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Two-Lung High-Frequency Jet Ventilation as an Alternative Ventilation Technique During Transthoracic Esophagectomy
Two-Lung High-Frequency Jet Ventilation as an Alternative Ventilation Technique During Transthoracic Esophagectomy Marc Buise, MD,*§ Jasper van Bommel, MD, PhD,*† Michel van Genderen, MD,* Huug Tilanus, MD, PhD,‡ André van Zundert, MD, PhD,§ and Diederik Gommers, MD, PhD*† Objective: The aim of this study was to evaluate two-lung high-frequency jet ventilation during esophagectomy and evaluate the influence of high-frequency jet ventilation on pulmonary complications as compared with one-lung ventilation. Design: A retrospective study. Settings: A single-center study in a university hospital. Participants: The authors analyzed the data of patients who had undergone an elective esophagectomy by transthoracic esophagectomy between January 2000 and December 2006. Intervention: The patients had undergone a cervicothoracoabdominal subtotal esophagectomy via a right-sided thoracotomy. Patients with high-frequency jet ventilation were intubated with a single-lumen endotracheal tube, and an oxygen insufflation catheter was placed inside the endotracheal tube and connected to a high-frequency jet ventilator. Measurements and Main Results: Eighty-seven patients were enrolled, 30 with high-frequency jet ventilation and 57
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RANSTHORACIC ESOPHAGECTOMY with one-lung ventilation (which leads to a total collapse of the contralateral lung) surgically exposes the esophagus. During this procedure, hypoxemia may occur because of shunting of the blood via the nonventilated lung as well as by surgery-induced compression of the mediastinum.1 In some cases of severe hypoxemia, the collapsed lung must be reinflated to restore tissue oxygenation, thus interrupting the surgical procedure. Operative hypoxemia and the duration of one-lung ventilation are even related to the development of postoperative acute respiratory distress syndrome.2 Pulmonary complications such as pneumonia and respiratory insufficiency are among the most frequently reported complications that develop after esophagectomy.3 In 1992, Crozier et al4 reported an incidence of pneumonia in half of their patients. The occurrence of pneumonia depends on many factors (eg, pulmonary complications are associated with the surgical approach used for esophagectomy). A Dutch study showed that limited transhiatal esophagectomy is associated with lower morbidity than is transthoracic esophagectomy with extended en bloc lymphadenectomy.5 In 1997, the British National Confidential Enquiry Into Perioperative Death reported deficiencies in the management of double-lumen tubes (DLTs) during esophagectomy.6 High-frequency jet ventilation (HFJV) to two lungs has been successfully used in several fields of thoracic surgery.7 To reduce the problems of hypoxemia and malpositioning of the DLT and in an attempt to decrease the incidence of postoperative pneumonia after esophagectomy (by decreasing the areas of atelectasis and shunting), the authors have begun using HFJV during esophagectomy at their institution.1,8 The aim of this study was to evaluate HFJV to two lungs through a single endotracheal tube during esophagectomy and the influence of HFJV on early postoperative pneumonia and compare the findings with patients undergoing one-lung ventilation by a double-lumen tube.
with 1-lung ventilation. Both groups were adequately oxygenated, but patients in the one-lung ventilation group had a higher PaCO2 (42.75 ⴞ 7.5 mm Hg) compared with that for the high-frequency jet ventilation group (35.25 ⴞ 8.25 mm Hg) (p < 0.05). There were no differences in postoperative respiratory complications between the 2 groups. Mean blood loss was significantly lower for patients in the highfrequency jet ventilation group (1,243 ⴞ 787 mL). Conclusions: High-frequency jet ventilation to 2 lungs, using a single-lumen tube, is a safe and adequate ventilation technique for use during esophagectomy. High-frequency jet ventilation had no influence on the incidence of postoperative pulmonary complications but reduced perioperative blood loss and led to a decreased need for fluid replacement. © 2009 Elsevier Inc. All rights reserved. KEY WORDS: transthoracic esophagectomy, two-lung ventilation, high-frequency jet ventilation METHODS The Institutional Ethical Review Board of the authors’ university hospital approved the use of the data for scientific purposes. Data from 30 elective esophagus resections by transthoracic esophagectomy, ventilated with two-lung HFJV, between January 2000 and December 2006 were reviewed. These data were compared with those of 57 patients selected for transthoracic esophagectomy, undergoing one-lung ventilation by a DLT, during the same period. Operations were performed with curative intent using a cervicothoracoabdominal subtotal esophagectomy (3-hole esophagectomy). A right-sided posterolateral thoracotomy was used in all patients. During the reviewed period of 6 years, anesthesia was provided following a clinical protocol. Before the induction of anesthesia, a thoracic epidural catheter was placed between T6 and T8 to provide perioperative and postoperative analgesia. After a test dose of 