ANESTHESIA AND THE LUNG

ANESTHESIA AND THE LUNG

DEVELOPMENTS IN CRITICAL CARE MEDICINE AND ANESTHESIOLOGY Prakash, O. (ed.): Applied Physiology in Clinical Respiratory Care. 1982. ISBN 90-247-2662-X. McGeown, Mary G.: Clinical Management of Electrolyte Disorders. 1983. ISBN 0-89838-559-8. Stanley, T.H., and Petty, W.C. (eds.): New Anesthetic Agents, Devices and Monitoring Techniques. 1983. ISBN 0-89838-566-0. Scheck, P.A., Sj6strand, V.H., and Smith, R.B. (eds.): Perspectives in High Frequency Ventilation. 1983. ISBN 0-89838-571-7. Prakash, O. (ed.): Computing in Anesthesia and Intensive Care. 1983. ISBN 0-89838-602-0. Stanley, T.H., and Petty, W.C. (eds.): Anesthesia and the Cardiovascular System. 1984. ISBN 0-89838-626-8. Van Kleef, l.w., Burm, A.G.L., and Spierdijk, l. (eds.): Current Concepts in Regional Anaesthesia. 1984. ISBN 0-89838-644-6. Prakash, O. (ed.): Critical Care of the Child. 1984. ISBN 0-89838-661-6. Stanley, T.H., and Petty, W.C. (eds.): Anesthesiology: Today and Tomorrow. 1985. ISBN 0-89838-705-1. Rahn, H., and Prakash, O. (eds.): Acid-base Regulation and Body Temperature. 1985. ISBN 0-89838-708-6. Stanley, T.H., and Petty, W.C. (eds.): Anesthesiology. 1986. 1986. ISBN 0-89838-779-5. de Lange, S., Hennis, P.l., and Kettler, D. (eds.): Cardiac Anaesthesia: Problems and Innovations. 1986. ISBN 0-89838-794-9. De Bruijn, N.P., and Clements, F.M.: Transesophageal Echocardiography. 1987. ISBN 0-89838-821-X. Graybar, G.B., and Bready, L.L. (eds.): Anesthesia for Renal Transplantation. 1987. ISBN 0-89838-837-6. Stanley, T.H., and Petty, W.C. (eds.): Anesthesia, the Heart and the Vascular System. 1987. ISBN 0-89838-851-1. Ronai, A.K.: Autologous Blood Transfusions. 1988. ISBN 0-89838-899-6. Stanley, T.H. (ed.): What's New in Anesthesiology. 1988. ISBN 0-89838-367-6. Woerlee, G.M.: Common Perioperative Problems and the Anaesthetist. 1988. ISBN 0-89838-402-8. Stanley, T.H., and Sperry, R.l. (eds.): Anesthesia and the Lung. 1989. ISBN 0-7923-0075-0.

ANESTHESIA AND THE LUNG edited by T.H. STANLEY and R.J. SPERRY Department of Anesthesiology, The University of Utah Medical School, Salt Lake City, Utah, USA. KLUWER ACADEMIC PUBLISHERS DORDRECHT / BOSTON / LONDON

