1. Update on one-lung ventilation: the use of continuous positive
airway pressure ventilation and positive end-expiratory pressure
ventilation – clinical application
Katherine P Grichnik and Andrew Shaw
.
Division of Cardiothoracic Anesthesia and Critical Care Purpose of review
Medicine, Duke University Medical Center, Durham,
North Carolina, USA
The purpose of this review is to examine the evidence for and the clinical use of
continuous positive airway pressure (CPAP) and positive end-expiratory pressure
Correspondence to Katherine Grichnik, MD, Professor
of Anesthesia, Division of Cardiothoracic Anesthesia (PEEP) for the management of one-lung ventilation during thoracic surgery. CPAP and
and Critical Care Medicine, Box 3094, Duke University PEEP use are important as we are increasingly challenged with patients with less
Medical Center, Durham, NC 27710, USA
Tel: +1 919 681 6893; fax: +1 919 681 8994; respiratory reserve and greater comorbidity leading to the need for greater clinical
e-mail: grich002@mc.duke.edu management and more interventions during one-lung ventilation for thoracic surgery to
Current Opinion in Anaesthesiology 2009,
prevent perioperative complications.
22:23–30 Recent findings
The focus of this article is on the most recent literature with selected classic articles.
First, the supportive literature and rationale for application of PEEP, CPAP or both
during thoracic surgery are reviewed, relative to the threats of hypoxemia, hyperoxia and
mechanical lung injury. The second part of the article focuses on the clinical use of PEEP
and CPAP. Algorithms for the application of CPAP and PEEP to patients both at risk and
not at risk of acute lung injury are presented.
Summary
CPAP and PEEP are useful not only to treat hypoxia and atelectasis as the consequence
of one-lung ventilation, perhaps more importantly, also as part of a protective lung-
ventilation strategy to ameliorate mechanical stress and prevent acute lung injury.
Keywords
acute lung injury, continuous positive airway pressure, hyperoxia, positive
end-expiratory pressure, protective lung ventilation
Curr Opin Anaesthesiol 22:23–30
ß 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
0952-7907
during OLV to optimize respiratory parameters during
Introduction surgery.
The management of patients for thoracic surgical pro-
cedures remains challenging. Not only do patients pre-
sent with a variety of comorbidites, but they are also Why do we use positive end-expiratory
subjected to a surgical insult with the requirement pressure and continuous positive airway
for one-lung ventilation (OLV). In addition to the pressure? Considerations for one-lung
physical considerations of the lateral decubitus position, ventilation for thoracic surgery
common intraoperative problems include proper iso- There are two main rationales for the use of PEEP and
lation of the lungs utilizing a dual lumen endotracheal CPAP during OLV: hypoxemia and to prevent ALI.
tube or bronchial blocker, the potential for dynamic
pulmonary hyperinflation and hypoxia. In preventing Hypoxemia
and treating these problems, one must be cognizant Hypoxemia is a constant threat during thoracic surgery
of the potential for causing acute lung injury (ALI) utilizing OLV with or without the lateral position, although
through a variety of mechanisms including barotrauma the incidence is now low during routine OLV [1,2].
and volutrauma. Traditionally, the use of 100% oxygen has been advocated
to prevent and treat oxygen desaturation during OLV,
The present study will focus on the rationale for and maximize blood flow to the dependent lung, decrease
perioperative use of continuous positive airway pressure nausea, improve peripheral oxygenation and decrease
(CPAP) and positive end-expiratory pressure (PEEP) wound infections [3,4,5], despite the acknowledgement
0952-7907 ß 2009 Wolters Kluwer Health | Lippincott Williams Wilkins DOI:10.1097/ACO.0b013e32831d7b41
Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.

2. 24 Thoracic anaesthesia
that high FIO2 can cause absorption atelectasis [6]. PEEP and CPAP used to treat the consequences of
However, there is evidence that the lowest possible position, muscle relaxation and dependent lung venti-
fraction of inspired oxygen (FIO2) should be delivered lation [19].
to the thoracic patient to prevent oxidative damage and
postoperative ALI [7]. Hyperoxia may promote the The bulk of the literature regarding ALI/ARDS is based
release of radical oxygen species (ROS), which could on animal studies demonstrating that high-volume, high-
perpetuate an inflammatory response [8,9]. ROS have pressure ventilation causes diffuse alveolar damage with
also been shown to be formed during pulmonary surgery subsequent increased capillary permeability, lung water
with OLV [10]; diseased lungs may be more susceptible gain, high protein pulmonary edema, inflammation acti-
to injury from moderate hyperoxia [11]. However, the vation and cytokine release [20–22]; there are also many
role of hyperoxia in lung injury acquired during thoracic clinical ICU studies in ALI/ARDS patients demonstrat-
surgery is unknown. Although the relationship of FIO2 to ing the benefit of a PLV strategy [23–28].
oxygen-induced lung injury has not been clearly defined
in ALI/acute respiratory distress (ARDS) patients, an Licker et al. [29] defined a measure called ‘ventilatory
FIO2 less than or equal to 0.6 is usually considered to be hyperpressure index’ – the product of inspiratory plateau
well tolerated. Thus, the problem of hypoxia during pressure more than 10 cmH2O and the duration of OLV.
