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Título

Propensity Matched Study of the Impact of Spontaneous Ventilation in Thoracic Surgery on Anesthesia Management and Operating Room Times

Descrição

Background: The basic principle of SV-VATS (Spontaneous Ventilation Video-assisted Thoracic Surgery) is to avoid endothracheal intubation for one-lung ventilation to prevent its adverse effects, while allowing continued spontaneous breathing as a lung protective measure during the procedure. Objective: This study aimed to evaluate whether SV-VATS provides better lung protection and hemodynamic stability. Method: Our clinical, controlled, observational study included 104 adult patients who underwent video-assisted thoracic surgery under general anesthesia combined with intercostal nerve block between 2017 and 2021. We used propensity score matching (2:1). The intraoperative hemodynamic and ventilation variables as well as processing times were collected in four groups of patients: 1. SV-VATS anatomical resections (N = 22); 2. SV-VATS non-anatomical resections (N = 16); 3. MV-VATS anatomical resections (N = 44); 4. MV-VATS non-anatomical resections (N = 32). In SV-VATS, the airway was secured with a laryngeal mask. Patients were offered pressure support ventilation prior to skin incision. An intrathoracic vagus nerve block was performed to attenuate the cough reflex. MV-VATS was performed using a double-lumen tube and one-lung ventilation. All patients gave written informed consent prior to enrollment in accordance with the Declaration of Helsinki and the Ethics Committee of the Bayerische Landesärztekammer (2020-1041) and the Bavarian Hospital Law (BayKrG §27). Results: There was a significant difference between the SV-VATS and MV-VATS groups in the mean of driving pressure (P < 0.001), which determines the applied tidal volume. The mean driving pressure in the MV-VATS group was 11.8 mbar to achieve a mean tidal volume of 5.6 ml/kg/PBW. In the SV-VATS group, the mean driving pressure was 4.8 mbar to achieve a mean tidal volume of 4.8 ml/kg/PBW. The same trend was observed for anatomic and non-anatomic resections. The SV-VATS group was characterized by significantly higher mean PaCO2 and lower mean pH and base excess values for both anatomic and non-anatomic resections. There were no significant differences in oxygenation between the SV-VATS and MV-VATS groups, but the inspiratory oxygen fraction was significantly higher in the MV-VATS group (P = 0.005). There were no significant differences in intraoperative lactate values between any of the patient groups. There was no significant difference in mean hemodynamic parameters and norepinephrine dose between all patient groups. Median time to recovery from anesthesia and median incision-suture times were significantly shorter in the SV-VATS group (P < 0.001 and P = 0.027, respectively). There was no significant difference in induction of anesthesia between the two groups. Conclusion: Our findings appear to indicate that SV-VATS provided lung
protection under tolerance of permissive hypercapnia and can contribute to accelerated recovery of patients.

Palavras Chave

SV-VATS; thoracic anesthesia; spontaneous ventilation