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Wang QY, Zhou Y, Wang MR, Jiao YY. Effects of starting one lung ventilation and applying individualized PEEP right after patients are placed in lateral decubitus position on intraoperative oxygenation for patients undergoing thoracoscopic pulmonary lobectomy: study protocol for a randomized controlled trial. Trials 2024; 25:500. [PMID: 39039591 DOI: 10.1186/s13063-024-08347-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 07/17/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND For patients receiving one lung ventilation in thoracic surgery, numerous studies have proved the superiority of lung protective ventilation of low tidal volume combined with recruitment maneuvers (RM) and individualized PEEP. However, RM may lead to overinflation which aggravates lung injury and intrapulmonary shunt. According to CT results, atelectasis usually forms in gravity dependent lung regions, regardless of body position. So, during anesthesia induction in supine position, atelectasis usually forms in the dorsal parts of lungs, however, when patients are turned into lateral decubitus position, collapsed lung tissue in the dorsal parts would reexpand, while atelectasis would slowly reappear in the lower flank of the lung. We hypothesize that applying sufficient PEEP without RM before the formation of atelectasis in the lower flank of the lung may beas effective to prevent atelectasis and thus improve oxygenation as applying PEEP with RM. METHODS A total of 84 patients scheduled for elective pulmonary lobe resection necessitating one lung ventilation will be recruited and randomized totwo parallel groups. For all patients, one lung ventilation is initiated the right after patients are turned into lateral decubitus position. For patients in the study group, individualized PEEP titration is started the moment one lung ventilation is started, while patients in the control group will receive a recruitment maneuver followed by individualized PEEP titration after initiation of one lung ventilation. The primary endpoint will be oxygenation index measured at T4. Secondary endpoints will include intrapulmonary shunt, respiratory mechanics, PPCs, and hemodynamic indicators. DISCUSSION Numerous previous studies compared the effects of individualized PEEP applied alone with that applied in combination with RM on oxygenation index, PPCs, intrapulmonary shunt and respiratory mechanics after atelectasis was formed in patients receiving one lung ventilation during thoracoscopic surgery. In this study, we will apply individualized PEEP before the formation of atelectasis while not performing RM in patients allocated to the study group, and then we're going to observe its effects on the aspects mentioned above. The results of this trial will provide a ventilation strategy that may be conductive to improving intraoperative oxygenation and avoiding the detrimental effects of RM for patients receiving one lung ventilation. TRIAL REGISTRATION www.Chictr.org.cn ChiCTR2400080682. Registered on February 5, 2024.
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Affiliation(s)
- Qing-Yuan Wang
- Department of Anesthesiology, Peking University Third Hospital, NO. 49, North Garden Road, Haidian District, Beijing, People's Republic of China.
| | - Yang Zhou
- Department of Anesthesiology, Peking University Third Hospital, NO. 49, North Garden Road, Haidian District, Beijing, People's Republic of China
| | - Meng-Rui Wang
- Department of Anesthesiology, Peking University Third Hospital, NO. 49, North Garden Road, Haidian District, Beijing, People's Republic of China
| | - You-You Jiao
- Department of Anesthesiology, Peking University Third Hospital, NO. 49, North Garden Road, Haidian District, Beijing, People's Republic of China
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Vivona L, Huhle R, Braune A, Scharffenberg M, Wittenstein J, Kiss T, Kircher M, Herzog P, Herzog M, Millone M, Gama de Abreu M, Bluth T. Variable ventilation versus stepwise lung recruitment manoeuvres for lung recruitment: A comparative study in an experimental model of atelectasis. Eur J Anaesthesiol 2023; 40:501-510. [PMID: 36809307 DOI: 10.1097/eja.0000000000001808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Variable ventilation recruits alveoli in atelectatic lungs, but it is unknown how it compares with conventional recruitment manoeuvres. OBJECTIVES To test whether mechanical ventilation with variable tidal volumes and conventional recruitment manoeuvres have comparable effects on lung function. DESIGN Randomised crossover study. SETTING University hospital research facility. ANIMALS Eleven juvenile mechanically ventilated pigs with atelectasis created by saline lung lavage. INTERVENTIONS Lung recruitment was performed using two strategies, both with an individualised optimal positive-end expiratory pressure (PEEP) associated with the best respiratory system elastance during a decremental PEEP trial: conventional recruitment manoeuvres (stepwise increase of PEEP) in pressure-controlled mode) followed by 50 min of volume-controlled ventilation (VCV) with constant tidal volume, and variable ventilation, consisting of 50 min of VCV with random variation in tidal volume. MAIN OUTCOME MEASURES Before and 50 min after each recruitment manoeuvre strategy, lung aeration was assessed by computed tomography, and relative lung perfusion and ventilation (0% = dorsal, 100% = ventral) were determined by electrical impedance tomography. RESULTS After 50 min, variable ventilation and stepwise recruitment manoeuvres decreased the relative mass of poorly and nonaerated lung tissue (percent lung mass: 35.3 ± 6.2 versus 34.2 ± 6.6, P = 0.303); reduced poorly aerated lung mass compared with baseline (-3.5 ± 4.0%, P = 0.016, and -5.2 ± 2.8%, P < 0.001, respectively), and reduced nonaerated lung mass compared with baseline (-7.2 ± 2.5%, P < 0.001; and -4.7 ± 2.8%, P < 0.001 respectively), while the distribution of relative perfusion was barely affected (variable ventilation: -0.8 ± 1.1%, P = 0.044; stepwise recruitment manoeuvres: -0.4 ± 0.9%, P = 0.167). Compared with baseline, variable ventilation and stepwise recruitment manoeuvres increased Pa O 2 (172 ± 85mmHg, P = 0.001; and 213 ± 73 mmHg, P < 0.001, respectively), reduced Pa CO 2 (-9.6 ± 8.1 mmHg, P = 0.003; and -6.7 ± 4.6 mmHg, P < 0.001, respectively), and decreased elastance (-11.4 ± 6.3 cmH 2 O, P < 0.001; and -14.1 ± 3.3 cmH 2 O, P < 0.001, respectively). Mean arterial pressure decreased during stepwise recruitment manoeuvres (-24 ± 8 mmHg, P = 0.006), but not variable ventilation. CONCLUSION In this model of lung atelectasis, variable ventilation and stepwise recruitment manoeuvres effectively recruited lungs, but only variable ventilation did not adversely affect haemodynamics. TRIAL REGISTRATION This study was registered and approved by Landesdirektion Dresden, Germany (DD24-5131/354/64).
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Affiliation(s)
- Luigi Vivona
- From the Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus at the Technische Universität Dresden, Dresden, Germany (LV, RH, AB, MS, JW, TK, PH, MH, MM, MGA, TB), Department of Pathophysiology and Transplantation, University of Milan, Italy (LV), Institute of Nuclear Medicine, University Hospital Carl Gustav Carus, Dresden (AB), Department of Anesthesiology, Elblandklinikum Radebeul, Radebeul (TK), Institute of Biomedical Engineering, Karlsruhe Institute of Technology (KIT), Karlsruhe (MK), Drägerwerk AG & Co KGaA, Lübeck, Germany (MK), IRCCS San Martino IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy (MM), Department of Intensive Care and Resuscitation (MGA) and Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio, USA (MGA)
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Papastefanou A, Rioja E. Severe Hypercapnia during Anaesthesia under Mechanical Ventilation in Two Paediatric Patients. Animals (Basel) 2023; 13:ani13040663. [PMID: 36830450 PMCID: PMC9951664 DOI: 10.3390/ani13040663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/07/2023] [Accepted: 02/11/2023] [Indexed: 02/17/2023] Open
Abstract
A 2-month-old male 1.56 kg Yorkshire terrier (Case No. 1) and a 3-month-old male 2.3 kg Jack Russell Terrier (Case No. 2) were scheduled for ophthalmological surgery under general anaesthesia and neuromuscular blockade. For both patients, volume-controlled ventilation (VCV) was used with set tidal volumes (VT) of 13 mL/kg and 20 mL/kg for cases No. 1 and 2, respectively. The type of ventilator used did not take into account the intrinsic compliance of the breathing system; therefore, a significant part of the delivered VT was wasted in the expansion of the breathing system, and did not reach the patients, causing alveolar hypoventilation. Both cases developed low dynamic compliance (CD), and after a recruitment manoeuvre, EtCO2 of up to 116 mmHg and 197 mmHg were revealed for cases No. 1 and 2, respectively. The two cases had to be ventilated manually, using positive inspiratory pressures (PIP) of 20-25 mmHg, in order to improve alveolar ventilation and reduce the EtCO2, as adjustments to the VCV were ineffective. Both patients maintained an oxygen haemoglobin saturation between 94% and 100% throughout the procedure and they recovered well. Using a higher VT from the beginning, to compensate for the compliance of the breathing system, or the use of pressure-controlled ventilation (PCV), could have potentially helped to avoid these two incidences of severe hypercapnia.
