Lung Recruitment Improves the Efficiency of Ventilation and
Gas Exchange During One-Lung Ventilation Anesthesia
Gerardo Tusman, MD*, Stephan H. Böhm, MD†,
Stefan Maisch, MD†
*Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina; †Department of
Anesthesiology, University Hospital Hamburg-Eppendorf, Hamburg, Germany; and ‡Department of Critical Care
Medicine, Fundación Jimenez Diaz, Madrid, Spain
Atelectasis in the dependent lung during one-lung ven-
tilation (OLV) impairs arterial oxygenation and in-
creases dead space. We studied the effect of an alveolar
recruitment strategy (ARS) on gas exchange and lung
efficiency during OLV by using the single-breath test of
CO2 (SBT-CO2). Twelve patients undergoing thoracic
surgery were studied at three points in time: (a) during
two-lung ventilation and (b) during OLV before and (c)
after an ARS. The ARS was applied selectively to the
dependent lung and consisted of an increase in peak
inspiratory pressure up to 40 cm H2O combined with a
peak end-expiratory pressure level of 20 cm H2O for 10
consecutive breaths. The ARS took approximately
3 min. Arterial blood gases, SBT-CO2, and metabolic
D
uring one-lung ventilation (OLV) anesthesia in
the lateral position, pulmonary shunt ranges
from 15% to 40% because of the total collapse of
the nondependent lung (1). In addition, there is clear
evidence from computerized tomography that zones
of compression atelectasis are redirected to the depen-
dent lung when patients are changed from the supine
to the lateral position (2,3). Both atelectasis and hy-
poventilated zones in the dependent lung contribute
to a ventilation/perfusion (V̇/Q̇) mismatch and have
an additive effect to the shunting in the nondependent
lung (4).
The V̇/Q̇ relationship describes the efficiency of gas
exchange and ranges from zero (shunt) to infinite
(alveolar dead space; VDalv). Total V̇/Q̇ depends on
the algebraic sum of the V̇/Q̇ ratio in every alveolus,
Accepted for publication March 6, 2003.
Address correspondence to Gerardo Tusman, MD, Department of
Anesthesiology, University Hospital Hamburg-Eppendorf, Martin-
istrasse 52, 20246 Hamburg, Germany. Address e-mail to
gtusman@hotmail.com. Reprints will not available from the author.
DOI: 10.1213/01.ANE.0000068484.67655.1A
1604 Anesth Analg 2004;98:1604–9
Fernando Suárez Sipmann, MD‡, and
and hemodynamic variables were recorded at the end
of each study period. Arterial oxygenation and dead
space were better during two-lung ventilation com-
pared with OLV. Pao2 increased during OLV after lung
recruitment (244 ⫾ 89 mm Hg) when compared with
OLV without recruitment (144 ⫾ 73 mm Hg; P ⬍ 0.001).
The SBT-CO2 analysis showed a significant decrease in
dead-space variables and an increase in the variables
related to the efficiency of ventilation during OLV after
an ARS when compared with OLV alone. In conclusion,
ARS improves gas exchange and ventilation efficiency
during OLV.
(Anesth Analg 2004;98:1604 –9)
and any deviation from the normal value of 1.0 causes
inefficiencies in gas exchange.
Blood oxygenation evaluates shunt, whereas dead
space (i.e., inefficient ventilation) is related to the
lung’s CO2 removal. However, shunt has a close
relationship to dead space, and vice versa (5), be-
cause both are related to gas exchange but use a
different gas for analysis. Thus, gas exchange and
ventilation efficiency (4,6,7) during general anesthe-
sia can be evaluated by the analysis of arterial blood
gases and by the single-breath test of CO2 (SBT-
CO2), the most commonly used tool for dead-space
analysis.
We have recently shown that an alveolar recruit-
ment strategy (ARS) improves arterial oxygenation
during OLV anesthesia after vascular clipping in lo-
bectomies (8). We hypothesized that improved V̇/Q̇
matching in the dependent lung was responsible for
the reduced intrapulmonary shunt. The objective of
this study was to evaluate the effect of a recruitment
maneuver on the gas exchange efficiency during OLV
without any kind of pulmonary vascular interruption
in the nondependent lung. Ventilatory and gas ex-
change efficiency was studied by SBT-CO2 and arterial
blood gas analysis.
