inovmedИнновационная медицина КубаниInnovative Medicine of Kuban2541-9897Scientific Research Institute – Ochapovsky Regional Clinical Hospital No. 110.35401/2541-9897-2022-25-4-32-38inovmed-599Research ArticleОРИГИНАЛЬНЫЕ СТАТЬИORIGINAL ARTICLESОптимизация протективной вентиляции легких в торакальной хирургииOptimization of protective lung ventilation in thoracic surgeryhttps://orcid.org/0000-0001-5147-5637ЖихаревВ. А.ZhikharevV. A.

 Жихарев Василий Александрович, д. м. н., врач-ординатор отделения анестезиологии и реанимации № 1, руководитель научного отдела инновационных методов интенсивнойтерапии; ассистент кафедры анестезиологии,  реаниматологии и трансфузиологии ФПК и ППС

 350086, Краснодар, ул. 1 Мая, 167 

Vasiliy A. Zhikharev, Dr. Sci. (Med.), Resident Physician of the Department of Anesthesiology and Intensive Care no. 1, head of the Scientific Department of Innovative Methods of Intensive Care; Assistant of the Department of  Anesthesiology, Resuscitation and Transfusiology, Faculty of AdvancedTraining and Professional Retraining of Specialists 

 1 Maya str., 167, Krasnodar, 350086 

Vasilii290873@yandex.ruhttps://orcid.org/0000-0002-1427-4032БушуевА. С.BushuevA. S.

Бушуев Александр Сергеевич, к. м. н., врач-ординатор отделения анестезиологии и реанимации № 1

 350086, Краснодар, ул. 1 Мая, 167 

 Alexander S. Bushuev, Cand. Sci. (Med.), Resident Physician of the Department of Anesthesiology and Resuscitation no. 1 

 1 Maya str., 167, Krasnodar, 350086 

https://orcid.org/0000-0002-3400-8989КорячкинВ. А.KoryachkinV. A.

Корячкин Виктор Анатольевич, д. м. н., профессоркафедры анестезиологии, реаниматологии и неотложной педиатрии ФП и ДПО

 Санкт-Петербург

Viktor A. Koryachkin, Dr. Sci. (Med.), Professor, Department of Anesthesiology, Resuscitation and Pediatric Emergency 

 Saint Petersburg 

https://orcid.org/0000-0003-0572-1395ПорхановВ. А.PorhanovV. A.

 Порханов Владимир Алексеевич, академик РАН, д. м. н.,профессор, главный врач; заведующий кафедрой онкологии с курсом торакальной хирургии ФПК и ППС

350086, Краснодар, ул. 1 Мая, 167

Vladimir A. Porhanov, Academician of Russian Academy of Sciences, Dr. Sci. (Med.), Professor, Chief Doctor; Head of Department of Oncology with the Course of Thoracic Surgery, Faculty of Advanced Training and Professional Retraining of Specialists 

 1 Maya str., 167, Krasnodar, 350086 

Научно-исследовательский институт – Краевая клиническая больница № 1 им. проф. С.В. Очаповского; Кубанский государственный медицинский университетРоссияScientific Research Institute – Ochapovsky Regional Clinical Hospital no. 1; Kuban State Medical UniversityRussian FederationНаучно-исследовательский институт – Краевая клиническая больница № 1 им. проф. С.В. ОчаповскогоРоссияScientific Research Institute – Ochapovsky Regional Clinical Hospital no. 1Russian FederationСанкт-Петербургский государственный педиатрический медицинский университетРоссияSaint Petersburg State Pediatric Medical UniversityRussian Federation202230122022043238Copyright © Жихарев В.А., Бушуев А.С., Корячкин В.А., Порханов В.А., 20222022Жихарев В.А., Бушуев А.С., Корячкин В.А., Порханов В.А.Zhikharev V.A., Bushuev A.S., Koryachkin V.A., Porhanov V.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.innovmedkub.ru/jour/article/view/599

