Mechanical ventilation during anesthesia in adults
- Ralph Gertler, MD
Ralph Gertler, MD
- Executive senior physician
- Clinic for Anesthesiology, Intensive Care Medicine and Emergency Medicine
Mechanical ventilation is used during general anesthesia for patients with endotracheal tubes or supraglottic airways in place. This topic will discuss the modes of ventilation, ventilator settings, and lung protective ventilation during anesthesia. The deleterious effects of mechanical ventilation are discussed in detail separately. (See "Ventilator-associated lung injury" and "Physiologic and pathophysiologic consequences of mechanical ventilation" and "Inflammatory mechanisms of lung injury during mechanical ventilation".)
Strategies for mechanical ventilation for specific patient populations and surgical procedures are also discussed separately. (See "Anesthesia for laparoscopic and abdominal robotic surgery in adults", section on 'Mechanical ventilation' and "Anesthesia for the obese patient", section on 'Ventilation management' and "Anesthesia for patients with chronic obstructive pulmonary disease", section on 'Mechanical ventilation' and "General principles of one lung ventilation", section on 'Ventilation strategies'.)
MODES OF INTRAOPERATIVE MECHANICAL VENTILATION
Ventilators on anesthesia work stations increasingly allow modes of ventilation with most, but not all, of the capabilities of ventilators used in the intensive care unit (ICU). Terminology for the modes of ventilation is not standardized, and comparison between the technologies available in the ICU and in the operating room can be confusing. The modes of assisted and controlled ventilation that are available with most anesthesia machines are discussed here. Modes of ventilation in the intensive care unit are discussed separately. (See "Modes of mechanical ventilation".)
Volume controlled ventilation (VCV) and pressure controlled ventilation (PCV) are the basic modes of controlled mechanical ventilation used during general anesthesia. Pressure support and pressure control with volume guarantee (PV-VG) are also available on newer anesthesia machines.
Volume-controlled ventilation — Volume-controlled ventilation (VC) is also called volume-limited, or volume-cycled ventilation. At a minimum, the clinician sets the tidal volume and respiratory rate (and thus the minute ventilation), and the ventilator delivers the tidal volume at a constant flow rate. Advantages of VCV are that the set minute ventilation is essentially guaranteed (unless peak pressures exceed the set limit), and the fact that VCV is a commonly used technique, familiar to clinicians. However, VCV is associated with higher peak pressure for a given inspired volume, compared with PCV. Barotrauma is possible, and gas distribution in the lung may be uneven, particularly in patients with lung disease.
- Bachiller PR, McDonough JM, Feldman JM. Do new anesthesia ventilators deliver small tidal volumes accurately during volume-controlled ventilation? Anesth Analg 2008; 106:1392.
- Rothen HU, Sporre B, Engberg G, et al. Prevention of atelectasis during general anaesthesia. Lancet 1995; 345:1387.
- Wetterslev J, Meyhoff CS, Jørgensen LN, et al. The effects of high perioperative inspiratory oxygen fraction for adult surgical patients. Cochrane Database Syst Rev 2015; :CD008884.
- Global guidelines for the prevention of surgical site infection. World Health Organization 2016 http://www.who.int/gpsc/global-guidelines-web.pdf?ua=1 (Accessed on November 08, 2016).
- LAS VEGAS investigators. Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: LAS VEGAS - an observational study in 29 countries. Eur J Anaesthesiol 2017; 34:492.
- Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017. JAMA Surg 2017; 152:784.
- Hedenstierna G, Perchiazzi G, Meyhoff CS, Larsson A. Who Can Make Sense of the WHO Guidelines to Prevent Surgical Site Infection? Anesthesiology 2017; 126:771.
- Staehr-Rye AK, Meyhoff CS, Scheffenbichler FT, et al. High intraoperative inspiratory oxygen fraction and risk of major respiratory complications. Br J Anaesth 2017; 119:140.
- Ball L, Lumb AB, Pelosi P. Intraoperative fraction of inspired oxygen: bringing back the focus on patient outcome. Br J Anaesth 2017; 119:16.
- Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 1996; 334:1209.
- Gottrup F, Firmin R, Rabkin J, et al. Directly measured tissue oxygen tension and arterial oxygen tension assess tissue perfusion. Crit Care Med 1987; 15:1030.
- Hunt TK, Pai MP. The effect of varying ambient oxygen tensions on wound metabolism and collagen synthesis. Surg Gynecol Obstet 1972; 135:561.
- Greif R, Laciny S, Rapf B, et al. Supplemental oxygen reduces the incidence of postoperative nausea and vomiting. Anesthesiology 1999; 91:1246.