©2004 by the International Anesthesia Research Society
0003-2999/04
ANESTH ANALG
2004;98:1604 –9
Methods
Twelve patients were studied during general anesthe-
sia for elective open thoracic surgery or thoracoscopy.
Patients with acute or chronic uncompensated cardio-
pulmonary disease were not included in the study.
Informed consent was obtained, and the study was
approved by the local ethics committee.
For open thoracotomies only, a thoracic epidural cath-
eter was placed at T2 to T4, and a total volume of
0.1 mL/kg of bupivacaine 0.5% without epinephrine
was administered. Before the epidural anesthesia, intra-
vascular volume was expanded by infusing 7 mL/kg of
a colloidal solution (Hemacell™) and maintained at
8 mL · kg⫺1 · h⫺1 of normal saline solution.
After 3 min of breathing 100% oxygen, general anes-
thesia was induced with fentanyl 5 ␮g/kg, thiopental
3 mg/kg, and vecuronium 0.08 mg/kg IV. Anesthesia
was maintained with isoflurane 0.5– 0.6 minimum alve-
olar anesthetic concentration and epidural lidocaine 1%
boluses of 5 mL for open thoracotomies. For thoracosco-
pies and minimally invasive coronary artery bypass
graft, anesthesia was maintained with isoflurane 0.7–
1 minimum alveolar anesthetic concentration and bo-
luses of fentanyl 2 ␮g/kg and vecuronium 0.015 mg/kg
as clinically necessary.
The trachea and the left bronchus were intubated
with a left double-lumen tube (DLT) of the appropri-
ate size (Broncho-Cath™; Mallinckrodt Laboratories,
Atholone, Ireland). Air leakage was assessed by intro-
ducing the capnograph’s sidestream sensor into each
lumen of the DLT while maintaining ventilation
through the other lumen. Bronchoscopy confirmed the
correct position of the DLT before and after the pa-
tients were positioned in the lateral position. During
OLV, the lumen of the nonventilated side was left
open to air.
Lungs were ventilated with a Servo 900 C in a
volume-controlled ventilation mode and an inspired
oxygen fraction of 1.0. The ventilator delivered a
square-wave flow with an inspiratory time of 33% and
no end-inspiratory pause. The respiratory rate was set
between 10 and 14 breaths/min, tidal volumes (Vt)
were maintained at 8 mL/kg, and positive end-
expiratory pressure (PEEP) was 8 cm H2O throughout
the study.
During OLV, Vt was reduced to 6 mL/kg to avoid
peak pressures more than 30 cm H2O. Respiratory rate
was increased to 15–18 breaths/min to maintain the
same minute ventilation as during two-lung ventila-
tion (TLV).
Standard monitoring was performed with the Car-
diocap II monitor. A Capnomac Ultima monitor was
used to measure the following ventilation variables
and gas concentrations: peak inspiratory pressure
(PIP), PEEP, expired Vt, respiratory rate, expired
minute volume, and oxygen and CO2 fractions.
CARDIOVASCULAR ANESTHESIA TUSMAN ET AL. 1605
ALVEOLAR RECRUITMENT DURING THORACIC ANESTHESIA
Carbon dioxide elimination (V̇co2) was calculated
as the product of alveolar ventilation and the mean
expired alveolar fraction of CO2. Oxygen consumption
(V̇o2) was calculated as the product of alveolar venti-
lation times the inspiratory-expiratory oxygen differ-
ence. The respiratory quotient (RQ) was calculated by
dividing V̇co2 by V̇o2.
The SBT-CO2 was performed by using the side-
stream infrared capnometer and the pneumotacho-
graph of the Capnomac Ultima and a signal processor.
Data were recorded and analyzed by a computer. The
capnograph and blood gas analyzer were calibrated
with a known gas concentration of CO2 (5%). This
calibration was performed in each patient before the
induction of anesthesia.
Airway flow and pressure measurements are based
on the measurement of kinetic gas pressure and are
performed by using the Pitot effect. Flow rate is mea-
sured and integrated to obtain Vt. The Capnomac
device restores normal airway volumes from standard
condition to body temperature, ambient pressure, and
water vapor saturation automatically. Volume calibra-
tion was performed with a 700-mL supersyringe be-
fore anesthesia induction by following the manufac-
turer’s guidelines.