OLV is compounded by the need to use the lowest Patients who developed primary ALI after thoracic
FIO2 possible during surgery. CPAP and PEEP are both surgery were managed with almost twice the ventilatory
used to address these issues. hyperpressure index than patients who did not develop
ALI. Further, in 190 patients for lung resection, van der
Acute lung injury Werff et al. [30] found that 42% of patients with consist-
For years, hypoxemia was considered the most important ent intraoperative peak inspiratory pressures of more than
(if not the only) problem during OLV [12]. Therefore, 40 cmH2O developed signs of ALI. Later, the factors
guidelines were published in multiple papers and books, associated with ALI after thoracotomy were investigated
many of them based on the studies by Katz et al. [13] who in 879 patients [31]. High intraoperative ventilation
found that large tidal volumes produced the highest pressure was found to be a significant risk for early onset
arterial oxygen tension (PaO2) during OLV, leading of ALI (distinct from late onset ALI with an obvious
to the recommendation that tidal volume during OLV precipitating factor) [32].
should be as high as in two-lung ventilation (i.e.,
8–12 ml/kg) [14]. However, ALI is now known to be a Choi et al. [33] examined patients scheduled for elective
problem after thoracic surgery [15], which may be aug- surgical procedures lasting 5 h or more. Patients were
mented or ameliorated by the strategies chosen for OLV. ventilated with nonprotective ventilation [12 ml/kg tidal
In fact, Misthos et al. [16] demonstrated significant oxi- volume, zero end-expiratory pressure (ZEEP)], or PLV
dative stress (using serum malondialdehyde levels) in (6 ml/kg tidal volume, 10 cmH2O PEEP). Nonprotective
thoracic patients, which was directly related to the degree mechanical ventilation led to procoagulant changes
of surgical tissue resection and the duration of OLV. One (increased soluble thrombomodulin and lower levels of
can postulate a ‘multiple hit’ theory for thoracic surgery bronchoalveolar-activated protein C in lavage fluids)
patients who may have increased susceptibility to ALI compared with PLV, potentially leading to fibrin deposits
due to underlying disease, prior therapies, type of within the airways. Others found that myeloperoxidase
surgery, the need for OLV and other perioperative events release during longer procedures was increased in
[17,18]. Although the causes for perioperative ALI patients managed with 12 ml/kg tidal volume and ZEEP
are clearly multifactorial, hyperinflation and repetitive compared with 6 ml/kg tidal volume and 10 cmH2O
inflation/deflation cycles of lung units (mechanical stress) PEEP [34].
are thought to be contributive to ALI. Excessive tidal
volume or mechanical stress may form the ‘primary’ hit or Esophageal patients were compared using conventional
create a ‘second’ hit in a susceptible patient. This leads to high tidal volume (9 ml/kg with ZEEP) during OLV to
the primary recommendations for protective lung venti- PLV (5 ml/kg tidal volume and 5 cmH2O PEEP) [35].
lation (PLV): tidal volume reduction to a maximum of The PLV group demonstrated lower levels of IL-1, IL-6
6 ml/kg predicted body weight (and ideally less) and and IL-8 at the end of OLV and 18 h after surgery as well
limiting the plateau airway pressures to less than as improved oxygenation and a shorter duration of post-
20 cmH2O. Further, most PLV protocols also rely on operative mechanical ventilation. In contrast, Wrigge
5–10 cmH2O PEEP to preserve dependent lung unit et al. [36] found no difference in inflammatory mediator
aeration, prevent atelectasis and reduce injury from release between high tidal volume (12–15 ml/kg tidal
mechanical stress. It is interesting to note that normal volume and ZEEP) compared with PLV (6 ml/kg tidal
mammalian tidal volumes are 6.3 ml/kg; it may thus be volume and 10 cmH2O PEEP) in thoracic or major
that PLV represents physiologic lung ventilation, with abdominal patients within 3 h of surgery.
Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.

3. Update on one-lung ventilation Grichnik and Shaw 25
Fernandez-Perez et al. [37] retrospectively analyzed Figure 1 A stratified protective lung ventilation proposal
prospectively collected data regarding the intraopera-
tive tidal volume of 170 patients undergoing pneumo-
nectomy. They found that 9% of patients developed Normal lung and no ALI risk
’ Abnormal lung and/or presence of
’
factors ( hits’) ALI risk factors ( hits’)
ALI/ARDS and an additional 9% developed milder
respiratory failure. The affected patients had been
Tidal volume 10 ml/kg PBW Tidal volume 6 ml/kg PBW
exposed to a significantly larger tidal volume (median plateau pressure 15--20 cmH2O plateau pressure 15--20 cmH2O
PEEP ≥ 5 cmH2O PEEP ≥ 5 cmH2O
8.3 vs. 6.7 ml/kg predicted body weight, P 0.001).
Multivariate logistic regression analysis identified larger
intraoperative tidal volume and larger intraoperative Suggested ventilator settings stratified by presence or absence of ALI
fluid volume as risk factors. PEEP was not specifically risk factors. Hits include factors that increase ALI risk such as sepsis,
aspiration, transfusions, or all. ALI, acute lung injury; PBW, predicted
addressed in this study, but in general, low tidal volume body weight; PEEP, positive end-expiratory pressure. Adapted with
ventilation mandates concurrent PEEP use to prevent permission from [17].
atelectasis.
