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Simonte R, Cammarota G, De Robertis E. Intraoperative lung protection: strategies and their impact on outcomes. Curr Opin Anaesthesiol 2024; 37:184-191. [PMID: 38390864 DOI: 10.1097/aco.0000000000001341] [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: 02/24/2024]
Abstract
PURPOSE OF REVIEW The present review summarizes the current knowledge and the barriers encountered when implementing tailoring lung-protective ventilation strategies to individual patients based on advanced monitoring systems. RECENT FINDINGS Lung-protective ventilation has become a pivotal component of perioperative care, aiming to enhance patient outcomes and reduce the incidence of postoperative pulmonary complications (PPCs). High-quality research has established the benefits of strategies such as low tidal volume ventilation and low driving pressures. Debate is still ongoing on the most suitable levels of positive end-expiratory pressure (PEEP) and the role of recruitment maneuvers. Adapting PEEP according to patient-specific factors offers potential benefits in maintaining ventilation distribution uniformity, especially in challenging scenarios like pneumoperitoneum and steep Trendelenburg positions. Advanced monitoring systems, which continuously assess patient responses and enable the fine-tuning of ventilation parameters, offer real-time data analytics to predict and prevent impending lung complications. However, their impact on postoperative outcomes, particularly PPCs, is an ongoing area of research. SUMMARY Refining protective lung ventilation is crucial to provide patients with the best possible care during surgery, reduce the incidence of PPCs, and improve their overall surgical journey.
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Affiliation(s)
- Rachele Simonte
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia
| | - Gianmaria Cammarota
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Edoardo De Robertis
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia
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Vidjak K, Farina L, Challapalli RS, Quinn AM, O'Halloran M, Lowery A, Ruvio G, Cavagnaro M. Histology-validated electromagnetic characterization of ex-vivo ovine lung tissue for microwave-based medical applications. Sci Rep 2024; 14:5940. [PMID: 38467672 PMCID: PMC10928158 DOI: 10.1038/s41598-024-55035-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/19/2024] [Indexed: 03/13/2024] Open
Abstract
Microwave thermal ablation is an established therapeutic technique for treating malignant tissue in various organs. Its success greatly depends on the knowledge of dielectric properties of the targeted tissue and on how they change during the treatment. Innovation in lung navigation has recently increased the clinical interest in the transbronchial microwave ablation treatment of lung cancer. However, lung tissue is not largely characterized, thus its dielectric properties investigation prior and post ablation is key. In this work, dielectric properties of ex-vivo ovine lung parenchyma untreated and ablated at 2.45 GHz were recorded in the 0.5-8 GHz frequency range. The measured dielectric properties were fitted to 2-pole Cole-Cole relaxation model and the obtained model parameters were compared. Based on observed changes in the model parameters, the physical changes of the tissue post-ablation were discussed and validated through histology analysis. Additionally, to investigate the link of achieved results with the rate of heating, another two sets of samples, originating from both ovine and porcine tissues, were heated with a microwave oven for different times and at different powers. Dielectric properties were measured in the same frequency range. It was found that lung tissue experiences a different behavior according to heating rates: its dielectric properties increase post-ablation while a decrease is found for low rates of heating. It is hypothesized, and validated by histology, that during ablation, although the tissue is losing water, the air cavities deform, lowering air content and increasing the resulting tissue properties.
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Affiliation(s)
- Klementina Vidjak
- Department of Information Engineering, Electronics, and Telecommunications, Sapienza University of Rome, Rome, Italy
| | | | - Ritihaas Surya Challapalli
- Discipline of Surgery, Lambe Institute for Translational Research, University of Galway, Galway, Ireland
| | - Anne Marie Quinn
- Department of Anatomic Pathology, University Hospital Galway, Galway, Ireland
| | - Martin O'Halloran
- Translational Medical Device Lab, National University of Ireland Galway, Galway, Ireland
| | - Aoife Lowery
- Discipline of Surgery, Lambe Institute for Translational Research, University of Galway, Galway, Ireland
| | | | - Marta Cavagnaro
- Department of Information Engineering, Electronics, and Telecommunications, Sapienza University of Rome, Rome, Italy.
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Tsukamoto M, Goto M, Hitosugi T, Matsuo K, Yokoyama T. Comparison of the tidal volume by the recruitment maneuver combined with positive end-expiratory pressure for mechanically ventilated children. Sci Rep 2023; 13:18690. [PMID: 37907687 PMCID: PMC10618173 DOI: 10.1038/s41598-023-45441-4] [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: 04/10/2023] [Accepted: 10/19/2023] [Indexed: 11/02/2023] Open
Abstract
The recruitment maneuver (RM) combined with PEEP to prevent atelectasis have beneficial effects. However, the change in tidal volume (VT) due to RM combined with PEEP in pediatric patients during the induction of general anesthesia is unknown. Therefore, we assessed the effects of RM combined with PEEP on VT. Pediatric patients were divided into three groups: infants, preschool children, and school children. The RM was performed by maintaining pressure control continuous mandatory ventilation (PC-CMV) with a 15 cmH2O and PEEP increase of 5 cmH2O. VT, respiratory function and hemodynamics were monitored before and after RM combined with PEEP. VT (mL) /ideal body weight (kg) before vs. after RM combined with PEEP were 9 vs 12 mL/kg (p < 0.05) in the infants, 9 vs 11 mL/kg (p < 0.05) in the preschool children, 8 vs 10 mL/kg (p < 0.05) in the school children, respectively. HR and BP before and after RM combined with PEEP increased by 2-3% and decreased by 4-7% in all groups. RM combined with PEEP resulted in an increase in VT per ideal body weight (1.1-1.2%). Therefore, this RM combined with PEEP method might improve the lung function in pediatric patients.