3 mL of bupivacaine 0.5%, an epidural blockade was started with a bolus of bupivacaine and sufentanil. General anesthesia was induced with propofol (1-2 mg/kg) or etomidate (0.15-0.3 mg/kg), sufentanil (0.2-0.4 g/kg), and rocuronium (0.5-1.0 mg/kg). Patients were intubated in the supine position and then placed in the left lateral decubitus position. Anesthesia was maintained by using a propofol infusion, and bolus sufentanil was administered as indicated. In all patients, standard hemodynamic monitoring was used including radial arterial blood pressure and, in the supine position, right atrial pressure measurements through a central venous catheter placed in the left internal jugular vein. In both groups, arterial blood gas analysis was performed during the thoracotomy at between 10 and 20 minutes after the stabilization of
From the Departments of *Anesthesiology, †Intensive Care Medicine, and ‡Surgery, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands; and §Department of Anesthesiology and Intensive Care and Pain Therapy, Catharina-ziekenhuis, Eindhoven, The Netherlands. Address reprint requests to Marc Buise, MD, Department of Anesthesiology and Intensive Care, Catharina-ziekenhuis, PO Box 1350, 5602 ZA Eindhoven, The Netherlands. E-mail: [email protected] © 2009 Elsevier Inc. All rights reserved. 1053-0770/09/2304-0013$36.00/0 doi:10.1053/j.jvca.2008.12.025
Journal of Cardiothoracic and Vascular Anesthesia, Vol 23, No 4 (August), 2009: pp 509-512
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hemodynamics and ventilation. Fluid management was liberal and was performed by using hydroxyethyl starch (HAES sterile 6% or Voluven; Fresenius Kabi’s-Hertogenbosch, The Netherlands), and crystalloids were given to maintain a mean arterial pressure above 60 mmHg and a right atrial pressure between 10 and 12 mmHg. Arterial oxygen and carbon dioxide partial pressures, hemoglobin concentration, and hemoglobin saturation were determined (ABL 707; Radiometer, Copenhagen, Denmark). Blood transfusions were given if the hemoglobin level was below 5.0 mmol/L (8.0 g/dL). Vasopressors were avoided in an attempt not to influence the microvascular blood flow of the constructed gastric tube. Patients in the HFJV group were intubated with a normal, singlelumen, endotracheal tube (male size, 8.5, and female size, 7.5; Portex). After the thoracotomy incision, the ventilator (Draeger Physioflex; Dräger Medical AG & Co KG, Lübeck, Germany) was disconnected, and an oxygen insufflation catheter (Baxter Healthcare Corp, New Providence, NJ) was placed inside the endotracheal tube and connected to a jet ventilator (AMS1000; Acutronic Medical Systems AG, Hirzel, Switzerland). The HFJV was set at a frequency of 100 per minute with a driving pressure of 2.0 atm; FIO2 was set at 0.6 to 1.0 to maintain adequate oxygenation. The surgeon gently manipulated the right lung outside the operative field to create exposure of the esophagus. Patients in the one-lung ventilation group received a left-sided DLT (male size, 39, and female size, 37; Portex, Smiths Medical International LTD, Watford, UK); correct placement was checked by auscultation and, if in doubt, by fiberoptic analysis. Tube position was checked after every repositioning of the patient. The right lung was collapsed after the right lateral thoracotomy and one-lung ventilation of the left lung was started (Draeger Physioflex). A tidal volume of 8 to 10 mL/kg and a frequency of 12 to 15 per minute were adjusted to achieve an end-tidal CO2 of 35 to 45 mmHg with plateau pressure lower than 35 cmH2O. Positive end-expiratory pressure (PEEP) was set at 5 to 7 cmH2O inspiration, expiration was set at 1:2, and FIO2 was between 0.6 and 1 to maintain oxygen saturation (plethysmography) above 95%. After thoracotomy, the patient was returned to the supine position before starting the abdominal part of the operation. In the two-lung ventilation group, the HFJV catheter was removed, and conventional mechanical ventilation was restarted at the same settings as described previously. In the one-lung ventilation group, the DLT was replaced by a normal endotracheal tube before transport to the intensive care unit (ICU). All patients in the intensive care unit were sedated and ventilated until the following morning (Draeger Evita 2 or Evita 4) at the following settings: bilevel positive airway pressure mode, 5 cmH2O PEEP, a peak pressure of 10 to 15 cmH2O above PEEP to achieve a tidal volume of 8 to 10 mL/kg, and a frequency of 15 to 25 needed to achieve normocapnic ventilation. The inspiration:expiration ratio was set at 1:2, and FIO2 was chosen to keep oxygen saturation above 95%. Table 1. Patient and Perioperative Characteristics
Mean age (y) Male/female OR stay (min) ICU stay (d) Blood loss (mL) Crystalloid infusion (mL) RBC transfusion (U) Pneumonia (patients) (%)
OLV (n ⫽ 57)
HFJV (n ⫽ 30)
p Values
62 ⫾ 9 37/20 364 ⫾ 89 13 ⫾ 23 1,883 ⫾ 941 7,333 ⫾ 2,164 1.6 ⫾ 1.5 20 (35)
61 ⫾ 10 13/17 363 ⫾ 82 11 ⫾ 13 1,243 ⫾ 787 6,031 ⫾ 1,793 0.8 ⫾ 1.1 11 (37)
NS NS NS NS 0.002 0.001 0.007 NS
NOTE. All data are given as mean ⫾ standard deviation, except pneumonia, which is given as the number of patients and percentage. Abbreviations: OR, operating room; ICU, intensive care unit; RBC, red blood cell; NS, nonsignificant.
