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. 2018 Jul;6(13):269.
doi: 10.21037/atm.2018.06.02.

Use of lung-protective strategies during one-lung ventilation surgery: a multi-institutional survey

Biniam Kidane  1   2 , Stephen Choi  3 , Dalilah Fortin  1   4   5 , Turlough O'Hare  6 , George Nicolaou  7 , Neal H Badner  7 , Richard I Inculet  1   4 , Peter Slinger  3 , Richard A Malthaner  1   4
Affiliations

Use of lung-protective strategies during one-lung ventilation surgery: a multi-institutional survey

Biniam Kidane et al. Ann Transl Med. 2018 Jul.

Abstract

Background: Limited evidence suggests that intraoperative lung-protective ventilation (LPV) during one-lung ventilation (OLV) may reduce respiratory complications after thoracic surgery. Little is known about LPV practices during OLV. Our purpose was to assess the state of practice/perspectives of anesthesiologists regarding LPV during elective OLV.

Methods: We conducted a multi-institutional cross-sectional survey of anesthesiologists performing OLV at high-volume Canadian tertiary/university centers. The survey was designed, refined and distributed by a multi-disciplinary team using the Dillman method. Univariable and multivariable analyses were used.

Results: Seventy-five (63%) of 120 eligible respondents completed the survey. Although the critical care literature focuses on minimizing tidal volume (TV) as the central strategy of LPV, most respondents (89%, n=50/56) focused on minimizing peak airway pressure (PAP) as their primary strategy of intraoperative LPV. Only 64% (n=37/58) reported actively trying to minimize TV. While 32% (n=17/54) were unsure about the current evidence regarding LPV, 67% (n=36/54) believed that the evidence favoured their use during OLV. Perceived clinical and institutional barriers were the only predictors of reduced attempts to minimize TV on univariate analyses. In multivariable/adjusted analyses, perceived institutional barriers were the only predictors of reduced attempts to minimize TV with adjusted odds ratio of 0.1 (95% CI: 0.03-0.6).

Conclusions: Most anesthesiologists defined low PAP as the primary strategy of LPV during OLV and attempted to minimize it. This study is the first to assess the practice/perspectives of anesthesiologists regarding LPV during OLV and also the first to explore predictors of LPV use. Randomized trials are currently ongoing. However, this study suggests that institutional barriers may subvert future knowledge translation and need to be addressed.

Keywords: Acute respiratory distress syndrome (ARDS); anesthesia; lung physiology; perioperative care.

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Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Target PAPs as reported by anesthesiologists. Respondents reported trying to keep PAP below a mean of 30.3 (5.8) cmH2O (median 30 cmH2O, interquartile range, 30–35). PAP, peak airway pressure.
Figure 2
Figure 2
Target tidal volumes as reported by anesthesiologists. Respondents reported trying to keep TV below a mean of 6.4 (1.5) cc/kg predicted body weight (median 6 cc/kg, interquartile range, 5–7). TV, tidal volume.
Figure 3
Figure 3
Rating of elements of lung protective ventilation. When asked to rate in order of importance what defines LPV, the aggregate order placed minimization of PAP as most important followed by minimization of TV. 1, Most defining/important element of LPV; 4, least defining/important element of LPV. LPV, lung-protective ventilation; PAP, peak airway pressure; TV, tidal volume.
Figure 4
Figure 4
Patient populations that would benefit from LPV during OLV surgery. In general, it appeared that respondents believed that LPV practices would benefit patients with poorer baseline lung function and those with larger pulmonary resections. GLF, good lung function; VATS, video-assisted thoracic surgery; PLF, poor lung function; LPV, lung-protective ventilation; OLV, one-lung ventilation.
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