differential lung ventilation during pulmonary lobectomy, but they are more rigid, longer, larger in diameter and irritable. Coughing at extubation sometimes causes airway and lung injury, which causes severe air leaks, prolonged cough and sore throat. We examined the prevalence of cough-associated air leaks at extubation and postoperative cough or sore throat after lobectomy and evaluated the efficacy of supraglottic airway (SGA) in preventing these complications. Patient characteristics and operative and postoperative factors data were collected from patients who underwent pulmonary lobectomy between January 2013 and March 2022. After propensity score matching, these data were compared between the SGA and DLT groups. A total of 1069 patients with lung cancer (SGA, 641; DLTs, 428) were enrolled and coughing at extubation occurred in 100 (23.4%) patients in the DLT group, 65 (65.0%) showed increased cough-associated air leaks at extubation and 20 (30.8%) showed prolonged air leaks. Coughing at extubation occurred in 6 (0.9%) in the SGA group. In 193 patients from each group after propensity score matching, coughing at extubation and the associated air leak increase were significantly lower in the SGA group. Visual analogue scale of postoperative cough and sore throat on postoperative days 2, 7 and 30 were significantly lower in the SGA group. SGA is effective and safe for preventing cough-associated air leaks and prolonged postoperative cough or sore throat at extubation following pulmonary lobectomy.

Case Report: Differential lung ventilation with jet ventilation via a bronchial blocker for a patient with a large thoracogastric airway fistula after esophagectomy

A thoracogastric airway fistula (TGAF) is a rare and potentially fatal complication of esophagectomy for esophageal and cardia carcinomas. Isolation of the fistula and pulmonary separation is necessary during the surgical repair of a tracheal fistula. However, currently, the reported airway management techniques are not suitable for patients with a large TGAF. This case study presents an alternative technique for performing differential lung ventilation in a patient with a thoracogastric airway fistula. A 70-year-old man was diagnosed with a thoracogastric airway fistula situated above the carina after esophagectomy, and a thoracoscope-assisted repair of the fistula and pectoralis major myocutaneous flap transplantation were scheduled. The patient could not tolerate one-lung ventilation and the complex intubating operation due to aspiration pneumonia and the size (3.5 cm × 1.7 cm) of the fistula. We, therefore, performed differential lung ventilation in which an extended 6.5#single-lumen endotracheal tube was inserted into the left main bronchus and a 9Fr bronchial blocker was placed in the right main bronchus by using the video-flexible intubation scope. The right lung was selectively inflated with jet ventilation, while positive pressure ventilation was maintained through the left endotracheal tube. The value of SPO2 remained above 95% throughout the operation. For patients with a large thoracogastric airway fistula, differential lung ventilation of a combination of positive pressure ventilation and jet ventilation is useful. Inserting an extended single-lumen endotracheal tube into the left main bronchus and a bronchial blocker into the right main bronchus could be another way of providing differential ventilation for patients with a large thoracogastric airway fistula.

Abstract No. : ABS2870: Continuous positive airway pressure versus differential lung ventilation during one lung ventilation for thoracic surgery

Background & Aims:The primary objective of the study was to observe the changes in oxygenation, ventilation and the surgeons’ perception of the surgical field using continuouspositive airway pressure (CPAP) or single lung ventilation (SLV) to the non-ventilated lung during the period of one lung ventilation (OLV) in patients undergoing thoracic surgery.Methods:In this single centre study, each patient acted as his own control as well as the two study groups. Patient were crossed over from SLV to CPAP or vice versa with an interval period during which only OLV was used (control period).Results:The study revealed that oxygenation was significantly better while using SLV to the non-ventilated lung during the period of OLV. However, the surgeon found significantly better surgical field when CPAP was applied.Conclusion:The study showed that using SLV to the non-ventilated lung during the period of OLV was superior in terms of oxygenation,although it interfered more with the surgical field.GroupPharmacotherapy other than Mg P No n (%)Yes n (%)Group M49 (98.0)1 (2.0)0.031Group C42 (84.0)8 (16.0)

Differential lung ventilation assessed by electrical impedance tomography in ultrasound-guided anterior suprascapular nerve block vs. interscalene brachial plexus block: A patient and assessor-blind, randomised controlled trial.