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Affiliation(s)
- Masanori Tsukamoto
- Department of Dental Anesthesiology, Graduate School of Medical and Dental Sciences, Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima, Kagoshima, 890-8544, Japan.
| | - Maho Goto
- Department of Dental Anesthesiology, Graduate School of Dental Science, Kyushu University, Fukuoka, Japan
| | - Takashi Hitosugi
- Department of Dental Anesthesiology, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
| | - Kazuya Matsuo
- Department of Control Engineering, Kyushu Institute of Technology, Kitakyushu, Japan
| | - Takeshi Yokoyama
- Department of Dental Anesthesiology, Faculty of Dental Science, Kyushu University, Fukuoka, Japan
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Braun M, Ruscher L, Fuchs A, Kämpfer M, Huber M, Luedi MM, Riva T, Vogt A, Riedel T. Atelectasis in obese patients undergoing laparoscopic bariatric surgery are not increased upon discharge from Post Anesthesia Care Unit. Front Med (Lausanne) 2023; 10:1233609. [PMID: 37727763 PMCID: PMC10505733 DOI: 10.3389/fmed.2023.1233609] [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: 06/05/2023] [Accepted: 07/31/2023] [Indexed: 09/21/2023] Open
Abstract
Background Obese patients frequently develop pulmonary atelectasis upon general anesthesia. The risk is increased during laparoscopic surgery. This prospective, observational single-center study evaluated atelectasis dynamics using Electric Impedance Tomography (EIT) in patients undergoing laparoscopic bariatric surgery. Methods We included adult patients with ASA physical status I-IV and a BMI of ≥40. Exclusion criteria were known severe pulmonary hypertension, home oxygen therapy, heart failure, and recent pulmonary infections. The primary outcome was the proportion of poorly ventilated lung regions (low tidal variation areas) and the global inhomogeneity (GI) index assessed by EIT before discharge from the Post Anesthesia Care Unit compared to these same measures prior to initiation of anesthesia. Results The median (IQR) proportion of low tidal variation areas at the different analysis points were T1 10.8% [3.6-15.1%] and T5 10.3% [2.6-18.9%], and the mean difference was -0.7% (95% CI: -5.8% -4.5%), i.e., lower than the predefined non-inferiority margin of 5% (p = 0.022). There were no changes at the four additional time points compared to T1 or postoperative pulmonary complications during the 14 days following the procedure. Conclusion We found that obese patients undergoing laparoscopic bariatric surgery do not leave the Post Anesthesia Care Unit with increased low tidal variation areas compared to the preoperative period.
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Affiliation(s)
- Matthias Braun
- Department of Anaesthesiology, Lindenhof Hospital, Bern, Switzerland
| | - Lea Ruscher
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Alexander Fuchs
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
- Unit for Research in Anaesthesia, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Martina Kämpfer
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Markus Huber
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Markus M. Luedi
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas Riva
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Andreas Vogt
- Department of Anaesthesiology and Pain Medicine, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas Riedel
- Division of Paediatric Intensive Care Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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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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Hennessey E, Bittner E, White P, Kovar A, Meuchel L. Intraoperative Ventilator Management of the Critically Ill Patient. Anesthesiol Clin 2023; 41:121-140. [PMID: 36871995 PMCID: PMC9985493 DOI: 10.1016/j.anclin.2022.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Strategies for the intraoperative ventilator management of the critically ill patient focus on parameters used for lung protective ventilation with acute respiratory distress syndrome, preventing or limiting the deleterious effects of mechanical ventilation, and optimizing anesthetic and surgical conditions to limit postoperative pulmonary complications for patients at risk. Patient conditions such as obesity, sepsis, the need for laparoscopic surgery, or one-lung ventilation may benefit from intraoperative lung protective ventilation strategies. Anesthesiologists can use risk evaluation and prediction tools, monitor advanced physiologic targets, and incorporate new innovative monitoring techniques to develop an individualized approach for patients.
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Affiliation(s)
- Erin Hennessey
- Stanford University - School of Medicine Department of Anesthesiology, Perioperative and Pain Medicine, 300 Pasteur Drive, Room H3580, Stanford, CA 94305, USA.
| | - Edward Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Peggy White
- University of Florida College of Medicine, Department of Anesthesiology, 1500 SW Archer Road, PO Box 100254, Gainesville, FL 32610, USA
| | - Alan Kovar
- Oregon Health and Science University, 3161 SW Pavilion Loop, Portland, OR 97239, USA
| | - Lucas Meuchel
- Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA
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Changes in lung volume estimated by electrical impedance tomography during apnea and high-flow nasal oxygenation: A single-center randomized controlled trial. PLoS One 2022; 17:e0273120. [PMID: 36170281 PMCID: PMC9518885 DOI: 10.1371/journal.pone.0273120] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/22/2022] [Indexed: 11/19/2022] Open
Abstract
Background
Previous studies concerning humidified, heated high-flow nasal oxygen delivered in spontaneously breathing patients postulated an increase in functional residual capacity as one of its physiological effects. It is unclear wheter this is also true for patients under general anesthesia.
Methodology
The sincle-center noninferiority trial was registered at ClinicalTrials.gov (NCT NCT03478774). This secondary outcome analysis shows estimated differences in lung volume changes using electrical impedance tomography between different flow rates of 100% oxygen in apneic, anesthetized and paralyzed adults prior to intubation. One hundred and twenty five patients were randomized to five groups with different flow rates of 100% oxygen: i) minimal-flow: 0.25 l.min-1 via endotracheal tube; ii) low-flow: 2 l.min-1 + continuous jaw thrust; iii) medium-flow: 10 l.min-1 + continuous jaw thrust; iv) high-flow: 70l.min-1 + continuous jaw thrust; and v) control: 70 l.min-1 + continuous video-laryngoscopy. After standardized anesthesia induction with non-depolarizing neuromuscular blockade, the 15-minute apnea period and oxygen delivery was started according to the randomized flow rate. Continuous electrical impedance tomography measurements were performed during the 15-minute apnea period. Total change in lung impedance (an estimate of changes in lung volume) over the 15-minute apnea period and times to 25%, 50% and 75% of total impedance change were calculated.
