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Intravenous versus inhalation anaesthesia for one-lung ventilation

  1. Norma SP Módolo1,
  2. Marília P Módolo2,
  3. Marcos A Marton2,
  4. Enilze Volpato3,
  5. Vinícius Monteiro Arantes4,
  6. Paulo do Nascimento Junior1,
  7. Regina El Dib5,*

Editorial Group: Cochrane Anaesthesia, Critical and Emergency Care Group

Published Online: 11 JUL 2013

Assessed as up-to-date: 7 FEB 2017

DOI: 10.1002/14651858.CD006313.pub3


How to Cite

Módolo NSP, Módolo MP, Marton MA, Volpato E, Monteiro Arantes V, do Nascimento Junior P, El Dib R. Intravenous versus inhalation anaesthesia for one-lung ventilation. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD006313. DOI: 10.1002/14651858.CD006313.pub3.

Author Information

  1. 1

    Botucatu Medical School, Universidade Estadual Paulista (UNESP), Department of Anaesthesiology, Botucatu, São Paulo, Brazil

  2. 2

    Botucatu Medical School, UNESP - Univ Estadual Paulista, Botucatu, São Paulo, Brazil

  3. 3

    Universidade Estadual Paulista Júlio de Mesquita Filho/ UNESP, Library, Botucatu, Brazil

  4. 4

    Botucatu Medical School, UNESP - Univ Estadual Paulista, Department of Anaesthesiology, Botucatu, São Paulo, Brazil

  5. 5

    Institute of Science and Technology, Unesp - Univ Estadual Paulista, Department of Biosciences and Oral Diagnosis, Botucatu, Brazil

*Regina El Dib, Department of Biosciences and Oral Diagnosis, Institute of Science and Technology, Unesp - Univ Estadual Paulista, Botucatu, Brazil. eldib@fmb.unesp.br. re.lucci@terra.com.br.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 11 JUL 2013

SEARCH

 
Characteristics of included studies [ordered by study ID]

MethodsDesign: RCT. Multicentre or single-centre: not reported. Period: not reported. Sample size: not reported. Follow-up: before intubation and 20 min after the onset of one-lung ventilation


ParticipantsN: 20 participants. Sex: not reported. Age, y (mean): not reported. Setting: not reported. Inclusion criteria: ASA I and II scheduled for thoracotomy. Exclusion criteria: not reported


InterventionsSevoflurane (2%) in group 1 versus propofol (1 mg/kg/h) and alfentanil (1.5 µg/kg/min) in group 2


OutcomesHaemodynamic measurement and blood gas values


NotesAnaesthesia was induced with propofol in all participants


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot reported

Allocation concealment (selection bias)Unclear riskNot reported

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported

Incomplete outcome data (attrition bias)
All outcomes
Low riskAll participants completed the study

Selective reporting (reporting bias)Unclear riskNot reported (abstract)

Other biasUnclear riskNot reported


MethodsDesign: RCT. Multicentre or single-centre: not reported. Period: not reported. Sample size: reported. Follow-up: after 30 min of TLV in the supine position; after 30 min stable OLV in the supine position and after opening of the pleura in the lateral decubitus position and before surgical manipulation of the lung (OLV)


ParticipantsN: 40 participants. Sex: group 1: 6 females and 13 males; group 2: 7 females and 12 males. Age, y (mean): sevoflurane group 58 and propofol group 62. Setting: not reported. Inclusion criteria: subjects requiring OLV for thoracic surgery. Exclusion criteria: not reported


InterventionsPropofol was infused continuously at an initial rate of 9 mg/kg-1/h-1 reduced to 6 mg/kg-1/h-1 after 10 min and sevoflurane of 1.8 vol% (end-expiratory concentration)


OutcomesCardiac index, mean arterial pressure, mean pulmonary artery pressure and PaCO2


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot reported

Allocation concealment (selection bias)Unclear riskNot reported

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported

Incomplete outcome data (attrition bias)
All outcomes
Low riskTwo participants, one from each group, were excluded from analysis because vasoactive drugs were given for hypotensive episodes during anaesthetic induction

Selective reporting (reporting bias)Low riskNo evidence

Other biasUnclear riskNot reported


MethodsDesign: RCT. Single-centre. Period: not reported. Sample size: reported (40% difference in expression on inflammatory mediators at a 5% level of statistical significance and a power of 80%). Follow-up: five days


ParticipantsN: 70 randomly assigned, but 54 analysed. Sex: sevoflurane: 13 females and 14 males; propofol: 9 female and 18 males. Age, y (mean): sevoflurane group 55 and propofol group 58. Setting: not reported. Inclusion criteria: adults with ASA physical status I to III, scheduled to undergo elective thoracic surgery with lung resection performed through thoracotomy or thoracoscopy. Exclusion criteria: any dose of systemic or topical steroids, acute pulmonary or extrapulmonary infections, severe chronic obstructive pulmonary disease (Gold stage 2 to 4), history of recurrent pneumothoraces, pneumonectomy and/or lung volume-reduction surgery