Table 2. Blood Gas Analysis During OLV
Blood Gas Analysis
One-Lung Ventilation (n ⫽ 57)
HFJV (n ⫽ 30)
p Values
pH PaCO2 (mmHg) PaO2 (mmHg) Bicarbonate (mEq/L) Base excess Saturation (%)
7.34 ⫾ 0.06 42.75 ⫾ 7.5 150 ⫾ 86.25 23.3 ⫾ 1.6 ⫺1.81 ⫾ 2.0 97 ⫾ 2.6
7.38 ⫾ 0.05 35.25 ⫾ 8.25 186 ⫾ 102 21.7 ⫾ 1.2 ⫺2.12 ⫾ 1.5 98 ⫾ 2.2
0.0003 0.0003 NS 0.0001 NS 0.02
NOTE. All data are given as mean ⫾ standard deviation. Abbreviation: NS, nonsignificant.
In the authors’ hospital, clinicopathologic data from all patients who are operated on are collected in a database. Pulmonary morbidity was scored including pneumonia (based on positive findings on a chest radiograph and positive results of a sputum culture) and acute respiratory distress syndrome (based on characteristic findings on a chest radiograph in combination with a PaO2/FIO2 ratio lower than 200 mmHg). To compare categoric data, the Fisher exact test was used. The Mann-Whitney U test was used to compare continuous variables. Two-tailed p values less than 0.05 were considered statistically significant. When variables were normally distributed, the mean and standard deviations are reported in Tables 1 and 2. All analyses were performed with Graphpad Prism software (version 3.0; Graphpad Software Inc, San Diego, CA). RESULTS
Thirty patients for elective transthoracic esophagectomy received two-lung mechanical ventilation by HFJV. This group was compared with 60 patients receiving one-lung ventilation by a DLT. Three patients’ anesthesia data were incomplete and, therefore, they were excluded. There was no difference in the patients’ characteristics (Table 1). The mean operation time was comparable between the groups. The mean length of stay in the ICU for patients in the HFJV group was 11 ⫾ 13 days (median ⫽ 6 days) compared with 13 ⫾ 23 days (median ⫽ 7 days) for patients in the one-lung ventilation group (not significant). During thoracotomy, the oxygen saturation was higher in the HFJV group than it was in the one-lung ventilation group; however, arterial oxygen tension was comparable between both groups during thoracotomy (Table 2). Both groups were normocapnic perioperatively, but the HFJV ventilation group had a significantly lower PaCO2 of 35.25 ⫾ 8.25 mmHg versus a PaCO2 of 42.75 ⫾ 7.5 mm Hg (Table 2). There was significantly less blood loss in patients in the HFJV group (1,243 ⫾ 787 mL) compared with the one-lung ventilation group (1,883 ⫾ 941 mL) (p ⫽ 0.002). This resulted in smaller red blood cell transfusions (0.8 ⫾ 1.1 U v 1.6 ⫾ 1.5 U, p ⫽ 0.007) and smaller crystalloid administrations (6,031 ⫾ 1,793 mL v 7,333 ⫾ 2,164 mL, p ⫽ 0.001) (Fig 1). In the HFJV group, pneumonia occurred in 11 patients (37%) compared with 20 patients (35%) in the one-lung ventilation group (not significant). Acute respiratory distress syndrome did not occur. There were no differences in surgical complications such as chylothorax, recurrent nerve pareses, or gastric tube leakage (data not shown).
JET VENTILATION DURING TRANSTHORACIC ESOPHAGECTOMY
Fig 1. Perioperative fluid management. Data given as mean ⴞ standard error of the mean. *p < 0.05.
DISCUSSION
In this retrospective observational study, the authors showed adequate ventilation of both lungs by HFJV during transthoracic esophagectomy using a single-lumen endotracheal tube. The authors compared the HFJV group to patients receiving one-lung ventilation by a DLT. The National Confidential Enquiry Into Perioperative Death report (1997) noted deficiencies in the recognition and management of badly positioned tubes during esophagectomy.8 In an editorial of the British Journal of Anesthesia, Sherry9 noted that even the most experienced anesthesiologists continue to have problems with DLT positioning and she asked for an alternative ventilation strategy. In the authors’ data analysis, no problems or complications were reported with double-tube positioning, but this could be because of the retrospective study design.10 However, using HFJV with a single-lumen tube avoids the problems associated with a DLT such as malpositioning, tube migration, laryngeal damage, and perforation of the bronchi.7 Also, the need to change tubes before transport to the ICU is avoided. Although the technique has been successfully used in other fields of thoracic surgery, to the best of the authors’ knowledge, this is the first study to describe a cohort of patients treated with two-lung HFJV during esophagectomy.7 Other authors have described HFJV in combination with conventional one-lung ventilation, as an additional support in the dependent lung, to restore decreased oxygenation during one-lung ventilation.11 When using high-frequency positive-pressure ventilation with a conventional ventilator (tidal volume, 300 mL; frequency, 100/ min), Tsui et al12 found less hypoxemia in patients treated with two-lung ventilation than in those treated with one-lung ventilation. HFJV to both lungs during esophageal surgery was successfully used to manage a patient with a transesophageal fistula.13 All previously mentioned additional ventilation strategies were used in an attempt to avoid hypoxic periods because perioperative hypoxemia and prolonged duration of one-lung ventilation most likely led to an increased incidence of postoperative pulmonary complications after esophagectomy.2