Results
One hundred and twenty five patients completed the original study. Six patients did not complete the 15-minute apnea period. Due to maloperation, malfunction and artefacts additional 54 measurements had to be excluded, resulting in 65 patients included into this secondary outcome analysis. We found no differences between groups with respect to decrease in lung impedance or curve progression over the observation period.
Conclusions
Different flow rates of humidified 100% oxygen during apnea result in comparable decreases in lung volumes. The demonstrated increase in functional residual capacity during spontaneous breathing with high-flow nasal oxygenation could not be replicated during apnea under general anesthesia with neuromuscular blockade.
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Lung aeration and volumes following alveolar recruitment maneuvers with three airway pressures in healthy anesthetized and mechanically ventilated Beagle dogs. Vet Anaesth Analg 2022; 49:443-451. [DOI: 10.1016/j.vaa.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 06/21/2022] [Accepted: 06/24/2022] [Indexed: 01/17/2023]
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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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Evidence-Based Mechanical Ventilatory Strategies in ARDS. J Clin Med 2022; 11:jcm11020319. [PMID: 35054013 PMCID: PMC8780427 DOI: 10.3390/jcm11020319] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 02/01/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) remains one of the leading causes of morbidity and mortality in critically ill patients despite advancements in the field. Mechanical ventilatory strategies are a vital component of ARDS management to prevent secondary lung injury and improve patient outcomes. Multiple strategies including utilization of low tidal volumes, targeting low plateau pressures to minimize barotrauma, using low FiO2 (fraction of inspired oxygen) to prevent injury related to oxygen free radicals, optimization of positive end expiratory pressure (PEEP) to maintain or improve lung recruitment, and utilization of prone ventilation have been shown to decrease morbidity and mortality. The role of other mechanical ventilatory strategies like non-invasive ventilation, recruitment maneuvers, esophageal pressure monitoring, determination of optimal PEEP, and appropriate patient selection for extracorporeal support is not clear. In this article, we review evidence-based mechanical ventilatory strategies and ventilatory adjuncts for ARDS.
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Boustead KJ, Grace JF, Buck RK, Zeiler GE. Comparative effects of three different ventilatory treatments on arterial blood gas values and oxygen extraction in healthy anaesthetised dogs. Vet Anaesth Analg 2022; 49:251-264. [DOI: 10.1016/j.vaa.2021.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 06/16/2021] [Accepted: 07/21/2021] [Indexed: 10/19/2022]
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Serrano Zueras C, Guilló Moreno V, Santos González M, Gómez Nieto FJ, Hedenstierna G, García Fernández J. Safety and efficacy evaluation of the automatic stepwise recruitment maneuver in the neonatal population: An in vivo interventional study. Can anesthesiologists safely perform automatic lung recruitment maneuvers in neonates? Paediatr Anaesth 2021; 31:1003-1010. [PMID: 34152683 DOI: 10.1111/pan.14243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND A new software has recently been incorporated in almost all new anesthesia machines to enable automatic lung recruitment maneuvers. To date, no studies have assessed the safety and efficacy of these automatic software programs in the neonatal population. AIMS We aimed to evaluate the safety and efficacy of the lung recruitment maneuver performed using the automatic stepwise recruitment maneuver software of the FLOW-i 4.3 Anesthesia System® in a healthy and live neonatal model. METHODS Eight male newborn piglets were included in the study. The lung recruitment maneuver was performed in pressure-controlled ventilation with a constant driving pressure (15 cmH2 O) in a stepwise increasing positive end-expiratory pressure (PEEP) model. The target peak inspiratory pressure (PIP) was 30 cmH2 O and PEEP was 15 cmH2 O. The maneuver lasted for 39 seconds. The hemodynamic variables were monitored using the PICCO® system. The following respiratory parameters were monitored: oxygen saturation, fraction of inspired oxygen, partial pressure of oxygen and carbon dioxide in the arterial blood, end-tidal carbon dioxide pressure, PIP, plateau pressure, PEEP, static compliance (Cstat ), and dynamic compliance (Cdyn ). Safety was evaluated by assessing the accuracy of the software, need for not interrupting the maneuver, hemodynamic stability, and absence of adverse respiratory events with the lung recruitment maneuver. Efficacy was evaluated by improvement in Cstat and Cdyn after performing the lung recruitment maneuver. RESULTS All lung recruitment maneuvers were safely performed as scheduled without any interruptions. No pneumothorax or other side effects were observed. Hemodynamic stability was maintained during the lung recruitment maneuver. We observed an improvement of 33% in Cdyn and 24% in Cstat after the maneuver. CONCLUSIONS The automatic stepwise recruitment maneuver software of the FLOW-i 4.3 Anesthesia System® is safe and efficacious in a healthy neonatal model. We did not observe any adverse respiratory or hemodynamic events during the implementation of the lung recruitment maneuver in the pressure-controlled ventilation mode using a stepwise increasing PEEP (30/15 cmH2 O) approach.