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Andrade FSRM, Ambrósio AM, Rodrigues RR, Faccó LL, Gonçalves LA, Garcia Filho SG, dos Santos RT, Rossetto TC, Pereira MAA, Fantoni DT. The optimal PEEP after alveolar recruitment maneuver assessed by electrical impedance tomography in healthy horses. Front Vet Sci 2022; 9:1024088. [PMID: 36570501 PMCID: PMC9780380 DOI: 10.3389/fvets.2022.1024088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 11/09/2022] [Indexed: 12/13/2022] Open
Abstract
Background Electrical impedance tomography (EIT) has been an essential tool for assessing pulmonary ventilation in several situations, such as the alveolar recruitment maneuver (ARM) in PEEP titration to maintain the lungs open after atelectasis reversion. In the same way as in humans and dogs, in horses, this tool has been widely used to assess pulmonary aeration undergoing anesthesia, mechanical ventilation, recruitment maneuver, standing horses, or specific procedures. Objectives The present study aimed to evaluate the distribution of regional ventilation during ARM based on lung monitoring assessment by EIT, with a focus on better recruitment associated with less or no overdistention. Methods Fourteen horses of 306 ± 21 kg undergoing isoflurane anesthesia in dorsal recumbency were used. The animals were mechanically ventilated with a tidal volume of 14 ml kg-1 and a respiratory rate of 7-9. An alveolar recruitment maneuver was instituted, increasing the PEEP by five cmH2O every 5 min until 32 cmH2O and decreasing it by five cmH2O every 5 min to 7 cmH2O. At each step of PEEP, arterial blood samples were collected for blood gas analysis, EIT images, hemodynamic, and respiratory mechanics. Results Associated with the CoV-DV increase, there was a significant decrease in the DSS during the ARM and a significant increase in the NSS when PEEP was applied above 12 cmH2O compared to baseline. The ComplROI showed a significant increase in the dependent area and a significant decrease in the non-dependent area during ARM, and both were compared to their baseline values. The driving pressure decreased significantly during the ARM, and Cst, PaO2, and PaO2/FiO2 ratio increased significantly. The VD/VT decreased significantly at DEPEEP17 and DEPEEP12. There was an HR increase at INPEEP27, INPEEP 32, and DEPEEP17 (p < 0.0001; p < 0.0001; and p < 0.05, respectively), those values being above the normal reference range for the species. The SAP, MAP, DAP, CI, and DO2I significantly decreased INPEEP32 (p < 0.05). Conclusion The ARM by PEEP titration applied in the present study showed better ventilation distribution associated with better aeration in the dependent lung areas, with minimal overdistention between PEEP 17 and 12 cmH2O decreasing step. Those changes were also followed by improvements in static and regional compliance associated with increased oxygenation and pulmonary ventilation. ARM promoted a transitory decrease in arterial blood pressure and depression in CI with a concomitant drop in oxygen delivery, which should be best investigated before its routine use in clinical cases.
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Di Bella C, Vicenti C, Araos J, Lacitignola L, Fracassi L, Stabile M, Grasso S, Crovace A, Staffieri F. Effects of two alveolar recruitment maneuvers in an “open-lung” approach during laparoscopy in dogs. Front Vet Sci 2022; 9:904673. [PMID: 36061108 PMCID: PMC9435385 DOI: 10.3389/fvets.2022.904673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/28/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives The aim of this study was to compare the effects of a sustained inflation alveolar recruiting maneuver (ARM) followed by 5 cmH2O of PEEP and a stepwise ARM, in dogs undergoing laparoscopic surgery. Materials and methods Twenty adult dogs were enrolled in this prospective randomized clinical study. Dogs were premedicated with methadone intramuscularly (IM); anesthesia was induced with propofol intravenously (IV) and maintained with inhaled isoflurane in pure oxygen. The baseline ventilatory setting (BVS) was as follows: tidal volume of 15 mL/kg, inspiratory pause of 25%, inspiratory to expiratory ratio of 1:2, and the respiratory rate to maintain the end-tidal carbon dioxide between 45 and 55 mmHg. 10 min after pneumoperitoneum, randomly, 10 dogs underwent sustained inflation ARM followed by 5 cmH2O of PEEP (ARMi), while 10 dogs underwent a stepwise recruitment maneuver followed by the setting of the “best PEEP” (ARMc). Gas exchange, respiratory system mechanics, and hemodynamic were evaluated before the pneumoperitoneum induction (BASE), 10 min after the pneumoperitoneum (PP), 10 min after the recruitment (ARM), and 10 min after the pneumoperitoneum resolution (PostPP). Statistical analysis was performed with the ANOVA test (p < 0.05). Results Static compliance decreased in both groups at PP (ARMc = 1.35 ± 0.21; ARMi = 1.16 ± 0.26 mL/cmH2O/kg) compared to BASE (ARMc = 1.78 ± 0.60; ARMi = 1.66 ± 0.66 mL/cmH2O/kg) and at ARM (ARMc = 1.71 ± 0.41; ARMi = 1.44 ± 0.84 mL/cmH2O/kg) and PostPP (ARMc = 1.75 ± 0.45; ARMi = 1.89 ± 0.59 mL/cmH2O/kg), and it was higher compared to PP and similar to BASE. The PaO2/FiO2, in both groups, was higher at ARM (ARMc = 455.11 ± 85.90; ARMi = 505.40 ± 31.70) and PostPP (ARMc = 521.30 ± 66.20; ARMi = 450.90 ± 70.60) compared to PP (ARMc = 369.53 ± 49.31; ARMi = 394.32 ± 37.72). Conclusion and clinical relevance The two ARMs improve lung function in dogs undergoing laparoscopic surgery similarly. Application of PEEP at the end of the ARMs prolonged the effects of the open-lung strategy.
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Affiliation(s)
- Caterina Di Bella
- School of Bioscience and Veterinary Medicine, University of Camerino, Camerino, Italy
| | - Caterina Vicenti
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
| | - Joaquin Araos
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Luca Lacitignola
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
| | - Laura Fracassi
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
| | - Marzia Stabile
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
| | - Salvatore Grasso
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
| | - Alberto Crovace
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
| | - Francesco Staffieri
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantations, University of Bari, Bari, Italy
- *Correspondence: Francesco Staffieri
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Li C, Ren Q, Li X, Han H, Peng M, Xie K, Wang Z, Wang G. Effect of sigh in lateral position on postoperative atelectasis in adults assessed by lung ultrasound: a randomized, controlled trial. BMC Anesthesiol 2022; 22:215. [PMID: 35820814 PMCID: PMC9275275 DOI: 10.1186/s12871-022-01748-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 06/02/2022] [Indexed: 11/16/2022] Open
Abstract
Background Postoperative atelectasis occurs in 90% of patients receiving general anesthesia. Recruitment maneuvers (RMs) are not always effective and frequently associated with barotrauma and hemodynamic instability. It is reported that many natural physiological behaviors interrupted under general anesthesia could prevent atelectasis and restore lung aeration. This study aimed to find out whether a combined physiological recruitment maneuver (CPRM), sigh in lateral position, could reduce postoperative atelectasis using lung ultrasound (LUS). Methods We conducted a prospective, randomized, controlled trial in adults with open abdominal surgery under general anesthesia lasting for 2 h or longer. Subjects were randomly allocated to either control group (C-group) or CPRM-group and received volume-controlled ventilation with the same ventilator settings. Patients in CPRM group was ventilated in sequential lateral position, with the addition of periodic sighs to recruit the lung. LUS scores, dynamic compliance (Cdyn), the partial pressure of arterial oxygen (PaO2) and fraction of inspired oxygen (FiO2) ratio (PaO2/FiO2), and other explanatory variables were acquired from each patient before and after recruitment. Results Seventy patients were included in the analysis. Before recruitment, there was no significant difference in LUS scores, Cdyn and PaO2/FiO2 between CPRM-group and C-group. After recruitment, LUS scores in CPRM-group decreased significantly compared with C-group (6.00 [5.00, 7.00] vs. 8.00 [7.00, 9.00], p = 4.463e-11 < 0.05), while PaO2/FiO2 and Cdyn in CPRM-group increased significantly compared with C-group respectively (377.92 (93.73) vs. 309.19 (92.98), p = 0.008 < 0.05, and 52.00 [47.00, 60.00] vs. 47.70 [41.00, 59.50], p = 6.325e-07 < 0.05). No hemodynamic instability, detectable barotrauma or position-related complications were encountered. Conclusions Sigh in lateral position can effectively reduce postoperative atelectasis even without causing severe side effects. Further large-scale studies are necessary to evaluate it’s long-term effects on pulmonary complications and hospital length of stay. Trial registration ChiCTR1900024379. Registered 8 July 2019, Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01748-9.
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Affiliation(s)
- Caifeng Li
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, NO.154, Anshan Road, Heping District, Tianjin, China
| | - Qian Ren
- Advertising Center, Tianjin Daily, Tianjin, China
| | - Xin Li
- Department of Cardiothoracic Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Hongqiu Han
- Department of General Surgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Min Peng
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, NO.154, Anshan Road, Heping District, Tianjin, China
| | - Keliang Xie
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, NO.154, Anshan Road, Heping District, Tianjin, China.
| | - Zhiqiang Wang
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, NO.154, Anshan Road, Heping District, Tianjin, China.
| | - Guolin Wang
- Department of Critical Care Medicine, Tianjin Medical University General Hospital, NO.154, Anshan Road, Heping District, Tianjin, China.
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Cylwik J, Buda N. The impact of ultrasound-guided recruitment maneuvers on the risk of postoperative pulmonary complications in patients undergoing general anesthesia. J Ultrason 2022; 22:e6-e11. [PMID: 35449694 PMCID: PMC9009342 DOI: 10.15557/jou.2022.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 11/17/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction Postoperative pulmonary complications are among the most frequent problems in perioperative care. The risk of their development depends not only on the parameters associated with the patient’s initial clinical condition, but also on the employed anesthesia technique, the method of mechanical ventilation, and the type and technique of the surgical procedure. Atelectasis is the most common complication, affecting nearly 90% of the patients undergoing general anesthesia. Aim The aim of this study was to determine whether it was possible to positively impact the postoperative period and reduce the frequency of postoperative pulmonary complications via patient-based intraoperative ultrasound-guided recruitment maneuvers. Methodology The course of the postoperative period was analyzed in two groups of patients. One of them comprised 100 patients in whom no recruitment maneuvers were performed during general anesthesia. The other group (100 patients) consisted of patients in whom patient-based ultrasound-guided pulmonary recruitment maneuvers were performed. Results In the recruitment group, the postoperative hospitalization was statistically significantly shorter (p = 0.003) and the risk of intensive care treatment significantly lower. Additionally, the need for prolonged postoperative mechanical ventilation was reduced, as was the risk of respiratory tract infections. Conclusions Intraoperative ultrasound-guided recruitment maneuvers reduce the frequency of postoperative pulmonary complications.