InterventionsPropofol (2.0 to 4.0 mcg/mL) or sevoflurane (1 MAC)


OutcomesInflammatory mediators in BALF; clinical postoperative outcomes (adverse events). Adverse events were defined as pulmonary infections necessitating antibiotic treatment; radiographically diagnosed pneumonia, atelectasis, effusion; fistula; reintubation; systemic inflammatory response syndrome; sepsis; acute respiratory distress syndrome; surgical revision and death


NotesAnaesthesia was induced with propofol in all participants.

We contacted the authors of the study on 8 August 2011 to ask about the generation of allocation, allocation concealment and blind assessment procedures. Furthermore, we asked which exact target concentration of protocol participants received during anaesthesia maintenance. The authors replied on 21 September 2011


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot reported

Allocation concealment (selection bias)Unclear riskNot reported

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
Low riskAssessors were blinded [information retrieved by email from the authors]

Incomplete outcome data (attrition bias)
All outcomes
Low riskThe authors analysed in all participants the BALF outcome. Only in 27 participants (14 propofol, 13 sevoflurane) the investigators analysed all BALF, cells and blood

Selective reporting (reporting bias)Low riskNo evidence

Other biasUnclear riskNot reported


MethodsDesign: RCT. Multicentre or single-centre: not reported. Period: participants started to be recruited in March 2007 (ongoing study) [information retrieved by email from the authors]. Sample size: calculated the sample size using STATATM, significance level of 5% and power of 80% [information retrieved by email from the authors]. Follow-up: 15 min after the termination of OLV


ParticipantsN: 60. Sex: not reported. Age, y (mean): not reported. Setting: not reported. Inclusion criteria: participants ASA I to III scheduled for elective lung surgery in the lateral position. Exclusion criteria: pulmonary fibrosis or interstitial pulmonary disease; pregnant woman; mental disorder; MMSE score less than 24; moderate and severe liver dysfunction; moderate and severe renal dysfunction and blood coagulation abnormality [information retrieved by email from the authors]


InterventionsPropofol (n = 30) versus sevoflurane (n = 30), both combined with fentanyl and epidural anaesthesia


OutcomesRegional cerebral oxygen saturation values, cognitive function


NotesConference proceedings. We contacted the main author on 13 November 2011 to ask about the full text. Egawa 2009 informed us, the day after we emailed them, that the study is ongoing, so we sent another email to ask for further information about the study. The author replied on 16, 23 and 25 November, 2011


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated [information retrieved by email from the authors]

Allocation concealment (selection bias)Low riskEnvelopes [information retrieved by email from the authors]

Blinding of participants and personnel (performance bias)
All outcomes
Low riskParticipants are blinded, but anaesthesiologists are not blinded to treatment allocation [information retrieved by email from the authors]

Blinding of outcome assessment (detection bias)
All outcomes
Low riskYes [information retrieved by email from the authors]

Incomplete outcome data (attrition bias)
All outcomes
Low riskFew drop-outs so far, <10% according to information retrieved by email from the authors

Selective reporting (reporting bias)Unclear riskNot reported (abstract)

Other biasLow riskNo conflict of interest


MethodsDesign: RCT. Multicentre or single-centre: not reported. Period: not reported. Sample size: not reported. Follow-up: after 30 min of TLV; after 30 min of OLV in supine position and during OLV in the lateral position with the chest open and before surgical manipulation of the lungs


ParticipantsN: 30. Sex: sevoflurane group: 6 males and 9 females; propofol group: 7 males and 8 females. Age, y (mean): sevoflurane group 50.7, propofol group 48.0. Setting: not reported. Inclusion criteria: participants requiring OLV for thoracic surgery. Exclusion criteria: not reported


InterventionsSevoflurane (1 MAC; n = 15) versus propofol (4 to 6 mg/kg/h; n = 15)


OutcomesHaemodynamic variables, pulmonary shunt, mixed venous oxygen tension, arterial oxygen tension and arterial carbon dioxide tension


NotesAll participants were premedicated with oral midazolam (0.1 mg/kg) one hour before surgery


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot reported

Allocation concealment (selection bias)Unclear riskNot reported

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot reported

Selective reporting (reporting bias)Low riskNo evidence

Other biasUnclear riskNot reported


MethodsDesign: RCT. Single-centre. Period: not reported. Sample size: based on the PaO2 values measured in a previous study. Follow-up: 45 minutes of OLV


