Journal of Cardiothoracic and Vascular Anesthesia 31 (2017) 1774–1775
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Editorial
Do Low Tidal Volumes Decrease Lung Injury
During One-Lung Ventilation?
“IF THE ANSWER is simple you don’t understand the
question.” I don’t know who said that originally, but I use the
phrase repeatedly when trying to figure out questions of
respiratory physiology as they relate to anesthesia. In this
issue of the Journal of Cardiothoracic and Vascular Anesthe-
sia, El Tahan et al present the results of a meta-analysis that
tries to answer this question.1 Although 14 trials were included
in the review, in many of the categories examined only 3 or
4 trials had data that could be compared. The definition of
“low” tidal volume during one-lung ventilation (OLV) varied
between 4 to 6 mL/kg and “high” between 8 to 10 mL/kg. The
patients’ weights were calculated as either ideal, actual, or
predicted according to the individual study. They found that
the use of lower tidal volumes was associated with lower PaO2
and higher PaCO2 during OLV, improved postoperative PaO2,
and a reduction in radiological lung infiltrates. However, there
was no association with overall postoperative pulmonary
complications or length of stay. The reader will probably
conclude that, on balance, there is no major benefit or harm to
the use of low tidal volumes during OLV
The most thorough single study of this question was a recent
retrospective Society of Thoracic Surgeons database analysis
by Blank et al.2 They examined the results of 1,019 cases of
thoracic surgery including both open and minimally invasive
surgery for lung cancer, esophageal surgery, and lung trans-
plantation. The range of tidal volumes during OLV was mainly
between 4 to 8 mL/kg predicted body weight with a mean of
6 mL/kg and an overall mean of 4 cmH2O positive end-
expiratory pressure (PEEP). They found that lower tidal
volumes were associated with increased respiratory complica-
tions and major postoperative morbidity (i.e., lower tidal
volumes are harmful). The interplay of tidal volumes, PEEP,
and driving pressure (plateau pressure – PEEP) during OLV
was unclear. There was a trend to the association of higher
driving pressure with respiratory complications.
Contrast these conclusions with those of some of the smaller
randomized-controlled trials such as that of Yang et al.3 They
randomized 100 patients to OLV with either 10 mL/kg predicted
body weight tidal volumes, no PEEP (volume-controlled
http://dx.doi.org/10.1053/j.jvca.2017.07.005
1053-0770/& 2017 Elsevier Inc. All rights reserved.
ventilation, FiO2 1.0), or to 5 mL/kg tidal volumes with 5 cmH2O
PEEP (pressure-controlled ventilation, FiO2 0.5). They found
improved PaO2/FiO2 ratios postoperatively and decreased radi-
ologic infiltrates and atelectasis in the low tidal volume group.
There was no difference in length of stay. This implies that low
tidal volumes during OLV are beneficial.
The reader has the right to be confused. Prospective trials,
database reviews and meta-analyses reach conflicting results.
There is more to the question of lung injury and OLV than just
tidal volume. A very useful insight can be gained from the pig
OLV studies of Kozian et al4 from Magdeburg, Germany.
These authors examined CT scans of animals during OLV and
thoracotomy. They found that with an OLV tidal volume of 10
mL/kg and 5 cmPEEP approximately two-thirds of the
ventilated (dependent) lung developed cyclic collapse during
expiration. Even with 5 mL/kg and 5 cmPEEP the ventilated
lung still had approximately half of its volume cyclically
recruited-derecruited every breath. This “atelectrauma” is
harmful to the lung.5 But this is optimal OLV as we know
it: tidal volume 5 mL/kg and 5 cmPEEP. If I had a pet pig, and
that pig needed a thoracotomy, that is how I would ask the
veterinarian to ventilate my pig! It seems that we cannot
escape the conclusion that OLV is harmful to the lung. This
injury is usually subclinical, but in other contexts: extended
pulmonary resections, massive transfusion, pulmonary fibrosis,
or cardiopulmonary bypass, it may become a clinical
problem.6
So, for the present, my thoughts about lung injury and OLV:
what I believe is (WIBI) [as opposed to what I know is (WIKI)]:
1. There has been a trend to a decreased incidence of adult
respiratory distress syndrome following lung cancer sur-
gery. This trend is primarily due to a decreased frequency
of pneumonectomy versus lobectomy (or other lung-sparing
procedures) as a percentage of lung cancer operations (now
approximately 5% v 20% before 2000).7
2. Low tidal volumes during OLV are associated with lower
PaO2 values during OLV. However, this is usually not
clinically important since the incidence of problematic
 Editorial / Journal of Cardiothoracic and Vascular Anesthesia 31 (2017) 1774–1775
desaturation during OLV is now o 5% (v 25% in the
1970s).6
3. In large animal studies, large tidal volumes (12 mL/kg)
without PEEP during pneumonectomy are clearly harmful
compared with smaller tidal volumes (6 mL/kg) plus
5 cmPEEP.8
4. One-lung ventilation always causes a subclinical lung
injury. In the vast majority of patients this injury does not
affect outcome. The only way to mitigate this injury is to
decrease the duration of one-lung ventilation or possibly
to use continuous positive airway pressure to the non-
ventilated lung.9
5. It is extremely difficult to isolate tidal volume as a single-factor
contributing to lung injury during OLV. Lung protective
ventilation includes recruitment, PEEP, fluids, inflammation,
anesthetic agents, and other yet unknown variables.
6. The use of a tidal volume of 4 to 6 mL/kg with 5 cm PEEP
while trying to maintain a driving pressure o 25 cmH2O
seem to be reasonable initial ventilatory parameters during
OLV with adjustment as indicated by the clinical context.
Peter D. Slinger, MD, FRCPC
Department of Anesthesia, University of Toronto
Toronto, ON, Canada
Address reprint requests to Peter D. Slinger, MD, Dept Anesthesia, 3EB441,
Toronto General Hospital, 200 Elizabeth St, Toronto, ON, Canada M5G 2C4.
E-mail address: peter.slinger@uhn.on.ca (P. D. Slinger).
1775
References
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one-lung ventilation. A meta-analysis of randomised trials. J Cardiothorac
Vasc Anesth 2017.
2 Blank RS, Colquhoun DA, Durieux ME, et al. Management of one-lung
ventilation. Impact of tidal volume on complications after thoracic surgery.
Anesthesiology 2016;124:1286–95.
3 Yang M, Ahn HJ, Kim K, et al. Does a protective ventilation strategy reduce
the risk of pulmonary complications after lung cancer surgery? Chest
2011;139:530–7.
4 Kozian A, Schilling T, Schutze H, et al. Ventilatory protective strategies
during thoracic surgery, the effects of alveolar recruitment maneuver and
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2011;114:1025–35.
5 Dixon D-L, Bersten Ad. Atelectrauma: Mechanistic insights tempered by
clinical relevance? Crit Care Med 2012;40:1009–10.
6 Lohser J, Slinger P. Lung injury after one-lung ventilation: A review of the
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lung. Anesth Analg 2015;121:302–18.
7 Tang S, Redmond K, Griffiths M, et al. The mortality from acute respiratory
distress syndrome after pulmonary resection is reducing: A 10-year single
institutional experience. Eur J Cardiothorac Surg 2008;34:898–902.
8 Kuzkov V, Subarov E, Kirov M, et al. Extravascular lung water after
pneumonectomy and one-lung ventilation in sheep. Crit Care Med 2007;35:
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9 Verhage RJJ, Boone J, Rijkers GT, et al. Reduced local immune response
with continuous positive airway pressure during one-lung ventilation for
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