- Pryor KO, Fahey TJ 3rd, Lien CA, Goldstein PA. Surgical site infection and the routine use of perioperative hyperoxia in a general surgical population: a randomized controlled trial. JAMA 2004; 291:79.
- Meyhoff CS, Wetterslev J, Jorgensen LN, et al. Effect of high perioperative oxygen fraction on surgical site infection and pulmonary complications after abdominal surgery: the PROXI randomized clinical trial. JAMA 2009; 302:1543.
- Orhan-Sungur M, Kranke P, Sessler D, Apfel CC. Does supplemental oxygen reduce postoperative nausea and vomiting? A meta-analysis of randomized controlled trials. Anesth Analg 2008; 106:1733.
- Whitesell R, Asiddao C, Gollman D, Jablonski J. Relationship between arterial and peak expired carbon dioxide pressure during anesthesia and factors influencing the difference. Anesth Analg 1981; 60:508.
- Wahba RW, Tessler MJ. Misleading end-tidal CO2 tensions. Can J Anaesth 1996; 43:862.
- Brian JE Jr. Carbon dioxide and the cerebral circulation. Anesthesiology 1998; 88:1365.
- Coles JP, Fryer TD, Coleman MR, et al. Hyperventilation following head injury: effect on ischemic burden and cerebral oxidative metabolism. Crit Care Med 2007; 35:568.
- Laffey JG, Kavanagh BP. Hypocapnia. N Engl J Med 2002; 347:43.
- Akça O, Doufas AG, Morioka N, et al. Hypercapnia improves tissue oxygenation. Anesthesiology 2002; 97:801.
- Hager H, Reddy D, Mandadi G, et al. Hypercapnia improves tissue oxygenation in morbidly obese surgical patients. Anesth Analg 2006; 103:677.
- Fleischmann E, Herbst F, Kugener A, et al. Mild hypercapnia increases subcutaneous and colonic oxygen tension in patients given 80% inspired oxygen during abdominal surgery. Anesthesiology 2006; 104:944.
- Picton P, Dering A, Alexander A, et al. Influence of Ventilation Strategies and Anesthetic Techniques on Regional Cerebral Oximetry in the Beach Chair Position: A Prospective Interventional Study with a Randomized Comparison of Two Anesthetics. Anesthesiology 2015; 123:765.
- Richecoeur J, Lu Q, Vieira SR, et al. Expiratory washout versus optimization of mechanical ventilation during permissive hypercapnia in patients with severe acute respiratory distress syndrome. Am J Respir Crit Care Med 1999; 160:77.
- Güldner A, Kiss T, Serpa Neto A, et al. Intraoperative protective mechanical ventilation for prevention of postoperative pulmonary complications: a comprehensive review of the role of tidal volume, positive end-expiratory pressure, and lung recruitment maneuvers. Anesthesiology 2015; 123:692.
- Hedenstierna G, Edmark L. The effects of anesthesia and muscle paralysis on the respiratory system. Intensive Care Med 2005; 31:1327.
- Wrigge H, Zinserling J, Stüber F, et al. Effects of mechanical ventilation on release of cytokines into systemic circulation in patients with normal pulmonary function. Anesthesiology 2000; 93:1413.
- Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med 2013; 369:428.
- PROVE Network Investigators for the Clinical Trial Network of the European Society of Anaesthesiology, Hemmes SN, Gama de Abreu M, et al. High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial. Lancet 2014; 384:495.
- Gu WJ, Wang F, Liu JC. Effect of lung-protective ventilation with lower tidal volumes on clinical outcomes among patients undergoing surgery: a meta-analysis of randomized controlled trials. CMAJ 2015; 187:E101.
- Guay J, Ochroch EA. Intraoperative use of low volume ventilation to decrease postoperative mortality, mechanical ventilation, lengths of stay and lung injury in patients without acute lung injury. Cochrane Database Syst Rev 2015; :CD011151.
- Wolthuis EK, Choi G, Dessing MC, et al. Mechanical ventilation with lower tidal volumes and positive end-expiratory pressure prevents pulmonary inflammation in patients without preexisting lung injury. Anesthesiology 2008; 108:46.
- Ladha K, Vidal Melo MF, McLean DJ, et al. Intraoperative protective mechanical ventilation and risk of postoperative respiratory complications: hospital based registry study. BMJ 2015; 351:h3646.
- Hemmes SN, Serpa Neto A, Schultz MJ. Intraoperative ventilatory strategies to prevent postoperative pulmonary complications: a meta-analysis. Curr Opin Anaesthesiol 2013; 26:126.
- Treschan TA, Kaisers W, Schaefer MS, et al. Ventilation with low tidal volumes during upper abdominal surgery does not improve postoperative lung function. Br J Anaesth 2012; 109:263.