Schilling et al. [38] investigated OLV in thoracic surgical Clinical use of positive end-expiratory
patients with either 5 or 10 ml/kg tidal volume. They pressure and continuous positive airway
found that low tidal volume ventilation resulted in pressure during one-lung ventilation
decreased alveolar inflammation with less release of The clinical uses of PEEP and CPAP are reviewed
tumor necrosis factor alpha and lower soluble intercel- relative to the treatment of hypoxemia and ALI.
lular adhesion molecule concentrations. Further, an anti-
inflammatory cytokine, IL-10 was depressed in the high Use of positive end-expiratory pressure
tidal volume ventilation group. Of note, this group used Concern has been expressed that the use of a low tidal
3 cmH2O PEEP during TLV but used ZEEP during volume strategy in otherwise healthy operative (nonthor-
OLV for both patient groups. acic) patients will lead to detrimental atelectasis, which in
turn would create impaired oxygenation, inflammation,
infection and counter-intuitively, the risk for infection,
Collectively, these studies provide strong support for the
ALI or all. Thus, on this basis alone (prevention of
use of a PLV strategy for patients undergoing OLV for atelectasis and preservation of oxygenation), many have
thoracic operative procedures and thus at risk for ALI.
advocated for the use of PEEP with or without intrao-
One can argue that all thoracic surgical patients are at risk
perative recruitment measures to accompany the use of
for the development of ALI and should be treated as such
low tidal volume ventilation.
[39]. But what about surgical patients not deemed at
high risk for ALI?
However, thoracic surgical patients face additional chal-
lenges. With the lateral decubitus position and OLV, the
Shultz et al. [17] recently reviewed the pertinent dependent lung is subjected to a unique situation includ-
literature regarding the effects of PLV in nonoperative ing gravitational compression of the dependent chest
mechanical ventilation patients without definite ALI/ cavity, probable significant atelectasis and the potential
ARDS [17]. They found that the collective, random- for elevated airway pressures. PEEP application should
ized studies did not definitely support the use of prevent atelectasis, improve shunt fraction and allow
low tidal volume ventilation, perhaps because of the the use of a lower tidal volume ventilatory strategy. As
measurement of surrogate markers (e.g. inflammatory a representative study, Fujiwara et al. [40] examined
mediators) instead of clinically relevant outcomes but 15 patients undergoing OLV with 10 ml/kg tidal volume
did note no harm. However, they further postulated under ZEEP alone, PEEP alone, CPAP alone and PEEP
that, although operative patients are subjected to much with CPAP, demonstrating that all three interventions
shorter duration of mechanical ventilation compared improved oxygenation and shunt fraction compared with
with ICU patients, those patients may still be at sig- ZEEP alone. Most consider these known data, but there
nificant risk of ALI as a consequence of the multitude of are still those who are not applying PEEP, CPAP or both
concurrent pathological processes that are taking place during OLV using low tidal volume [41]. Lohser [39]
in an operating room setting (‘the multiple hit theory’). eloquently stated, ‘Use of protective OLV with low tidal
They therefore proposed that a stratified PLV strategy volume but no PEEP is not rational, as derecruitment is
should be used in all mechanical ventilation patients to harmful and auto-PEEP unreliable in terms of homo-
reduce at least one risk factor for postoperative respir- geneous lung recruitment.’
atory failure. PLV algorithms are proposed for patients
with and without risk factors for ALI as presented in Lung recruitment maneuvers to open collapsed depen-
Fig. 1. dent lung units followed by the application of 5 cmH2O
Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.

4. 26 Thoracic anaesthesia
PEEP is reportedly the best method to employ PEEP Figure 3 Change in arterial oxygenation as determined by the
during OLV. Success using this maneuver to improve net change in inflection point-positive end-expiratory pressure
gradient
oxygenation during OLV has been documented [42,43]
with the caution that recruitment can transiently decrease
cardiac index and blood pressure. Further benefit has Change in PaO2 (mmHg)
been documented in a rat model as recruitment maneu-
vers followed by 6 cmH2O PEEP had an additive effect 100
in improving oxygenation and pulmonary mechanics with 80
attenuation cytokine release [44]. 60
40
An important clinical concept is the interaction between 20
PEEP and tidal volume, with the need to adjust both
0
to find the optimal combination to minimize alveolar --6 --4 --2 0 2 4 6
--20
damage and maintain alveolar recruitment [45–47].
There is wide variation in individual pulmonary --40
responses to the application of PEEP [48,49]. Further, --60
one needs to consider the probability of coexistent auto- --80
PEEP in patients with severe chronic obstructive pul-
monary disease (COPD) presenting for lung resection. Net change IP-EEP gradient (cm H2O)
However, external PEEP may not increase total PEEP or
aggravate auto-PEEP if the expiratory time is appropri- The positive or negative change in arterial oxygenation (PaO2), as
ately long [50]. determined by the net change in IP-EEP gradient after the application
of 5 cmH2O PEEP. IP, inflection point; PEEP, positive end-expiratory
pressure. Adapted with permission from [51].
