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Ann Thorac Surg 1996;61:945-948
© 1996 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Selective Lung Ventilation During Thoracoscopy: Effects of Insufflation on Hemodynamics

Departments of Surgery and Anesthesiology, West Virginia University School of Medicine, Morgantown, West Virginia

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. Positive-pressure insufflation during thoracoscopy has been advocated by some authors to facilitate exposure of the intrathoracic structures by expediting collapse of the lung. We hypothesized that insufflation during thoracoscopy may result in hemodynamic compromise despite selective lung ventilation.

Methods. After placement of invasive monitoring lines, six adult swine underwent selective lung ventilation and thoracoscopy. Baseline measurements of hemodynamic indices were taken before selective lung ventilation. The right lung then was collapsed; data were obtained at insufflation pressures up to 10 mm Hg and were compared with baseline values using Student's t test.

Results. Cardiac index, mean arterial pressure, and left ventricular stroke work index decreased, whereas pulmonary artery and central venous pressures increased (p < 0.05) at insufflation pressures of 5 mm Hg and greater.

Conclusions. Positive-pressure insufflation during thoracoscopy resulted in significant hemodynamic compromise despite the use of selective lung ventilation. Conversion to thoracotomy may be an alternative if positive-pressure insufflation is necessary to perform the thoracoscopic procedure.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
See also page 948.

Initial enthusiasm for video-assisted thoracic surgery (VATS) procedures has been tempered by reports of perioperative complications such as prolonged air leaks after parenchymal resection, dysrhythmias, and bleeding [1–4]. Although many of the postoperative complications associated with VATS have been identified, reports of intraoperative complications relating to the technique of VATS are few [5, 6].

Several authors have advocated insufflation of carbon dioxide to expedite collapse of the lung to visualize the intrathoracic structures [5, 7–9]. We have shown previously that positive-pressure insufflation during thoracoscopy resulted in substantial hemodynamic compromise in the swine model [10]. However, one of the criticisms of that study was that selective lung ventilation was not used [5]. The majority of VATS procedures use selective lung ventilation with either a double-lumen endotracheal tube (92.5%) or bronchial blocker (5.8%) [11]. The following study was designed to evaluate the hemodynamic response to insufflation pressures during thoracoscopy in swine using a more clinically relevant selective lung ventilation model.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Six healthy adult pigs weighing between 50 and 70 kg were given preanesthetic injections of telezol (2.72 mg/kg), xylazine (2.0 mg/kg), and glycopyrrolate (0.11 mg/kg) intramuscularly. A double-lumen endotracheal tube was placed 10 minutes after the injections. Correct positioning of the endotracheal tube was confirmed by fiberoptic bronchoscopy. Anesthesia for the remainder of the preoperative preparation and surgical procedure was maintained by a semiclosed circuit with inhalation of isoflurane (1% to 3%). No ß-blocking agents were used during the procedure. Ventilator settings were as follows: tidal volume, 7 mL/kg; inspired oxygen fraction, 0.50; and positive end-expiratory pressure, 5 cm H₂O. Lactated Ringer's solution was infused at a constant rate of 2 mL•kg^-1•h^-1. Continuous intraarterial pressures were measured by a femoral artery catheter. A pulmonary artery catheter was placed in the jugular vein and positioned in the pulmonary artery until pulmonary artery capillary wedge pressure (PCWP) could be recorded. Continuous electrocardiographic monitoring was used. Baseline measurements of heart rate, central venous pressure (CVP), mean arterial pressure (MAP), cardiac index (CI), mean pulmonary artery pressure, left ventricular stroke work index, and PCWP were obtained. The CI was determined by the thermodilution technique using three values within 10% of each other, with no more than five values obtained at a time.

After recording baseline data, we began selective left lung ventilation. A 12-mm trocar with valve was inserted into the right hemithorax percutaneously, a wide-angle zero-degree thoracoscope (Karl Storz Endoscopy America, Inc, Culver City, CA) was placed through the trocar, and the ipsilateral hemithorax was explored (Fig 1).

View larger version (15K): [in this window] [in a new window]   Fig 1. . Experimental design. A, double-lumen endotracheal tube. B, pulmonary artery catheter. C, thoracoscopic port for verifying lung collapse, insufflating CO2 into the pleural space, and recording the insufflation pressures. D, arterial pressure catheter.

We obtained a total of six values for each hemodynamic variable per insufflation pressure. Statistical analysis was performed using Student's paired t test. Data are expressed as the mean +/- standard error of the mean.