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Affiliation(s)
- Jolanta Cylwik
- Anesthesiology and Intensive Care Unit, Mazovia Regional Hospital in Siedlce, Poland
| | - Natalia Buda
- Department of Internal Medicine, Connective Tissue Diseases and Geriatrics, Medical University of Gdansk, Poland
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Bruins S, Powers N, Sommerfield D, von Ungern-Sternberg BS. Impact of airway and a standardized recruitment maneuver on CT chest imaging quality in a pediatric population: A retrospective review. Paediatr Anaesth 2022; 32:572-576. [PMID: 34811851 DOI: 10.1111/pan.14341] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/07/2021] [Accepted: 11/15/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION When performing computerized tomography chest imaging in children, obtaining high quality, motion-free images is important in the accurate diagnosis of underlying pathology. General anesthesia is associated with the development of atelectasis, which can impair accurate diagnosis by obscuring or altering the appearance of the lung parenchyma or airways. Recruitment maneuvers, performed by anesthesiologists, can be used to effectively re-expand atelectatic lung. METHODS The computerized tomography chest imaging in 44 children aged between 2 months and 7 years, undergoing serial imaging for monitoring of cystic fibrosis, were reviewed and graded for atelectasis. The first scan performed on each child was performed with a supraglottic airway device and a non-standardized recruitment maneuver. The second scan on each child was performed with a cuffed endotracheal tube and a standardized recruitment maneuver. RESULTS When a supraglottic airway device and a non-standardized recruitment maneuver were used, 77% of patients demonstrated atelectasis of any degree on their computerized tomography chest imaging, compared with only 39% when a cuffed endotracheal tube and standardized recruitment maneuver were used. The percentage of computerized tomography chest scans that were scored acceptable (with either a total combined lung atelectasis score of 0 or 1) improved from 37% to 75% when a cuffed endotracheal tube and standardized recruitment maneuver were used. In particular, the mean atelectasis score for both lungs improved from 2.91 (SD ± 2.6) to 1.11 (SD ± 1.9), with a mean difference of 1.8 (95% CI 0.82-2.77; p: .0004). CONCLUSION The use of a cuffed endotracheal tube and a standardized recruitment maneuver is an effective way to reduce atelectasis as a result of general anesthesia. Anesthesiologists can actively contribute toward improved image quality through their choice of airway and recruitment maneuver.
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Affiliation(s)
- Suze Bruins
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia
| | - Neil Powers
- Department of Medical Imaging, Perth Children's Hospital, Perth, WA, Australia
| | - David Sommerfield
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Perth, WA, Australia
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, WA, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Perth, WA, Australia
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Rodrigues RR, Ambrósio AM, Engbruch AM, Gonçalves LA, Villela PA, Sanchez AF, Fantoni DT. Intraoperative Protective Mechanical Ventilation in Dogs: A Randomized Clinical Trial. Front Vet Sci 2022; 9:842613. [PMID: 35372547 PMCID: PMC8964628 DOI: 10.3389/fvets.2022.842613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 02/17/2022] [Indexed: 12/16/2022] Open
Abstract
Objective To evaluate gas exchange, respiratory mechanics, and hemodynamic impact of mechanical ventilation with low tidal volume (VT) in dogs with the use of positive end-expiratory pressure (PEEP) or preceded by alveolar recruitment maneuver (ARM). Study Design Prospective randomized clinical trial. Animals Twenty-one healthy client-owned mesocephalic healthy dogs, 1-7 years old, weighing 10-20 kg, and body condition scores 4-6/9 admitted for periodontal treatment. Methods Isoflurane-anesthetized dogs in dorsal recumbency were ventilated until 1 h with a volume-controlled ventilation mode using 8 mL kg-1 of VT. The dogs were distributed in 2 groups: in the ARM group, PEEP starts in 0 cmH2O, increasing gradually 5 cmH2O every 3 min, until reach 15 cmH2O and decreasing in the same steps until 5 cmH2O, maintaining this value until the end; and PEEP group, in which the pressure 5 cmH2O was instituted from the beginning of anesthesia and maintained the same level up to the end of the anesthesia. Cardiopulmonary, metabolic, oxygenation parameters, and respiratory mechanics were recorded after the anesthesia induction (baseline-BL), 15, 45, and 75 min after BL and during the recovery. Results The ARM increased the static compliance (Cst) (15 min after baseline) when compared with baseline moment (24.9 ± 5.8 mL cmH20-1 vs. 20.7 ± 5.4 mL cmH20-1-p = 0.0364), oxygenation index (PaO2/FIO2) (505.6 ± 59.2 mmHg vs. 461.2 ± 41.0 mmHg-p = 0.0453) and reduced the shunt fraction (3.4 ± 2.4% vs. 5.5 ± 1.6%-p = 0.062). In the PEEP group, no statistical differences were observed concerning the variables evaluated. At the beginning of the evaluation, the driving pressure (DP) before ARM was significantly greater than all other evaluation time points (6.9 ± 1.8 cmH20). Conclusions and Clinical Relevance The use of 8 mL kg-1 of VT and 5 cmH20 PEEP without ARM maintain adequate oxygenation and mechanical ventilation in dental surgeries for up to 1 h. The use of ARM slightly improved compliance and oxygenation during the maneuver.
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Physiological benefits of lung recruitment in the semi-lateral position after laparoscopic surgery: a randomized controlled study. Sci Rep 2022; 12:3909. [PMID: 35273175 PMCID: PMC8913840 DOI: 10.1038/s41598-022-04841-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 12/22/2021] [Indexed: 11/08/2022] Open
Abstract
We evaluated the physiological benefits of performing lung recruitment maneuver (LRM) in the semi-lateral position compared in the supine position. Seventy-nine patients undergoing laparoscopic prostatectomy were randomly assigned to either the supine or semi-lateral group according to body position during the LRM. At the end of surgery, LRM (35 cmH2O for 20 s) was performed twice in the assigned posture. The primary outcome was the maximal decrease in systolic arterial pressure during LRM. Secondary outcomes were changes in PaO2/FiO2 and the regional lung volume distribution after LRM. The decrease in systolic arterial pressure during the LRM was significantly higher in the supine group than in the semi-lateral group (mean ± standard deviation, [-] 27.6 ± 14.6% vs. [-] 18.6 ± 9.9%, P = 0.001). Improvement in PaO2/FiO2 ratio after the LRM was evident in both groups but was more prominent in the semi-lateral group than in the supine group (median [interquartile range], 39.3% [20.2, 63.6] vs. 18.2% [8.4, 29.2], P = 0.001). Among the horizontal lung divisions, regional lung volume in the most dependent portion (the dorsal division) was significantly increased after the LRM only in the semi-lateral group (P = 0.024). Performing lung recruitment in a semi-lateral position protected against hemodynamic deterioration during the LRM and increased regional lung ventilation in the dependent portion of the lung, leading to an improvement in arterial oxygenation after laparoscopic procedures.Trial registration Clinical Research Information Service ( https://cris.nih.go.kr/ ). Identifier: KCT0003756.
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Bruins S, Sommerfield D, Powers N, von Ungern-Sternberg BS. Atelectasis and lung recruitment in pediatric anesthesia: An educational review. Paediatr Anaesth 2022; 32:321-329. [PMID: 34797011 DOI: 10.1111/pan.14335] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/11/2021] [Accepted: 11/15/2021] [Indexed: 12/24/2022]
Abstract
General anesthesia is associated with development of pulmonary atelectasis. Children are more vulnerable to the development and adverse effects of atelectasis. We review the physiology and risk factors for the development of atelectasis in pediatric patients under general anesthesia. We discuss the clinical significance of atelectasis, the use and value of recruitment maneuvers, and other techniques available to minimize lung collapse. This review demonstrates the value of a recruitment maneuver, maintaining positive end-expiratory pressure (PEEP) until extubation and lowering FiO2 where possible in the daily practice of the pediatric anesthetist.