In a classic article, Slinger et al. [51] also focused on the
relationship of external PEEP with the lower inflection
point (LIP) of patients’ static compliance curves and ameliorating the need for a high FiO2 and reducing
their effect on oxygenation. They found that the the potential for oxidative injury.
addition of PEEP improved oxygenation in 14%, had
no effect in 65% and caused decreased oxygenation in Michelet et al. [52] also supported the tenet of ‘best’
21% of patients (Fig. 2). Further investigation revealed PEEP in a porcine study of various PEEP levels. They
that when the addition of 5 cm PEEP caused the plateau found that 5 and 10 cmH2O PEEP were associated with
end-expiratory pressure (EEP) to move towards the improved oxygenation and continuous lung volume
inflection point (decreased IP-EEP) of a patient’s static recruitment but 15 cmH2O PEEP resulted in overdisten-
compliance curve, oxygenation improved. Conversely, tion and increased shunt compared with the other PEEP
when the addition of external PEEP pushed the EEP levels. Similarly, Maisch et al. [53] propose that ‘best
past the lower inflection point (LIP) (increased IP-EEP), PEEP’ is found only after a recruitment maneuver, as
oxygenation deteriorated. The authors acknowledged evidenced by the highest compliance with the lowest
that measurement of compliance curves intraoperatively dead space fraction to yield a maximum amount
to predict who would benefit from PEEP would be of effectively expanded alveoli. Lachmann et al. [54]
cumbersome (Fig. 3). However, this maneuver can emphasized the importance of not using excessive PEEP
improve oxygenation in selected patients, perhaps as high levels of PEEP, conventional lung ventilation or
both caused significantly more bacterial translocation
than an open PLV model.
Figure 2 Oxygenation change with addition of 5 cmH2O positive
end-expiratory pressure during one-lung ventilation
Thus, PEEP use is exceedingly important to treat and
prevent hypoxemia – but its use must be moderated by
20% decrease
the possibility for causing lung overdistention, variable
response and, when used excessively, possibly causing or
No change contributing to ALI.
20% increase
Use of continuous positive airway pressure
0 10 20 30 40 50 60 70 CPAP has been traditionally used to treat hypoxemia
due to the obligatory shunt created by nondependent
Percentage change in oxygenation from OLV baseline to the addition of lung collapse [3]. Application of CPAP has been
5 cmH2O PEEP to OLV. OLV, one-lung ventilation; PEEP, positive end- suggested to be used in the deflation phase of a tidal
expiratory pressure. Adapted with permission from [51].
volume breath often after the PEEP use has led to
Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.

5. Update on one-lung ventilation Grichnik and Shaw 27
increased shunting of perfusion to the nonventilated, Figure 4 Use of selective anatomical or lobar continuous
nondependent lung. positive airway pressure
The use of CPAP may allow the use of a lower FIO2 during
OLV. Senturk et al. [55] demonstrated that the combination
of CPAP and a FIO2 of 0.5 resulted in better oxygenation
and decreased shunt compared with OLV with no CPAP
and a FIO2 of 1.0. Further, their surgeons reported com-
parable operative conditions. Although Senturk et al. [55]
reported comparable operating conditions with CPAP
compared with no CPAP, it is important to note that this
study was conducted with thoracotomy patients, not video-
assisted thoracoscopy surgical (VATS) patients.
Textbook recommendations continue to state that CPAP
should be used for the treatment of hypoxia during OLV,
and VATS is a low priority indication for OLV. We
disagree with both statements. It is more critical to have
effective lung separation and OLV for VATS procedures
than it is for an open procedure as our surgical colleagues
are operating through small incisions and cannot assist
with lung deflation or manipulation through hand decom-
pression. Further, the use of traditional CPAP during a
VATS procedure can serve to keep the nondependent
lung partially inflated, making the identification and Use of a bronchial blocker (pictured here) or suction port of a fiberoptic
visualization of the lung disorder more difficult (and bronchoscope to insufflate oxygen to the selected pulmonary anatomy;
pictured here – the bronchus intermedius. Adapted with permission
sometimes impossible) for the surgeon. Thus, the appli- from [57].
cation of CPAP must be used cautiously in VATS surgery.
Another problem arises when a bronchial blocker or CPAP may be used safely in COPD patients, as it is
single lumen endotracheal tube (SLT) advanced into a unlikely that CPAP will contribute to ventilation diffi-
bronchus are used to achieve lung separation and OLV. culties intraoperatively. However, COPD patients may
Both situations limit the use of CPAP as a maneuver to benefit from CPAP use perioperatively. Soares et al. [60]
improve oxygenation during OLV. Although it is imposs- examined 21 stable, nonoperative COPD patients to
ible to apply CPAP with an endobronchial SLT, CPAP determine that each patient had a ‘best’ CPAP level that
may be cautiously applied to the tiny lumen of a bronchial actually improved inspiratory capacity, reduced inspira-
blocker once the wire stylet has been removed. This does tory load and reduced hyperinflation. In contrast, the
not achieve the same degree of CPAP as with a dual benefit of CPAP used intraoperatively may not persist
lumen tube, but may improve oxygenation. Yoon et al. postoperatively. Ramelli et al. [61] investigated the
[56] recently published a letter illustrating a simple application of CPAP to 40 postlung resection patients.
method to apply a disposable CPAP device to the blocker They found improved oxygenation in the first 24 h but no
lumen of a Univent endotracheal tube using an endo- improvement in the overall incidence of respiratory
tracheal tube connector; clinically this method resulted in complications.
significantly improved oxygenation during OLV.