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In the present study, although there was no hypoxemia in either of the study groups, gas exchange was better using two-lung ventilation than one-lung ventilation during thoracotomy. In thoracic operations other than esophagectomy, the use of HFJV compared with one-lung ventilation has led to prolonged improvement in oxygenation even up to 7 days after surgery.6 There was no difference in the length of stay in the hospital or the ICU between the study groups. Other studies have shown that patients with HFJV had a reduced mean hospital stay. This reduction could be attributed to a lower incidence of postoperative chest infections (as recognized by the findings of pyrexia, purulent sputum, and positive culture results).6 In the present study patients, there was no difference in postoperative pneumonia. The length of ICU stay was relatively long in both study groups (11 ⫾ 13 days [median, 6 days] v 13 ⫾ 23 days [median, 7 days]). This is partly because of the strategy to ventilate the patients for the night on the day of surgery and the policy not to send this particular patient group to a step-down unit. Although not the focus of this study, the authors observed a greater need for fluid replacement and more blood loss in patients in the one-lung ventilation group. Blood loss is mainly dependent on surgical technique. No extended lymphadenectomy was performed, and in both groups the same technique was used by the same surgeon (HWT). Previous studies have shown no change in cardiac output during one-lung ventilation; however, those studies showed increases in pulmonary wedge pressure and pulmonary vascular resistance caused by hypoxic pulmonary vasoconstriction.14,15 Tachibana et al1 showed that the effect of pulmonary vasoconstriction and shunting provides a relative flow obstruction to the left ventricle, and this, in combination with compression of the mediastinum, leads to a greater need for fluid replacement and an increased central venous pressure. In their study, no change in outcome between one-lung or two-lung conventional ventilation was found. The authors did not analyze the central venous pressure because of the unreliability of this measurement during lateral positioning.16 However, an increased central venous pressure, and thus, splanchnic congestion, may be an explanation for the blood loss in patients in the one-lung ventilation group. The influence of higher central venous pressure on operative blood loss is well known during hepatic surgery.17 The observed decrease in blood loss in the HFJV group resulted in a decreased need for transfusions. Blood transfusions during radical esophagectomy are associated with a poorer prognosis.18 Additionally, when used as part of a multimodal approach to reduce the high morbidity and mortality after esophagectomy, decreased blood transfusions and a restrictive fluid management seem to be beneficial.19,20 CONCLUSIONS
HFJV to two lungs using a single-lumen tube is a safe and adequate ventilation technique for use during esophagectomy. When using HFJV, the problems associated with double-lumen tubes are avoided. HFJV has no influence on the incidence of postoperative pulmonary complications, but it does lead to reduced perioperative blood loss and a decreased need for fluid replacement. This retrospective study suggests that a prospective, multicenter randomized study of HFJV on postoperative outcomes in transthoracic esophagectomy is warranted.
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REFERENCES 1. Tachibana M, Abe S, Tabara H, et al: One-lung or two-lung ventilation during transthoracic oesophagectomy? Can J Anaesth 41: 710-715, 1994 2. Tandon S, Batchelor A, Bullock R, et al: Perioperative risk factors for acute lung injury after elective oesophagectomy. Br J Anaesth 86:633-638, 2001 3. Law S, Wong KH, Kwok KF, et al: Predictive factors for postoperative pulmonary complications and mortality after esophagectomy for cancer. Ann Surg 240:791-800, 2004 4. Crozier TA, Sydow M, Siewert JR, et al: Postoperative pulmonary complication rate and long-term changes in respiratory function following esophagectomy with esophagogastrostomy. Acta Anaesthesiol Scand 36:10-15, 1992 5. Hulscher JB, van Sandick JW, de Boer AG, et al: Extended transthoracic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus. N Engl J Med 347:1662-1669, 2002 6. The Report of the National Confidential Enquiry Into Perioperative Deaths 1996/1997. London: NCEPOD, 1998 7. Misiolek H, Knapik P, Swanevelder J, et al: Comparison of double-lung jet ventilation and one-lung ventilation for thoracotomy. Eur J Anaesthesiol 25:15-21, 2008 8. Nevin M, Van Besouw JP, Williams CW, et al: A comparative study of conventional versus high-frequency jet ventilation with relation to the incidence of postoperative morbidity in thoracic surgery. Ann Thorac Surg 44:625-627, 1987 9. Sherry KM: How can we improve the outcome of oesophagectomy? Br J Anaesth 86:611-613, 2001 10. Barach P, Small SD: Reporting and preventing medical mishaps: Lessons from non-medical reporting systems. Br Med J 320:759-763, 2000 11. Imamura M, Yanagibashi K, Tobe T, et al: Transthoracic resection of esophageal cancer in patients with pulmonary dysfunction. Usefulness of high-frequency ventilation during thoracotomy. Ann Surg 208:601-605, 1988