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Affiliation(s)
- Clara Serrano Zueras
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro en Majadahonda, Majadahonda, Spain
| | - Verónica Guilló Moreno
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro en Majadahonda, Majadahonda, Spain
| | - Martín Santos González
- Medical and surgical research unit Instituto de Investigación Sanitaria Puerta de Hierro-Segovia de Arana Hospital Universitario Puerta de Hierro en Majadahonda, Majadahonda, Spain
| | - Francisco Javier Gómez Nieto
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro en Majadahonda, Majadahonda, Spain
| | | | - Javier García Fernández
- Department of Anaesthesiology, Intensive Care and Pain, Hospital Universitario Puerta de Hierro en Majadahonda, Majadahonda, Spain
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Individualized versus Fixed Positive End-expiratory Pressure for Intraoperative Mechanical Ventilation in Obese Patients: A Secondary Analysis. Anesthesiology 2021; 134:887-900. [PMID: 33843980 DOI: 10.1097/aln.0000000000003762] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND General anesthesia may cause atelectasis and deterioration in oxygenation in obese patients. The authors hypothesized that individualized positive end-expiratory pressure (PEEP) improves intraoperative oxygenation and ventilation distribution compared to fixed PEEP. METHODS This secondary analysis included all obese patients recruited at University Hospital of Leipzig from the multicenter Protective Intraoperative Ventilation with Higher versus Lower Levels of Positive End-Expiratory Pressure in Obese Patients (PROBESE) trial (n = 42) and likewise all obese patients from a local single-center trial (n = 54). Inclusion criteria for both trials were elective laparoscopic abdominal surgery, body mass index greater than or equal to 35 kg/m2, and Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score greater than or equal to 26. Patients were randomized to PEEP of 4 cm H2O (n = 19) or a recruitment maneuver followed by PEEP of 12 cm H2O (n = 21) in the PROBESE study. In the single-center study, they were randomized to PEEP of 5 cm H2O (n = 25) or a recruitment maneuver followed by individualized PEEP (n = 25) determined by electrical impedance tomography. Primary endpoint was Pao2/inspiratory oxygen fraction before extubation and secondary endpoints included intraoperative tidal volume distribution to dependent lung and driving pressure. RESULTS Ninety patients were evaluated in three groups after combining the two lower PEEP groups. Median individualized PEEP was 18 (interquartile range, 16 to 22; range, 10 to 26) cm H2O. Pao2/inspiratory oxygen fraction before extubation was 515 (individual PEEP), 370 (fixed PEEP of 12 cm H2O), and 305 (fixed PEEP of 4 to 5 cm H2O) mmHg (difference to individualized PEEP, 145; 95% CI, 91 to 200; P < 0.001 for fixed PEEP of 12 cm H2O and 210; 95% CI, 164 to 257; P < 0.001 for fixed PEEP of 4 to 5 cm H2O). Intraoperative tidal volume in the dependent lung areas was 43.9% (individualized PEEP), 25.9% (fixed PEEP of 12 cm H2O) and 26.8% (fixed PEEP of 4 to 5 cm H2O) (difference to individualized PEEP: 18.0%; 95% CI, 8.0 to 20.7; P < 0.001 for fixed PEEP of 12 cm H2O and 17.1%; 95% CI, 10.0 to 20.6; P < 0.001 for fixed PEEP of 4 to 5 cm H2O). Mean intraoperative driving pressure was 9.8 cm H2O (individualized PEEP), 14.4 cm H2O (fixed PEEP of 12 cm H2O), and 18.8 cm H2O (fixed PEEP of 4 to 5 cm H2O), P < 0.001. CONCLUSIONS This secondary analysis of obese patients undergoing laparoscopic surgery found better oxygenation, lower driving pressures, and redistribution of ventilation toward dependent lung areas measured by electrical impedance tomography using individualized PEEP. The impact on patient outcome remains unclear. EDITOR’S PERSPECTIVE
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Li L, Zhao L, Wang T, Xu N, Wang P, An Y, Li Z, Jiao L, Yang B, Hua Y. Alveolar Recruitment Maneuver Reduces Cerebral Oxygen Saturation and Cerebral Blood Flow Velocity in Patients During Carotid Endarterectomy. Med Sci Monit 2021; 27:e930617. [PMID: 34148051 PMCID: PMC8223757 DOI: 10.12659/msm.930617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND This study aimed to determine the effects of alveolar recruitment maneuver (RM) on cerebral oxygen saturation and cerebral blood velocity in patients undergoing carotid endarterectomy (CEA) before clamping of the carotid artery. MATERIAL AND METHODS In this crossover exploratory study, all patients were randomized to undergo an RM (30 cmH₂O of continuous airway pressure for 30 s) and a "sham" maneuver (SM; 5 cmH₂O for 30 s), followed by an alternative intervention after a 5-min equilibration period. Near-infrared spectroscopy (NIRS) was used to monitor regional cerebral oxygen saturation (rSO₂), and transcranial Doppler ultrasonography (TCD) to evaluate blood velocity of the middle cerebral artery (V-MCA). Changes in rSO₂, V-MCA, mean arterial pressure (MAP), and heart rate (HR) in response to the 2 interventions were compared. RESULTS A total of 59 patients underwent the study procedure. RM reduced rSO₂, V-MCA, MAP, and HR, but these variables slightly changed during SM. A significant drop in rSO₂ was observed immediately after RM compared with the baseline value (68.51±4.4% vs 64.12±5.15%; P<0.001). The decrease in rSO₂ was higher during the RM than during the SM (-6±4% vs 1±2%; P<0.001). Similarly, change in V-MCA was more significant in response to RM than SM (-26±19% vs 19±16%; P<0.001). The V-MCA value changed from 39 cm/s to 29 cm/s after RM. In addition, V-MCA of the ipsilateral to the surgical side decreased more obviously than the contralateral side (-26±19% vs -20±17%; P=0.001). CONCLUSIONS An RM at 30 cmH₂O of continuous airway pressure for 30 s decreased rSO₂ and V-MCA. In addition, MAP and HR were affected.
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Affiliation(s)
- Lixia Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Lei Zhao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Na Xu
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Ping Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Yi An
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Zhongjia Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Liqun Jiao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Bin Yang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
| | - Yang Hua
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, China (mainland)
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Fogagnolo A, Montanaro F, Al-Husinat L, Turrini C, Rauseo M, Mirabella L, Ragazzi R, Ottaviani I, Cinnella G, Volta CA, Spadaro S. Management of Intraoperative Mechanical Ventilation to Prevent Postoperative Complications after General Anesthesia: A Narrative Review. J Clin Med 2021; 10:jcm10122656. [PMID: 34208699 PMCID: PMC8234365 DOI: 10.3390/jcm10122656] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 01/02/2023] Open
Abstract
Mechanical ventilation (MV) is still necessary in many surgical procedures; nonetheless, intraoperative MV is not free from harmful effects. Protective ventilation strategies, which include the combination of low tidal volume and adequate positive end expiratory pressure (PEEP) levels, are usually adopted to minimize the ventilation-induced lung injury and to avoid post-operative pulmonary complications (PPCs). Even so, volutrauma and atelectrauma may co-exist at different levels of tidal volume and PEEP, and therefore, the physiological response to the MV settings should be monitored in each patient. A personalized perioperative approach is gaining relevance in the field of intraoperative MV; in particular, many efforts have been made to individualize PEEP, giving more emphasis on physiological and functional status to the whole body. In this review, we summarized the latest findings about the optimization of PEEP and intraoperative MV in different surgical settings. Starting from a physiological point of view, we described how to approach the individualized MV and monitor the effects of MV on lung function.