A multimodal strategy
Three authors have recently advocated the use of lobar Taken together, Licker et al. [62] proposed a multimodal
CPAP to treat hypoxemia during OLV [57–59]. The strategy for operative patients stratified by those at mini-
technique utilizes a bronchial blocker or fiberoptic mal risk vs. those at higher risk for ALI. This approach
bronchoscope advanced into a nonoperative lobe or area utilizes CPAP, PEEP and recruitment maneuvers in
of the nondependent lung under direct vision and (if minimal risk patients to avoid postoperative atelectasis
possible) surgical guidance. Then, 1–3 l/min of oxygen and its consequences. In contrast to Shultz et al.’s [17]
is carefully insufflated through the bronchial blocker suggestions, they did not specify lower tidal volume venti-
lumen or suction port lumen, leading to selective lobar lation in this group. However, in patients at higher risk for
expansion. This can lead to immediate improvement of ALI (including lung resection patients), they proposed a
oxygenation without impairment of the surgical field strict PLV protocol utilizing tidal volume 4–5 ml/kg and
(Fig. 4). limiting plateau pressures to less than 20 cmH2O (Fig. 5).
Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.

6. 28 Thoracic anaesthesia
Figure 5 A multimodal approach to protective lung ventilation Alternatives to continuous positive airway pressure and
positive end-expiratory pressure during one-lung
ventilation
• Anesthesia
• Surgery
Mechanical A completely different approach to the maintenance of
Thorax abdomen ventilation
1 Preinduction
CPAP
normoxoia was investigated by McMullen et al. [66], who
Post-intubation
2
PEEP + CMV BARO-trauma examined a pig OLV model to compare conventional
Assisted ventilation
(BiPAP, PSV) mechanical ventilation (CMV) with biologically variable
Recruitment maneuver ATELEC- VOLU-
trauma trauma mechanical ventilation (BVV) using low tidal volume.
They found that BVV resulted in superior gas exchange
3 Intraop
4 Post-extubation
Lung expansion
Broncho- BIO-trauma Pplateau 20 cmH2O and static compliance, which persisted with restoration
pneumonia alveolo-capillary membrane VT 4--5 ml/kg
interventions
of two-lung ventilation. This is important to consider as
ALI-ARDS
• Lung resection PEEP and CPAP are most often used to increase oxygen-
• Trauma -- shock
• Ischemia -- reperfusion ation but may adversely affect respiratory mechanics. A
• Restrictive lung disease
SIRS • Transfusion study of BVV with and without PEEP/CPAP in thora-
MODS • Sepsis
cotomy patients should be considered.
A multimodal approach to lung protection in the routine surgical patient. There are methods other than the use of CPAP/PEEP,
ALI, acute lung injury; ARDS, acute respiratory distress; BiPAP, bilevel
positive airway pressure; CMV, conventional mechanical ventilation;
which can be concurrently or independently employed
CPAP, continuous positive airway pressure; MODS, multiple organ to improve oxygenation during OLV. These include
dysfunction syndrome; PEEP, positive end-expiratory pressure; PSV, accurate lung separation technique (double lumen endo-
pressure support ventilation; SIRS, systemic inflammatory response
syndrome. Adapted with permission from [62].
tracheal tube, DLT) or bronchial blocker properly
positioned and maintained during surgery, cautious
optimization of cardiac output and pulmonary blood
flow during surgery [67,68], use of ‘blow-by’ oxygen
Additional considerations (1–2 l/min oxygen delivered to endotracheal lumen of
Three additional considerations include other uses for nondependent lung), use of high-frequency jet ven-
CPAP, cardiopulmonary bypass (CPB) and alternatives to tilation, judicious use of intravascular volume and
CPAP and PEEP. occasional low tidal volume hand ventilation at noncriti-
cal points in the surgical procedure.
Other uses for continuous positive airway pressure
CPAP has been used to position the heart or the lung
within the mediastinum to achieve a particular goal. Conclusion
Elliot et al. [63] report the use of OLV and CPAP Clinically, it appears best to employ a PLV ventilation
with air to perform radiofrequency ablation (RFA) of strategy with the initiation of OLV: low tidal volume
pulmonary tumors. This technique achieves a quiet ventilation and limiting plateau airway pressures to less
operative field and partially inflated lung to maximize than 30 cmH2O. PEEP should be added with the onset of
the distance of the radiofrequency ablation (RFA) probe PLV with attention paid to the possibility for dependent
to the hilum. Mittnacht et al. [64] also used CPAP on the lung overdistention when significant intrinsic PEEP
dependent lung to facilitate congenital cardiac surgery exists. The level of PEEP should be adjusted by deter-
via thoracotomy as it positioned the heart towards mining the tidal volume to PEEP ratio that achieves the
the incision. best oxygenation, providing an appropriately long expira-
tory time, measuring total PEEP and consider limiting its
Cardiopulmonary bypass use in severe COPD. It is likely that CPAP or blow-by
CPAP has been used to attempt to decrease the impair- oxygen will have to be added soon after the initiation of
ment of pulmonary function after CPB. CPAP was OLV and PEEP to treat hypoxemia.