ParticipantsN: 36 randomly assigned and 32 considered on the final analysis. Sex: 11 male and 5 female in propofol group, 7 male and 9 female in sevoflurane group. Age, y (mean): 67 in both groups. Setting: a university hospital. Inclusion criteria: participants with ASA status I and II requiring OLV during anaesthesia for selective thoracic surgery. Exclusion criteria: patients with severe cardiovascular or respiratory disease, morbid obesity (body mass index > 30) or ASA physical status 3 or 4


InterventionsPropofol (3 to 5 mg/kg/h) versus sevoflurane (1.4% to 1.6%)


OutcomesRelationship between the initial ETCO2 difference and the lowest PaO2 value recorded during the first 45 minutes of OLV


NotesWe contacted the authors of the study by email on 21 July 2011 to ask whether the participants from the Iwata 2008 study were the same as those in their clinical trial. Fukuoka 2009 replied to the email on 26 July 2011, saying that "...the patients from both publications are not the same". We resent an email to ask if perhaps some of the participants were the same as in the Iwata 2008 study and to clarify whether participants and personnel were blinded to treatment allocation. The authors confirmed that participants from the two publications are not the same


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated codes

Allocation concealment (selection bias)Low riskSealed and opaque envelopes

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe anaesthesiologist who assessed the study data were blinded to group assignments

Incomplete outcome data (attrition bias)
All outcomes
Low riskOnly four participants were lost (these participants were excluded because of re-inflation of the nondependent lung)

Selective reporting (reporting bias)Low riskNo evidence

Other biasLow riskNo evidence


MethodsDesign: RCT. Multicentre or single-centre: not reported. Period: not reported. Sample size: not reported. Follow-up: 10 min after induction of anaesthesia, when the participant was in the supine position and both lungs were ventilated; 10 min after a position shift (left lateral); 10 min of left OLV; 20 min of left OLV; 10 min ventilation of both lungs in the lateral position


ParticipantsN: 47. Sex: not reported. Age, y (mean): not reported. Setting: not reported. Inclusion criteria: participants with ASA grades I and II, admitted for right-sided diagnostic or therapeutic elective VATS procedures. Exclusion criteria: patients with oxygen haemoglobin saturation < 97% were immediately (preoperatively) excluded from the study


InterventionsHalothane (0.4% to 0.6%), isoflurane (0.5% to 1.0%) or propofol (10-8-6 mg/kg/h)


OutcomesVATS procedures: resection of emphysematous bullae, lung biopsy, biopsy of a peripheral lung nodule, dissection of adhesions, resection of a pericardial cyst. Blood gas values, alveolar-arterial differences of oxygen partial pressure and Qs/Qt


NotesThe halothane and isoflurane groups also received nitrous oxide, whilst the propofol group received air


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot reported

Allocation concealment (selection bias)Unclear riskNot reported

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot reported

Selective reporting (reporting bias)Low riskNo evidence

Other biasUnclear riskNot reported


MethodsDesign: RCT. Single-centre. Period: from August 2003 to July 2004 [information retrieved by email from the authors]. Sample size: 80% of power, 0.05 alpha, analysed by statistics specialist from their hospital [information retrieved by email from the authors]. Follow-up: only during the intraoperative period (T1: the first 2LV just before performing OLV; T2: near the end of OLV just before resuming 2LV, mostly 30 to 45 minutes after OLV; T3: 5 minutes after resuming 2LV and T4: 20 min after resuming 2LV)


ParticipantsN: 30. Sex: 19 men and 11 women. Age, y (mean): propofol 44 and isoflurane 40. Setting: Taiwan University Hospital. Inclusion criteria: participants with ASA physical status I and II, 20 to 60 years of age, scheduled to undergo thoracoscopic surgery or oesophageal surgery, with limited lung trauma but lengthy OLV. Exclusion criteria: reoperation, steroid use, and antioxidant or immunosuppressant usage [information retrieved by email from the authors]


InterventionsPropofol (started at 10 mg/kg/h for 10 min and then switched to 8 mg/kg/h throughout the study; n = 15) versus isoflurane (1% to 2%; n = 15)


OutcomesHaemodynamic data; reactive oxygen species (ROS) production and total antioxidant status (TAS)


NotesWe contacted the authors of the study on 13 November 2011 to ask about the following:

  • Study period (e.g. participants were recruited from February 1999 to June 2001);
  • Sample size calculation;
  • Generation of allocation;
  • Allocation concealment (i.e. sealed and opaque envelopes or by a third party);
  • Participants blinded to treatment allocation;
  • Drop-outs and how many participants remained in the final analysis;
  • Follow-up period;
  • Exclusion criteria; and
  • Any other bias in the study (i.e. conflict of interest, etc).