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Affiliation(s)
- Alberto Fogagnolo
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
- Correspondence:
| | - Federica Montanaro
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
| | - Lou’i Al-Husinat
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Cecilia Turrini
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
| | - Michela Rauseo
- Department of Anesthesia and Intensive Care, University of Foggia, 71122 Foggia, Italy; (M.R.); (L.M.); (G.C.)
| | - Lucia Mirabella
- Department of Anesthesia and Intensive Care, University of Foggia, 71122 Foggia, Italy; (M.R.); (L.M.); (G.C.)
| | - Riccardo Ragazzi
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
| | - Irene Ottaviani
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
| | - Gilda Cinnella
- Department of Anesthesia and Intensive Care, University of Foggia, 71122 Foggia, Italy; (M.R.); (L.M.); (G.C.)
| | - Carlo Alberto Volta
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
| | - Savino Spadaro
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
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Bergmann A, Schilling T. [Intraoperative Ventilation Approaches to One-lung Ventilation]. Anasthesiol Intensivmed Notfallmed Schmerzther 2021; 56:329-341. [PMID: 34038972 DOI: 10.1055/a-1189-8031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The management of thoracic surgery patients is challenging to the anesthetist, since one-lung ventilation (OLV) includes at least two major conditions: sufficient oxygenation and lung protection. The first is mainly because the ventilation of one lung is stopped while perfusion to that lung continues; the latter is related to the fact that the whole ventilation is applied to only a single lung. Recommendations for maintaining the oxygenation and methods of lung protection may contradict each other (e. g. high vs. low inspiratory oxygen fraction (FiO2), high vs. low tidal volume, etc.). Therefore, a high degree of pathophysiological understanding and manual skills are required in the management of these patients.In light of recent clinical studies, this review focuses on a current protective strategy for OLV, which includes a possible decrease in FiO2, lowered VT, the application of positive end-expiratory pressure (PEEP) to the dependent and continuous positive airway pressure (CPAP) to the non-dependent lung and alveolar recruitment manoeuvres as well. Other approaches such as the choice of anaesthetics, remote ischemic preconditioning, fluid management and pain therapy can support the success of ventilatory strategy. The present work describes new developments that may change the classical approach in this respect.
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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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Sümer I, Topuz U, Alver S, Umutoglu T, Bakan M, Zengin SÜ, Coşkun H, Salihoglu Z. Effect of the "Recruitment" Maneuver on Respiratory Mechanics in Laparoscopic Sleeve Gastrectomy Surgery. Obes Surg 2021; 30:2684-2692. [PMID: 32207048 PMCID: PMC7224081 DOI: 10.1007/s11695-020-04551-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Purpose LSG surgery is used for surgical treatment of morbid obesity. Obesity, anesthesia, and pneumoperitoneum cause reduced pulmoner functions and a tendency for atelectasis. The alveolar “recruitment” maneuver (RM) keeps airway pressure high, opening alveoli, and increasing arterial oxygenation. The aim of our study is to research the effect on respiratory mechanics and arterial blood gases of performing the RM in LSG surgery. Materials and Methods Sixty patients undergoing LSG surgery were divided into two groups (n = 30) Patients in group R had the RM performed 5 min after desufflation with 100% oxygen, 40 cmH2O pressure for 40 s. Group C had standard mechanical ventilation. Assessments of respiratory mechanics and arterial blood gases were made in the 10th min after induction (T1), 10th min after insufflation (T2), 5th min after desufflation (T3), and 15th min after desufflation (T4). Arterial blood gases were assessed in the 30th min (T5) in the postoperative recovery unit. Results In group R, values at T5, PaO2 were significantly high, while PaCO2 were significantly low compared with group C. Compliance in both groups reduced with pneumoperitoneum. At T4, the compliance in the recruitment group was higher. In both groups, there was an increase in PIP with pneumoperitoneum and after desufflation this was identified to reduce to levels before pneumoperitoneum. Conclusion Adding the RM to PEEP administration for morbidly obese patients undergoing LSG surgery is considered to be effective in improving respiratory mechanics and arterial blood gas values and can be used safely.
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Affiliation(s)
- Ismail Sümer
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey.