The sidestream CO2 signal has a time delay com-
pared with the flow signal. The software automati-
cally corrected for the CO2 delay by using mathemat-
ical algorithms similar to those described by Breen et
al. (9). The Vtco2,br or area under the curve was com-
puted by integrating expired flow and Fco2 in each
breath.
Analysis of dead space was performed off-line by
using Fowler’s analysis (10) and adding the Paco2
value to the SBT-CO2 curve (Fig. 1, A and B). The
mean value of three consecutive SBT-CO2 tests was
used for each variable. The apparatus’s dead space
was 60 mL (10 mL from D-LITE™ plus 50 mL from
DLT connections) and was subtracted from the airway
dead-space value (VDaw). Dead-space variables are
described in Figure 1 and in Table 1. All measure-
ments were performed with the patient in the lateral
position. Arterial blood gases, SBT-CO2, and ventila-
tory and hemodynamic data were recorded at three
points:
1. TLV: 15 min after placing the patient in the lat-
eral position, with the chest still closed.
2. OLVPRE: after 20 min of OLV ventilation, before
applying the ARS.
3. OLVARS: 20 min after applying the ARS selec-
tively to the dependent lung.
Patients were studied during OLV before any vas-
cular interruption in the nondependent lung. During
OLV, patients were studied at the moment of highest
shunt before any vascular clipping in the nondepen-
dent lung. The recruitment maneuver was applied
1606 CARDIOVASCULAR ANESTHESIA TUSMAN ET AL. ANESTH ANALG
ALVEOLAR RECRUITMENT DURING THORACIC ANESTHESIA 2004;98:1604 –9

critical alveolar opening pressure was assumed to be

at 40 cm H2O, as described for healthy lungs (11,13).
The ARS protocol was as follows:
1. Inspiratory time was increased to 50%.
2. Respiratory frequency was set to 12 breaths/min.
3. The inspiratory pressure gradient was limited to
20 cm H2O to avoid large Vts during the maneu-
ver. PIP and PEEP were sequentially increased
from 30/10 to 35/15 in steps of 5 breaths. The
recruitment pressure of 40/20 cm H2O was ap-
plied for 10 breaths.
4. Airway pressures were then gradually de-
Figure 1. The single-breath test for CO2 (SBT-CO2). A, Classic dead-
space subdivisions (6,10). Z ⫽ airway dead space (VDaw); Y ⫽
creased, returning to baseline settings but main-
alveolar dead space; X ⫽ area under the curve; Vtalv ⫽ alveolar tidal taining a PEEP level of 8 cm H2O.
volume; Paco2 ⫽ arterial partial pressure of CO2 (mm Hg); Paeco2
⫽ mean partial pressure of CO2 in alveolar air, defined as the After the ARS was completed, the ventilator was set
middle of the a-b line. B, Phase I, II, and III of the SBT-CO2. Slopes back to volume control. The ARS took approximately
of Phase II and III were derived from least-squares linear regression 3 min.
by using data points collected between 25% and 75% of the corre- Before the recruitment maneuvers, central venous
sponding phase; 50% of the Phase II slope defines the limit between
airway and alveolar gas. pressure values were maintained ⬎10 mm Hg to
avoid hemodynamic side effects caused by the in-
creased intrathoracic pressures (14). Hemodynamic
Table 1. Dead-Space Data and ventilatory variables were monitored closely
OLV OLV while the ARS was performed. If mean arterial blood
before after pressure or heart rate changed by ⬎15% from base-
Variable TLV ARS ARS line, the ARS was discontinued and 500 mL of crys-
Absolute values (mL) talloid solution was administered. After hemody-
VDaw 160 ⫾ 28 123 ⫾ 29* 107 ⫾ 30† namic stability returned, the ARS was tried again.