The authors replied on 16 November, 2011.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskRandom table [information retrieved by email from the authors]

Allocation concealment (selection bias)Low riskBy another anaesthesiologist who was not involved in the study [information retrieved by email from the authors]

Blinding of participants and personnel (performance bias)
All outcomes
Low riskParticipants were blinded, but the anaesthesiologist was aware of the study objectives [information retrieved by email from the authors]

Blinding of outcome assessment (detection bias)
All outcomes
Low riskInvestigators responsible for analyses of ROC production and TAS level were blinded to the anaesthetic technique

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo drop-outs [information retrieved by email from the authors]

Selective reporting (reporting bias)Low riskNo evidence

Other biasLow riskNone of the authors had conflicts of interest [information retrieved by email from the authors]


MethodsDesign: RCT. Single-centre. Period: not reported. Sample size: based on the formula for normal distribution and assuming a type I error of 0.05 and a power of 0.95. Follow-up: 15 min after the termination of OLV


ParticipantsN: 52. Sex: 16 male and 10 female in propofol group; 17 male and 9 female in sevoflurane group. Age, y (mean): 61 in propofol group and 63 in sevoflurane group. Setting: university hospital. Inclusion criteria: participants scheduled for elective thoracic procedures in the lateral position. Exclusion criteria: renal insufficiency, liver dysfunction, cerebral infarction, documented coagulopathy or coronary or vascular disease


InterventionsSevoflurane versus propofol combined with epidural anaesthesia


OutcomesHaemodynamic variables, SpO2 and blood gas analyses


NotesWe contacted the authors of the study on 27 September 2011 to ask about the period of the study, the generation of allocation, allocation concealment and blind assessment of outcomes. Furthermore, we have asked whether this study evaluated the same participants as were included in Fukuoka 2009. We are awaiting their reply


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated random numbers

Allocation concealment (selection bias)Unclear riskNot reported

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot reported

Selective reporting (reporting bias)Low riskNo evidence

Other biasUnclear riskNot reported


MethodsDesign: RCT. Multicentre or single-centre: not reported. Period: not reported. Sample size: not reported. Follow-up: TLV, after 20 min of the allocated maintenance regimen during TLV; OLV, after 20 min of stable OLV before ligation or division of any pulmonary vessels or bronchi; end, during wound closure after at least 20 min of stable ventilation of all remaining lung tissue


ParticipantsN: 22 (10 isoflurane group and 12 propofol group). Sex: isoflurane group: 3 female and 7 male; propofol group-2 female and 10 male. Age, y (mean): not reported. Setting: not reported. Inclusion criteria: participants undergoing elective thoracotomy requiring OLV. Exclusion criteria: patients were excluded if they were younger than 18 or older than 75 years old, and if their cardiac rhythm was not predominantly sinus


InterventionsIsoflurane (1% to 1.5%) versus propofol (10 mg/kg/h, reducing at 10 min intervals to 8 and then 6 mg/kg/h)


OutcomesCardiac index, heart rate, mean arterial pressure, pulmonary vascular resistance index, right ventricular ejection fraction, end-systolic and end-diastolic volume indices, shunt fraction and changes in haemodynamic data


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot reported

Allocation concealment (selection bias)Unclear riskNot reported

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
High riskAfter induction, all measurements were made by the same observer, who was not blinded to the anaesthetic regimen used

Incomplete outcome data (attrition bias)
All outcomes
Low riskOne participant in the isoflurane group was eliminated from the study after arterial desaturation that did not respond to increasing concentration of inspired oxygen

Selective reporting (reporting bias)Low riskNo evidence

Other biasUnclear riskNot reported


MethodsDesign: RCT. Single-centre. Sample size: not reported. Follow-up: not reported


ParticipantsN: 50. Sex: 43 female and 7 male. Age, y (mean): 63.8. Inclusion criteria: ASA II and III. Exclusion criteria: not reported


InterventionsGroup A propofol (4 to 7 mg/kg/h), fentanyl (1.5 to 2 µg/kg/h), atracurium (0.5 mg/kg/h) versus group B isoflurane (0.7% to 1.2%), fentanyl (1.2 to 1.5 µg/kg/h), atracurium (0.5 mg/kg/h)


OutcomesPressure values, heart rate, PaO2 and PaCO2 levels, SPO2 and PECO2


NotesPremedication with diazepam 10 mg plus atropine 0.5 mg


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot reported

Allocation concealment (selection bias)Unclear riskNot reported

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot reported

Selective reporting (reporting bias)Low riskNo evidence

Other biasUnclear riskNot reported


MethodsDesign: RCT. Multicentre. Period: author could not provide the period of the study [information retrieved by email contact with the authors]. Sample size: two-tailed, alpha error of 5% and beta error of 20%. Follow-up: 40 min after initiation