Актуальность: На сегодняшний день протективная вентиляция легких является преобладающей вентиляционной методикой и включает в себя использование малого дыхательного объема, ограничение давления на вдохе и применение положительного давления в конце выдоха. Однако несколько ретроспективных исследований показали, что дыхательный объем, давление вдоха и положительное давление в конце выдоха (ПДКВ) не связаны с результатами лечения пациентов или связаны только тогда, когда они влияют на «движущее давление» (driving pressure).Цель работы: Оптимизация стратегии протективной однолегочной вентиляции под контролем driving pressure для снижения ранних послеоперационных респираторных осложнений у пациентов, оперированных по поводу рака легкого.Материал и методы: Проведено проспективное контролируемое исследование 110 пациентов после расширенных анатомических резекций легкого с последующим сравнением клинических результатов, в зависимости от уровня driving pressure во время проведения однолегочной вентиляции. Результирующей точкой были послеоперационные легочные осложнения, основанные на шкалах Мельбурнского опросника, в течение 3-х суток после операции.Результаты: Установлена корреляционная связь между величиной уровня driving pressure и уровнем PaO2 в интраоперационном периоде – высокая обратная (r = –0,901). Наибольшее значение в развитии послеоперационной дыхательной недостаточности имеет driving pressure, превышающей 15 см вод. ст. (Odds ratio = 18,25). В первые 3-е суток послеоперационные легочные осложнения, определяемые по Мельбурнской групповой шкале, возникли у 9 (8,2%) пациентов, у которых driving pressure превышал 15 см вод. ст. и у 3-х пациентов (2,7%) – с уровнем driving pressure менее 15 см вод. ст. (р = 0,016).Выводы: Превышение driving pressure более 15 см вод. ст. достоверно увеличивает частоту послеоперационных легочных осложнений. Фиксированное ПДКВ будет неуместным, независимо от того, высокое оно или низкое, а индивидуализированное ПДКВ, титруемое по CStat, может снизить driving pressure и стать следующим этапом протективной однолегочной вентиляции.

Background: Today protective ventilation is the predominant ventilation methodology. It includes the use of low tidal volume, inspiratory pressure limitation, and the application of positive end-expiratory pressure. However, several retrospective studies have shown that tidal volume, inspiratory pressure, and Positive End-Expiratory Pressure (PEEP) are not associated with patients’ treatment outcomes, but could be associated only when they influence driving pressure.Objective: Optimization of the strategy of protective one-lung ventilation under the control of driving pressure, to reduce early postoperative respiratory complications in patients operated for lung cancer.Material and methods: A prospective controlled study was conducted on 110 patients undergoing extended anatomical lung resections with subsequent comparison of clinical results depending on the level of driving pressure during one-lung ventilation. Postoperative pulmonary complications based on the Melbourne scale that appeared within 3 days after surgery became the endpoint.Results: A correlation was established between the level of driving pressure and the level of PaO2 in the intraoperative period – high inverse (r = – 0.901). The greatest value in the development of postoperative respiratory failure is driving pressure, exceeding 15 cm of water (Odds ratio = 18.25). In the first 3 days, postoperative pulmonary complications, determined by the Melbourne group scale, occurred in 9 (8.2%) patients in whom the driving pressure exceeded 15 cm of water, and in 3 patients (2.7%) with a driving pressure level less than 15 cm of water (p = 0.016).Conclusion: Driving pressure excess with values of more than 15 cm of water significantly increases the incidence of postoperative pulmonary complications. Fixed PEEP will be inappropriate both high and low, and individualized PEEP titrated by CStat may reduce driving pressure and become the next step in protective one-lung ventilation.