Ultrasound-guided interscalene brachial plexus block (ISB) is used to control pain after shoulder surgery. Though effective, drawbacks include phrenic nerve block and motor block of the hand. The ultrasound-guided anterior approach to perform suprascapular nerve block (SSNB) may provide a good alternative. To compare lung ventilation and diaphragmatic activity on the operated side in ISB and SSNB. Randomised, controlled patient-blinded and assessor-blinded trial. Outpatient surgical clinic with recruitment from June 2017 to January 2018. Fifty-five outpatients scheduled for arthroscopic shoulder surgery were allocated randomly to receive SSNB or ISB. Technical problems with monitoring devices unrelated to the intervention led to exclusion of seven patients. The remaining 48 (n=24 in each group) were followed up for 24 h without drop-outs. Patients received 10 ml of ropivacaine 1.0% wt/vol for both procedures. Percentage lung ventilation on the operated side was the primary endpoint as assessed with electrical impedance tomography (EIT). Secondary endpoints were hemidiaphragmatic motion on the operated side, pain, opioid use, hand strength and numbness, and patient satisfaction. Before regional anaesthesia, the lung on the operated side contributed a median [IQR] of 50 [42 to 56]% of the total lung ventilation. Postoperatively, it was 40 [3 to 50]% (SSNB) vs. 3 [1 to 13]% (ISB) for an adjusted difference of 23 (95% CI, 13 to 34)%, (P < 0.001). Hemidiaphragmatic motion was 1.90 (95% CI, 1.37 to 2.44 cm), (P < 0.001) lower in the ISB group compared with the SSNB group. Hand strength was 11.2 (95% CI 3.6 to 18.9), (P = 0.0024) kg greater for SSNB and numbness was observed in 0% (SSNB) vs. 46% (ISB) of patients, P < 0.001. Pain was low in the first 6 h after surgery in both groups with slightly, but not significantly, lower values for ISB. No meaningful or significant differences were found for opioid use or patient satisfaction. An ultrasound-guided anterior approach to SSNB preserves ipsilateral lung ventilation and phrenic function better than a standard ISB. drks.de identifier: DRKS00011787.

A case of re-expansion pulmonary edema after minimally invasive cardiac surgery managed through the use of differential lung ventilation and the affected lung up lateral position

A case of re-expansion pulmonary edema after minimally invasive cardiac surgery managed through the use of differential lung ventilation and the affected lung up lateral position

Unilateral pulmonary edema after minimally invasive mitral valve surgery

Introduction Unilateral right-sided pulmonary edema (UPE) is a rare but potentially life-threatening complication after minimally invasive mitral valve surgery (MICS). Methods We will present a case of severe unilateral pulmonary edema with cardiopulmonary instability after mitral valve repair with right minithoracotomy. Results A 45-year-old man (182 cm, 82 kg) was referred to the authors’ hospital for surgical treatment of mitral regurgitation. His medical history included hypertension and chronic obstructive pulmonary disease. Mitral valve repair was performed with plication of prolapsed part of the posterior leaflet and annuloplasty, under general anesthesia. The right lung was decompressed with differential lung ventilation by a double-lumen tracheal tube. Cross-clamp time was 128 min, and CPB time was long (193 min). Three hours after the surgery, oxygen saturation suddenly dropped to approximately 90 %, and frothy pink sputum was blast out from the tracheal tube. Chest radiograph showed unilateral right-sided massive infiltrate. No evidence of residual mitral insufficiency was detected by trans-thoracic echocardiography. Arterial pressure was maintained with high dose norepinephrine. Cardiac output was maintained with epinephrine and dobutamine, which were gradually attenuated within the first postoperative day. Mechanical ventilation was performed with high PEEP and high FiO2 (12 mmHg, 100 %, respiratory rate 16/min, tidal volume 5 ml/kg) by assist/control mode to maintain oxygenation. Pulse steroid therapy was applied for 3 days. Urine output was maintained at least 50 ml/h through the perioperative period. Patient was extubated 21 h after surgery. On the postoperative day 2, chest radiography showed reduced right-sided infiltration. Patient was discharged home on the 8th postoperative day. Discussion The reasons of unilateral right-sided pulmonary edema are multifactorial, including complete lung collapse and ischemic reperfusion injury, systemic inflammatory reaction and extracorporeal circulation, level of mean pulmonary arterial pressure, chronic obstructive pulmonary disease, and increasing CPB time. Perioperative medical team should be aware of the heightened perioperative risk of UPE during MICS.