ParticipantsN: 80 randomly assigned and 65 completed the study. Sex: sevoflurane, 7 female and 26 male; propofol, 7 female and 25 male. Age, y (mean): 62 and 57, respectively, sevoflurane and propofol. Inclusion criteria: participants undergoing lobectomy requiring OLV, age between 18 and 70 years of age, ASA I to III and indication for thoracic epidural anaesthesia. Exclusion criteria: patients taking vasoactive drug at the time of selection


InterventionsPropofol versus sevoflurane


OutcomesThe primary outcome was defined as the lowest PaO2 during the study period. Other outcomes were measured: arterial blood gas analysis, end-tidal carbon dioxide concentration, heart rate, mean arterial pressure and BIS value


NotesWe contacted the authors of the study on 5 October 2011 to ask about the period of study, allocation concealment and blind assessment of outcome. The authors replied on the same day, saying that neither outcome assessment nor allocation was concealed. With regard to the period of the study, the authors could not provide this information


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated randomization list

Allocation concealment (selection bias)High riskNo protection [information retrieved by email from the authors]

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
High riskNo blinding [information retrieved by email from the authors]

Incomplete outcome data (attrition bias)
All outcomes
High risk15 participants were lost: 20% and 17.5%, respectively, propofol and sevoflurane

Selective reporting (reporting bias)Low riskNo evidence

Other biasUnclear riskNot reported


MethodsDesign: RCT. Multicentre or single-centre: not reported. Period: not reported. Sample size: not reported. Follow-up: 5, 15, 30 and 45 min after establishment of OLV and again 15 min after re-establishment of two-lung ventilation


ParticipantsN: 24 men. Age, y (mean): group one 55 and group two 60. Setting: not reported. Inclusion criteria: elective lung resections for carcinoma. Exclusion criteria: not reported


InterventionsKetamine 2 mg/kg followed by 0.65 mg/kg of d-tubocurare intravenously versus 1% to 3% enflurane


OutcomesArterial blood samples, cardiac output, intrapulmonary shunt, cardiac index, oxygen delivery, oxygen consumption, stroke volume index, left and right ventricular stroke work indices, pulmonary vascular resistance and systemic vascular resistance


NotesAll participants were given 10 mg of diazepam and 5 mg of droperidol intravenously before monitoring lines were inserted. The groups received different induction drugs (ketamine and thiopental) and different maintenance drugs (ketamine at 2 mg/kg/h vs enflurane 1% to 3%)


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated randomization schedule

Allocation concealment (selection bias)Unclear riskNot reported

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported

Incomplete outcome data (attrition bias)
All outcomes
Low riskThree participants were removed from the study because of the shortness of the period of OLV and hence failure to gather sufficient data (12.5%)

Selective reporting (reporting bias)Low riskNo evidence

Other biasUnclear riskNot reported


MethodsDesign: RCT. Single-centre: tertiary care university hospital. Period: not reported. Sample size: not reported. Follow-up: during two-lung ventilation and after 20 and 30 minutes of OLV with each anaesthetic technique


ParticipantsN: 30. Sex: not reported. Age, y (mean): for all participants 59. Setting: tertiary care university hospital. Inclusion criteria: participants undergoing thoracoscopic pulmonary surgery or oesophageal surgery. Exclusion criteria: not reported


InterventionsParticipants received either propofol-alfentanil infusion anaesthesia or one minimum alveolar concentration (MAC) of isoflurane during the initial period of two-lung ventilation and the first 30 minutes of OLV and then were switched to the other anaesthetic for the duration of OLV


OutcomesArterial blood gases and haemodynamic variables


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskBy lottery

Allocation concealment (selection bias)Unclear riskNot reported

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported

Incomplete outcome data (attrition bias)
All outcomes
High risk10 participants; in 3, the study protocol was terminated prematurely because of arterial oxygen desaturation < 90%; in the other 7, the protocol was terminated because re-inflation of the nonventilated lung was required for surgical reasons before the study protocol could be completed

Selective reporting (reporting bias)Low riskNo evidence

Other biasUnclear riskNot reported


MethodsDesign: RCT. Multicentre or single-centre: not reported. Period: not reported. Sample size: not reported. Follow-up: 30 min after start of OLV


ParticipantsN: 40. Sex: not reported. Age, y (mean): not reported. Setting: not reported. Inclusion criteria: participants with ASA physical status I to III scheduled for elective lobectomy. Exclusion criteria: not reported


InterventionsPropofol (n = 20) versus desflurane (n = 20) combined with thoracic anaesthesia


OutcomesHaemodynamic and respiratory parameters, stroke volume and cardiac index


NotesConference proceedings. We contacted the main author on 5 October 2011 to ask about the full text. We are awaiting the reply


