ArticleFrontiers in cardiovascular medicine2026
Case Report: Paradoxical worsening of hypoxemia with PEEP during one-lung ventilation: a case of pressure-dependent intracardiac shunting.
Article in Frontiers in cardiovascular medicine, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: Perioperative hypoxemia during one-lung ventilation (OLV) is commonly managed by applying positive end-expiratory pressure (PEEP) to recruit the dependent lung. However, in rare instances, PEEP escalation may paradoxically compromise oxygenation. We describe a case in which a transient rise in right-sided pressures relative to left-sided pressures likely unmasked a pressure-dependent right-to-left intracardiac shunt. Case presentation: A 55-year-old male underwent elective video-assisted thoracoscopic surgery (VATS) right upper lobe resection. During otherwise stable OLV, mild hypoxemia (SpO Conclusions: This case illustrates that PEEP can be a double-edged sword during OLV. Under certain conditions, escalating airway pressure may transiently reverse the interatrial pressure gradient and facilitate right-to-left shunting across a PFO. When oxygenation deteriorates following a recruitment maneuver, clinicians should resist reflexive PEEP escalation and consider an intracardiac shunt as a potentially reversible cause; in this context, PEEP reduction may serve as both a diagnostic probe and a therapeutic rescue.
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