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Affiliation(s)
- Suze Bruins
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, WA, Australia
| | - David Sommerfield
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Crawley, WA, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Nedlands, WA, Australia
| | - Neil Powers
- Department of Medical Imaging, Perth Children's Hospital, Nedlands, WA, Australia
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Nedlands, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, The University of Western Australia, Crawley, WA, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Nedlands, WA, Australia
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12
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Hoeberg E, Levionnois O, Andréïs S. Successful management of hypoxaemia in a mule during general anaesthesia. VETERINARY RECORD CASE REPORTS 2021. [DOI: 10.1002/vrc2.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Emma Hoeberg
- Department for Clinical Veterinary Science Unit of Anaesthesiology and Pain Therapy Universität Bern Vetsuisse Fakultät Bern Switzerland
| | - Olivier Levionnois
- Department for Clinical Veterinary Science Unit of Anaesthesiology and Pain Therapy Universität Bern Vetsuisse Fakultät Bern Switzerland
| | - Sabrina Andréïs
- Department of Clinical Veterinary Science Universität Bern Vetsuisse Fakultät Bern Switzerland
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Effects of two stepwise lung recruitment strategies on respiratory function and haemodynamics in anaesthetised pigs: A randomised crossover study. Eur J Anaesthesiol 2021; 38:634-643. [PMID: 33967255 DOI: 10.1097/eja.0000000000001480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Lung recruitment manoeuvres and positive end-expiratory pressure (PEEP) can improve lung function during general anaesthesia. Different recruitment manoeuvre strategies have been described in large international trials: in the protective ventilation using high vs. low PEEP (PROVHILO) strategy, tidal volume (VT) was increased during volume-controlled ventilation; in the individualised peri-operative open-lung approach vs. standard protective ventilation in abdominal surgery (iPROVE) strategy, PEEP was increased during pressure-controlled ventilation. OBJECTIVES To compare the effects of the PROVHILO strategy and the iPROVE strategy on respiratory and haemodynamic variables. DESIGN Randomised crossover study. SETTING University hospital research facility. ANIMALS A total of 20 juvenile anaesthetised pigs. INTERVENTIONS Animals were assigned randomly to one of two sequences: PROVHILO strategy followed by iPROVE strategy or vice-versa (n = 10/sequence). In the PROVHILO strategy, VT was increased stepwise by 4 ml kg-1 at a fixed PEEP of 12 cmH2O until a plateau pressure of 30 to 35 cmH2O was reached. In the iPROVE strategy, at fixed driving pressure of 20 cmH2O, PEEP was increased up to 20 cmH2O followed by PEEP titration according to the lowest elastance of the respiratory system (ERS). MAIN OUTCOME MEASURES We assessed regional transpulmonary pressure (Ptrans), respiratory system mechanics, gas exchange and haemodynamics, as well as the centre of ventilation (CoV) by electrical impedance tomography. RESULTS During recruitment manoeuvres with the PROVHILO strategy compared with the iPROV strategy, dorsal Ptrans was lower at end-inspiration (16.3 ± 2.7 vs. 18.6 ± 3.1 cmH2O, P = 0.001) and end-expiration (4.8 ± 2.6 vs. 8.8 ± 3.4 cmH2O, P < 0.001), and mean arterial pressure (MAP) was higher (77 ± 11 vs. 60 ± 14 mmHg, P < 0.001). At 1 and 15 min after recruitment manoeuvres, ERS was higher in the PROVHILO strategy than the iPROVE strategy (24.6 ± 3.9 vs. 21.5 ± 3.4 and 26.7 ± 4.3 vs. 24.0 ± 3.8 cmH2O l-1; P < 0.001, respectively). At 1 min, PaO2 was lower in PROVHILO compared with iPROVE strategy (57.1 ± 6.1 vs. 59.3 ± 5.1 kPa, P = 0.013), but at 15 min, values did not differ. CoV did not differ between strategies. CONCLUSION In anaesthetised pigs, the iPROVE strategy compared with the PROVHILO strategy increased dorsal Ptrans at the cost of lower MAP during recruitment manoeuvres, and decreased ERS thereafter, without consistent improvement of oxygenation or shift of the CoV. TRIAL REGISTRATION This study was registered and approved by the Landesdirektion Dresden, Germany (DD24-5131/338/28).
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Cylwik J, Buda N. Lung Ultrasonography in the Monitoring of Intraoperative Recruitment Maneuvers. Diagnostics (Basel) 2021; 11:diagnostics11020276. [PMID: 33578960 PMCID: PMC7916700 DOI: 10.3390/diagnostics11020276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 02/06/2021] [Accepted: 02/08/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction: Postoperative respiratory failure is a serious problem in patients who undergo general anesthesia. Approximately 90% of mechanically ventilated patients during the surgery may develop atelectasis that leads to perioperative complications. Aim: The aim of this study is to determine whether it is possible to optimize recruitment maneuvers with the use of chest ultrasonography, thus limiting the risk of respiratory complications in patients who undergo general anesthesia. Methodology: The method of incremental increases in positive end-expiratory pressure (PEEP) values with simultaneous continuous ultrasound assessments was employed in mechanically ventilated patients. Results: The study group comprised 100 patients. The employed method allowed for atelectasis reduction in 91.9% of patients. The PEEP necessary to reverse areas of atelectasis averaged 17cmH2O, with an average peak pressure of 29cmH2O. The average PEEP that prevented repeat atelectasis was 9cmH2O. A significant improvement in lung compliance and saturation was obtained. Conclusions: Ultrasound-guided recruitment maneuvers facilitate the patient-based adjustment of the process. Consequently, the reduction in ventilation pressures necessary to aerate intraoperative atelectasis is possible, with the simultaneous reduction in the risk of procedure-related complications.
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Affiliation(s)
- Jolanta Cylwik
- Anesthesiology and Intensive Care Unit, Mazovia Regional Hospital, 08-110 Siedlce, Poland;
| | - Natalia Buda
- Department of Internal Medicine, Connective Tissue Diseases and Geriatrics, Medical University of Gdansk, 80-210 Gdańsk, Poland
- Correspondence:
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15
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Frassanito L, Sonnino C, Pitoni S, Zanfini BA, Catarci S, Gonnella GL, Germini P, Vizzielli G, Scambia G, Draisci G. Lung ultrasound to monitor the development of pulmonary atelectasis in gynecologic oncologic surgery. Minerva Anestesiol 2020; 86:1287-1295. [DOI: 10.23736/s0375-9393.20.14687-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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16
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Schumann S, Feth A, Borgmann S, Wirth S. Dependency of respiratory system mechanics on positive end-expiratory pressure and recruitment maneuvers in lung healthy pediatric patients-A randomized crossover study. Paediatr Anaesth 2020; 30:905-911. [PMID: 32445609 DOI: 10.1111/pan.13927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/07/2020] [Accepted: 05/14/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The lungs of pediatric patients are subjected to tidal derecruitment during mechanical ventilation and in contrast to adult patients this unfavorable condition cannot be resolved with small c increases. This raises the question if higher end-expiratory pressure increases or recruitment maneuvers may resolve tidal derecruitment in pediatric patients. AIMS We hypothesized that higher PEEP resolves tidal derecruitment in pediatric patients and that recruitment maneuvers between the pressure changes support the improvement of respiratory system mechanics. METHODS The effects of end-expiratory pressure changes from 3 to 7 cmH2 O and vice versa without and with intermediate recruitment maneuvers on respiratory system mechanics and regional ventilation were investigated in 57 mechanically ventilated pediatric patients. The intratidal respiratory system compliance was determined from volume and pressure data before and after PEEP changes and categorized to indicate tidal derecruitment. RESULTS Tidal derecruitment occurred comparably frequently at PEEP 3 cmH2 O without (13 out of 14 cases) and with recruitment maneuver (14 out of 14 cases) and at PEEP 7 cmH2 O without (13 out of 14 cases) and with recruitment maneuver (13 out of 15 cases). CONCLUSIONS We conclude that contrary to our hypothesis, PEEP up to 7 cmH2 O is not sufficient to resolve tidal derecruitment and that recruitment maneuvers may be dispensable in mechanically ventilated pediatric patients.
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Affiliation(s)
- Stefan Schumann
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Arne Feth
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Silke Borgmann
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Steffen Wirth
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
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Asorey I, Pellegrini L, Canfrán S, Ortiz-Díez G, Aguado D. Factors affecting respiratory system compliance in anaesthetised mechanically ventilated healthy dogs: a retrospective study. J Small Anim Pract 2020; 61:617-623. [PMID: 32715489 DOI: 10.1111/jsap.13194] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 05/25/2020] [Accepted: 06/15/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To determine the influence of several factors on respiratory system compliance in volume-controlled mechanically ventilated healthy anaesthetised dogs. MATERIALS AND METHODS Review of 100 dogs anaesthetised for elective surgeries between 2015 and 2016. Dogs were mechanically ventilated with a respiratory rate adjusted to maintain normocapnia and a fraction of inspired oxygen of 50%. Body weight, body condition score, age, thoracic shape, time in spontaneous ventilation before volume-controlled ventilation, time with a fraction of inspired oxygen of 100% until starting mechanical ventilation, type of surgery and patient position were recorded. Respiratory system compliance, expressed per kg of bodyweight, was recorded every 15 minutes following initiation of volume-controlled ventilation. RESULTS Baseline respiratory system compliance was 1.3 ± 0.3 mL/cmH2 O/kg and was reduced by high body condition score and barrel-shaped thorax but not by age, type of surgery or patient position, time in spontaneous ventilation nor time with a fraction of inspired oxygen of 100%. CLINICAL SIGNIFICANCE Respiratory system compliance is lower in overweight and barrel-chested dogs and should be taken into account during monitoring of lung function and ventilation management under general anaesthesia.
