Effect Of Selective Segmental Ventilation During Thoracoscopic Lobectomy On Postoperative Pulmonary Complications

BACKGROUNDThe morbidity and mortality of lung cancer are in the forefront of malignant tumors.Surgery is one of the best option of comprehensive treatments for lung cancer.Lung isolation techniques are primarily designed to facilitate one-lung ventilation(OLV)in patients undergoing procedures involving the chest cavity,and used to protect the lung from soiling by the contralateral lung.Hypoxemia is a common problem during OLV.Increasing the fraction of inspired oxygen(FiO2)can optimize oxygenation during OLV,whereas might also aggravate oxidative stress injury,and increase the incidence of postoperative pulmonary complications(PPCs).In our previous study,a comprehensive pulmonary protection procedure was established for preventing OLV hypoxemia and we reported successful cases of intersegmental plane identification assisted using highly selective independent segmental ventilation during thoracoscopic segmentectomy with specialized instruments and proper intubation techniques.Selective segmental ventilation can prevent hypoxemia by increasing the ventilation area,avoid inhaling high concentration of oxygen during OLV,which may lead to reduce the occurrence of postoperative pulmonary complications.Base on the above protocol together with selective segmental ventilation,the patients’ peroperative outcome might be improved.OBJECTThe purpose of this study was to observe whether selective segmental ventilation during OLV can reduce the incidence of hypoxemia and the incidence of postoperative pulmonary complications in patients undergoing thoracoscopic lobectomy.MATERIALS AND METHODS1.1 Patients and randomizationWith Ethics Committee approval and written informed consent,the study included 90 patients(41 males and 49 females)who underwent video-assisted thoracoscopic surgery lobectomy due to non-small cell lung cancer.The patients were American Standards Association physical status I or II,age rangedfrom 19 to 65years old,and their body mass index(BMI)were 18 to 25 kg/m2.They were randomly divided into three groups:FiO2 1.0 during OLV(group A),FiO2 0.7 during OLV(group B),FiO2 0.7+selective segmental ventilation during OLV(group C),with 30 cases in each group.1.2 AnestheticThe continuous blood pressure was monitored by a radial arterial catheter under local anesthesia before induction.Propofol and remifentanil were induced by target control infusion,then a double-lumen endobronchial tube(DLT)was inserted.The position of the DLT was confirmed by fiberoptic bronchoscopy after the patient was placed in the lateral position.Then the preconditioning was started by clamping the DLT non-ventilated side and OLV for 1 min,switched two-lung ventilation for 1 min,by 3 times.Start of OLV 3 minutes before the operation,and set the FiO2 of each group according to the design of the study.The treatment of the selective lung segmental ventilation group is as follows.When the lung reexpansion was satisfied at the end of the operation,twol lung ventilation was restored and FiO2 was adjusted to 0.5 until extubation.1.3 Implementation of selective segmental ventilationThe left lower lobe basal segment ventilation for thoracoscopic left upper lobectomy;the left upper lobe anterior segment ventilation for thoracoscopic left lower lobectomy;the right lower lobe basal segment ventilation for thoracoscopic right upper lung or right middle lung resection;the right upper lobe anterior segment ventilation for thoracoscopic right lower lung resection.The selective segmental ventilation catheter was placed under the guidance of fiberoptic bronchoscope and connected to the oxygen supply device with oxygen 2L/min.RESULTAll patients completed the study.The groups were comparable in terms of age,BMI,male/female ratio,preoperative pulmonary function and hemoglobin,procedure duration,OLV duration,intrathoracic exposure,volume of fluids,blood loss and urinary output(P>0.05).There was no significant difference in hemodynamics,respiratory mechanics,arterial oxygen saturation and depth of anesthesia among the three groups(P>0.05).During OLV,significant desaturation(SpO2<90%)occurred in 3 cases of group B.After removing the secretion and increasing FiO2 to 1.0,SpO2 was hold steady at about 95%.No cases were switched to two lung ventilation during the procedure in all groups.The oxygenation index in group C was higher than that in group A and B 15min and 45 min after atelectatic(P<0.05 or 0.01).The IL-6 and IL-10 in group A was higher than that in group C on the first postoperative day(P<0.05),the IL-6 in group A was higher than that in group C(P<0.05).The postoperative pro-BNP and CK of the three groups was higher than those before operation,and there was a steeper postoperative rise of pro-BNP in group A(P<0.05).Different kinds of PPCs occurred in group A(n=9),group B(n=1)and group C(n=2).The incidence of postoperative pulmonary complications in group A was higher than that in group B and C.The length of postoperative chest tube retention and the length of postoperative stay in group A was longer than that in group B and C(P<0.05).CONCLUSIONBased on the pulmonary protection procedures for the prevention of hypoxemia during OLV,selective segmental ventilation can further improve oxygenation index during OLV,diminish postoperative inflammatory reaction,reduce the incidence of PPCs,shorten the length of postoperative chest tube indwelling and length of postoperative stay.