Differential lung ventilation for increased oxygenation during one lung ventilation for video assisted lung surgery

BackgroundOne lung ventilation (OLV) is the technique used during lung resection surgery in order to facilitate optimal surgical conditions. OLV may result in hypoxemia due to the shunt created. Several techniques are used to overcome the hypoxemia, one of which is continuous positive airway pressure (CPAP) to the non-dependent lung. Another technique is ventilating the non-dependent lung with a minimal volume, thus creating differential lung ventilation (DLV). In this study we compared the efficacy of CPAP to DLV during video assisted thoracoscopic lung resection.Patients and methodThis is a prospective study of 30 adult patients undergoing elective video assisted thoracoscopic lung lobectomy. Each patient was ventilated in four modes: two lung ventilation, OLV, OLV + CPAP and OLV + DLV. Fifteen patients were ventilated with CPAP first and DLV next, and the other 15 were ventilated with DLV first and then CPAP. Five minutes separated each mode, during which the non-dependent lung was open to room air. We measured the patient’s arterial blood gas during each mode of ventilation. The surgeons, who were blinded to the ventilation technique, were asked to assess the surgical conditions at each stage.ResultsOxygenation during OLV+ CPAP was significantly lower that OLV + DLV (p = 0.018). There were insignificant alterations of pH, PCO2 and HCO3 during the different ventilating modes. The surgeons’ assessments of interference in the field exposure between OLV + CPAP or OLV + DLV was found to be insignificant (p = 0.073).ConclusionsDuring OLV, DLV is superior to CPAP in improving patient’s oxygenation, and may be used where CPAP failed.Trial registrationClinicalTrials.gov NCT03563612. Registered 9 June 2018, retrospectively (due to clerical error).

Computerised decision support for differential lung ventilation.

Differential lung ventilation treatment is a mechanical ventilation strategy used for unilateral lung disease or injury. This treatment can be provided to patients who fail to respond to conventional mechanical ventilation to both lungs and is technically challenging to medical personnel. An effective computerised decision support system (CDSS) can be used as a support system to intensivists in providing this treatment to their patients. In this study, a CDSS for differential lung ventilation is presented. By using this system, the mode of ventilation to each lung can be pressure controlled or volume controlled and all ventilation parameters including the peak inspiratory pressure (P insp), tidal volume (V t), positive end-expiratory pressure, fraction of inspired oxygen (n}{}F_{{rm I}{rm O}_2}), and the respiratory rate (f) can be assigned individually to each lung. The proposed CDSS has the potential to be used as a support system to clinicians in providing differential lung ventilation treatments to patients.