applied during CPB and was demonstrated to improve
intraoperative post-CPB shunt fraction and alveolar–
arterial oxygen partial pressure compared with control, References and recommended reading
but these benefits did not extend into the postoperative Papers of particular interest, published within the annual period of review, have
been highlighted as:
period [65]. It is reasonable to remember that OLV is of special interest
used for (mini)thoracotomy approaches to some types of of outstanding interest
Additional references related to this topic can also be found in the Current
cardiac surgery – primarily valvular surgery. Thus, the World Literature section in this issue (pp. 130–131).
tenets of PLV with the use of PEEP must be considered.
1 Brodsky J, Lemmens HJ. Left double-lumen tubes: clinical experience with
If the surgeon is using a minithoracotomy or VATS 1,170 patients. J Cardiothorac Vasc Anesth 2003; 17:289–298.
approach, one must judge carefully whether to use CPAP 2 Slinger P. Pro: low tidal volume is indicated during one-lung ventilation.
as the operative view may be obscured. Anesth Analg 2006; 103:268–270.
Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.

7. Update on one-lung ventilation Grichnik and Shaw 29
3 Lytle FT, Brown DR. Appropriate ventilatory settings for thoracic surgery: 29 Licker M, de Perrot M, Hohn L, et al. Perioperative mortality and major cardio-
intraoperative and postoperative. Semin Cardiothorac Vasc Anesth 2008; pulmonary complications after lung surgery for nonsmall cell carcinoma. Eur J
12:97–108. Cardiothorac Surg 1999; 15:314–319.
A good review of all of the considerations for ventilatory strategies (type of
30 Van der Werff YD, van der Houwen HK, Heilmans PJM, et al. Postpneumo-
ventilator, etc.) for thoracic surgery.
nectomy pulmonary edema: a retrospective analysis of incidence and possible
4 Belda FJ, Aguilera L, Garcia de la Asuncion J, et al. Supplemental periopera- risk factors. Chest 1997; 111:1278–1284.
tive oxygen and the risk of surgical wound infection: a randomized controlled
31 Licker M, De Perrot M, Spiliopoulos A, et al. Risk factors for acute lung injury
trial. JAMA 2005; 294:2035–2042.
after thoracic surgery for lung cancer. Anesth Analg 2003; 97:1558–
5 Puckridge PJ, Saleem HA, Vasudevan TM, et al. Perioperative high dose 1565.
oxygen therapy in vascular surgery. ANZ J Surg 2007; 77:433–436.
32 Slinger PD. Acute lung injury after pulmonary resection: more pieces of the
6 Magnusson L, Spahn DR. New Concepts of atelectasis during general puzzle. Anesth Analg 2003; 97:1555–1557.
anesthesia. Br J Anaesth 2003; 91:61–72.
33 Choi G, Wolthuis EK, Bresser P, et al. Mechanical ventilation with lower tidal
7 Williams EA, Quinlan GJ, Goldstraw P, et al. Postoperative lung injury and volumes and positive end-expiratory pressure prevents alveolar coagulation in
oxidative damage in patients undergoing pulmonary resection. Eur Respir J patients without lung injury. Anesthesiology 2006; 105:689–695.
1998; 11:1028–1034.
34 Wolthuis EK, Choi G, Dessing MC, et al. Mechanical ventilation with lower
8 Carvalho CR, Schettino GPP, Maranhao B, et al. Hyperoxia and lung disease. tidal volumes and positive end expiratory pressure prevents pulmonary
Curr Opin Pulm Med 1998; 4:300–304. inflammation in patients without preexisting lung injury. Anesthesiology
2008; 108:46–54.
9 Szarek JL, Ramsay HL, Andringa A, et al. Time course of airway hyperrespon-
siveness and remodeling induced by hyperoxia in rats. Am J Physiol 1995; 35 Michelet P, D’Journo XB, Roch A, et al. Protective ventilation influences
269 (2 Pt 1):L227–L233. systemic inflammation after esophagectomy: a randomized controlled study.
Anesthesiology 2006; 105:911–919.
10 Lases EC, Duurkens VA, Gerristen WB, et al. Oxidative stress after lung
resection therapy: a pilot study. Chest 2000; 117:999–1003. 36 Wrigge H, Uhlig U, Zinserling J, et al. The effects of different ventilatory
settings on pulmonary and systemic inflammatory responses during major
11 Witschi HR, Haschek WM, Klein-Szanto AJ, et al. Potentiation of diffuse lung
surgery. Anesth Analg 2004; 98:775–781.
damage by oxygen: determining variables. Am Rev Respir Dis 1981; 123:98–
103. 37 Fernandez-Perez ER, Keegan MT, Brown DR, et al. Intraoperative tidal volume
as a risk factor for respiratory failure after pneumonectomy. Anesthesiology
12 S ¨ rk M. Protective ventilation during one-lung ventilation. Anesthesiology
¸entu
2006; 105:14–18.