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot reported

Allocation concealment (selection bias)Unclear riskNot reported

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot reported

Selective reporting (reporting bias)Unclear riskNot reported (abstract)

Other biasUnclear riskNo evidence


MethodsDesign: RCT. Single-centre. Period: November 2006 to June 2008 [information retrieved by email from the authors]. Sample size: reported; on the basis of previous studies, significance level of 5% and power of 80%. Follow-up: 30 min after the surgical procedure


ParticipantsN: 63. Sex: 41 male and 22 female. Age, y (mean): 64 for propofol group, 60 for desflurane group and 63 for sevoflurane group. Setting: Otto-von-Guericke-Universty Magdeburg. Inclusion criteria: participants scheduled for open thoracic surgery and OLV. Exclusion criteria: persistent tobacco abuse, body mass index greater than 35 kg/m2, history of treatment with immunodepressant drugs in the 6 weeks before surgery, cardiac failure (New York Heart Association greater than II), clinically relevant obstructive or restrictive lung disease (vital capacity or forced expiratory volume in 1 s < 50% of predicted value), pulmonary hypertension (mean pulmonary arterial pressure greater than 25 mm Hg) or preexisting coagulation disorders and participants with evidence of pulmonary or systemic infection


InterventionsPropofol (4 mg/kg/h) or sevoflurane (1 MAC)


OutcomesCytokine concentrations (concentrations of TNF-a and IL-1b, IL-6, IL-8, IL-10 and IL-12 p70 in bronchoalveolar lavage fluids and serum samples), ventilation and gas exchange data and haemodynamic data


NotesAnaesthesia was induced with propofol in all participants

We contacted the authors of the study on 5 October 2011 to ask about the period of the study, allocation concealment and blind assessment of outcome. The authors answered our queries.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Low riskComputer-generated software (i.e. randomization was done by EXCEL scripts, which deliver columns (according to the number of groups needed) of random numbers) [information retrieved by email from the authors]

Allocation concealment (selection bias)Low riskRandomization list was password-protected and white sealed envelopes were used [information retrieved by email from the authors]

Blinding of participants and personnel (performance bias)
All outcomes
High riskParticipants were blinded, but anaesthesiologists who provided the anaesthesia were not [information retrieved by email from the authors]

Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe persons who did the immunological/pathohistological analyses were blinded to the study protocol [information retrieved by email from the authors]

Incomplete outcome data (attrition bias)
All outcomes
Low riskAll enrolled participants completed the study successfully

Selective reporting (reporting bias)Low riskNo evidence

Other biasUnclear riskNot reported


MethodsDesign: RCT. Single-centre. Period: not reported. Sample size: not reported. Follow-up: 30 min after beginning of OLV


ParticipantsN: 60 randomly assigned and 54 completed the study. Sex: sevoflurane male:female 19:9; propofol 16:10. Age, y (mean): sevoflurane 61 and propofol 57. Setting: University Hospital in Jena, Germany. Inclusion criteria: participants with ASA grade I to III scheduled for thoracic surgery, with limited lung trauma but lengthy OLV. Exclusion criteria: not reported


InterventionsPropofol (range 3 to 6 mg/kg/h) versus sevoflurane (1 MAC)


OutcomesArterial blood gases, haemodynamic and respiratory parameters


NotesIn both groups, anaesthesia was induced with propofol.

We contacted the authors of the study on 13 November 2011 to ask about the following:

  • Study period (e.g. participants were recruited from February 1999 to June 2001);
  • Sample size calculation;
  • Generation of allocation;
  • Allocation concealment (i.e. sealed and opaque envelopes or by a third party);
  • Participants blinded to treatment allocation;
  • Exclusion criteria; and
  • Any other bias in the study (e.g. conflict of interest, etc).


We are awaiting the authors' reply.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot reported

Allocation concealment (selection bias)Unclear riskNot reported

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported

Incomplete outcome data (attrition bias)
All outcomes
Low riskA total of 6.7% and 13.4% of withdrawals in sevoflurane and propofol, respectively

Selective reporting (reporting bias)Low riskNo evidence

Other biasUnclear riskNot reported


MethodsDesign: RCT. Single-centre or multicentre: not reported. Period: not reported. Sample size: not reported. Follow-up: during TLV; 15 min after induction in the supine position; 20 min after surgical opening of the chest in the lateral decubitus position; 20 min after start of OLV and after extubation


ParticipantsN: 28. Sex: not reported. Age, y (mean): not reported. Setting: not reported. Inclusion criteria: ASA risk groups II and III. Exclusion criteria: not reported


InterventionsPropofol (10 mg/kg/h) versus enflurane (1 MAC)