| | - Ufuk Topuz
- Health Cares Vocational School, İstanbul Esenyurt University, Istanbul, Turkey
- İstanbul Acıbadem Taksim Hospital, Istanbul, Turkey
| | - Selçuk Alver
- Department of Anesthesiology and Reanimation, Faculty of Medicine, İstanbul Medipol University, Istanbul, Turkey
| | | | - Mefkur Bakan
- Health Cares Vocational School, İstanbul Esenyurt University, Istanbul, Turkey
- İstanbul Acıbadem Taksim Hospital, Istanbul, Turkey
| | - Seniyye Ülgen Zengin
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Marmara University, Istanbul, Turkey
| | - Halil Coşkun
- Department of General Surgery, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey
| | - Ziya Salihoglu
- Department of Anesthesiology and Reanimation, Cerrahpasa Faculty of Medicine, İstanbul University Cerrahpasa, Istanbul, Turkey
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Prasad TK, Gnanasekar N, Priyadharsini KS, Chacko RS. Randomized double-blind trial comparing effects of low-flow vs high-flow anesthesia on postoperative lung functions using respirometer. J Anaesthesiol Clin Pharmacol 2021; 36:535-540. [PMID: 33840937 PMCID: PMC8022052 DOI: 10.4103/joacp.joacp_410_19] [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: 12/05/2019] [Accepted: 03/06/2020] [Indexed: 11/26/2022] Open
Abstract
Background and Aims: Modern anesthetic practice utilizes low-flow anesthesia with evolving evidence on its pulmonary effects. Studies comparing measurement of vital capacity and inspiratory reserve volume using respirometer in both low-flow and high-flow anesthesia are sparse. We evaluated the effects of low-flow and high-flow anesthesia on postoperative pulmonary functions using respirometer. Material and Methods: This was a prospective randomized double blind study wherein One hundred and ten patients undergoing peripheral surgeries under general anesthesia were allocated into two groups Group I- Low-flow anesthesia with O2 + N2O + Sevoflurane (0.5L + 0.5L + 3.5%) and Group II- High-flow anesthesia with O2 + N2O + Sevoflurane (2L + 2L + 2%). The difference in vital capacity (VC), inspiratory reserve volume (IRV), and peak expiratory flow rates (PEFR) from the preoperative period were compared in both the groups postoperatively. Results: The difference in VC, IRV, and PEFR measured in both the groups between the preoperative and postoperative period were found to be similar and statistically insignificant (P - 0.173, 1.00 and 0.213 respectively). The difference in single breath count (SBC), breath holding time (BHT), and respiratory rates (RR) were also similar in both the groups (P – 0.101, 0.698, and 0.467) respectively. Conclusions: The pulmonary effects of low-flow anesthesia are comparable with the high-flow ones in patients undergoing elective surgeries under general anesthesia.
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Affiliation(s)
- T Krishna Prasad
- Department of Anesthesiology, Shri Sathya Sai Medical College and Research Institute, (Sri Balaji Vidyapeeth, Deemed to be University), Kancheepuram, Tamil Nadu, India
| | - N Gnanasekar
- Department of Anesthesiology, Shri Sathya Sai Medical College and Research Institute, (Sri Balaji Vidyapeeth, Deemed to be University), Kancheepuram, Tamil Nadu, India
| | - K Soundarya Priyadharsini
- Department of Pharmacology, Shri Sathya Sai Medical College and Research Institute, (Sri Balaji Vidyapeeth, Deemed to be University), Kancheepuram, Tamil Nadu, India
| | - Robin Sajan Chacko
- Department of Anesthesiology, Shri Sathya Sai Medical College and Research Institute, (Sri Balaji Vidyapeeth, Deemed to be University), Kancheepuram, Tamil Nadu, India
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Nguyen TK, Mai DH, Le AN, Nguyen QH, Nguyen CT, Vu TA. A review of intraoperative lung-protective mechanical ventilation strategy. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2020.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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21
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Nakahira J, Nakano S, Minami T. Evaluation of alveolar recruitment maneuver on respiratory resistance during general anesthesia: a prospective observational study. BMC Anesthesiol 2020; 20:264. [PMID: 33069208 PMCID: PMC7568405 DOI: 10.1186/s12871-020-01182-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 10/12/2020] [Indexed: 12/02/2022] Open
Abstract
Background Alveolar recruitment maneuvers enable easily reopening nonaerated lung regions via a transient elevation in transpulmonary pressure. To evaluate the effect of these maneuvers on respiratory resistance, we used an oscillatory technique during mechanical ventilation. This study was conducted to assess the effect of the alveolar recruitment maneuvers on respiratory resistance under routine anesthesia. We hypothesized that respiratory resistance at 5 Hz (R5) after the maneuver would be decreased after the lung aeration. Methods After receiving the ethics committee’s approval, we enrolled 33 patients who were classified with an American Society of Anesthesiologists physical status of 1, 2 or 3 and were undergoing general anesthesia for transurethral resection of a bladder tumor within a 12-month period from 2017 to 2018. The recruitment maneuver was performed 30 min after endotracheal intubation. The maneuver consisted of sustained manual inflation of the anesthesia reservoir bag to a peak inspiratory pressure of 40 cmH2O for 15 s, including 5 s of gradually increasing the peak inspiratory pressure. Respiratory resistance was measured using the forced oscillation technique before and after the maneuver, and the mean R5 was calculated during the expiratory phase. The respiratory resistance and ventilator parameter results were analyzed using paired Student’s t-tests, and p < 0.05 was considered statistically significant. Results We analyzed 31 patients (25 men and 6 women). R5 was 7.3 ± 1.6 cmH2O/L/sec before the recruitment maneuver during mechanical ventilation and was significantly decreased to 6.4 ± 1.7 cmH2O/L/sec after the maneuver. Peak inspiratory pressure and plateau pressure were significantly decreased, and pulmonary compliance was increased, although the values were not clinically relevant. Conclusion The recruitment maneuver decreased respiratory resistance and increased lung compliance during mechanical ventilation. Trial registration Name of registry: Japan Medical Association Center for Clinical Trials. Trial registration number: reference JMA-IIA00136. Date of registration: 2 September 2013. URL of trial registry record: https://dbcentre3.jmacct.med.or.jp/JMACTR/App/JMACTRE02_04/JMACTRE02_04.aspx?kbn=3&seqno=3582
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Affiliation(s)
- Junko Nakahira
- Department of Anesthesiology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan.