VDalv 106 ⫾ 31 107 ⫾ 24 97 ⫾ 23
VDphys 266 ⫾ 42 230 ⫾ 39 204 ⫾ 34† During surgery, oxygen saturation was maintained
VTalv 392 ⫾ 42 260 ⫾ 39* 279 ⫾ 40† ⬎90% at all times. If, during OLV, Spo2 decreased to
VTco2,br 19 ⫾ 2.8 13 ⫾ 2.7 14 ⫾ 2.5 less than 90%, surgery was temporarily interrupted to
Ratios resume TLV (intermittent ventilation) until oxygen
VD/VT 0.50 ⫾ 0.04 0.60 ⫾ 0.05* 0.53 ⫾ 0.04†
VDaw/VT 0.30 ⫾ 0.05 0.33 ⫾ 0.07 0.29 ⫾ 0.08 saturation recovered to at least 97%. Blood samples
VDalv/VTalv 0.28 ⫾ 0.07 0.43 ⫾ 0.1* 0.35 ⫾ 0.07 were processed within 5 min of extraction by the
VolI/VT 0.23 ⫾ 0.03 0.24 ⫾ 0.06 0.19 ⫾ 0.04‡ blood gas analyzer ABL 520 (Radiometer, Copenha-
Vol II/VT 0.29 ⫾ 0.05 0.30 ⫾ 0.05 0.25 ⫾ 0.04‡
Vol III/VT 0.48 ⫾ 0.07 0.47 ⫾ 0.1 0.56 ⫾ 0.07‡
gen, Denmark), and values were corrected for body
Slope II (%/L) 16 ⫾ 3.5 15 ⫾ 3.9 18 ⫾ 3.9 temperature. This device was calibrated with the same
Slope III/N (1/L) 0.58 ⫾ 0.3 1.08 ⫾ 0.3* 0.72 ⫾ 0.2‡ CO2 concentration as the capnograph (5%).
TLV ⫽ two-lung ventilation; VDaw ⫽ airway dead space; VDalv ⫽ alveolar Descriptive statistical analysis was performed for
dead space; VDphys ⫽ physiological dead space. The physiological dead space each variable by using INSTAT 2.0. Comparison of
(VDphys) was calculated by Enghoff’s modification of the Bohr equation,11
where VDphys/VT ⫽ Paco2 ⫺ PAEco2/Paco2. VDalv was calculated by
variables between points was performed with
subtracting physiological from airway dead space. VTalv ⫽ alveolar tidal repeated-measures analysis of variance. If the analysis
volume, VTCO2,br ⫽ expired volume of CO2 per breath; VD/VT ⫽ physio- of variance F statistic was significant, the Student-
logical dead space to tidal volume, VDaw/VT ⫽ airway dead space to tidal
volume, VDalv/VTalv ⫽ alveolar dead space to alveolar tidal volume, Vol I, II Newman-Keuls posttest detected significant differ-
and III/VT ⫽ volume of phase I, II and III to tidal volume respectively, and ences. Values are reported as mean ⫾ sd, and P ⬍ 0.05
slope II and III/N ⫽ normalized phase II and III slopes dividing absolute
value by the mean alveolar fraction of CO2 (FAECO2, in %). was considered significant.
* TLV against OLVPRE, P ⬍ 0.05; † OLVARS against TLV, P ⬍ 0.05; and
‡ OLVARS against OLVPRE, P ⬍ 0.05.

selectively to the dependent lung immediately after
the measurement at Point 2. First, the ventilator was
switched to pressure-control ventilation, adjusting the
level of pressure to obtain the same Vt as during
volume-control ventilation. Ventilation was then al-
lowed to equilibrate for 3 min. Thereafter, the ARS
was performed as described previously (8,11) on the
basis of the concept described by Lachmann (12). The
Results
Twelve patients—10 men and 2 women—were in-
cluded in this study (Table 2). Only Patient 7 received
inhaled bronchodilators sporadically as needed.
Pao2 was significantly higher during TLV (379 ⫾
67 mm Hg) compared with OLVPRE (144 ⫾ 73 mm Hg;
P ⬍ 0.001) and OLVARS (244 ⫾ 89 mm Hg; P ⬍ 0.001).
During OLV, the difference in Pao2 before and after
the ARS also reached significance (Fig. 2).
ANESTH ANALG
2004;98:1604 –9
Hemoglobin oxygen saturation was lower at
OLVPRE (95.5% ⫾ 2.6%) as compared with TLV (98.7%
⫾ 0.4%; P ⬍ 0.001) and OLVARS (97.8% ⫾ 0.9%; P ⬍
0.01). Only Patient 8 needed four cycles of intermittent
ventilation during OLV before the ARS (Spo2 ⬍90%).