Abstract PCCLB-13: DIFFERENTIAL LUNG VENTILATION IN A PEDIATRIC PATIENT ON ECMO USING A BRONCHIAL BLOCKER: A CASE REPORT

Aims & Objectives: Differential lung ventilation (DLV) may be a useful alternative ventilation strategy in patients with disparate lung disease. We describe a patient with respiratory failure post cardiac arrest that was cannulated to VA ECMO. The patient developed right sided interstitial emphysema along with air leak and left sided Hemothorax with secondary atelectasis. The patient was ventilated with DLV using left sided ETT and a right sided bronchial blocker. Methods A fiberoptic bronchoscope was loaded with a 5.5 cuffed ETT and the 7Fr Arndt bronchial blocker was attached to the ETT via the guide loop on the distal end. The bronchoscope was advanced into the right mainstem bronchus and deployed in position releasing the guide loop. The cuff of the bronchial blocker was inflated to ensure complete occlusion of the right mainstem bronchus. The scope was then advanced into the left mainstem and the ETT was placed in good position. ETT and bronchial blockers were noted to be in good position by direct visualization, then attached to 2 separate ventilators.Results The left lung was recruited with PC-SIMV PIP-30, PEEP-12, iTime-3 secs and the right lung rested with CPAP-12, via bronchial blocker; at this pressure level, no air leak was noted. Thirty six hours later, Arndt blocker was removed, the ETT was pulled back into the trachea and the patient transitioned to conventional ventilation strategy. The patient was subsequently decannulated from ECMO and weaned to room air. Conclusions DLV may be performed in patients on ECMO with differential lung disease as an alternative ventilation strategy.

Differential lung ventilation via tracheostomy using two endotracheal tubes in an infant: a case report

BackgroundThis case report presents differential lung ventilation in an infant. The aim is to define an alternative technique for performing differential lung ventilation in children. To the best of our knowledge, this is the first report of this kind.Case presentationA 4.2-kg, 2.5-month-old Asian boy was referred to our facility with refractory hypoxemia and hypercarbia due to asymmetric lung disease with atelectasis of the left lung and hyperinflation of the right lung. He was unresponsive to conventional ventilator strategies; different ventilator settings were required. To perform differential lung ventilation, two separate single-lumen endotracheal tubes were inserted into the main bronchus of each lung by tracheotomy; the tracheal tubes were attached to discrete ventilators. The left lung was ventilated with a lung salvage strategy using high-frequency oscillatory ventilation, and the right lung was ventilated with a lung-protective strategy using pressure-regulated volume control mode. Differential lung ventilation was performed successfully with this technique without complications.ConclusionsDifferential lung ventilation may be a lifesaving procedure in select patients who have asymmetric lung disease. Inserting two single-lumen endotracheal tubes via tracheotomy for differential lung ventilation can be an effective and safe alternative method.

胸膜肺全摘術後気管支瘻併発呼吸不全に対して分離肺換気およびCustomized Dumon Yステントにより軽快したびまん性胸膜中皮腫症例

胸膜肺全摘術後気管支瘻併発呼吸不全に対して分離肺換気およびCustomized Dumon Yステントにより軽快したびまん性胸膜中皮腫症例

Efficacy of Supraglottic Airway for Preventing Lung Injury Associated with Coughing at Extubation after Pulmonary Lobectomy.

The use of double-lumen endobronchial tubes (DLTs) is necessary for differential lung ventilation during pulmonary lobectomy. However, when used with conventional extubation procedures, coughing is more likely and is associated with an increased risk for parenchymal air leak along the staple line and possible subsequent lung injury. We examined the prevalence of coughing-associated air leaks at extubation and the efficacy of using supraglottic airways (SGAs) to prevent air leaks with post-lobectomy extubation. This study included 150 patients with pulmonary emphysema diagnosed using preoperative computed tomography, who underwent pulmonary lobectomy between April 2010 and March 2015. The patients were chronologically enrolled in two groups: the DLT group (60 patients) from April 2010 to August 2012, and the SGA group (90 patients) from September 2012 to March 2015. (Note: the DLT group only included cases without air leak present just prior to extubation). Data were collected on specific patient characteristics and operative and postoperative factors. Coughing at extubation occurred in 15 (25.0%) of 60 DLT patients, and parenchymal air leaks developed in 10 (66.7%) of these 15. Comparison of groups revealed the SGA group was significantly lower for the following: patients with coughing at extubation (P<0.001), coughing-associated air leaks at extubation (P<0.001), air leaks >7days (P=0.006), reoperation due to air leaks (P=0.013), and duration of chest tube drainage (P<0.001). The SGA is effective for preventing air leaks associated with coughing during conventional DLT extubation in post-lobectomy patients.