Library of Congress Cataloging in Publication Data hlesthesia and the lung. (Developments in critical care medicine and anaesthesiology) '~efresher course manuscripts of the presentations of the 34th Annual Postgraduate Course in Anesthesiology which took place at the Cliff Conference Center in Snowbird, Utah, February 17-21, 1989"--Pref. 1. Lungs--Diseases--Complications and sequelae- Congresses. 2. Anesthetics--Pathophysiology--Congresses. 3. Lungs--Effect of drugs on--congresses. 4. Lungs- Pathophysiology--Congresses. 1. Stanley, Theodore H. (Theodore Henry), 1940- II. Sperry, R. J. III. Utah Postgraduate Course in Anesthesiology (34th 1989 : Snowbird, Utah) IV. Series. [DNLM: 1. Anesthesia--congresses. 2. Lung--drug effects--congresses. 3. Lung Diseases--congresses. WF 600 AS79 1989] RD87.3.L8SAS4 1989 617'.96 88-27362 ISBN -13: 978-94-010-6893-2 e-isbn-13: 978-94-009-0899-4 DOl: 10_1007/978-94-009-0899-4 Published by Kluwer Academic Publishers, P.O. Box 17, 3300 AA Dordrecht, The Netherlands. Kluwer Academic Publishers incorporates the publishing programmes of D. Reidel, Martinus Nijhoff, Dr W. Junk and MTP Press. Sold and distributed in the U.S.A. and Canada by Kluwer Academic Publishers, 101 Philip Drive, Norwell, MA 02061, U.S.A. In all other countries, sold and distributed by Kluwer Academic Publishers Group, P.O. Box 322,3300 AH Dordrecht, The Netherlands. All Rights Reserved 1989 by Kluwer Academic Publishers Sof tcover reprint of the hardcover 1 st edition 1989 No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical including photocopying, recording or by any information storage and retrieval system, without written permission from the copyright owner.

PREFACE Theodore H. Stanley, M.D. Anesthesia and the Lung contains the Refresher Course manuscripts of the presentations of the 34th Annual Postgraduate Course in Anesthesiology which took place at The Cliff Conference Center in Snowbird, Utah, February 17-21, 1989. The chapters reflect recent advances in the diagnosis, pre-, intra-, and postoperative anesthetic management of patients with lung disease, presenting for pulmonary and non-pulmonary surgery. They also deal with ventilation-perfusion issues, the lung as a metabolic organ, the effects of anesthesia on pulmonary mechanics and pulmonary blood flow. In addition there are chapters that will focus around hypoxia; regional differences in the lung; pulmonary surfactant; recent advances in the understanding of pulmonary edema; high altitude disease; anesthesia and the control of breathing; recent developments in oximetry; instrumentation designed to measure pulmonary oxygen tension, P02 and PC02 transcutaneously; differential lung ventilation; reactive airways; septic shock; the adult respiratory distress syndrome and numerous aspects of ventilatory support. The purposes of the textbook are to 1) act as a reference for the anesthesiologists attending the meeting, and 2) serve as a vehicle to bring many of the latest concepts in anesthesiology to others within a short time of the formal presentation. Each chapter is a brief but sharply focused glimpse of the interests in anesthesia expressed at the conference. This book and its chapters should not be considered complete treatises on the subjects addressed but rather attempts to summarize the most salient points. This textbook is the seventh in a continuing series documenting the proceedings of the Postgraduate Course in Salt Lake City. v

We hope that this and the past and future volumes reflect the rapid and continuing evolution of anesthesiology in the late twentieth century.

TABLE OF CONTENTS List of Contributors ix Regional Differences in the Lung John B. West, M.D., Ph.D. Regulation of the Pulmonary Circulation 3 Bryan E. Marshall, M.D. New Concepts in the Regulation of the Pulmonary Vasculature: Biochemical Activities of Endothelial Cells that influence Pulmonary Vascular Tone and Blood Flow 17 Guy A. Zimmerman, M.D. Pathophysiology of Pulmonary Edema: Implications for Clinical Management 29 Steven J. Allen, M.D. Control of Breathing 41 Thomas F. Hornbein, M.D. Pulmonary Surfacant: An Endogenous Mediator of Alveolar Stability and a Therapeutic Agent 47 Guy A. Zimmerman, M.D. High Altitude Diseases 55 John B. West, M.D., Ph.D. Preparing the Patient with COPD for Surgery 59 Roger C. Bone, M.D. Anesthetic Influences on the Pulmonary Circulation 69 Bryan E. Marshall, M.D. Ventilation-Perfusion Mismatching During Anesthesia 79 John F. Nunn, M.D., Ph.D. Anesthesia and Changes in Lung Volume 85 John F. Nunn, M.D., Ph.D. Oximetry I: Nomenclature, History, Accuracy and Uses 93 John W. Severinghaus, M.D., Ph.D. What is the Required Inspired Oxygen Consumption During Anesthesia? 99 John F. Nunn, M.D., Ph.D.