12. Tsui SL, Chan CS, Chan AS, et al: A comparison of two-lung high-frequency positive-pressure ventilation and one-lung ventilation plus 5 cm H2O nonventilated lung CPAP, in patients undergoing anaesthesia for oesophagectomy. Anaesth Intensive Care 19:205-212, 1991 13. Tsui SL, Lee TW, Chan AS, et al: High-frequency jet ventilation in the anesthetic management of a patient with tracheoesophageal fistula complicating carcinoma of the esophagus. Anesth Analg 72:835838, 1991 14. Benumof JL: One-lung ventilation and hypoxic pulmonary vasoconstriction: Implications for anesthetic management. Anesth Analg 64:821-833, 1985 15. Scherer R, Van Aken H, Lawin P: Hemodynamic and respiratory changes in operations of the esophagus by unilateral ventilation [in German]. Chirurg 55:665-669, 1984 16. Emerson RJ, Banasik JL: Effect of position on selected hemodynamic parameters in postoperative cardiac surgery patients. Am J Crit Care 3:289-299, 1994 17. Melendez JA, Arslan V, Fischer ME, et al: Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: Blood loss, blood transfusion, and the risk of postoperative renal dysfunction. J Am Coll Surg 187:620-625, 1998 18. Dresner SM, Lamb PJ, Shenfine J, et al: Prognostic significance of perioperative blood transfusion following radical resection for oesophageal carcinoma. Eur J Surg Oncol 26:492-497, 2000 19. Brodner G, Pogatzki E, Van Aken H, et al: A multimodal approach to control postoperative pathophysiology and rehabilitation in patients undergoing abdominothoracic esophagectomy. Anesth Analg 86:228-234, 1998 20. Neal JM, Wilcox RT, Allen HW, et al: Near-total esophagectomy: The influence of standardized multimodal management and intraoperative fluid restriction. Reg Anesth Pain Med 28:328-334, 2003
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RANSTHORACIC ESOPHAGECTOMY with one-lung ventilation (which leads to a total collapse of the contralateral lung) surgically exposes the esophagus. During this procedure, hypoxemia may occur because of shunting of the blood via the nonventilated lung as well as by surgery-induced compression of the mediastinum.1 In some cases of severe hypoxemia, the collapsed lung must be reinflated to restore tissue oxygenation, thus interrupting the surgical procedure. Operative hypoxemia and the duration of one-lung ventilation are even related to the development of postoperative acute respiratory distress syndrome.2 Pulmonary complications such as pneumonia and respiratory insufficiency are among the most frequently reported complications that develop after esophagectomy.3 In 1992, Crozier et al4 reported an incidence of pneumonia in half of their patients. The occurrence of pneumonia depends on many factors (eg, pulmonary complications are associated with the surgical approach used for esophagectomy). A Dutch study showed that limited transhiatal esophagectomy is associated with lower morbidity than is transthoracic esophagectomy with extended en bloc lymphadenectomy.5 In 1997, the British National Confidential Enquiry Into Perioperative Death reported deficiencies in the management of double-lumen tubes (DLTs) during esophagectomy.6 High-frequency jet ventilation (HFJV) to two lungs has been successfully used in several fields of thoracic surgery.7 To reduce the problems of hypoxemia and malpositioning of the DLT and in an attempt to decrease the incidence of postoperative pneumonia after esophagectomy (by decreasing the areas of atelectasis and shunting), the authors have begun using HFJV during esophagectomy at their institution.1,8 The aim of this study was to evaluate HFJV to two lungs through a single endotracheal tube during esophagectomy and the influence of HFJV on early postoperative pneumonia and compare the findings with patients undergoing one-lung ventilation by a double-lumen tube.
with 1-lung ventilation. Both groups were adequately oxygenated, but patients in the one-lung ventilation group had a higher PaCO2 (42.75 ⴞ 7.5 mm Hg) compared with that for the high-frequency jet ventilation group (35.25 ⴞ 8.25 mm Hg) (p < 0.05). There were no differences in postoperative respiratory complications between the 2 groups. Mean blood loss was significantly lower for patients in the highfrequency jet ventilation group (1,243 ⴞ 787 mL). Conclusions: High-frequency jet ventilation to 2 lungs, using a single-lumen tube, is a safe and adequate ventilation technique for use during esophagectomy. High-frequency jet ventilation had no influence on the incidence of postoperative pulmonary complications but reduced perioperative blood loss and led to a decreased need for fluid replacement. © 2009 Elsevier Inc. All rights reserved. KEY WORDS: transthoracic esophagectomy, two-lung ventilation, high-frequency jet ventilation METHODS The Institutional Ethical Review Board of the authors’ university hospital approved the use of the data for scientific purposes. Data from 30 elective esophagus resections by transthoracic esophagectomy, ventilated with two-lung HFJV, between January 2000 and December 2006 were reviewed. These data were compared with those of 57 patients selected for transthoracic esophagectomy, undergoing one-lung ventilation by a DLT, during the same period. Operations were performed with curative intent using a cervicothoracoabdominal subtotal esophagectomy (3-hole esophagectomy). A right-sided posterolateral thoracotomy was used in all patients. During the reviewed period of 6 years, anesthesia was provided following a clinical protocol. Before the induction of anesthesia, a thoracic epidural catheter was placed