| | - Shoko Nakano
- Department of Anesthesiology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
| | - Toshiaki Minami
- Department of Anesthesiology, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka, 569-8686, Japan
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22
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Tonelotto B, Pereira SM, Tucci MR, Vaz DF, Vieira JE, Malbouisson LM, Gay F, Simões CM, Carvalho Carmona MJ, Monsel A, Amato MB, Rouby JJ, Costa Auler JO. Intraoperative pulmonary hyperdistention estimated by transthoracic lung ultrasound: A pilot study. Anaesth Crit Care Pain Med 2020; 39:825-831. [PMID: 33080407 DOI: 10.1016/j.accpm.2020.09.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 08/17/2020] [Accepted: 09/03/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Transthoracic lung ultrasound can assess atelectasis reversal and is considered as unable to detect associated hyperdistention. In this study, we describe an ultrasound pattern highly suggestive of pulmonary hyperdistention. METHODS Eighteen patients with normal lungs undergoing lower abdominal surgery were studied. Electrical impedance tomography was calibrated, followed by anaesthetic induction, intubation and mechanical ventilation. To reverse posterior atelectasis, a recruitment manoeuvre was performed. Positive-end expiratory pressure (PEEP) titration was then obtained during a descending trial - 20, 18, 16, 14, 12, 10, 8, 6 and 4cmH2O. Ultrasound and electrical impedance tomography data were collected at each PEEP level and interpreted by two independent observers. Spearman correlation test and receiving operating characteristic curve were used to compare lung ultrasound and electrical impedance tomography data. RESULTS The number of horizontal A lines increased linearly with PEEP: from 3 (0, 5) at PEEP 4cmH2O to 10 (8, 13) at PEEP 20cmH2O. The increase number of A lines was associated with a parallel and significant decrease in intercostal space thickness (p=0.001). The lung ultrasound threshold for detecting pulmonary hyperdistention was defined as the number of A lines counted at the PEEP preceding the PEEP providing the best respiratory compliance. Six A lines was the median threshold for detecting pulmonary hyperdistention. The area under the receiving operating characteristic curve was 0.947. CONCLUSIONS Intraoperative transthoracic lung ultrasound can detect lung hyperdistention during a PEEP descending trial. Six or more A lines detected in normally aerated regions can be considered as indicating lung hyperdistention. TRIAL REGISTRATION NCT02314845 Registered on ClinicalTrials.gov.
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Affiliation(s)
- Bruno Tonelotto
- Divisão de Anestesiologia, Hospital Sírio-Libanês, Dona Adma Jafet Street, 91, São Paulo 1308050, Brazil.
| | - Sérgio Martins Pereira
- Divisão de Anestesiologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av Doutor Eneas de Carvalho Aguiar, 255, São Paulo 0540300, Brazil
| | - Mauro Roberto Tucci
- Divisão de Pneumologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av Doutor Eneas de Carvalho Aguiar, 255, São Paulo 0540300, Brazil
| | - Diogo Florenzano Vaz
- Divisão de Anestesiologia, Hospital Sírio-Libanês, Dona Adma Jafet Street, 91, São Paulo 1308050, Brazil
| | - Joaquim Edson Vieira
- Divisão de Anestesiologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av Doutor Eneas de Carvalho Aguiar, 255, São Paulo 0540300, Brazil
| | - Luiz Marcelo Malbouisson
- Divisão de Anestesiologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av Doutor Eneas de Carvalho Aguiar, 255, São Paulo 0540300, Brazil
| | - Frédérick Gay
- Department of Parasitology-Mycology, La Pitié-Salpêtrière hospital, Assistance Publique Hôpitaux de Paris, Sorbonne University of Paris, 47, Boulevard de l'Hôpital, 75013 Paris, France
| | - Claudia Marquez Simões
- Divisão de Anestesiologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av Doutor Eneas de Carvalho Aguiar, 255, São Paulo 0540300, Brazil
| | - Maria José Carvalho Carmona
- Divisão de Anestesiologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av Doutor Eneas de Carvalho Aguiar, 255, São Paulo 0540300, Brazil
| | - Antoine Monsel
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtrière hospital, Assistance Publique Hôpitaux de Paris, Sorbonne University of Paris, 47, Boulevard de l'Hôpital, 75013 Paris, France
| | - Marcelo Brito Amato
- Divisão de Pneumologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av Doutor Eneas de Carvalho Aguiar, 255, São Paulo 0540300, Brazil
| | - Jean-Jacques Rouby
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, La Pitié-Salpêtrière hospital, Assistance Publique Hôpitaux de Paris, Sorbonne University of Paris, 47, Boulevard de l'Hôpital, 75013 Paris, France
| | - José Otavio Costa Auler
- Divisão de Anestesiologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Av Doutor Eneas de Carvalho Aguiar, 255, São Paulo 0540300, Brazil
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Kudoh O, Satoh D, Hori N, Kawagoe I, Inada E. The effects of a recruitment manoeuvre with positive end-expiratory pressure on lung compliance in patients undergoing robot-assisted laparoscopic radical prostatectomy. J Clin Monit Comput 2020; 34:303-310. [PMID: 30968327 PMCID: PMC7080675 DOI: 10.1007/s10877-019-00306-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 03/25/2019] [Indexed: 12/03/2022]
Abstract
The effects of a recruitment manoeuvre (RM) with positive end-expiratory pressure (PEEP) on lung compliance (CLUNG) are not well characterised in robot-assisted laparoscopic radical prostatectomy (RARP). Patients were allocated to group R (n = 10; with an RM) or C (n = 9; without an RM). An RM involved sustained inflation of 30 cmH2O for 30 s. The lungs were ventilated with volume-controlled ventilation with tidal volume of 7 mL kg-1 of predicted body weight and fraction of inspired oxygen of 0.5. End-tidal carbon dioxide pressure was maintained at normocapnia. Patients were in the horizontal lithotomy position (pre-op). After pneumoperitoneum, patients underwent RARP in a steep Trendelenburg lithotomy position at a PEEP level of 0 cmH2O (RARP0). An RM was used in the R group but not in the C group. Patients were then ventilated with 5 cmH2O PEEP for 1 h after RARP0 (RARP5.1) and 2 h after RARP0 (RARP5.2). Oesophageal pressure and airway pressure were measured for calculating CLUNG and chest wall compliance. CLUNG significantly decreased from pre-op to RARP0 and did not significantly increase from RARP0 to RARP5.1 and RARP5.2 in either group. CLUNG differed significantly between groups at RARP5.1 and RARP5.2 (103 ± 30 vs. 68 ± 11 mL cm-1 H2O and 106 ± 35 vs. 72 ± 9 mL cm-1 H2O; P < 0.05). In patients undergoing RARP, with the addition of RM, the CLUNG was effectively increased from the horizontal lithotomy position to the steep Trendelenburg lithotomy position under pneumoperitoneum.