All animals received humane care and were treated in compliance with the ``Guide for the Care and Use of Laboratory Animals'' published by the National Institutes of Health (NIH publication 85-23, revised 1985).

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
The effects of the different insufflation pressures during thoracoscopy on the hemodynamic indices of the animals are shown in Table 1. There was no significant difference between baseline data and data obtained after the institution of selective left lung ventilation and insertion of the thoracoscope, with the exception of a small decrease in MAP.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Initial reports of the technique used to perform thoracoscopy advocated anesthesia through a single-lumen endotracheal tube or with regional techniques [12–15]. Exposure of the intrathoracic structures in these studies often was facilitated by the use of positive-pressure insufflation. As experience with VATS increased and the procedures became more complex, the majority of thoracic surgeons preferred selective lung ventilation [11]. Selective lung ventilation is an excellent technique to facilitate exposure and assist the surgeon in identifying the pathologic process. Despite the widespread use of selective lung ventilation for VATS procedures, many authors still advocate positive-pressure insufflation to enhance exposure of the intrathoracic structures and to expedite collapse of the lung [5, 7, 9, 16].

Positive-pressure insufflation during thoracoscopy creates a physiologic response very similar to that of a tension pneumothorax. Bitto and associates [17] clearly identified the hemodynamic and respiratory effects of unilateral tension pneumothorax during positive-pressure ventilation in a sheep model. There were progressive decreases in cardiac output and stroke volume in addition to significant increases in pulmonary artery and central venous pressures. In an effort to identify the hemodynamic response to positive-pressure insufflation during thoracoscopy, we previously demonstrated a significant decrease in CI, MAP, stroke volume, and left ventricular stroke work index with as little as 5 mm Hg insufflation pressure [10]. However, in that study, selective lung ventilation was not used.

The present study found significant reductions in CI, MAP, and left ventricular stroke work index and increases in CVP, mean pulmonary artery pressure, and PCWP during incremental increases in positive-pressure insufflation despite selective lung ventilation. These results are similar to the hemodynamic profile seen in our previous study [10]. Heart rate did decrease slightly in this study, but this decrease should not have accounted for the hemodynamic changes seen at the various insufflation pressures.

The clinical impact of positive-pressure pleural insufflation during VATS procedures remains controversial. Several authors have found no untoward sequelae with its use [5, 7, 12, 16], whereas others have reported major problems [6, 14, 18, 19]. Wolfer and colleagues [5] prospectively studied 32 patients undergoing a VATS procedure with selective lung ventilation. They found no significant hemodynamic compromise, except for an increase in CVP, with insufflation pressures up to 14 mm Hg. In that study, no invasive hemodynamic monitoring was used (except for a central line in 14 patients), which makes it difficult to compare findings between studies.

Many patients may have parietal adhesions, ``stiff lungs,'' or other conditions that prevent adequate collapse of the lung after institution of selective lung ventilation. Insufflation of carbon dioxide under these conditions may be of no benefit and may cause more hemodynamic compromise because of the noncompliant lung. Other potential complications associated with insufflation under these conditions, despite the use of selective lung ventilation, include hemodynamic collapse, ventricular dysrhythmias, and the development of a contralateral pneumothorax [6, 14, 19]. If complete collapse of the lung is necessary to perform the VATS procedure safely, one could argue that conversion to a minithoracotomy should be done instead of instituting positive-pressure insufflation, which may cause perioperative complications.

In conclusion, we have found that insufflation pressures of 5 mm Hg in the swine model resulted in significant hemodynamic compromise despite the use of selective lung ventilation. This hemodynamic compromise was accentuated by additional pleural insufflation pressures of 10 mm Hg. Although positive-pressure insufflation during VATS remains a possibility, conversion to a thoracotomy should be considered.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
This study was funded by a grant from Auto Suture Company. We express our appreciation to Gerald Hobbs, PhD, for statistical analyses and Ms Balinda Schwartz for preparation of the manuscript. Appreciation is also extended to Mr James DeShong, Mr Joseph Collins, Mr Robert McTaggart, and Mr Larry Hicks for their assistance in the laboratory.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Presented at the Forty-second Annual Meeting of the Southern Thoracic Surgical Association, San Antonio, TX, Nov 9–11, 1995.

Address reprint requests to Dr Hill, Department of Surgery, West Virginia University School of Medicine, PO Box 9238 HSCN, Morgantown, WV 26506-9238.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Ronald C. Hill David R. Jones Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hill, R. C. Articles by Kalantarian, B. Search for Related Content PubMed PubMed Citation Articles by Hill, R. C. Articles by Kalantarian, B. Related Collections Related Article