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Affiliation(s)
- I Asorey
- Dick White Referrals, Station Farm - London Road, Six Mile Bottom, Cambridgeshire, CB8 0UH, UK
| | - L Pellegrini
- Department of Animal Medicine and Surgery, School of Veterinary Medicine, Complutense University of Madrid, Avda. Puerta de Hierro s/n, Madrid, 28040, Spain
| | - S Canfrán
- Department of Animal Medicine and Surgery, School of Veterinary Medicine, Complutense University of Madrid, Avda. Puerta de Hierro s/n, Madrid, 28040, Spain
| | - G Ortiz-Díez
- Department of Animal Medicine and Surgery, School of Veterinary Medicine, Complutense University of Madrid, Avda. Puerta de Hierro s/n, Madrid, 28040, Spain
| | - D Aguado
- Department of Animal Medicine and Surgery, School of Veterinary Medicine, Complutense University of Madrid, Avda. Puerta de Hierro s/n, Madrid, 28040, Spain
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Rostin P, Teja BJ, Friedrich S, Shaefi S, Murugappan KR, Ramachandran SK, Houle TT, Eikermann M. The association of early postoperative desaturation in the operating theatre with hospital discharge to a skilled nursing or long-term care facility. Anaesthesia 2019; 74:457-467. [DOI: 10.1111/anae.14517] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2018] [Indexed: 12/17/2022]
Affiliation(s)
- P. Rostin
- Department of Anesthesia, Critical Care, and Pain Medicine; Massachusetts General Hospital and Harvard Medical School; Boston MA USA
- Department of Anaesthesiology and Intensive Care Medicine; University Duisburg-Essen; Essen Germany
| | - B. J. Teja
- Department of Anesthesia, Critical Care and Pain Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
| | - S. Friedrich
- Department of Anesthesia, Critical Care, and Pain Medicine; Massachusetts General Hospital and Harvard Medical School; Boston MA USA
- Department of Anesthesia, Critical Care and Pain Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
| | - S. Shaefi
- Department of Anesthesia, Critical Care and Pain Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
| | - K. R. Murugappan
- Department of Anesthesia, Critical Care and Pain Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
| | - S. K. Ramachandran
- Department of Anesthesia, Critical Care and Pain Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
| | - T. T. Houle
- Department of Anesthesia, Critical Care, and Pain Medicine; Massachusetts General Hospital and Harvard Medical School; Boston MA USA
| | - M. Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine; Beth Israel Deaconess Medical Center and Harvard Medical School; Boston MA USA
- Department of Anaesthesiology and Intensive Care Medicine; University Duisburg-Essen; Essen Germany
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19
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Andrade FSRM, Facó LL, Ida KK, Silva LCLC, Fantoni DT, Ambrósio AM. Effects of 12 and 17 cmH2O positive end-expiratory pressure applied after alveolar recruitment maneuver on pulmonary gas exchange and compliance in isoflurane-anesthetized horses. Vet Anaesth Analg 2019; 46:64-73. [DOI: 10.1016/j.vaa.2018.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 08/24/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
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20
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Di Bella C, Lacitignola L, Grasso S, Centonze P, Greco A, Ostuni R, Crovace A, Staffieri F. An alveolar recruitment maneuver followed by positive end-expiratory pressure improves lung function in healthy dogs undergoing laparoscopy. Vet Anaesth Analg 2018; 45:618-629. [DOI: 10.1016/j.vaa.2018.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/27/2018] [Accepted: 03/07/2018] [Indexed: 01/16/2023]
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21
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Ferrando C, Tusman G, Suarez-Sipmann F, León I, Pozo N, Carbonell J, Puig J, Pastor E, Gracia E, Gutiérrez A, Aguilar G, Belda FJ, Soro M. Individualized lung recruitment maneuver guided by pulse-oximetry in anesthetized patients undergoing laparoscopy: a feasibility study. Acta Anaesthesiol Scand 2018; 62:608-619. [PMID: 29377061 DOI: 10.1111/aas.13082] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 12/21/2017] [Accepted: 01/02/2018] [Indexed: 01/27/2023]
Abstract
BACKGROUND We conducted this study to test whether pulse-oximetry hemoglobin saturation (SpO2 ) can personalize the implementation of an open-lung approach during laparoscopy. Thirty patients with SpO2 ≥ 97% on room-air before anesthesia were studied. After anesthesia and capnoperitoneum the FIO2 was reduced to 0.21. Those patients whose SpO2 decreased below 97% - an indication of shunt related to atelectasis - completed the following phases: (1) First recruitment maneuver (RM), until reaching lung's opening pressure, defined as the inspiratory pressure level yielding a SpO2 ≥ 97%; (2) decremental positive end-expiratory (PEEP) titration trial until reaching lung's closing pressure defined as the PEEP level yielding a SpO2 < 97%; (3) second RM and, (4) ongoing ventilation with PEEP adjusted above the detected closing pressure. RESULTS When breathing air, in 24 of 30 patients SpO2 was < 97%, PaO2 /FIO2 ˂ 53.3 kPa and negative end-expiratory transpulmonary pressure (PTP-EE ). The mean (SD) opening pressures were found at 40 (5) and 33 (4) cmH2 O during the first and second RM, respectively (P < 0.001; 95% CI: 3.2-7.7). The closing pressure was found at 11 (5) cmH2 O. This SpO2 -guided approach increased PTP-EE (from -6.4 to 1.2 cmH2 O, P < 0.001) and PaO2 /FIO2 (from 30.3 to 58.1 kPa, P < 0.001) while decreased driving pressure (from 18 to 10 cmH2 O, P < 0.001). SpO2 discriminated the lung's opening and closing pressures with accuracy taking the reference parameter PTP-EE (area under the receiver-operating-curve of 0.89, 95% CI: 0.80-0.99). CONCLUSION The non-invasive SpO2 monitoring can help to individualize an open-lung approach, including all involved steps, from the identification of those patients who can benefit from recruitment, the identification of opening and closing pressures to the subsequent monitoring of an open-lung condition.
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Affiliation(s)
- C. Ferrando
- Department of Anaesthesiology and Critical Care; Hospital Clínico Universitario; Valencia Spain
- CIBER de Enfermedades Respiratorias; Instituto de Salud Carlos III; Madrid Spain
| | - G. Tusman
- Department of Anesthesiology; Hospital Privado de Comunidad Mar de Plata; Mar de Plata Argentina
| | - F. Suarez-Sipmann
- Department of Anaesthesiology and Critical Care; Hospital Clínico Universitario; Valencia Spain
- Deparment of Intensive Care; Hospital Universitario La Princesa; Madrid Spain
| | - I. León
- Department of Anaesthesiology and Critical Care; Hospital Clínico Universitario; Valencia Spain
| | - N. Pozo
- Department of Anaesthesiology and Critical Care; Hospital Clínico Universitario; Valencia Spain
| | - J. Carbonell
- Department of Anaesthesiology and Critical Care; Hospital Clínico Universitario; Valencia Spain
| | - J. Puig
- Department of Anaesthesiology and Critical Care; Hospital Clínico Universitario; Valencia Spain
| | - E. Pastor
- Department of Anaesthesiology and Critical Care; Hospital Clínico Universitario; Valencia Spain
| | - E. Gracia
- Department of Anaesthesiology and Critical Care; Hospital Clínico Universitario; Valencia Spain
| | - A. Gutiérrez
- Department of Anaesthesiology and Critical Care; Hospital Clínico Universitario; Valencia Spain
| | - G. Aguilar
- Department of Anaesthesiology and Critical Care; Hospital Clínico Universitario; Valencia Spain
| | - F. J. Belda
- Department of Anaesthesiology and Critical Care; Hospital Clínico Universitario; Valencia Spain
| | - M. Soro
- Department of Anaesthesiology and Critical Care; Hospital Clínico Universitario; Valencia Spain
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Tusman G, Acosta CM, Böhm SH, Waldmann AD, Ferrando C, Marquez MP, Sipmann FS. Postural lung recruitment assessed by lung ultrasound in mechanically ventilated children. Crit Ultrasound J 2017; 9:22. [PMID: 29030754 PMCID: PMC5640559 DOI: 10.1186/s13089-017-0073-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 09/20/2017] [Indexed: 01/03/2023] Open
Abstract
Background Atelectasis is a common finding in mechanically ventilated children with healthy lungs. This lung collapse cannot be overcome using standard levels of positive end-expiratory pressure (PEEP) and thus for only individualized lung recruitment maneuvers lead to satisfactory therapeutic results. In this short communication, we demonstrate by lung ultrasound images (LUS) the effect of a postural recruitment maneuver (P-RM, i.e., a ventilatory strategy aimed at reaerating atelectasis by changing body position under constant ventilation). Results Data was collected in the operating room of the Hospital Privado de Comunidad, Mar del Plata, Argentina. Three anesthetized children undergoing mechanical ventilation at constant settings were sequentially subjected to the following two maneuvers: (1) PEEP trial in the supine position PEEP was increased to 10 cmH2O for 3 min and then decreased to back to baseline. (2) P-RM patient position was changed from supine to the left and then to the right lateral position for 90 s each before returning to supine. The total P-RM procedure took approximately 3 min. LUS in the supine position showed similar atelectasis before and after the PEEP trial. Contrarily, atelectasis disappeared in the non-dependent lung when patients were placed in the lateral positions. Both lungs remained atelectasis free even after returning to the supine position. Conclusions We provide LUS images that illustrate the concept and effects of postural recruitment in children. This maneuver has the advantage of achieving recruitment effects without the need to elevate airways pressures. Electronic supplementary material The online version of this article (doi:10.1186/s13089-017-0073-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, 7600, Mar del Plata, Buenos Aires, Argentina.
| | - Cecilia M Acosta
- Department of Anesthesiology, Hospital Privado de Comunidad, 7600, Mar del Plata, Buenos Aires, Argentina
| | | | | | - Carlos Ferrando
- Department of Anesthesiology, University Hospital Valencia, Valencia, Spain
| | - Manuel Perez Marquez
- Department of Intensive Care Medicine, Instituto de Investigación Sanitaria Fundación Jiménez Díaz, IIS-FJD, Madrid, Spain
| | - Fernando Suarez Sipmann
- Hedenstierna Laboratory, Department of Surgical Sciences, Section of Anesthesia and Critical Care, Uppsala University Hospital, Uppsala, Sweden.,CIBERES, Madrid, Spain.,Department of Critical Care, Hospital La Fe, Valencia, Spain
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Ambrisko TD, Schramel JP, Auer U, Moens YPS. Impact of four different recumbencies on the distribution of ventilation in conscious or anaesthetized spontaneously breathing beagle dogs: An electrical impedance tomography study. PLoS One 2017; 12:e0183340. [PMID: 28922361 PMCID: PMC5603158 DOI: 10.1371/journal.pone.0183340] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 08/02/2017] [Indexed: 11/18/2022] Open
Abstract
The aim was to examine the effects of recumbency and anaesthesia on distribution of ventilation in beagle dogs using Electrical Impedance Tomography (EIT). Nine healthy beagle dogs, aging 3.7±1.7 (mean±SD) years and weighing 16.3±1.6 kg, received a series of treatments in a fixed order on a single occasion. Conscious dogs were positioned in right lateral recumbency (RLR) and equipped with 32 EIT electrodes around the thorax. Following five minutes of equilibration, two minutes of EIT recordings were made in each recumbency in the following order: RLR, dorsal (DR), left (LLR) and sternal (SR). The dogs were then positioned in RLR, premedicated (medetomidine 0.01, midazolam 0.1, butorphanol 0.1 mg kg-1 iv) and pre-oxygenated. Fifteen minutes later anaesthesia was induced with 1 mg kg-1 propofol iv and maintained with propofol infusion (0.1–0.2 mg kg-1 minute-1 iv). After induction, the animals were intubated and allowed to breathe spontaneously (FIO2 = 1). Recordings of EIT were performed again in four recumbencies similarly to conscious state. Centre of ventilation (COV) and global inhomogeneity (GI) index were calculated from the functional EIT images. Repeated-measures ANOVA and Bonferroni tests were used for statistical analysis (p < 0.05). None of the variables changed in the conscious state. During anaesthesia left-to-right COV increased from 46.8±2.8% in DR to 49.8±2.9% in SR indicating a right shift, and ventral-to-dorsal COV increased from 49.8±1.7% in DR to 51.8±1.1% in LLR indicating a dorsal shift in distribution of ventilation. Recumbency affected distribution of ventilation in anaesthetized but not in conscious dogs. This can be related to loss of respiratory muscle tone (e.g. diaphragm) and changes in thoracic shape. Changing position of thoraco-abdominal organs under the EIT belt should be considered as alternative explanation of these findings.