2007; 107:176–177.
38 Schilling T, Kozian A, Huth C, et al. The pulmonary immune effects of
13 Katz JA, Laverne RG, Fairley HB, et al. Pulmonary oxygen exchange during
mechanical ventilation in patients undergoing thoracic surgery. Anesth Analg
endobronchial anesthesia: effect of tidal volume and PEEP. Anesthesiology
2005; 101:957–965.
1982; 56:164–171.
39 Lohser J. Evidence based management of one lung ventilation. Anesthesiol-
14 Brodsky JB, Fitzmaurice B. Modern anesthetic techniques for thoracic opera-
ogy Clin 2008; 26:241–272.
tions. World J Surg 2001; 25:162–166.
This is a well written, up-to-date and comprehensive article on how to manage OLV
15 Grichnik KP, D’Amico TD. Acute lung injury and acute respiratory distress for thoracic surgery with 117 references.
syndrome after pulmonary resection. Semin Cardiothorac Vasc Anesth 2004;
40 Fujiwara M, Abe K, Mashimo T. The effect of positive end-expiratory pressure
8:317–334.
and continuous positive airway pressure on the oxygenation and shunt
16 Misthos P, Katsaragakis S, Milingos N, et al. Postresectional pulmonary fraction during one-lung ventilation with propofol anesthesia. J Clin Anesth
oxidative stress in lung cancer patients: the role of one-lung ventilation. 2001; 13:473–477.
Eur J Cardiothorac Surg 2005; 27:379–383.
41 Wolthuis EK, Korevaar JC, Spronk P, et al. Feedback and education improve
17 Shultz MJ, Haitsma JJ, Slutsky AS, et al. What tidal volumes should be used in physician compliance in use of lung-protective mechanical ventilation. Inten-
patients without acute lung injury? Anesthesiology 2007; 106:1226–1231. sive Care Med 2005; 31:540–547.
A well written review of the issues surrounding the use of protective lung ventilation
for patients without ALI. 42 Cinnella G, Grasso S, Natale C, et al. Physiological effects of a lung-recruiting
strategy applied during one-lung ventilation. Acta Anaesthesiol Scand 2008;
18 Lytle FT, Brown DR. Appropriate ventilatory settings for thoracic surgery: 52:766–775.
intraoperative and postoperative. Semin Cardiothorac Vasc Anesth 2008;
12:97–108. ˜ ´
43 Alonso-Inigo JM, Beltran R, Garcıa-Covisa NL, et al. Effects of alveolar
recruitment strategy in gas exchange during one-lung ventilation. Anesthe-
19 Tenney SM, Remmers JE. Comparative quantitative morphology of the mam- siology 2007; 107:A1827.
malian lung: diffusing area. Nature 1963; 197:54–56.
44 Ko SC, Zhang H, Haitsma JJ, et al. Effects of PEEP levels following repeated
20 Wheeler AP, Bernard GR. Acute lung injury and the acute respiratory distress recruitment maneuvers on ventilator-induced lung injury. Acta Anaesthesiol
syndrome: a clinical review. Lancet 2007; 369:1553–1564. Scand 2008; 52:514–521.
21 De Abrue MG, Heintz M, Heller A, et al. One-lung ventilation with high tidal 45 Michelet P. Protective ventilation during one-lung ventilation. Anesthesiology
volumes and zero positive end-expiratory pressure is injurious in the isolated 2007; 107:176–177.
rabbit lung model. Anesth Analg 2003; 96:220–228.
46 Ranieri V, Mascia L, Fiore T, et al. Cardiorespiratory effects of positive end-
22 Kuzkov VV, Suborov EV, Kirov MY, et al. Extravascular lung water after
expiratory pressure during progressive tidal volume reduction (permissive
pneumonectomy and one-lung ventilation in sheep. Crit Care Med 2007;
hypercapnia) in patients with acute respiratory distress syndrome. Anesthe-
35:1550–1559.
siology 1995; 83:710–720.
23 Amato MB, Barbas CS, Medeiros DM, et al. Effect of a protective ventilation
47 Richard J, Brochard L, Vandelet P, et al. Respective effects of end-expiratory
strategy on mortality in the acute respiratory distress syndrome. New Engl J
Med 2000; 338:347–354. and end inspiratory pressures on alveolar recruitment in acute lung injury. Crit
Care Med 2003; 31:89–92.
24 The ARDS Network. Ventilation with lower tidal volumes as compared with
traditional tidal volumes for acute lung injury and acute respiratory distress 48 Gattinoni L, Caironi P, Cressoni M, et al. Lung recruitment in patients with
syndrome. N Engl J Med 2000; 342:1301–1308. the acute respiratory distress syndrome. N Engl J Med 2006; 354:1775–
1786.