Blood gases were taken after the fourth cycle of inter-
mittent TLV immediately before the recruitment ma-
neuver. In this patient, the ARS relieved the arterial
hypoxemia instantaneously (Spo2 from 88% to 98%),
and no more episodes of hemoglobin desaturation
occurred.
Paco2 was 43 ⫾ 6 mm Hg during OLVARS but was
not significantly different from the other conditions.
However, Paco2 was higher during OLVPRE (46 ⫾
6 mm Hg) compared with TLV (38 ⫾ 4 mm Hg; P ⬍
0.05). ETco2 and the mean partial pressure of CO2 in
alveolar air (Paeco2) were stable during the protocol,
without any significant differences among the meas-
urement points. The Pa-ETco2 difference was signifi-
cantly higher during OLVPRE (14.2 ⫾ 4.8 mm Hg)
compared with TLV (8.8 ⫾ 3.2 mm Hg) and OLVARS
(11.6 ⫾ 4.6 mm Hg). The arterial pH remained in the
normal range throughout the study period.
All dead-space variables (Table 1) decreased during
OLVARS compared with OLVPRE, but differences
showed statistical significance only for the dead-space
gas volume/Vt ratio, Vol I, II, III/Vt, and Phase III
slope. Vts were higher during TLV (506 ⫾ 83 mL)
compared with OLVPRE (377 ⫾ 45 mL) and OLVARS
(382 ⫾ 42 mL). Minute ventilation was similar be-
tween OLVPRE (5.9 L/min) and OLVARS (5.8 L/min),
but both values were significantly smaller than during
TLV (7 L/min). PIP values were higher during
OLVPRE (25.3 ⫾ 1.7 cm H2O) compared with TLV (20.6
⫾ 1.7 cm H2O; P ⬍ 0.001) and OLVARS (23.2 ⫾ 2 cm
H2O; P ⬍ 0.05), with no differences between the last
two.
Hemodynamic variables, minute CO2 elimination,
oxygen consumption, and RQ were similar at all time
points. The total time of OLV ranged from 50 to
105 min. No hemodynamic or ventilatory side effects
related to the recruitment maneuver were detected.
Discussion
The results of this study indicate an improved effi-
ciency in gas exchange after a lung recruitment ma-
neuver during OLV. This finding agrees with our
previous results (8) and can be explained by a recruit-
ment effect on both shunt and dead space, taking into
account that hemodynamic, metabolic, and ventilatory
conditions were stable along the protocol.
Arterial oxygenation is a common measurement
used to describe the extent of lung collapse. Different
authors (15,16) propose that a Pao2 ⬎450 mm Hg
defines an “open lung” condition during pure oxygen
CARDIOVASCULAR ANESTHESIA TUSMAN ET AL. 1607
ALVEOLAR RECRUITMENT DURING THORACIC ANESTHESIA
breathing. Arterial oxygenation, however, is an unspe-
cific variable to evaluate the recruitment effect because
it depends on the hemodynamic and metabolic status.
Because these two conditions remained stable
throughout the study period, a true recruitment effect
is the most likely explanation for the increases seen in
Pao2.
During TLV, a mean Pao2 of 379 ⫾ 67 mm Hg
indicated some extent of lung collapse, a common
finding during general anesthesia (Fig. 2). Oxygen-
ation was further impaired during OLVPRE but in-
creased after the dependent lung was recruited.
The nomogram of Benatar et al. (17) was used to
calculate the approximate shunt in our patients: at
TLV, shunt values ranged from 8% to 22% (mean,
16%), values typically seen in general anesthesia. Dur-
ing OLV, they ranged from 18% to 45% (mean, 28%),
and during OLVARS they ranged from 12% to 27%
(mean, 21%). After lung recruitment, oxygenation was
sufficient to maintain hemoglobin saturation ⬎95%.
Paco2 increased during OLV at the same ETco2 and
Paeco2 values as those observed during TLV. In-
creases in dead space during OLV can explain this
decrease in the efficiency of CO2 removal. Because
arterial oxygenation is only one of the variables de-
scribing the effects of recruitment in the protocol, we
included the dead-space analysis, a well known tool
for evaluating the lung’s efficiency of gas exchange.