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Affiliation(s)
- Tamas D Ambrisko
- Anaesthesiology and Perioperative Intensive-Care Medicine, Department for Companion Animals and Horses, University of Veterinary Medicine, Vienna, Austria
| | - Johannes P Schramel
- Anaesthesiology and Perioperative Intensive-Care Medicine, Department for Companion Animals and Horses, University of Veterinary Medicine, Vienna, Austria
| | - Ulrike Auer
- Anaesthesiology and Perioperative Intensive-Care Medicine, Department for Companion Animals and Horses, University of Veterinary Medicine, Vienna, Austria
| | - Yves P S Moens
- Anaesthesiology and Perioperative Intensive-Care Medicine, Department for Companion Animals and Horses, University of Veterinary Medicine, Vienna, Austria
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24
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Bernhard C, Masseau I, Dodam J, Outi H, Krumme S, Bishop K, Graham A, Reinero C. Effects of positive end-expiratory pressure and 30% inspired oxygen on pulmonary mechanics and atelectasis in cats undergoing non-bronchoscopic bronchoalveolar lavage. J Feline Med Surg 2017; 19:665-671. [PMID: 27250742 PMCID: PMC11128820 DOI: 10.1177/1098612x16651471] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives The objective of this study was to determine if modification of inspired oxygen concentration or positive end-expiratory pressure (PEEP) would alter bronchoalveolar lavage (BAL)-induced changes in pulmonary mechanics or atelectasis, as measured using ventilator-acquired pulmonary mechanics and thoracic CT. Methods Six experimentally asthmatic cats underwent anesthesia and non-bronchoscopic BAL, each under four randomized treatment conditions: 100% oxygen, zero PEEP; 30% oxygen, zero PEEP; 100% oxygen, PEEP 2 cmH2O; and 30% oxygen, PEEP 2 cmH2O. Pulse oximetry was used to estimate oxygen saturation (SpO2). Ventilator-acquired pulmonary mechanics and thoracic CT scans were collected prior to BAL and at 1, 5 and 15 mins post-BAL. Results While receiving 100% oxygen, no cat had SpO2 <91%. Some cats receiving 30% oxygen had decreased saturation immediately post-BAL (mean ± SD 70.8 ± 31%), but 6/8 of these had SpO2 >90% by 1 min later. There was a significant increase in airway resistance and a decrease in lung compliance following BAL, but there was no significant difference between treatment groups. Cats receiving no PEEP and 30% oxygen conserved better aeration of the lung parenchyma in BAL-sampled areas than those receiving no PEEP and 100% oxygen. Conclusions and relevance Alterations in pulmonary mechanics or atelectasis may not be reflected by SpO2 following BAL. The use of 30% inspired oxygen concentration failed to show any significant improvement in pulmonary mechanics but did diminish atelectasis. In some cats, it was also associated with desaturation of hemoglobin. The use of PEEP in this study did not show any effect on our outcome parameters. Further studies using higher PEEP (5-10 cmH2O) and intermediate inspired oxygen concentration (40-60%) are warranted to determine if they would confer clinical benefit in cats undergoing diagnostic BAL.
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Affiliation(s)
| | - Isabelle Masseau
- Current address: Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Montréal, Québec, Canada
| | | | | | | | | | | | - Carol Reinero
- Carol Reinero DVM, PhD, DACVIM (Small Animal Internal Medicine), Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, 900 East Campus Drive, Columbia, MO 65211, USA
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Safety and effectiveness of alveolar recruitment maneuvers and positive end-expiratory pressure during general anesthesia for cesarean section: a prospective, randomized trial. Int J Obstet Anesth 2017; 30:30-38. [DOI: 10.1016/j.ijoa.2016.12.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 09/08/2016] [Accepted: 12/12/2016] [Indexed: 11/24/2022]
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Ambrisko TD, Schramel J, Hopster K, Kästner S, Moens Y. Assessment of distribution of ventilation and regional lung compliance by electrical impedance tomography in anaesthetized horses undergoing alveolar recruitment manoeuvres. Vet Anaesth Analg 2017; 44:264-272. [DOI: 10.1016/j.vaa.2016.03.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Revised: 01/18/2016] [Accepted: 03/04/2016] [Indexed: 10/20/2022]
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Acosta CM, Tusman G, Costantini M, Echevarría C, Pollioto S, Abrego D, Suarez-Sipmann F, Böhm SH. Doppler images of intra-pulmonary shunt within atelectasis in anesthetized children. Crit Ultrasound J 2016; 8:19. [PMID: 27910005 PMCID: PMC5133206 DOI: 10.1186/s13089-016-0055-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 11/24/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Doppler images of pulmonary vessels in pulmonary diseases associated with subpleural consolidations have been described. Color Doppler easily identifies such vessels within consolidations while spectral Doppler analysis allows the differentiation between pulmonary and bronchial arteries. Thus, Doppler helps in diagnosing the nature of consolidations. To our knowledge, Doppler analysis of pulmonary vessels within anesthesia-induced atelectasis has never been described before. The aim of this case series is to demonstrate the ability of lung ultrasound to detect the shunting of blood within atelectatic lung areas in anesthetized children. FINDINGS Three anesthetized and mechanically ventilated children were scanned in the supine position using a high-resolution linear probe of 6-12 MHz. Once subpleural consolidations were detected in the most dependent posterior lung regions, the probe was rotated such that its long axis followed the intercostal space. In this oblique position, color Doppler mapping was performed to detect blood flow within the consolidation. Thereafter, pulsed waved spectral Doppler was applied in the previously identified vessels during a short expiratory pause, which prevented interferences from respiratory motion. Different flow patterns were identified which corresponded to both, pulmonary and bronchial vessels. Finally, a lung recruitment maneuver was performed which leads to the complete resolution of the aforementioned consolidation thereby confirming the pathophysiological entity of anesthesia-induced atelectasis. CONCLUSIONS Lung ultrasound is a non-invasive imaging tool that not only enables the diagnosis of anesthesia-induced atelectasis in pediatric patients but also analysis of shunting blood within this consolidation.
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Affiliation(s)
- Cecilia M Acosta
- Department of Anesthesia, Hospital Privado de Comunidad, Córdoba 4545, 7600, Mar Del Plata, Buenos Aires, Argentina.
| | - Gerardo Tusman
- Department of Anesthesia, Hospital Privado de Comunidad, Córdoba 4545, 7600, Mar Del Plata, Buenos Aires, Argentina
| | - Mauro Costantini
- Department of Anesthesia, Hospital Privado de Comunidad, Córdoba 4545, 7600, Mar Del Plata, Buenos Aires, Argentina
| | - Camila Echevarría
- Department of Radiology, Hospital Privado de Comunidad, Mar Del Plata, Buenos Aires, Argentina
| | - Sergio Pollioto
- Department of Pediatric Surgery, Hospital Privado de Comunidad, Mar Del Plata, Buenos Aires, Argentina
| | - Diego Abrego
- Department of Pediatric Surgery, Hospital Privado de Comunidad, Mar Del Plata, Buenos Aires, Argentina
| | - Fernando Suarez-Sipmann
- Section of Anesthesia and Critical Care Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden.,CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
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Tusman G, Acosta CM, Costantini M. Ultrasonography for the assessment of lung recruitment maneuvers. Crit Ultrasound J 2016; 8:8. [PMID: 27496127 PMCID: PMC4975737 DOI: 10.1186/s13089-016-0045-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Accepted: 07/27/2016] [Indexed: 02/07/2023] Open
Abstract
Lung collapse is a known complication that affects most of the patients undergoing positive pressure mechanical ventilation. Such atelectasis and airways closure lead to gas exchange and lung mechanics impairment and has the potential to develop an inflammatory response in the lungs. These negative effects of lung collapse can be reverted by a lung recruitment maneuver (RM) i.e. a ventilatory strategy that resolves lung collapse by a brief and controlled increment in airway pressures. However, an unsolved question is how to assess such RM at the bedside. The aim of this paper is to describe the usefulness of lung sonography (LUS) to conduct and personalize RM in a real-time way at the bedside. LUS has favorable features to assess lung recruitment due to its high specificity and sensitivity to detect lung collapse together with its non-invasiveness, availability and simple use.