between T6 and T8 to provide perioperative and postoperative analgesia. After a test dose of 3 mL of bupivacaine 0.5%, an epidural blockade was started with a bolus of bupivacaine and sufentanil. General anesthesia was induced with propofol (1-2 mg/kg) or etomidate (0.15-0.3 mg/kg), sufentanil (0.2-0.4 g/kg), and rocuronium (0.5-1.0 mg/kg). Patients were intubated in the supine position and then placed in the left lateral decubitus position. Anesthesia was maintained by using a propofol infusion, and bolus sufentanil was administered as indicated. In all patients, standard hemodynamic monitoring was used including radial arterial blood pressure and, in the supine position, right atrial pressure measurements through a central venous catheter placed in the left internal jugular vein. In both groups, arterial blood gas analysis was performed during the thoracotomy at between 10 and 20 minutes after the stabilization of
From the Departments of *Anesthesiology, †Intensive Care Medicine, and ‡Surgery, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands; and §Department of Anesthesiology and Intensive Care and Pain Therapy, Catharina-ziekenhuis, Eindhoven, The Netherlands. Address reprint requests to Marc Buise, MD, Department of Anesthesiology and Intensive Care, Catharina-ziekenhuis, PO Box 1350, 5602 ZA Eindhoven, The Netherlands. E-mail: [email protected] © 2009 Elsevier Inc. All rights reserved. 1053-0770/09/2304-0013$36.00/0 doi:10.1053/j.jvca.2008.12.025
Journal of Cardiothoracic and Vascular Anesthesia, Vol 23, No 4 (August), 2009: pp 509-512
509
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BUISE ET AL
hemodynamics and ventilation. Fluid management was liberal and was performed by using hydroxyethyl starch (HAES sterile 6% or Voluven; Fresenius Kabi’s-Hertogenbosch, The Netherlands), and crystalloids were given to maintain a mean arterial pressure above 60 mmHg and a right atrial pressure between 10 and 12 mmHg. Arterial oxygen and carbon dioxide partial pressures, hemoglobin concentration, and hemoglobin saturation were determined (ABL 707; Radiometer, Copenhagen, Denmark). Blood transfusions were given if the hemoglobin level was below 5.0 mmol/L (8.0 g/dL). Vasopressors were avoided in an attempt not to influence the microvascular blood flow of the constructed gastric tube. Patients in the HFJV group were intubated with a normal, singlelumen, endotracheal tube (male size, 8.5, and female size, 7.5; Portex). After the thoracotomy incision, the ventilator (Draeger Physioflex; Dräger Medical AG & Co KG, Lübeck, Germany) was disconnected, and an oxygen insufflation catheter (Baxter Healthcare Corp, New Providence, NJ) was placed inside the endotracheal tube and connected to a jet ventilator (AMS1000; Acutronic Medical Systems AG, Hirzel, Switzerland). The HFJV was set at a frequency of 100 per minute with a driving pressure of 2.0 atm; FIO2 was set at 0.6 to 1.0 to maintain adequate oxygenation. The surgeon gently manipulated the right lung outside the operative field to create exposure of the esophagus. Patients in the one-lung ventilation group received a left-sided DLT (male size, 39, and female size, 37; Portex, Smiths Medical International LTD, Watford, UK); correct placement was checked by auscultation and, if in doubt, by fiberoptic analysis. Tube position was checked after every repositioning of the patient. The right lung was collapsed after the right lateral thoracotomy and one-lung ventilation of the left lung was started (Draeger Physioflex). A tidal volume of 8 to 10 mL/kg and a frequency of 12 to 15 per minute were adjusted to achieve an end-tidal CO2 of 35 to 45 mmHg with plateau pressure lower than 35 cmH2O. Positive end-expiratory pressure (PEEP) was set at 5 to 7 cmH2O inspiration, expiration was set at 1:2, and FIO2 was between 0.6 and 1 to maintain oxygen saturation (plethysmography) above 95%. After thoracotomy, the patient was returned to the supine position before starting the abdominal part of the operation. In the two-lung ventilation group, the HFJV catheter was removed, and conventional mechanical ventilation was restarted at the same settings as described previously. In the one-lung ventilation group, the DLT was replaced by a normal endotracheal tube before transport to the intensive care unit (ICU). All patients in the intensive care unit were sedated and ventilated until the following morning (Draeger Evita 2 or Evita 4) at the following settings: bilevel positive airway pressure mode, 5 cmH2O PEEP, a peak pressure of 10 to 15 cmH2O above PEEP to achieve a tidal volume of 8 to 10 mL/kg, and a frequency of 15 to 25 needed to achieve normocapnic ventilation. The inspiration:expiration ratio was set at 1:2, and FIO2 was chosen to keep oxygen saturation above 95%. Table 1. Patient and Perioperative Characteristics
Mean age (y) Male/female OR stay (min) ICU stay (d) Blood loss (mL) Crystalloid infusion (mL) RBC transfusion (U) Pneumonia (patients) (%)
OLV (n ⫽ 57)
HFJV (n ⫽ 30)
p Values
62 ⫾ 9 37/20 364 ⫾ 89 13 ⫾ 23 1,883 ⫾ 941 7,333 ⫾ 2,164 1.6 ⫾ 1.5 20 (35)
61 ⫾ 10 13/17 363 ⫾ 82 11 ⫾ 13 1,243 ⫾ 787 6,031 ⫾ 1,793 0.8 ⫾ 1.1 11 (37)
NS NS NS NS 0.002 0.001 0.007 NS
NOTE. All data are given as mean ⫾ standard deviation, except pneumonia, which is given as the number of patients and percentage. Abbreviations: OR, operating room; ICU, intensive care unit; RBC, red blood cell; NS, nonsignificant.