Successful management of severe unilateral re-expansion pulmonary edema after mitral valve repair with mini-thoracotomy using extracorporeal membrane oxygenation

A 60-year-old man received mitral valve repair via right mini-thoracotomy, which was followed by unilateral re-expansion pulmonary edema on the right side and severe hemoptysis just after the surgery. Despite differential lung ventilation with unilateral high positive end expiratory pressure was initiated for the affected right lung, respiratory function did not improved and hemodynamics was collapsed in the next day. Veno-venous extracorporeal membrane oxygenation was initiated by cannulation of the right jugular and the left femoral vein. After pulmonary function recovered gradually, veno-venous extracorporeal membrane oxygenation was terminated on the fifth postoperative day. He was discharged in ambulatory condition on postoperative day 52.

"High Frequency/Small Tidal Volume Differential Lung Ventilation": A Technique of Ventilating the Nondependent Lung of One Lung Ventilation for Robotically Assisted Thoracic Surgery.

With the introduction of new techniques and advances in the thoracic surgery fields, challenges to the anesthesia techniques had became increasingly exponential. One of the great improvements that took place in the thoracic surgical field was the use of the robotically assisted thoracic surgical procedure and minimally invasive endoscopic thoracic surgery. One lung ventilation technique represents the core anesthetic management for the success of those surgical procedures. Even with the use of effective one lung ventilation, the patient hemodynamics and respiratory parameters could be deranged and could not be tolerating the procedure that could compromise the end result of surgery. We are presenting our experience in managing one patient who suffered persistent hypoxia and hemodynamic instability with one lung ventilation for robotically assisted thymectomy procedure and how it was managed till the completion of the surgery successfully.

Hydrothorax with alveolar-pleural fistula mimicking re-expansion pulmonary edema during liver transplantation: a case report.

We present a case of an alveolar-pleural fistula with hepatic hydrothorax in a patient undergoing orthotropic liver transplantation, which was detected by drainage of transudate through an endotracheal tube during operation. A standard endotracheal tube was changed to a double-lumen tube to provide differential lung ventilation. The patient was diagnosed with an alveolar-pleural fistula by direct vision of an air leak during positive-pressure ventilation through a diaphragmatic incision. There was still a concern about worsening his ventilation due to persistent aspiration of pleural effusion towards the ipsilateral lung during the remaining operation period. Surgeon repaired the defect on the exposed lung surface via diaphragmatic opening. Anesthesiologists should consider an alveolar-pleural fistula as a possible differential diagnosis with re-expansion pulmonary edema when transudate emanating from the endotracheal tube is obtained in patients with massive hydrothorax.

Movements of the double-lumen endotracheal tube due to lateral position with head rotation and tube fixation: a Thiel-embalmed cadaver study.

Following successful double-lumen endotracheal tube (DLT) insertion for pulmonary surgery, the body position of a patient is changed from supine to lateral. This change occasionally leads to the malposition of the DLT and difficulty in differential lung ventilation. In this study, we investigated movements of the DLT induced by change in body position from supine to lateral, using Thiel-embalmed cadavers. Thiel-embalmed cadavers retain full flexibility of the body and preservation of natural colours, using novel preservation techniques. After the tip of the DLT was directly fixed with forceps at the appropriate position in the bronchus, the DLT depth was measured at the lip in supine and lateral positions. The depth of DLT insertion measured at the lip in right (25.2 ± 0.3 cm; mean ± SEM) and left (25.1 ± 0.3 cm) lateral positions was significantly increased compared to the supine position (24.7 ± 0.3 cm). We recommend that the depth of DLT insertion should be advanced by approximately 0.5 cm from the best position, before changing from the supine to lateral position.

Use of Arndt bronchial blocker and the Fastrach laryngeal mask airway for differential lung ventilation in patient with thyroplasty

Granell, M.1; Diago, Gomez L.1; Martín, A.1; Roselló, M.1; Guijarro, R.2; De Andrés, J.1 Author Information