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Affiliation(s)
- Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Córdoba 4545, 7600, Mar del Plata, Buenos Aires, Argentina.
| | - Cecilia M Acosta
- Department of Anesthesiology, Hospital Privado de Comunidad, Córdoba 4545, 7600, Mar del Plata, Buenos Aires, Argentina
| | - Mauro Costantini
- Department of Anesthesiology, Hospital Privado de Comunidad, Córdoba 4545, 7600, Mar del Plata, Buenos Aires, Argentina
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Fantoni DT, Ida KK, Lopes TFT, Otsuki DA, Auler JOC, Ambrósio AM. A comparison of the cardiopulmonary effects of pressure controlled ventilation and volume controlled ventilation in healthy anesthetized dogs. J Vet Emerg Crit Care (San Antonio) 2016; 26:524-30. [DOI: 10.1111/vec.12485] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 01/17/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Denise T. Fantoni
- Disciplina de Anestesiologia, Laboratório de Investigação Médica 8, Faculdade de Medicina; Universidade de São Paulo; São Paulo SP Brazil
| | - Keila K. Ida
- Disciplina de Anestesiologia, Laboratório de Investigação Médica 8, Faculdade de Medicina; Universidade de São Paulo; São Paulo SP Brazil
| | - Thomas F. T. Lopes
- Departamento de Cirurgia, Faculdade de Medicina Veterinária e Zootecnia; Universidade de São Paulo; São Paulo SP Brazil
| | - Denise A. Otsuki
- Disciplina de Anestesiologia, Laboratório de Investigação Médica 8, Faculdade de Medicina; Universidade de São Paulo; São Paulo SP Brazil
| | - José Otávio C. Auler
- Disciplina de Anestesiologia, Laboratório de Investigação Médica 8, Faculdade de Medicina; Universidade de São Paulo; São Paulo SP Brazil
| | - Aline M. Ambrósio
- Departamento de Cirurgia, Faculdade de Medicina Veterinária e Zootecnia; Universidade de São Paulo; São Paulo SP Brazil
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Tusman G, Acosta CM, Nicola M, Esperatti M, Bohm SH, Suarez-Sipmann F. Real-time images of tidal recruitment using lung ultrasound. Crit Ultrasound J 2015; 7:19. [PMID: 26660526 PMCID: PMC4676770 DOI: 10.1186/s13089-015-0036-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 11/24/2015] [Indexed: 12/14/2022] Open
Abstract
Background Ventilator-induced lung injury is a form of mechanical damage leading to a pulmonary inflammatory response related to the use of mechanical ventilation enhanced by the presence of atelectasis. One proposed mechanism of this injury is the repetitive opening and closing of collapsed alveoli and small airways within these atelectatic areas—a phenomenon called tidal recruitment. The presence of tidal recruitment is difficult to detect, even with high-resolution images of the lungs like CT scan. The purpose of this article is to give evidence of tidal recruitment by lung ultrasound. Findings A standard lung ultrasound inspection detected lung zones of atelectasis in mechanically ventilated patients. With a linear probe placed in the intercostal oblique position. We observed tidal recruitment within atelectasis as an improvement in aeration at the end of inspiration followed by the re-collapse at the end of expiration. This mechanism disappeared after the performance of a lung recruitment maneuver. Conclusions Lung ultrasound was helpful in detecting the presence of atelectasis and tidal recruitment and in confirming their resolution after a lung recruitment maneuver. Electronic supplementary material The online version of this article (doi:10.1186/s13089-015-0036-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gerardo Tusman
- Department of Anesthesia, Hospital Privado de Comunidad, Córdoba 4545, 7600, Mar del Plata, Buenos Aires, Argentina.
| | - Cecilia M Acosta
- Department of Anesthesia, Hospital Privado de Comunidad, Córdoba 4545, 7600, Mar del Plata, Buenos Aires, Argentina.
| | - Marco Nicola
- Department of Anesthesia, Hospital Privado de Comunidad, Córdoba 4545, 7600, Mar del Plata, Buenos Aires, Argentina.
| | - Mariano Esperatti
- Intensive Care Medicine, Hospital Privado de Comunidad, Mar del Plata, Buenos Aires, Argentina.
| | | | - Fernando Suarez-Sipmann
- Department of Surgical Sciences, Section of Anesthesia and Critical Care Hedenstierna Laboratory, Uppsala University Hospital, Uppsala, Sweden. .,CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
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Pathophysiology and Prevention of Intraoperative Atelectasis: A Review of the Literature. J Perianesth Nurs 2015; 30:516-527. [DOI: 10.1016/j.jopan.2014.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 03/17/2014] [Accepted: 03/23/2014] [Indexed: 11/23/2022]
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Lohser J, Slinger P. Lung Injury After One-Lung Ventilation: A Review of the Pathophysiologic Mechanisms Affecting the Ventilated and the Collapsed Lung. Anesth Analg 2015. [PMID: 26197368 DOI: 10.1213/ane.0000000000000808] [Citation(s) in RCA: 231] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Lung injury is the leading cause of death after thoracic surgery. Initially recognized after pneumonectomy, it has since been described after any period of 1-lung ventilation (OLV), even in the absence of lung resection. Overhydration and high tidal volumes were thought to be responsible at various points; however, it is now recognized that the pathophysiology is more complex and multifactorial. All causative mechanisms known to trigger ventilator-induced lung injury have been described in the OLV setting. The ventilated lung is exposed to high strain secondary to large, nonphysiologic tidal volumes and loss of the normal functional residual capacity. In addition, the ventilated lung experiences oxidative stress, as well as capillary shear stress because of hyperperfusion. Surgical manipulation and/or resection of the collapsed lung may induce lung injury. Re-expansion of the collapsed lung at the conclusion of OLV invariably induces duration-dependent, ischemia-reperfusion injury. Inflammatory cytokines are released in response to localized injury and may promote local and contralateral lung injury. Protective ventilation and volatile anesthesia lessen the degree of injury; however, increases in biochemical and histologic markers of lung injury appear unavoidable. The endothelial glycocalyx may represent a common pathway for lung injury creation during OLV, because it is damaged by most of the recognized lung injurious mechanisms. Experimental therapies to stabilize the endothelial glycocalyx may afford the ability to reduce lung injury in the future. In the interim, protective ventilation with tidal volumes of 4 to 5 mL/kg predicted body weight, positive end-expiratory pressure of 5 to 10 cm H2O, and routine lung recruitment should be used during OLV in an attempt to minimize harmful lung stress and strain. Additional strategies to reduce lung injury include routine volatile anesthesia and efforts to minimize OLV duration and hyperoxia.
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Affiliation(s)
- Jens Lohser
- From the *Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada; and †Department of Anesthesia, University of Toronto, Toronto General Hospital, Toronto, Ontario, Canada
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Pressure safety range of barotrauma with lung recruitment manoeuvres: a randomised experimental study in a healthy animal model. Eur J Anaesthesiol 2014; 30:567-74. [PMID: 23857081 DOI: 10.1097/eja.0b013e3283607875] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
CONTEXT Recruitment manoeuvres aim at reversing atelectasis during general anaesthesia but are associated with potential risks such as barotrauma. OBJECTIVE To explore the range of pressures that can be used safely to fully recruit the lung without causing barotrauma in an ex-vivo healthy lung rabbit model. DESIGN Prospective, randomised, experimental study. SETTING Experimental Unit, La Paz University Hospital, Madrid, Spain. ANIMALS Fourteen healthy young New Zealand rabbits of 12 weeks of age. INTERVENTIONS Animals were euthanised, the thorax and both pleural spaces were opened and the animals were allocated randomly into one of two groups submitted to two distinct recruitment manoeuvre strategies: PEEP-20 group, in which positive end-expiratory pressure (PEEP) was increased in 5-cmH2O steps from 0 to 20 cmH2O and PEEP-50 group, in which PEEP was increased in 5-cmH2O steps from 0 to 50 cmH2O. In both groups, a driving pressure of 15 cmH2O was maintained until maximal PEEP and its corresponding maximal inspiratory pressures (MIPs) were reached. From there on, driving pressure was progressively increased in 5-cmH2O steps until detectable barotrauma occurred. Two macroscopic conditions were defined: anatomically open lung and barotrauma. MAIN OUTCOME MEASURES We measured open lung and barotrauma MIP, PEEP and driving pressure obtained using each strategy. A pressure safety range, defined as the difference between barotrauma MIP and anatomically open lung MIP, was also determined in both groups. RESULTS Open lung MIP was similar in both groups: 23.6 ± 3.8 and 23.3 ± 4.1 cmH2O in the PEEP-50 and PEEP-20 groups, respectively (P = 0.91). However, barotrauma MIP in the PEEP-50 group was higher (65.7 ± 3.4 cmH2O) than in the PEEP-20 group (56.7 ± 5 0.2 cmH2O) (P = 0.003) resulting in a safety range of pressures of respectively 33.3 ± 8.7 and 42.1 ± 3.9 cmH2O (P = 0.035). CONCLUSION In this ex-vivo model, we found a substantial difference between recruitment and barotrauma pressures using both recruitment strategies. However, a higher margin of safety was obtained when a higher PEEP and lower driving pressure strategy was used for recruiting the lung.
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Lan CC, Hsu HH, Wu CP, Lee SC, Peng CK, Chang H. Positive end-expiratory pressure attenuates positional effect after thoracotomy. Ann Thorac Med 2014; 9:112-9. [PMID: 24791175 PMCID: PMC4005157 DOI: 10.4103/1817-1737.128860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 01/24/2014] [Indexed: 02/05/2023] Open
Abstract
CONTEXT: Thoracotomy is a common procedure. However, thoracotomy leads to lung atelectasis and deteriorates pulmonary gas exchange in operated side. Therefore, different positions with operated side lowermost or uppermost may lead to different gas exchange after thoracotomy. Besides, PEEP (positive end-expiratory pressure) influence lung atelectasis and should influence gas exchange. AIMS: The purpose of this study was to determine the physiological changes in different positions after thoracotomy. In addition, we also studied the influence of PEEP to positional effects after thoracotomy. MATERIALS AND METHODS: There were eight pigs in each group. Group I received left thoracotomy with zero end-expiratory pressure (ZEEP), and group II with PEEP; group III received right thoracotomy with ZEEP and group IV with PEEP. We changed positions to supine, LLD (left lateral decubitus) and RLD (right lateral decubitus) in random order after thoracotomy. RESULTS: PaO2 was decreased after thoracotomy and higher in RLD after left thoracotomy and in LLD after right thoracotomy. PaO2 in groups II and IV was higher than in groups I and III if with the same position. In group I and III, PaCO2 was increased after thoracotomy and was higher in LLD after left thoracotomy and in RLD after right thoracotomy. In groups II and IV, there were no PaCO2 changes in different positions after thoracotomy. Lung compliance (Crs) was decreased after thoracotomy in groups I and III and highest in RLD after left thoracotomy and in LLD after right thoracotomy. In groups II and IV, there were no changes in Crs regardless of the different positions. CONCLUSION: There were significant changes with regards to pulmonary gas exchange, hemodynamics and Crs after thoracotomy. The best position was non-operated lung lowermost Applying PEEP attenuates the positional effects.