During TLV, the values of dead space-derived vari-
ables are larger than normal (18) because of the DLT,
lung collapse, open-chest condition, and the use of
positive-pressure ventilation.
Surprisingly, VDalv did not change during OLV de-
spite a significant increase in shunt. We cannot explain
the absence of an increase in VDalv despite a marked
shunt effect (apparent dead space) during OLV com-
pared with TLV. We believe that during TLV, a de-
crease in the perfusion of the nondependent lung can
increase VDalv (real VDalv) despite a lower shunt
(6,19).
Large tidal values during TLV result also in abso-
lute large values for VDaw, alveolar tidal volume
(Vtalv), and physiological dead space than the ones
observed during OLV, thus making their direct com-
parison questionable. Nevertheless, when these vari-
ables are adjusted to account for differences in Vt, this
comparison may become useful.
The variables that represent efficiency of ventilation
and CO2 exchange (Vtco2,br, dead-space gas
volume/Vt ratio, Pa-ETco2, Vtalv, and VDalv/Vtalv)
were higher during TLV compared with OLV. During
OLV, all variables improved only after the recruitment
maneuver.
Even more interesting was the behavior of the vari-
ables that show the distribution of Vt throughout the
SBT-CO2 phases. Distribution of volume was most
efficient during OLV after the ARS, as indicated by a
1608 CARDIOVASCULAR ANESTHESIA TUSMAN ET AL. ANESTH ANALG
ALVEOLAR RECRUITMENT DURING THORACIC ANESTHESIA 2004;98:1604 –9

Table 2. Patient Data

Patient Age BMI FEV1 Pao2 Paco2 Smoking
No. (yr) Sex (kg/m2) (LL/%) pH (mm Hg) (mm Hg) (packs/yr) Surgery
1 71 M 26 2.1/84 7.39 64 36 50 RUL
2 48 M 28 3.0/93 7.43 101 39 No RUL
3 57 F 24 2.4/101 7.43 91 40 No RML
4 65 M 23 — 7.40 84 44 No Thoracoscopy
5 66 M 29 2.5/85 7.36 95 39 30 Mini-CABG
6 72 F 23 1.8/73 7.44 81 39 25 Mini-CABG
7 73 M 26 1.7/67 7.50 73 38 41 LUL
8 73 M 27 1.9/78 7.35 84 42 22 Thoracoscopy
9 19 M 23 — 7.44 99 37 No Thoracoscopy
10 58 M 30 2.9/89 7.34 89 43 No RLL
11 74 M 28 2.2/79 7.48 75 41 45 RUL/RML
12 66 M 27 2.6/96 7.34 83 39 No Mini-CABG
Mean 62 26 7.41 85 40
sd 15 2.4 0.06 11 2.3
BMI ⫽ body mass index; FEV1 ⫽ forced expiratory volume in 1 s; mini-CABG ⫽ minimally invasive coronary bypass graft; RUL ⫽ right upper lobe; RML ⫽
right median lobe; LUL ⫽ left upper lobe; RLL ⫽ right lower lobe.
Pao2, Paco2, and pH awake values were in room air. In Patients 4 and 9, respiratory test were not performed because of pneumothoraces.

“stationary diffusion front” demarcates the transition

Figure 2. Pao2 (mm Hg) in all patients during two-lung ventilation
(TLV) and during one-lung ventilation before (OLVPRE) and after
(OLVARS) the alveolar-recruitment strategy. Each symbol represents
one patient in every point of the study. Horizontal bars represent
mean values at each point.
decrease in Phase I and II volumes and a concomitant
increase in Phase III volume. The absolute value of the
Phase III/Vt ratio observed after recruitment was
even higher than during TLV.
Phase II represents a transition between alveolar and
airway gas transport (10,20). An increase in the cross-
sectional area of the bronchial tree in the lung periphery
decreases the linear velocity of the bulk flow until a point
where the two transport mechanisms within the lungs—
convection and diffusion—are of equal magnitude. This
between airway and alveolar gas. On expiration, this
front corresponds to Phase II and is used to measure
VDaw in Fowler’s analysis (10).
