Comparison of the efficacy of high-flow oxygen insufflations and continuous positive airway pressure during one-lung ventilation undergoing video-assisted thoracoscopic surgery

Isolation of one-lung leads to ventilation-perfusion mismatch and increases intrapulmonary shunt, which in some cases may lead to clinically significant hypoxemia.

The objective was to compare the efficacy of hypoxemia correction and the convenience of surgical work during one-lung ventilation with the use of high-flow oxygen insufflation (HFI) and continuous positive airway pressure (CPAP) in the non-ventilated lung during video-assisted thoracoscopic surgery (VATS).

Materials and methods. The study included 60 patients who underwent surgical intervention in the form of VATS lobectomy. All studied patients were randomly divided into two groups: group 1 included patients who received HFI into non-ventilated lung to correct hypoxemia, and group 2 – CPAP into non-ventilated lung. The study was divided into four stages. Stage I – two-lung ventilation. Stage II – one-lung ventilation. At stage III, HFI of 60 L/min (FiO₂ = 0,5) into non-ventilated lung was used to correct hypoxemia in group 1, and CPAP of 5 cm H₂O into non-ventilated lung was used in group 2. At stage IV, HFI of 30 L/min (FiO₂ = 0,5) into non-ventilated lung was used to correct hypoxemia in group 1, and CPAP of 2 cm H₂O into non-ventilated lung was used in group 2. The following parameters were recorded during the stages of the study: PaO₂, PaCO₂, SpO₂, Qs/Qt, and surgical team satisfaction with lung collapse by 10-point visual analogue scale (VAS).

Results. At stages I and II, there was no statistically significant difference between groups in such parameters as PaO₂, PaCO₂, SaO₂, and SpO₂ (p > 0.05). Starting from stage III, a statistically significant difference between the two groups was found for a parameter PaO₂ (U 26.0; Z = –6.27; p < 0.001). For group 1, it was equal to 134.5 (126.0; 141.75) and for group 2 – 108.5 (104.0; 114.5) correspondingly. At stage IV, the values of PaO₂ were higher in group 1: 118.5 (113.0; 122.25) vs 92.5 (89.0; 98.25) in group 2 (U 0.0; Z = –6.66; p < 0.001). When comparing PaCO₂ between the two groups, there were no statistically significant differences at all stages (p > 0.35). When comparing SaO₂ at stages I (U 450.0; Z = 0.0; p = 1.0), II (U 422.5; Z = –0.4; p = 0.69), III (U 339.0; Z = –1.8; p = 0.69), no statistically significant differences were indicated between the two groups. However, at stage IV, the value of SaO₂ was higher (97 (96; 97)) in group 1 than in group 2 (94 (94; 95)), U 69.5; Z = –5.75; p < 0.001. When comparing SpO2 between the two groups, there was no statistical difference at all stages (p > 0.69). Comparing the two groups by such indicator as Qs/Qt, no statistically significant differences were found at the first three stages (p > 0.4). A comparison of Qs/Qt at stage IV revealed statistically significant differences (U 69.0; Z = –5.6; p < 0.001). This parameter was equal to 10.7% (9.5; 15.7) in group 1 and 21.3% (18.4; 23.9) in group 2 correspondingly. When assessing surgical team satisfaction levels with surgical field visualization by VAS, there were statistically significant differences between group 1 and group 2 at stage III (p < 0.001) and stage IV (p < 0.001). The satisfaction level was significantly higher in group 1.

Conclusions. The usage of high-flow oxygen insufflation during one-lung ventilation undergoing VATS allows to effectively correcting hypoxemia similar to the CPAP method, but as opposed to CPAP, it can provide comfortable conditions for carrying out the surgical procedures.

1. Vlasenko A.V., Koryakin A.G., Evdokimov E.A. The use of high-flow oxygen therapy in the manifestation of acute respiratory failure of various genesis. Medical Alphabet, 2018, vol. 2, no. 18, pp. 58–58. (In Russ.).

2. Vyzhigina M.A., Mizikov V.M., Sandrikov V.A. et al. Modern features of respiratory support in thoracic surgery. Traditional problems and innovative solutions (experience of more than 2 thousand anesthesias). Anesthesiology and resuscitation, 2013, no. 2, pp. 34–41. (In Russ.). Doi: 10.21292/2078-5658-2022-19-6-41-47.

3. Grachev I.N., Shatalov V.I., Klimov A.G. et al. Comparative analysis of the use of high-flow and traditional oxygen therapy in patients with severe community-acquired pneumonia. Bulletin of Intensive Care named after A.I. Saltanov, 2020, no. 3, pp. 95–103. (In Russ.). Doi: 10.21320/1818-474X-2020-3-95-103.