OutcomesHaemodynamics and arterial and mixed venous blood gases


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot reported

Allocation concealment (selection bias)Unclear riskNot reported

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot reported

Selective reporting (reporting bias)Low riskNo evidence

Other biasUnclear riskNot reported


MethodsDesign: RCT. Multicentre or single-centre: not reported. Period: not reported. Sample size: not reported. Follow-up: not reported


ParticipantsN: 18 randomly assigned. Sex: not reported. Age, y (mean): not reported. Setting: not reported. Inclusion criteria: participants undergoing major thoracic surgery. Exclusion criteria: not reported


InterventionsPropofol (n = 9) versus sevoflurane (n = 9)


OutcomesInflammatory mediators


NotesConference proceedings. We contacted the main author on 13 November 2011 to ask about the full text. We are awaiting the reply


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot reported

Allocation concealment (selection bias)Unclear riskNot reported

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNot reported

Selective reporting (reporting bias)Unclear riskNot reported (abstract)

Other biasUnclear riskNot reported


MethodsDesign: RCT. Multicentre or single-centre: single-centre. Period: February 2007 to February 2008. Sample size: not reported. Follow-up: the end of surgery


ParticipantsN: 50. Sex: propofol (14 males and 11 females); sevoflurane (10 males and 15 females). Age, y (mean): propofol 72.0 and sevoflurane 66.8. Setting: university hospital. Inclusion criteria: ASA I or II, diagnosed with lung tumour and scheduled for lung lobectomy requiring OLV. Exclusion criteria: patients with cerebrovascular disease; patients with impaired pulmonary function


InterventionsPropofol (2 to 3 mcg/mL, n = 25) versus sevoflurane (1% to 2%, n = 25)


OutcomesCerebral regional oxygen saturation during surgery; PaO2, PaCO2, HR, mean arterial pressure, arterial pressure-based cardiac index, haemoglobin concentration, body temperature


NotesArticle in Japanese, only the abstract was written in English. Mina Nishimori, a Cochrane review author, kindly translated and extracted data from the Yamada 2008 study


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot reported

Allocation concealment (selection bias)Unclear riskNot reported

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskNot reported

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskNot reported

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo withdrawals/drop-outs

Selective reporting (reporting bias)Low riskNo evidence

Other biasUnclear riskNot reported

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Abe 1998aRandomized controlled trial comparing isoflurane and sevoflurane

Abe 1998bRandomized controlled trial comparing isoflurane and sevoflurane

Benumof 1987Randomized controlled trial comparing halothane and isoflurane

Boldt 1996Randomized controlled trial comparing intravenous anaesthetics

Bovill 1984Randomized controlled trial comparing intravenous anaesthetics

Canet 1994Randomized controlled trial comparing halothane and isoflurane

Carlsson 1987Case series evaluating isoflurane

Celik 2009Randomized controlled trial of desflurane versus sevoflurane

Cigarini 1990Randomized controlled trial comparing thiopental and propofol

Dikmen 2003Case series comparing inhalation anaesthetics

Dupont 1999Randomized cross-over design comparing sevoflurane, desflurane and isoflurane

Furugen 1989Case series evaluating propofol

He 1996Randomized clinical trial evaluating sevoflurane

He 1999Evaluated only isoflurane and desflurane

Koishi 1998Retrospective study

Koishi 1999Retrospective study comparing intravenous anaesthetics

Ma 1998Randomized controlled trial comparing halothane and sevoflurane

Merli 1991Case series evaluating propofol

Pagel 1998Randomized controlled trial comparing isoflurane and desflurane

Pueyo 1994Case series evaluating propofol

Rogers 1985Randomized controlled trial comparing halothane and isoflurane

Rosso 1995Prospective study with propofol

Saito 2000Randomized cross-over design comparing sevoflurane and isoflurane

Satoh 1998Case series evaluating isoflurane

Shimizu 1997Randomized controlled trial evaluating isoflurane and sevoflurane

Sjögren 1995Case series comparing inhalation anaesthetics

Slinger 1988Randomized controlled trial comparing enflurane and isoflurane

Slinger 1995Case series evaluating isoflurane

Solares 1992Case series evaluating isoflurane

Steegers 1990Case series evaluating intravenous anaesthetics

Temp 1992Case series evaluating isoflurane

Van Keer 1989Case series evaluating intravenous anaesthetics

Van Leeuwen 1990Randomized controlled trial evaluating intravenous anaesthetics

Wang 1998Randomized cross-over design evaluating sevoflurane and isoflurane

Wang 2000Randomized prospective cross-over study evaluating desflurane and isoflurane

Yamada 1990Controlled clinical trial

Yondov 1999Comparative controlled study

 
Characteristics of studies awaiting assessment [ordered by study ID]

MethodsDesign: RCT. Multicentre or single-centre: single-centre. Setting: not reported. Period: not reported. Sample size: not reported. Follow-up: not reported