25 Meade MO, Cook DJ, Guyatt GH, et al. Ventilation strategy using low tidal
volumes, recruitment maneuvers, and high positive end expiratory pressures 49 Leong LMC, Chatterjee S, Gao F. The effect of positive end expiratory
for acute lung injury and acute respiratory distress syndrome: a randomized pressure on the respiratory profile during one-lung ventilation for thoracotomy.
controlled trial. JAMA 2008; 299:637–645. Anaesthesia 2007; 62:23–26.
26 Dellinger RP, Levy MM, Carlet JM, et al. Surviving sepsis campaign: interna- 50 Slinger PD, Hickey DR. The interaction between applied peep and auto-peep
tional guidelines for management of severe sepsis and shock. Intensive Care during one-lung ventilation. J Cardiothorac Vasc Anesth 1998; 12:133–136.
Med 2008; 34:17–60. 51 Slinger PD, Kruger M, McRae K, et al. Relation of the static compliance curve
27 Gothard J. Lung Injury after thoracic surgery and one lung ventilation. Curr and positive end-expiratory pressure to oxygenation during one-lung ventila-
Opin Anaesthesiol 2006; 19:5–10. tion. Anesthesiology 2001; 95:1096–1102.
28 Guerin C, Richard J-C. Current ventilatory management of patients with acute 52 Michelet P, Roch A, Brousse D, et al. Effects of PEEP on oxygenation and
lung injury/acute respiratory distress syndrome. Exp Rev Respir Med 2008; respiratory mechanics during one-lung ventilation. Br J Anaesth 2005;
2:119–133. 95:267–273.
Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.

8. 30 Thoracic anaesthesia
53 Maisch S, Reissmann H, Fuellekrug B, et al. Compliance and dead space 61 Ramelli A, Casati A, Bobbio A, et al. Effects of postoperative continuous
fraction indicate an optimal level of positive end-expiratory pressure after positive airway pressure via helmet after lung resection. Anesthesiology 2007;
recruitment in anesthetized patients. Anesth Analg 2008; 106:175–181. 107:A1807.
54 Lachmann RA, van Kaam AH, Haitsma JJ, et al. High positive end-expiratory 62 Licker M, Diaper J, Ellenberger RAC. Perioperative protective ventilatory
pressure levels promote bacterial translocation in experimental pneumonia. strategies in patients without acute lung injuries. Anesthesiology 2008;
Intensive Care Med 2007; 33:1800–1804. 108:335–336.
A well thought out and reasoned editorial to complement Shultz et al. [17] article
55 S ¨ rk M, Layer M, Pembeci K, et al. A comparison of the effects of 50%
¸entu
with a slightly different perspective.
oxygen combined with CPAP to the nonventilated lung vs. 100% oxygen on
oxygenation during one lung ventilation. Anasthesiol Intensivemed Notfallmed 63 Elliot BA, Curry BA, Atwell TD, et al. Lung isolation, one-lung ventilation, and
Schmerzther 2004; 39:360–364. continuous positive airway pressure with air for radiofrequency ablation of
neoplastic pulmonary. Lesions Anesth Analg 2006; 103:463–464.
56 Yoon S-Z, Lee Y-H, Bahk J-H. A simple method to apply continuous positive
airway pressure during the use of a Univent tube. Anesth Analg 2006; 64 Mittnacht AJC, Joashi U, Nguyen K, et al. Continuous positive airway pressure
103:1042–1043. and lung separation during cardiopulmonary bypass to facilitate congenital
heart surgery via the right thorax in children. Pediatric Anesthesia 2007;
57 McGlade DP, Slinger PD. The elective combined use of a double lumen tube
17:693–696.
and endobronchial blocker to provide selective lobar isolation for lung resection
following contralateral lobectomy. Anesthesiology 2003; 99:1021–1022. 65 Altmay E, Karaca P, Yurtseven N, et al. Continuous positive airway pressure
does not improve lung function after cardiac surgery. Can J Anesth 2006; 53:
58 Sumitani M, Matsubara Y, Mashimo T, et al. Selective lobar bronchial blockade
919–925.
using a double-lumen endotracheal tube and bronchial blocker. Gen Thorac
Cardiovasc Surg 2007; 55:225–227. 66 McMullen MC, Girling LG, Graham MR, et al. Biologically variable ventilation
improves oxygenation and respiratory mechanics in a porcine model of one
59 Hansen LK, Koefoed-Nielsen J, Nielsen J, Larsson A. Are selective lung
lung ventilation. Can J Anesthesiol 2006; 105:91–97.
recruitment maneuvers hemodynamically safe in severe hypovolemia? An
experimental study in hypovolemic pigs with lobar collapse. Anesth Analg 67 Levin AI, Coetzee JF, Coetzee A. Arterial oxygenation and one lung ventilation.
2007; 105:729–734. Curr Opin Anesth 2008; 21:2128–2136.
60 Soares SM, Oliveira RA, Franca SA, et al. Continuous positive airway pressure 68 Schreiber T, Hueter L, Gaser E, et al. Effects of a catecholamine-induced
increases inspiratory capacity of COPD patients. Respirology 2008; 13: increase in cardiac output on lung injury after experimental unilateral pulmonary
387–393. cid instillation. Crit Care Med 2007; 35:1741–1748.
Copyright © Lippincott Williams Wilkins. Unauthorized reproduction of this article is prohibited.