viii Postoperative Hypoxia Thomas F. Hornbein, M.D. The 1981 American Medical Research Expedition to Mt. Everest John B. West, M.D., Ph.D. Effects of Anesthetics on Pulmonary Gas Exchange Brian E. Marshall, M.D. Oximetry II: Limitations and Effects on Other Monitors John W. Severinghaus, M.D. Anesthesia for Thoracic Surgery: Part I - Double-Lumen Tube Intubation Jonathan L. Benumof, M.D. Anesthesia for Thoracic Surgery: Part II - Management of One-Lung Ventilation Jonathan L. Benumof, M.D. Anesthetic Management of the Patient with Reactive Airways Steven J. Allen, M.D. Differential Lung Ventilation Jonathan L. Benumof, M.D. Physiologic Effects of Raised Airway Pressure John B. Downs, M.D. HF JV, PS, IRV, MMV, APRV, "New" Ventilatory Modes Steven J. Allen, M.D. Adult Respiratory Distress Syndrome Roger e. Bone, M.D. Hemodynamics and Therapy in ARDS Warren M. Zapol, M.D. Septic Shock Roger e. Bone, M.D. Respiratory Mechanics in leu Patients Joseph Milic-Emili, M.D. and A. Rossi, M.D. Dynamic Hyperinflation: Intrinsic PEEP and Its Ramifications in Patients with Respiratory Failure Joseph Milic-Emili, M.D., S.B. Gottfried, M.D. and A. Rossi, M.D. 107 111 117 127 133 141 149 165 173 215 221 233 239 253 261

Why Intermittent Mandatory Ventilation (IMV) Fails? John B. Downs, M.D. Weaning from Ventilatory Support John B. Downs, M.D. ECMO: A View from the East Warren M. Zapol, M.D. 269 277 295

LIST OF CONTRIBUTORS Allen, S.J. Department of Anesthesiology, Center for Microvascular and Lymphatic Studies, The University or Texas Medical School at Houston, 6431 Fannin, Houston, TX 77004, U.S.A. Benumof, J.L. Anesthesia Research Lab, T-OOl, The University of California San Diego, La Jolla, CA 92093, U.S.A. Bone, R.C. Department of Medicine, Rush Presbyterian/St. Luke Medical Center, Chicago, IL 60612, U.S.A. Downs, J.B. Department of Anesthesiology, The University of South Florida College of Medicine, Tampa, FL 33612, U.S.A. Hornbein, Th.F. Department of Anesthesiology, The University of Washington School of Medicine, Seattle, WA 98195, U.S.A. Marshall, B.E. Department of Anesthesia, The University of Pennsylvania School of Medicine, Philadelphia, PA 19104, U.S.A. Milic-Emili, J. Meakins-Christie Laboratories, McGill University, Montreal, Quebec, H3A 2B4, Canada Nunn, J.F. Division of Anesthesia, Clinical Research Center, Harrow, Middlesex, U.K. Severinghaus, J.W. Anesthesia Research Center, The University of California, San Francisco, School of Medicine, San Francisco, CA 94102, U.S.A. Stanley, T.H. Department of Anesthesiology, The University of Utah Medical School, Salt Lake City, UT 84132, U.S.A. West, J.B. Department of Medicine, The University of California San Diego, La Jolla, CA 92093-0623, U.S.A.

xii Zapol, W.M. Department of Anesthesia, Massachusetts General Hospital, Boston, MA 02114, U.S.A. Zimmerman, G.A. Department of Medicine, The University of Utah Medical School, Salt Lake City, UT 84132, U.S.A.