'Best' PEEP during one-lung ventilation

Abstract

Eight patients were studied under general anaesthesia for elective pulmonary lobectomy to see if intrinsic positive end-expired pressure (PEEPi) would appear or increase in the dependent lung during one-lung ventilation (OLV) or if application of external PEEP equal to individually measured PEEPi would produce better arterial oxygenation, haemodynamic state and oxygen delivery than either zero PEEP (ZEEP) or an external PEEP 5 cm H2O greater than PEEPi. Patients were non-obese, without obstructive airways disease, aged 53-76 yr and ASA < III. They received standardized anaesthesia with fentanyl, 50% nitrous oxide in oxygen and isoflurane; monitoring included radial and fibreoptic pulmonary arterial catheters and intermittent positive pressure ventilation with a tidal volume of 8 ml kg-1, 16 bpm, and an I:E ratio of 1:2. PEEPi was measured during two-lung ventilation (TLV) and OLV, using rapid airway occlusion at end-expiration. There was no PEEPi during TLV, but 2-6 mmHg of PEEPi appeared during OLV. Applying external PEEP equal to individually measured PEEPi reduced venous admixture and increased Pa(O2) without a decrease in cardiac index (thus Increasing oxygen delivery) compared with ZEEP, but the improvement in pulmonary gas exchange was lost and an additional penalty of reduced cardiac output was imposed when external PEEP was increased to 5 mmHg above PEEPi.