протективная однолегочная вентиляция«движущее давление» (driving pressure)послеоперационные легочные осложненияprotective one-lung ventilationdriving pressurepostoperative pulmonary complicationsReferencesМалявин А.Г., Бабак С.Л., Колоскова Н.Н. Оценка рисков развития дыхательной недостаточности у пациентов, нуждающихся в оперативном лечении. Эндоскопическая хирургия. 2017;2:32–38. https://doi.org/10.17116/endoskop201723232-38Malyavin AG, Babak SL, Koloskova NN. Risks assessment of respiratory failure in patients before surgery. Endoscopic Surgery. 2017;2:32–38. (In Russ.). https://doi.org/10.17116/endoskop201723232-38Kelkar KV. Post-operative pulmonary complications after non-cardiothoracic surgery. Indian Journal of Anaesthesiology. 2015;59(9):599–605. PMID: 26556919. PMCID: PMC4613407. http://doi.org/10.4103/0019-5049.165857Kelkar KV. Post-operative pulmonary complications after non-cardiothoracic surgery. Indian Journal of Anaesthesiology. 2015;59(9):599–605. PMID: 26556919. PMCID: PMC4613407. http://doi.org/10.4103/0019-5049.165857Hu X-Y, Du B. Lung-protective ventilation during one-lung ventilation: known knowns, and known unknowns. J Thorac Dis. 2019;11(3):237–240. PMID: 30997186. PMCID: PMC6424720. http://doi.org/10.21037/jtd.2019.01.45Hu X-Y, Du B. Lung-protective ventilation during one-lung ventilation: known knowns, and known unknowns. J Thorac Dis. 2019;11(3):237–240. PMID: 30997186. PMCID: PMC6424720. http://doi.org/10.21037/jtd.2019.01.45Lohser J. Evidence-based management of one-lung ventilation. Anesthesiol Clin. 2008;26:241–72. PMID: 18456211. http://doi.org/10.1016/j.anclin.2008.01.011Lohser J. Evidence-based management of one-lung ventilation. Anesthesiol Clin. 2008;26:241–72. PMID: 18456211. http://doi.org/10.1016/j.anclin.2008.01.011Ahn HJ, Park M, Kim JA, et al. Driving pressure guided ventilation. Korean J Anesthesiol. 2020;73(3):194–204. PMID: 32098009. PMCID: PMC7280884. http://doi.org/10.4097/kja.20041Ahn HJ, Park M, Kim JA, et al. Driving pressure guided ventilation. Korean J Anesthesiol. 2020;73(3):194–204. PMID: 32098009. PMCID: PMC7280884. http://doi.org/10.4097/kja.20041Villar J, Martín-Rodríguez C, Domínguez-Berrot AM, et al. Spanish Initiative for Epidemiology, Stratification and Therapies for ARDS (SIESTA) Investigators Network: A quantile analysis of plateau and driving pressures: Effects on mortality in patients with acute respiratory distress syndrome receiving lung-protective ventilation. Crit Care Med. 2017;45(5):843–850. PMID: 28252536. http://doi.org/10.1097/CCM.0000000000002330Villar J, Martín-Rodríguez C, Domínguez-Berrot AM, et al. Spanish Initiative for Epidemiology, Stratification and Therapies for ARDS (SIESTA) Investigators Network: A quantile analysis of plateau and driving pressures: Effects on mortality in patients with acute respiratory distress syndrome receiving lung-protective ventilation. Crit Care Med. 2017;45(5):843–850. PMID: 28252536. http://doi.org/10.1097/CCM.0000000000002330Трембач Н.В., Заболотских И.Б., Стаканов А.В. и др. Протективная вентиляция легких в абдоминальной хирургии. Анестезиология и реаниматология. 2018;3:25–32. https://doi.org/10.17116/anaesthesiology201803125Trembach NV, Zabolotskikh IB, Stakanov AV. Protective ventilation in abdominal surgery. The Russian Journal of Anaesthesiology and Reanimatology. 2018;3:25–32. (In Russ.). https://doi.org/10.17116/anaesthesiology201803125Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307:2526–2533. http://doi.org/10.1001/jama.2012.5669Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307:2526–2533. http://doi.org/10.1001/jama.2012.5669Parry S, Denehy L, Berney S, et al. Clinical application of the Melbourne risk prediction tool in a high-risk upper abdominal surgical population: an observational cohort study. Physiotherapy. 2014;100:47–53. PMID: 23958308. http://doi.org/10.1016/j.physio.2013.05.002Parry S, Denehy L, Berney S, et al. Clinical application of the Melbourne risk prediction tool in a high-risk upper abdominal surgical population: an observational cohort study. Physiotherapy. 2014;100:47–53. PMID: 23958308. http://doi.org/10.1016/j.physio.2013.05.002Maslow AD, Stafford TS, Davignon KR, et al. A randomized comparison of different ventilator strategies during thoracotomy for pulmonary resection. J Thorac Cardiovasc Surg. 2013;146:38–44. PMID: 23380515. http://doi.org/10.1016/j.jtcvs.2013.01.021Maslow AD, Stafford TS, Davignon KR, et al. A randomized comparison of different ventilator strategies during thoracotomy for pulmonary resection. J Thorac Cardiovasc Surg. 2013;146:38–44. PMID: 23380515. http://doi.org/10.1016/j.jtcvs.2013.01.021Blank RS, Colquhoun DA, Durieux ME. Management of one-lung ventilation: Impact of tidal volume on complications after thoracic surgery. Anesthesiology. 