Impact of Lower Tidal Volumes During One-Lung Ventilation: A 2022 Update of the Meta-analysis of Randomized Controlled Trials

Mohamed R El Tahan; Evangelia Samara; Nandor Marczin; Giovanni Landoni; Laura Pasin

doi:10.1053/j.jvca.2023.04.018

Impact of Lower Tidal Volumes During One-Lung Ventilation: A 2022 Update of the Meta-analysis of Randomized Controlled Trials

J Cardiothorac Vasc Anesth. 2023 Oct;37(10):1983-1992. doi: 10.1053/j.jvca.2023.04.018. Epub 2023 Apr 20.

Authors

Mohamed R El Tahan¹, Evangelia Samara², Nandor Marczin³, Giovanni Landoni⁴, Laura Pasin⁵

Affiliations

¹ Anesthesiology Department, College of Medicine, Imam Abdulrahman Bin Faisal University, Al Khubar, Dammam, Saudi Arabia.
² Department of Anesthesiology and Postoperative Intensive Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, Ioannina, Greece.
³ The Royal Brompton and Harefield NHS Foundation Trust, London, UK; Section of Anesthesia, Pain Medicine, and Intensive Care, Imperial College London, London, UK; Semmelweis University, Budapest, Hungary.
⁴ Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milano, Italy.
⁵ Department of Anesthesia and Intensive Care, Azienda Ospedale-Università di Padova, Padua, Italy. Electronic address: laurapasin1704@gmail.com.

PMID: 37225546
DOI: 10.1053/j.jvca.2023.04.018

Abstract

Objectives: To clarify the influence of lower tidal volume (4-7 mL/kg) compared with higher tidal volume (8-15 mL/kg) during one-lung ventilation (OLV) on gas exchange and postoperative clinical outcome.

Design: Meta-analysis of randomized trials.

Setting: Thoracic surgery.

Participants: Patients receiving OLV.

Interventions: Lower tidal volume during OLV.

Measurements and main results: Primary outcome was PaO₂_-to-the oxygen fraction (PaO₂/FIO₂) ratio at the end of the surgery, after the reinstitution of two-lung ventilation. Secondary endpoints included perioperative changes in PaO₂/FIO₂ ratio and carbon dioxide (PaCO₂) tension, airway pressure, the incidence of postoperative pulmonary complications, arrhythmia, and length of hospital stay. Seventeen randomized controlled trials (1,463 patients) were selected. Overall analysis showed that the use of low tidal volume during OLV was associated with a significantly higher PaO₂/FIO₂ ratio 15 minutes after the start of OLV and at the end of surgery (mean difference 33.7 mmHg [p = 0.02] and mean difference 18.59 mmHg [p < 0.001], respectively). The low tidal volume also was associated with higher PaCO₂ values 15 minutes and 60 minutes after the start of OLV and with lower airway pressure, which was maintained during two-lung ventilation after surgery. Moreover, the application of lower tidal volume was associated with fewer postoperative pulmonary complications (odds ratio 0.50; p < 0.001) and arrhythmias (odds ratio 0.58; p = 0.009), with no difference in length of hospital stay.

Conclusions: The use of lower tidal volume, a component of protective OLV, increases the PaO₂/FIO₂ ratio, reduces the incidence of postoperative pulmonary complications, and should be considered strongly in daily practice.

Keywords: anesthesia; one-lung ventilation; postoperative complications; thoracic anesthesia; ventilator-induced lung injury.

Publication types

Meta-Analysis

MeSH terms

Humans
Lung
One-Lung Ventilation*
Postoperative Complications / epidemiology
Postoperative Complications / etiology
Postoperative Complications / prevention & control
Randomized Controlled Trials as Topic
Respiration, Artificial
Thoracic Surgical Procedures* / adverse effects
Tidal Volume