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BJA Advance Access published online on July 9, 2004
British Journal of Anaesthesia, doi:10.1093/bja/aeh209
© 2004 by The Board of Management and Trustees of the British Journal of Anaesthesia
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Accepted March 20, 2004

Clinical Investigation

The open lung concept: effects on right ventricular afterload after cardiac surgery

D. Reis Miranda 1, D. Gommers 1, A. Struijs 2, H. Meeder 1, R. Schepp 1, W. Hop 3, A. Bogers 2, J. Klein 1, B. Lachmann 1*

1 Department of Anesthesiology, Erasmus Medical Centre, Rotterdam, The Netherlands
2 Department of Cardio-Thoracic Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
3 Department of Biostatistics, Erasmus Medical Centre, Rotterdam, The Netherlands

* To whom correspondence should be addressed. E-mail: b.lachmann{at}erasmusmc.nl.


  Abstract

Background. The open lung concept (OLC) is a method of ventilation intended to maintain end-expiratory lung volume by increased airway pressure. Since this could increase right ventricular afterload, we studied the effect of this method on right ventricular afterload in patients after cardiac surgery.

Methods. We studied 24 stable patients after coronary artery surgery and/or valve surgery with cardiopulmonary bypass. Patients were randomly assigned to OLC or conventional mechanical ventilation (CMV). In the OLC group, recruitment manoeuvres were applied until PaO2/FIO2 was greater than 50 kPa (reflecting an open lung). This value was maintained by sufficient positive airway pressure. In the CMV group, volume-controlled ventilation was used with a PEEP of 5 cm H2O. Cardiac index, right ventricular preload, contractility and afterload were measured with a pulmonary artery thermodilution catheter during the 3-h observation period. Blood gases were monitored continuously.

Results. To achieve PaO2/FIO2 > 50 kPa, 5.3 (3) (mean, SD) recruitment attempts were performed with a peak pressure of 45.5 (2) cm H2O. To keep the lung open, PEEP of 17.0 (3) cm H2O was required. Compared with baseline, pulmonary vascular resistance and right ventricular ejection fraction did not change significantly during the observation period in either group.

Conclusion. No evidence was found that ventilation according to the OLC affects right ventricular afterload.

Keywords: heart, right ventricular afterload; heart, right ventricular ejection fraction; lung, PEEP; lung, open lung concept; lung, recruitment manoeuvre.
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