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Affiliation(s)
- Chou-Chin Lan
- Division of Pulmonary Medicine, Department of Internal Medicine, Taipei Tzuchi Hospital, The Buddhist Tzuchi Medical Foundation, New Taipei City, Republic of China ; School of Medicine, Tzuchi University, Hualien, Republic of China
| | - Hsian-He Hsu
- Department of Radiology, Tri-Service General Hospital, Taipei, Republic of China
| | - Chin-Pyng Wu
- Department of Critical Care Medicine, Li-Shin Hospital, Tao-Yuan County, Taipei, Republic of China
| | - Shih-Chun Lee
- Department of Surgery, Division of Thoracic Surgery, Taipei, Republic of China
| | - Chung-Kan Peng
- Division of Pulmonary Medicine, Department of Internal Medicine, Tri-Service General Hospital, Taipei, Republic of China
| | - Hung Chang
- Department of Surgery, Division of Thoracic Surgery, Taipei, Republic of China ; Department and Graduate Institute of Physiology and Biophysics, National Defense Medical Center, Taipei, Taiwan, Republic of China
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Moens Y, Schramel JP, Tusman G, Ambrisko TD, Solà J, Brunner JX, Kowalczyk L, Böhm SH. Variety of non-invasive continuous monitoring methodologies including electrical impedance tomography provides novel insights into the physiology of lung collapse and recruitment – case report of an anaesthetized horse. Vet Anaesth Analg 2014; 41:196-204. [DOI: 10.1111/vaa.12098] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Alveolar Recruitment Maneuvers for One-Lung Ventilation During Thoracic Anesthesia. CURRENT ANESTHESIOLOGY REPORTS 2014. [DOI: 10.1007/s40140-014-0054-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Higher fraction of inspired oxygen in anesthesia induction does not affect functional residual capacity reduction after intubation: a comparative study of higher and lower oxygen concentration. J Anesth 2013; 27:385-9. [DOI: 10.1007/s00540-012-1547-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 12/16/2012] [Indexed: 10/27/2022]
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De Monte V, Grasso S, De Marzo C, Crovace A, Staffieri F. Effects of reduction of inspired oxygen fraction or application of positive end-expiratory pressure after an alveolar recruitment maneuver on respiratory mechanics, gas exchange, and lung aeration in dogs during anesthesia and neuromuscular blockade. Am J Vet Res 2013; 74:25-33. [DOI: 10.2460/ajvr.74.1.25] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
PURPOSE OF REVIEW Supplemental oxygen is often administered during anesthesia and in critical illness to treat hypoxia, but high oxygen concentrations are also given for a number of other reasons such as prevention of surgical site infection (SSI). The decision to use supplemental oxygen is, however, controversial, because of large heterogeneity in the reported results and emerging reports of side-effects. The aim of this article is to review the recent findings regarding benefits and harms of oxygen therapy in anesthesia and acute medical conditions. RECENT FINDINGS Large randomized trials have not found significant reductions in SSI with 80% oxygen during and after abdominal surgery and cesarean section. There is no documented benefit of hyperbaric oxygen treatment for acute ischemic stroke, and there is emerging data to suggest increased mortality with normobaric supplemental oxygen for myocardial infarction without heart failure. Survival and neurologic outcome seem to be adversely affected by hyperoxia in patients with return of spontaneous circulation after cardiac arrest. SUMMARY The benefits of supplemental oxygen are not yet confirmed, and new findings suggest that potential side-effects should be considered if the inspired oxygen concentration is increased above what is needed to maintain normal arterial oxygen saturation.
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Henrichsen T, Lindenskov PHH, Shaffer TH, Loekke RJV, Fugelseth D, Lindemann R. Perfluorodecalin lavage of a longstanding lung atelectasis in a child with spinal muscle atrophy. Pediatr Pulmonol 2012; 47:415-9. [PMID: 22006656 DOI: 10.1002/ppul.21565] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2011] [Accepted: 08/24/2011] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Persistent lung atelectasis is difficult to treat and perfluorochemical (PFC) liquid may be an option for bronchioalveolar lavage (BAL). CASE REPORT A 4-year-old girl with spinal muscle atrophy was admitted in respiratory failure. On admission, the X-ray confirmed the persistence of total right-sided lung atelectasis, which had been present for 14 months. She was endotracheally intubated and ventilated from the day of admission. BAL with normal saline was performed twice without improvement. Following failed extubation and being dependent on continuous respiratory support, a trial of BAL using PFC liquid (Perfluorodecalin HP) was carried out. The PFC was delivered through the endotracheal tube on three consecutive days. A loading dose of 3 ml/kg was administered, followed by a varying dose in order to more effectively lavage the lungs. She tolerated the procedure well the first 2 days, although there were no clinical signs of improvement in the atelectasis. Intentionally, higher inflation pressures were applied after PFC instillation on day 3. Chest X-ray then showed hazy infiltrates on her left lung and she required more ventilatory support. However, lung infiltrates cleared over the next 3 days. A tracheotomy was done 6 days after the last PFC instillation. She had a slow recovery and was successfully decanulated. Clinical improvement of lung function was seen including less need of BiPAP and oxygen. A chest CT scan showed then functional lung tissue appearing in the previous total atelectatic right lung. CONCLUSION Lavage with PFC can safely be performed with a therapeutic effect in a child with unilateral total lung atelectasis.
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Affiliation(s)
- Thore Henrichsen
- Department of Pediatrics, Pediatric Intensive Care Unit, Oslo University Hospital, Oslo, Norway
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Dresse C, Joris JL, Hans GA. Mechanical ventilation during anaesthesia: Pathophysiology and clinical implications. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2012.01.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Unzueta C, Tusman G, Suarez-Sipmann F, Böhm S, Moral V. Alveolar recruitment improves ventilation during thoracic surgery: a randomized controlled trial. Br J Anaesth 2012; 108:517-24. [DOI: 10.1093/bja/aer415] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Tusman G, Böhm SH, Warner DO, Sprung J. Atelectasis and perioperative pulmonary complications in high-risk patients. Curr Opin Anaesthesiol 2012; 25:1-10. [DOI: 10.1097/aco.0b013e32834dd1eb] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Karsten J, Luepschen H, Grossherr M, Bruch HP, Leonhardt S, Gehring H, Meier T. Effect of PEEP on regional ventilation during laparoscopic surgery monitored by electrical impedance tomography. Acta Anaesthesiol Scand 2011; 55:878-86. [PMID: 21658014 DOI: 10.1111/j.1399-6576.2011.02467.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Anesthesia per se and pneumoperitoneum during laparoscopic surgery lead to atelectasis and impairment of oxygenation. We hypothesized that a ventilation with positive end-expiratory pressure (PEEP) during general anesthesia and laparoscopic surgery leads to a more homogeneous ventilation distribution as determined by electrical impedance tomography (EIT). Furthermore, we supposed that PEEP ventilation in lung-healthy patients would improve the parameters of oxygenation and respiratory compliance. METHODS Thirty-two patients scheduled to undergo laparoscopic cholecystectomy were randomly assigned to be ventilated with ZEEP (0 cmH(2)O) or with PEEP (10 cmH(2)O) and a subsequent recruitment maneuver. Differences in regional ventilation were analyzed by the EIT-based center-of-ventilation index (COV), which quantifies the distribution of ventilation and indicates ventilation shifts. RESULTS Higher amount of ventilation was examined in the dorsal parts of the lungs in the PEEP group. Throughout the application of PEEP, a lower shift of ventilation was found, whereas after the induction of anesthesia, a remarkable ventral shift of ventilation in ZEEP-ventilated patients (COV: ZEEP, 40.6 ± 2.4%; PEEP, 46.5 ± 3.5%; P<0.001) was observed. Compared with the PEEP group, ZEEP caused a ventral misalignment of ventilation during pneumoperitoneum (COV: ZEEP, 41.6 ± 2.4%; PEEP, 44 ± 2.7%; P=0.013). Throughout the study, there were significant differences in the parameters of oxygenation and respiratory compliance with improved values in PEEP-ventilated patients. CONCLUSION The effect of anesthesia, pneumoperitoneum, and different PEEP levels can be evaluated by EIT-based COV monitoring. An initial recruitment maneuver and a PEEP of 10 cmH(2)O preserved homogeneous regional ventilation during laparoscopic surgery in most, but not all, patients and improved oxygenation and respiratory compliance.
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Affiliation(s)
- J Karsten
- Department of Anesthesiology, University of Lübeck, Lübeck, Germany
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Abstract
Patients are at risk for several types of lung injury in the perioperative period including atelectasis, pneumonia, pneumothorax, acute lung injury, and acute respiratory distress syndrome. Anaesthetic management can cause, exacerbate, or ameliorate these injuries. This review examines the effects of perioperative mechanical ventilation and its role in ventilator-induced lung injury. Lung protective ventilatory strategies to specific clinical situations such as cardiopulmonary bypass and one-lung ventilation along with newer novel lung protective strategies are discussed.
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Affiliation(s)
- B Kilpatrick
- Department of Anaesthesia, 3 EN, The Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4.
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