Changes in inspiratory flow, Vt, and peripheral
cross-sectional area of bronchioli have an effect on the
diffusion front and, thus, on the volume and slope of
Phase II (10,19,20). If inspiratory flow and Vt are
constant, as during OLV, any change in Phase II must
be interpreted as a recruitment-related increase in the
cross-sectional area of the bronchioli leading to a more
homogeneous gas emptying of lung acini.
The slope of Phase II, which depends on the spread
of transit time of different lung units, increased during
OLV after the recruitment maneuver when compared
with the other study conditions. However, differences
were not significant. This increase in Phase II slope, in
combination with a decrease in its volume, can be
considered as a more synchronous and homogeneous
emptying of acini during expiration. Both asthma and
emphysema have an opposite effect on Phase II (21–
23). These conditions show a wide dispersion on the
transit time of gas emptying among lung units, mak-
ing the slope of Phase II flatter and its volume larger.
Diffusion is the most important mechanism of gas
transport within the acinus. Phase III volume repre-
sents the amount of gas exposed to the capillary bed
and therefore depends on an effective pulmonary per-
fusion and CO2 production. Phase III slope is directly
related to the V̇/Q̇ relationship and represents the
diffusional resistance for CO2 at the alveolar-capillary
membrane. Its positive slope is explained by lung
pendelluft, continuous evolution of CO2 from the
blood into the acini, and a stratified inhomogeneity
(19,20,24).
During OLVARS, Phase III volume increased while
its slope decreased compared with OLVPRE. Schwardt
ANESTH ANALG
2004;98:1604 –9
et al. (24), using a mathematical model, described the
effects of independent changes of physiologic vari-
ables and acinar structures on the slope of Phase III.
Regarding these data and maintaining all variables
that can influence diffusional CO2 resistance constant,
as in this study, any change in the slope can be ex-
plained by a change in the area of gas exchange.
Clinical data support our findings: Ream et al. (25)
described a decrease in normalized Phase III slope in
children during normal growth as a result of an in-
crease in the “alveolated” airway. A decrease in func-
tional lung acini in emphysema is related to an in-
crease in Phase III slope.
We studied patients submitted to different thoracic
surgeries, including classical thoracotomies (lobecto-
mies), minimally invasive thoracotomies (minimally
invasive coronary artery bypass graft), and closed-
chest surgeries (thoracoscopies). Possible differences
in lung mechanics can account for the changes in
arterial oxygenation and ventilation efficiency among
these different type of surgeries. However, oxygen-
ation and dead-space behavior were similar and he-
modynamic and metabolic conditions were constant
throughout the study period. For these reasons, we
believe that the changes in gas exchange and dead
space that we observed were related to the therapeutic
effect of the recruitment maneuver.
Epidural anesthesia used in open thoracotomies can
cause hemodynamic and metabolic changes that could
influence gas exchange. However, these conditions
were stable, and no differences were seen in Pao2
between open thoracotomies and thoracoscopies with-
out epidural anesthesia. We used empirical values of
40 cm H2O of PIP as an opening pressure and 8 cm
H2O of PEEP to keep the lung open (8,11,13) because
individual levels of these pressures are difficult to
determine at the bedside.
Because of a mediastinal displacement, the sur-
geon’s manipulation and the chest fixation opening
and closing pressures in the dependent lung could be
higher during thoracic surgery as compared with the
other types of surgeries. In addition, PIP may not
represent true alveolar pressure when a narrow DLT
is used. For this reason, it is possible that true opening
and closing pressures were not reached in each pa-
tient, which could have resulted in the absence of the
maximal effect of the ARS on oxygenation and lung
efficiency. The number of patients studied was small,
but our main goal was to show the physiologic effect
of the lung-recruitment maneuver on gas exchange
and dead space during OLV.
We conclude that lung recruitment improves gas
exchange and ventilation efficiency during OLV anes-
thesia. Our results suggest that one simple recruitment
maneuver during OLV is enough to increase Pao2 to
safer levels, thereby eliminating the need for any ad-
ditional therapeutic intervention.
CARDIOVASCULAR ANESTHESIA TUSMAN ET AL. 1609
ALVEOLAR RECRUITMENT DURING THORACIC ANESTHESIA
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