Table 2. Blood Gas Analysis During OLV
Blood Gas Analysis
One-Lung Ventilation (n ⫽ 57)
HFJV (n ⫽ 30)
p Values
pH PaCO2 (mmHg) PaO2 (mmHg) Bicarbonate (mEq/L) Base excess Saturation (%)
7.34 ⫾ 0.06 42.75 ⫾ 7.5 150 ⫾ 86.25 23.3 ⫾ 1.6 ⫺1.81 ⫾ 2.0 97 ⫾ 2.6
7.38 ⫾ 0.05 35.25 ⫾ 8.25 186 ⫾ 102 21.7 ⫾ 1.2 ⫺2.12 ⫾ 1.5 98 ⫾ 2.2
0.0003 0.0003 NS 0.0001 NS 0.02
NOTE. All data are given as mean ⫾ standard deviation. Abbreviation: NS, nonsignificant.
In the authors’ hospital, clinicopathologic data from all patients who are operated on are collected in a database. Pulmonary morbidity was scored including pneumonia (based on positive findings on a chest radiograph and positive results of a sputum culture) and acute respiratory distress syndrome (based on characteristic findings on a chest radiograph in combination with a PaO2/FIO2 ratio lower than 200 mmHg). To compare categoric data, the Fisher exact test was used. The Mann-Whitney U test was used to compare continuous variables. Two-tailed p values less than 0.05 were considered statistically significant. When variables were normally distributed, the mean and standard deviations are reported in Tables 1 and 2. All analyses were performed with Graphpad Prism software (version 3.0; Graphpad Software Inc, San Diego, CA). RESULTS
Thirty patients for elective transthoracic esophagectomy received two-lung mechanical ventilation by HFJV. This group was compared with 60 patients receiving one-lung ventilation by a DLT. Three patients’ anesthesia data were incomplete and, therefore, they were excluded. There was no difference in the patients’ characteristics (Table 1). The mean operation time was comparable between the groups. The mean length of stay in the ICU for patients in the HFJV group was 11 ⫾ 13 days (median ⫽ 6 days) compared with 13 ⫾ 23 days (median ⫽ 7 days) for patients in the one-lung ventilation group (not significant). During thoracotomy, the oxygen saturation was higher in the HFJV group than it was in the one-lung ventilation group; however, arterial oxygen tension was comparable between both groups during thoracotomy (Table 2). Both groups were normocapnic perioperatively, but the HFJV ventilation group had a significantly lower PaCO2 of 35.25 ⫾ 8.25 mmHg versus a PaCO2 of 42.75 ⫾ 7.5 mm Hg (Table 2). There was significantly less blood loss in patients in the HFJV group (1,243 ⫾ 787 mL) compared with the one-lung ventilation group (1,883 ⫾ 941 mL) (p ⫽ 0.002). This resulted in smaller red blood cell transfusions (0.8 ⫾ 1.1 U v 1.6 ⫾ 1.5 U, p ⫽ 0.007) and smaller crystalloid administrations (6,031 ⫾ 1,793 mL v 7,333 ⫾ 2,164 mL, p ⫽ 0.001) (Fig 1). In the HFJV group, pneumonia occurred in 11 patients (37%) compared with 20 patients (35%) in the one-lung ventilation group (not significant). Acute respiratory distress syndrome did not occur. There were no differences in surgical complications such as chylothorax, recurrent nerve pareses, or gastric tube leakage (data not shown).
JET VENTILATION DURING TRANSTHORACIC ESOPHAGECTOMY
Fig 1. Perioperative fluid management. Data given as mean ⴞ standard error of the mean. *p < 0.05.