2016;124:1286–1295. https://doi.org/10.1097/ALN.0000000000001100Blank RS, Colquhoun DA, Durieux ME. Management of one-lung ventilation: Impact of tidal volume on complications after thoracic surgery. Anesthesiology. 2016;124:1286–1295. https://doi.org/10.1097/ALN.0000000000001100Marret E, Cinotti R, Berard L, et al. Protective ventilation during anaesthesia reduces major postoperative complications after lung cancer surgery: a double-blind randomised controlled trial. Eur J Anaesthesiol. 2018;35:727–735. PMID: 29561278. http://doi.org/10.1097/EJA.0000000000000804Marret E, Cinotti R, Berard L, et al. Protective ventilation during anaesthesia reduces major postoperative complications after lung cancer surgery: a double-blind randomised controlled trial. Eur J Anaesthesiol. 2018;35:727–735. PMID: 29561278. http://doi.org/10.1097/EJA.0000000000000804Fernandez-Bustamante A, Frendl G, Sprung J, et al. Postoperative pulmonary complications, early mortality, and hospital stay following noncardiothoracic surgery: a multicenter study by the perioperative research network investigators. JAMA Surg. 2017;152:157–166. PMID: 27829093. PMCID: PMC5334462. http://doi.org/10.1001/jamasurg.2016.4065Fernandez-Bustamante A, Frendl G, Sprung J, et al. Postoperative pulmonary complications, early mortality, and hospital stay following noncardiothoracic surgery: a multicenter study by the perioperative research network investigators. JAMA Surg. 2017;152:157–166. PMID: 27829093. PMCID: PMC5334462. http://doi.org/10.1001/jamasurg.2016.4065Park M, Ahn HJ, Kim JA, et al. Driving pressure during thoracic surgery: a randomized clinical trial. Anesthesiology. 2019;130:385–393. PMID: 30664548. http://doi.org/10.1097/ALN.0000000000002600Park M, Ahn HJ, Kim JA, et al. Driving pressure during thoracic surgery: a randomized clinical trial. Anesthesiology. 2019;130:385–393. PMID: 30664548. http://doi.org/10.1097/ALN.0000000000002600Fuller BM, Page D, Stephens RJ, et al. Pulmonary Mechanics and Mortality in Mechanically Ventilated Patients Without Acute Respiratory Distress Syndrome: A Cohort Study. Shock. 2018;49:311–316. PMID: 28846571. PMCID: PMC5809252. https://doi.org/10.1097/shk.0000000000000977Fuller BM, Page D, Stephens RJ, et al. Pulmonary Mechanics and Mortality in Mechanically Ventilated Patients Without Acute Respiratory Distress Syndrome: A Cohort Study. Shock. 2018;49:311–316. PMID: 28846571. PMCID: PMC5809252. https://doi.org/10.1097/shk.0000000000000977Власенко А.В., Евдокимов Е.А., Родионов Е.П. Современные алгоритмы респираторной поддержки при ОРДС различного генеза (лекция). Вестник анестезиологии и реаниматологии. 2020;17(4):41–58. https://doi.org/10.21292/2078-5658-2020-17-4-41-58Vlasenko AV, Evdokimov EA, Rodionov EP. Contemporary procedure for respiratory support in acute respiratory distress syndrome of various genesis (lecture). Messenger of Anesthesiology and Resuscitation. 2020;17(4):41–58. (In Russ.). https://doi.org/10.21292/2078-5658-2020-17-4-41-58Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. New England Journal of Medicine. 2015;372(8):747–755. PMID: 25693014. https://doi.org/10.1056/nejmsa1410639Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. New England Journal of Medicine. 2015;372(8):747–755. PMID: 25693014. https://doi.org/10.1056/nejmsa1410639Neto AS, Hemmes SN, Barbas CS, et al. Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: a meta-analysis of individual patient data. Lancet Respir Med. 2016;4(4):272–280. PMID: 26947624. https://doi.org/10.1016/s2213-2600(16)00057-6Neto AS, Hemmes SN, Barbas CS, et al. Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: a meta-analysis of individual patient data. Lancet Respir Med. 2016;4(4):272–280. PMID: 26947624. https://doi.org/10.1016/s2213-2600(16)00057-6Bellani G, Laffey JG, Pham T, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315(8):788–800. PMID: 26903337. https://doi.org/10.1001/jama.2016.0291Bellani G, Laffey JG, Pham T, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315(8):788–800. PMID: 26903337. https://doi.org/10.1001/jama.2016.0291Cinnella G, Grasso S, Raimondo P, et al. Physiological effects of the open lung approach in patients with early, mild, diffuse acute respiratory distress syndrome: an electrical impedance tomography study. Anesthesiology. 2015;123(5):1113–1121. PMID: 26397017. https://doi.org/10.1097/aln.0000000000000862Cinnella G, Grasso S, Raimondo P, et al. Physiological effects of the open lung approach in patients with early, mild, diffuse acute respiratory distress syndrome: an electrical impedance tomography study. Anesthesiology. 2015;123(5):1113–1121. PMID: 26397017. https://doi.org/10.1097/aln.0000000000000862

The authors declare that there are no conflicts of interest present.