4. Kavochkin A.A., Vyzhigina M.A., Kabakov D.G. et al. Anesthetic support of thoracoscopic operations on lungs and mediastinal organs. Messenger of Anesthesiology and Resuscitation, 2020, vol. 17, no. 4, pp. 113–122. (In Russ.). Doi: 10.21292/2078-5658-2020-17-4-113-122.

5. Kassil V.L., Vyzhigina M.A., Khapiy H.H. Mechanical ventilation in anesthesiology and intensive care, Moscow, Medpress-inform, 2009, pp. 34–45. (In Russ.).

6. Farshatov A.G., Khalikov A.D., Ershov E.N. et al. Evaluation of the effectiveness of high-flow oxygen insufflation during single-lung ventilation. Anesthesiology and resuscitation, 2022, no. 5, pp. 18–22. (In Russ.). Doi: 10.17116/anaesthesiology202205118.

7. Duwat A., Courivaud P., Dusart E. et al. High-flow oxygen therapy for peroperative hypoxemia during one-lung ventilation. Journal of Anesthesia & Clinical Research, 2019, vol. 10, issue 2, pp. 9–11. Doi: 10.4172/2155-6148.1000880.

8. Fujiwara M., Abe K., Mashimo T. The effect of positive end-expiratory pressure and continuous positive airway pressure on the oxygenation and shunt fraction during one-lung ventilation with propofol anesthesia. Journal of Clinical Anesthesia, 2001, vol. 13, no. 7, pp. 473–477. Doi: 10.1016/s0952-8180(01)00310-5.

9. Guenoun T., Journois D., Silleran-Chassany J. et al. Prediction of arterial oxygen tension during one-lung ventilation: Analysis of preoperative and intraoperative variables. Journal of Cardiothoracic and Vascular Anesthesia, 2002, vol. 16, no. 2, pp. 199–203. Doi: 10.1053/jcan.2002.31067.

10. Helmerhorst H.J.F., Schultz M.J., van der Voort P.H.J. Bench-to-bedside review: the effects of hyperoxia during critical illness. Crit Care, 2015, no. 19, pp. 284. Doi: 10.1186/s13054-015-0996-4.

11. Lewis S.R., Baker P.E., Parker R. et al. High-flow nasal cannulae for respiratory support in adult intensive care patients. Cochrane Database of Systematic Reviews, 2021, no. 3. Doi: 10.1002/14651858.CD010172.pub3.

12. Karzai W., Schwarzkopf K. Hypoxemia during one-lung ventilation: prediction, prevention, and treatment. Anesthesiology, 2009, no. 6, pp. 1402–1411. Doi: 10.1097/ALN.0b013e31819fb15d.

13. Miller R.D. Anesthesia. Philadelphia, 2020, vol. 2, chapter 53, pp. 1648–1716.

14. Pavlík M., Ctvrtecková D., Zvonícek V. et al. The improvement of arterial oxygenation during one-lung ventilation – effect of different CPAP levels. Acta Chir Hung, 1999, vol. 38, no. 1, pp. 103–105. PMID: 10439108.

15. Rees D.I., Wansbrough S.R. One-lung anesthesia: percent shunt and arterial oxygen tension during continuous insufflation of oxygen to the nonventilated lung. Anesthesia & Analgesia, 1982, vol. 61, no. 15, pp. 507–512. PMID: 7200740.

16. Roca O., Hernández G., Díaz-Lobato S. et al. Current evidence for the effectiveness of heated and humidified high flow nasal cannula supportive therapy in adult patients with respiratory failure. Crit Care, 2016, vol. 28, no. 1, pp. 109. Doi: 10.1186/s13054-016-1263-z.

17. Slinger P., Suissa S., Triolet W. Predicting arterial oxygenation during one-lung anaesthesia. Canadian Journal Anaesthesia, 1992, vol. 39, no. 10, pp. 1030–1035. Doi: 10.1007/BF03008370.

18. Slinger P.D., Campos J.H. Anesthesia for thoracic surgery. Miller’s anesthesia, 7th ed., Philladelfia, 2010, pp. 1852–1853.

19. Umari M., Falini S., Segat M. et al. Anesthesia and fast track in Anesthesia and fast-track in video-assisted thoracic surgery (VATS): from evidence to practice: from evidence to practice. Journal of Thoracic Disease, 2018, vol. 10, no. 4, pp. 542–554. Doi: 10.21037/jtd.2017.12.83.