ParticipantsN: 44. Inclusion criteria: aged between 18 and 65, ASA physical status I or II, undergo- ing OLV/2LV for thoracic surgery. Exclusion criteria: patients with ASA score of III or more and severe metabolic, renal, or hepatic diseases, using cigarettes or antioxidant agents

InterventionsSevoflurane versus propofol

OutcomesMean arterial pressures, heart rate, blood gas analyses

Notes


MethodsDesign: RCT. Multicentre or single-centre: single-centre. Setting: Alexandria Main University Hospital. Period: not reported. Sample size: not reported. Follow-up: 2nd postoperative day

ParticipantsN: 40. Inclusion criteria: patients schedule to elective lung resection surgery through thoracotomy. Exclusion criteria: acute pulmonary or extra pulmonary infections; severe chronic obstructive pulmonary diseases, and history of recurrent pneumothoraces; pneumonectomy and lung volume reduction surgery; contraindications for epidural catheter insertio; patients on chemotherapy, radiotherapy, immunosuppressant drugs or corticosteroids; history of allergy to local anaesthetic drugs; and trauma patients

InterventionsSevoflurane versus propofol

OutcomesSystemic inflammatory response, pulmonary inflammatory response, C-reactive protein, leucocyte count, and recovery status

Notes


MethodsDesign: RCT. Multicentre or single-centre: single-centre. Setting: University Medical Centre Ljubljana. Period: 2009-2013. Sample size: significance level of 0.05 and a power of 80%, it was enough to have 16 patients in each group. Follow-up: 6 hours after surgery

ParticipantsN: 40. Inclusion criteria: the study included patients aged 20-70 years with the American Society of Anesthesiologists (ASA) physical status I-III, scheduled for elective open lobectomy with OLV. Exclusion criteria: history of drug hypersensitivity, drug addiction, treatment with psychotropic drugs, severe psychiatric and central nerve system diseases, persistent tobacco abuse, autoimmune system diseases, diabetes mellitus, cardiac failure (New York Heart Association class greater than 2), clinically relevant obstructive and restrictive lung diseases (vital capacity or forced expiratory volume in 1 s lower than 50% of the predicted values), pulmonary hypertension (mean pulmonary arterial pres- sure greater than 25 mm Hg), pre-existing coagulation disorders, and history of treatment with immunosuppressant drugs in the 4 weeks before surgery. Patients with evidence of pulmonary or systemic infections (CRP serum concentration greater than 5 mg/L, leucocytosis greater than 10.0 gigaparticles/L or body temperature greater than 37°C) were also excluded, as well as the patients who had received perioperative blood derivatives, steroids, or NSAIDs

InterventionsSevoflurane versus propofol

OutcomesInflammatory mediators (interleukins 6, 8, and 10, C-reactive protein [CRP], and pro-calcitonin) and clinical postoperative outcome

Notes


MethodsDesign: RCT. Multicentre or single-centre: single-centre. Setting: not reported. Period: not reported. Sample size: not reported. Follow-up: not reported

ParticipantsN: 20. Inclusion criteria: American Society of Anesthesiologists Physical Status category I-II, undergoing cervico-thoraco-abdominal three-field lymph node dissection through a right thoracotomy. Exclusion criteria: neurologic or psychiatric disease, cardiac disease classified as NYHA classes II-IV, preoperative severe impairment of respiratory function (such as a vital capacity of <50% or a forced expiratory volume in 1 sec of <50% of that predicted), and pre-existing coagulopathy or thrombocytopenia. Subjects were also excluded if they exhibited systemic or local active infections (either clinically defined or evidenced by elevated C-reactive protein levels, leukocytosis or body temperature of >38̊C)

InterventionsSevoflurane versus propofol

OutcomesInflammatory cytokines and chemokine [tumour necrosis factor (TNF)-α, interleukin (IL)-1β, IL-6, IL-8, IL-10 and IL-12p70]

Notes

 
Summary of findings for the main comparison.

Intravenous compared with inhalation anaesthesia for one-lung ventilation

Patient or population: participants ventilated by one-lung

Settings:

Intervention: intravenous anaesthesia

Comparison: inhalation anaesthesia

OutcomesRelative effect
(95% CI)
No. of participants
(studies)
Quality of the evidence
(GRADE)

Death (at one month)

Follow-up: 5 days (De Conno 2009)
RR 0

(0 to 0)
54 (1 study)⊕⊝⊝⊝
very low

Adverse postoperative outcomes

Follow-up: 5 days (De Conno 2009); 20 minutes after resuming 2LV (Huang 2008) and 15 min after termination of OLV (Egawa 2009).
RR1.56

(1.07 to 2.29)
132 (3 studies)⊕⊕⊝⊝
low

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk Ratio.

GRADE Working Group grades of evidence:
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.