DISCUSSION
In this retrospective observational study, the authors showed adequate ventilation of both lungs by HFJV during transthoracic esophagectomy using a single-lumen endotracheal tube. The authors compared the HFJV group to patients receiving one-lung ventilation by a DLT. The National Confidential Enquiry Into Perioperative Death report (1997) noted deficiencies in the recognition and management of badly positioned tubes during esophagectomy.8 In an editorial of the British Journal of Anesthesia, Sherry9 noted that even the most experienced anesthesiologists continue to have problems with DLT positioning and she asked for an alternative ventilation strategy. In the authors’ data analysis, no problems or complications were reported with double-tube positioning, but this could be because of the retrospective study design.10 However, using HFJV with a single-lumen tube avoids the problems associated with a DLT such as malpositioning, tube migration, laryngeal damage, and perforation of the bronchi.7 Also, the need to change tubes before transport to the ICU is avoided. Although the technique has been successfully used in other fields of thoracic surgery, to the best of the authors’ knowledge, this is the first study to describe a cohort of patients treated with two-lung HFJV during esophagectomy.7 Other authors have described HFJV in combination with conventional one-lung ventilation, as an additional support in the dependent lung, to restore decreased oxygenation during one-lung ventilation.11 When using high-frequency positive-pressure ventilation with a conventional ventilator (tidal volume, 300 mL; frequency, 100/ min), Tsui et al12 found less hypoxemia in patients treated with two-lung ventilation than in those treated with one-lung ventilation. HFJV to both lungs during esophageal surgery was successfully used to manage a patient with a transesophageal fistula.13 All previously mentioned additional ventilation strategies were used in an attempt to avoid hypoxic periods because perioperative hypoxemia and prolonged duration of one-lung ventilation most likely led to an increased incidence of postoperative pulmonary complications after esophagectomy.2
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In the present study, although there was no hypoxemia in either of the study groups, gas exchange was better using two-lung ventilation than one-lung ventilation during thoracotomy. In thoracic operations other than esophagectomy, the use of HFJV compared with one-lung ventilation has led to prolonged improvement in oxygenation even up to 7 days after surgery.6 There was no difference in the length of stay in the hospital or the ICU between the study groups. Other studies have shown that patients with HFJV had a reduced mean hospital stay. This reduction could be attributed to a lower incidence of postoperative chest infections (as recognized by the findings of pyrexia, purulent sputum, and positive culture results).6 In the present study patients, there was no difference in postoperative pneumonia. The length of ICU stay was relatively long in both study groups (11 ⫾ 13 days [median, 6 days] v 13 ⫾ 23 days [median, 7 days]). This is partly because of the strategy to ventilate the patients for the night on the day of surgery and the policy not to send this particular patient group to a step-down unit. Although not the focus of this study, the authors observed a greater need for fluid replacement and more blood loss in patients in the one-lung ventilation group. Blood loss is mainly dependent on surgical technique. No extended lymphadenectomy was performed, and in both groups the same technique was used by the same surgeon (HWT). Previous studies have shown no change in cardiac output during one-lung ventilation; however, those studies showed increases in pulmonary wedge pressure and pulmonary vascular resistance caused by hypoxic pulmonary vasoconstriction.14,15 Tachibana et al1 showed that the effect of pulmonary vasoconstriction and shunting provides a relative flow obstruction to the left ventricle, and this, in combination with compression of the mediastinum, leads to a greater need for fluid replacement and an increased central venous pressure. In their study, no change in outcome between one-lung or two-lung conventional ventilation was found. The authors did not analyze the central venous pressure because of the unreliability of this measurement during lateral positioning.16 However, an increased central venous pressure, and thus, splanchnic congestion, may be an explanation for the blood loss in patients in the one-lung ventilation group. The influence of higher central venous pressure on operative blood loss is well known during hepatic surgery.17 The observed decrease in blood loss in the HFJV group resulted in a decreased need for transfusions. Blood transfusions during radical esophagectomy are associated with a poorer prognosis.18 Additionally, when used as part of a multimodal approach to reduce the high morbidity and mortality after esophagectomy, decreased blood transfusions and a restrictive fluid management seem to be beneficial.19,20 CONCLUSIONS
HFJV to two lungs using a single-lumen tube is a safe and adequate ventilation technique for use during esophagectomy. When using HFJV, the problems associated with double-lumen tubes are avoided. HFJV has no influence on the incidence of postoperative pulmonary complications, but it does lead to reduced perioperative blood loss and a decreased need for fluid replacement. This retrospective study suggests that a prospective, multicenter randomized study of HFJV on postoperative outcomes in transthoracic esophagectomy is warranted.
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12. Tsui SL, Chan CS, Chan AS, et al: A comparison of two-lung high-frequency positive-pressure ventilation and one-lung ventilation plus 5 cm H2O nonventilated lung CPAP, in patients undergoing anaesthesia for oesophagectomy. Anaesth Intensive Care 19:205-212, 1991 13. Tsui SL, Lee TW, Chan AS, et al: High-frequency jet ventilation in the anesthetic management of a patient with tracheoesophageal fistula complicating carcinoma of the esophagus. Anesth Analg 72:835838, 1991 14. Benumof JL: One-lung ventilation and hypoxic pulmonary vasoconstriction: Implications for anesthetic management. Anesth Analg 64:821-833, 1985 15. Scherer R, Van Aken H, Lawin P: Hemodynamic and respiratory changes in operations of the esophagus by unilateral ventilation [in German]. Chirurg 55:665-669, 1984 16. Emerson RJ, Banasik JL: Effect of position on selected hemodynamic parameters in postoperative cardiac surgery patients. Am J Crit Care 3:289-299, 1994 17. Melendez JA, Arslan V, Fischer ME, et al: Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: Blood loss, blood transfusion, and the risk of postoperative renal dysfunction. J Am Coll Surg 187:620-625, 1998 18. Dresner SM, Lamb PJ, Shenfine J, et al: Prognostic significance of perioperative blood transfusion following radical resection for oesophageal carcinoma. Eur J Surg Oncol 26:492-497, 2000 19. Brodner G, Pogatzki E, Van Aken H, et al: A multimodal approach to control postoperative pathophysiology and rehabilitation in patients undergoing abdominothoracic esophagectomy. Anesth Analg 86:228-234, 1998 20. Neal JM, Wilcox RT, Allen HW, et al: Near-total esophagectomy: The influence of standardized multimodal management and intraoperative fluid restriction. Reg Anesth Pain Med 28:328-334, 2003