- Yang D, Grant MC, Stone A, et al. A Meta-analysis of Intraoperative Ventilation Strategies to Prevent Pulmonary Complications: Is Low Tidal Volume Alone Sufficient to Protect Healthy Lungs? Ann Surg 2016; 263:881.
- Treschan TA, Schaefer M, Kemper J, et al. Ventilation with high versus low peep levels during general anaesthesia for open abdominal surgery does not affect postoperative spirometry: A randomised clinical trial. Eur J Anaesthesiol 2017.
- Hedenstierna G, Edmark L. Protective Ventilation during Anesthesia: Is It Meaningful? Anesthesiology 2016; 125:1079.
- Neumann P, Rothen HU, Berglund JE, et al. Positive end-expiratory pressure prevents atelectasis during general anaesthesia even in the presence of a high inspired oxygen concentration. Acta Anaesthesiol Scand 1999; 43:295.
- Bindslev L, Hedenstierna G, Santesson J, et al. Airway closure during anaesthesia, and its prevention by positive end expiratory pressure. Acta Anaesthesiol Scand 1980; 24:199.
- Tusman G, Böhm SH, Tempra A, et al. Effects of recruitment maneuver on atelectasis in anesthetized children. Anesthesiology 2003; 98:14.
- de Jong MA, Ladha KS, Melo MF, et al. Differential Effects of Intraoperative Positive End-expiratory Pressure (PEEP) on Respiratory Outcome in Major Abdominal Surgery Versus Craniotomy. Ann Surg 2016; 264:362.
- Rothen HU, Sporre B, Engberg G, et al. Re-expansion of atelectasis during general anaesthesia: a computed tomography study. Br J Anaesth 1993; 71:788.
- Rothen HU, Neumann P, Berglund JE, et al. Dynamics of re-expansion of atelectasis during general anaesthesia. Br J Anaesth 1999; 82:551.
- Pelosi P, Gama de Abreu M, Rocco PR. New and conventional strategies for lung recruitment in acute respiratory distress syndrome. Crit Care 2010; 14:210.
- Dyhr T, Laursen N, Larsson A. Effects of lung recruitment maneuver and positive end-expiratory pressure on lung volume, respiratory mechanics and alveolar gas mixing in patients ventilated after cardiac surgery. Acta Anaesthesiol Scand 2002; 46:717.
- Park HP, Hwang JW, Kim YB, et al. Effect of pre-emptive alveolar recruitment strategy before pneumoperitoneum on arterial oxygenation during laparoscopic hysterectomy. Anaesth Intensive Care 2009; 37:593.
- Cakmakkaya OS, Kaya G, Altintas F, et al. Restoration of pulmonary compliance after laparoscopic surgery using a simple alveolar recruitment maneuver. J Clin Anesth 2009; 21:422.
- Whalen FX, Gajic O, Thompson GB, et al. The effects of the alveolar recruitment maneuver and positive end-expiratory pressure on arterial oxygenation during laparoscopic bariatric surgery. Anesth Analg 2006; 102:298.
- Almarakbi WA, Fawzi HM, Alhashemi JA. Effects of four intraoperative ventilatory strategies on respiratory compliance and gas exchange during laparoscopic gastric banding in obese patients. Br J Anaesth 2009; 102:862.
- Dobbinson TL, Nisbet HI, Pelton DA, Levison H. Functional residual capacity (FRC) and compliance in anaesthetized paralysed children. II. Clinical results. Can Anaesth Soc J 1973; 20:322.
- Kaditis AG, Motoyama EK, Zin W, et al. The effect of lung expansion and positive end-expiratory pressure on respiratory mechanics in anesthetized children. Anesth Analg 2008; 106:775.
- MODES OF INTRAOPERATIVE MECHANICAL VENTILATION
- Volume-controlled ventilation
- Pressure controlled ventilation
- Pressure control with volume guarantee
- Pressure support
- Synchronized intermittent mandatory ventilation modes
- CHOICE OF MODE OF VENTILATION
- FRACTION OF INSPIRED OXYGEN
- GOAL END TIDAL CARBON DIOXIDE
- RESPIRATORY RATE
- INSPIRATORY TO EXPIRATORY RATIO
- MONITORING PULMONARY MECHANICS
- Pressure volume loops
- Flow volume loops
- LUNG PROTECTIVE VENTILATION DURING ANESTHESIA
- Pulmonary effects of general anesthesia
- Our approach
- Components of intraoperative lung protective ventilation
- Tidal volume
- Plateau pressure
- Positive end expiratory pressure
- Recruitment maneuvers
- NONINVASIVE VENTILATION
- CRITICALLY ILL PATIENTS
- SUMMARY AND RECOMMENDATIONS