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Affiliation(s)
- Osamu Kudoh
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Daizoh Satoh
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Naosuke Hori
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Izumi Kawagoe
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
| | - Eiichi Inada
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations. Br J Anaesth 2019; 123:898-913. [DOI: 10.1016/j.bja.2019.08.017] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/22/2019] [Accepted: 08/04/2019] [Indexed: 12/16/2022] Open
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Jiang R, Sun Y, Wang H, Liang M, Xie X. Effect of different carbon dioxide (CO2) insufflation for laparoscopic colorectal surgery in elderly patients: A randomized controlled trial. Medicine (Baltimore) 2019; 98:e17520. [PMID: 31593122 PMCID: PMC6799792 DOI: 10.1097/md.0000000000017520] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Evidence suggests that dry CO2 insufflation during laparoscopic colorectal surgery results in greater structural injury to the peritoneum and longer hospital stay than the use of warm, humidified CO2. We aimed to test the hypothesis that warm, humidified CO2 insufflation could reduce postoperative pain and improve recovery in laparoscopic colorectal surgery. METHODS One hundred fifty elderly patients undergoing laparoscopic colorectal surgery under general anesthesia from May 2017 to October 2018 were randomly divided into 3 groups. The primary outcomes were resting pain, cough pain, and consumption of sufentanil at 2, 4, 6, 12, 24, and 48 hours postoperatively. Quality of visual image, hemodynamic changes, esophageal temperature, mean skin temperature, mean body temperature, recovery time, days to first flatus and solid food intake, shivering, incidence of postoperative ileus, length of hospital stay, surgical site infections, patients and surgeon satisfaction scores, adverse events, prothrombin time, activated partial thromboplastin time, and thrombin time were recorded. RESULTS Group CE patients were associated with significantly higher early postoperative cough pain and sufentanil consumption than the other 2 groups (P < .05). Compared with group CE, patients in both groups WH and CF had significantly reduced intraoperative hypothermia, recovery time of PACU, days to first flatus and solid food intake, and length of hospital stay, while the satisfaction scores of both patients and surgeon were significantly higher (P < .05). Prothrombin time, activated partial thromboplastin time, and thrombin time were significantly higher in group CE from 60 minutes after pneumoperitoneum to the end of pneumoperitoneum than the other 2 groups (P < .05). The number of patients with a shivering grade of 0 was significantly lower and grade of 3 was significantly higher in group CE than in the other 2 groups (P < .05). CONCLUSION Use of either warm, humidified CO2 insufflations or 20°C, 0% relative humidity CO2 combined with forced-air warmer set to 38°C during insufflations can both reduce intraoperative hypothermia, dysfunction of coagulation, early postoperative cough pain, sufentanil consumption, days to first flatus, solid food intake, and length of hospital stay.
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Affiliation(s)
- Rongjuan Jiang
- Department of Anesthesiology, Chengdu Second People's Hospital
| | - Yan Sun
- Department of Anesthesiology, Chengdu Second People's Hospital
| | - Huaiming Wang
- Department of Anesthesiology, Sichuan Cancer Hospital, Chengdu, Sichuan
| | - Min Liang
- Department of Anesthesiology, Liaocheng People's Hospital, Liaocheng, Shandong, China
| | - Xianfeng Xie
- Department of Anesthesiology, Chengdu Second People's Hospital
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Varner KM, Hopster K, Driessen B. Comparison of various types of inert gas components on efficacy of an alveolar recruitment maneuver in dorsally recumbent anesthetized horses. Am J Vet Res 2019; 80:631-636. [PMID: 31246120 DOI: 10.2460/ajvr.80.7.631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess effects of nitrogen and helium on efficacy of an alveolar recruitment maneuver (ARM) for improving pulmonary mechanics and oxygen exchange in anesthetized horses. ANIMALS 6 healthy adult horses. PROCEDURES Horses were anesthetized twice in a randomized crossover study. Isoflurane-anesthetized horses in dorsal recumbency were ventilated with 30% oxygen and 70% nitrogen (treatment N) or heliox (30% oxygen and 70% helium; treatment H) as carrier gas. After 60 minutes, an ARM was performed. Optimal positive end-expiratory pressure was identified and maintained for 120 minutes. Throughout the experiment, arterial blood pressures, heart rate, peak inspiratory pressure, dynamic compliance (Cdyn), and Pao2 were measured. Variables were compared with baseline values and between treatments by use of an ANOVA. RESULTS The ARM resulted in significant increases in Pao2 and Cdyn and decreases in the alveolar-arterial gradient in the partial pressure of oxygen in all horses. After the ARM and during the subsequent 120-minute phase, mean values were significantly lower for treatment N than treatment H for Pao2 and Cdyn. Optimal positive end-expiratory pressure was consistently 15 cm H2O for treatment N, but it was 10 cm H2O (4 horses) and 15 cm H2O (2 horses) for treatment H. CONCLUSIONS AND CLINICAL RELEVANCE An ARM in anesthetized horses might be more efficacious in improving Pao2 and Cdyn when animals breathe helium instead of nitrogen as the inert gas.
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Affiliation(s)
- Karen B Domino
- From the Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
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Selective Recruitment of Large Lower Lobe Atelectasis on Donor Back Table in Rejected Donor Lungs. Transplant Direct 2019; 5:e453. [PMID: 31165088 PMCID: PMC6511443 DOI: 10.1097/txd.0000000000000889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 02/20/2019] [Accepted: 02/25/2019] [Indexed: 11/25/2022] Open
Abstract
Background Large atelectatic areas in donor lungs are frequently resistant to standard recruitment maneuvers, producing a tenaciously low PO2/FiO2 ratio. The aim of this study is to investigate the optimal protocol for the recruitment of large atelectatic areas in the context of ex vivo lung perfusion (EVLP). Methods Seventeen rejected lungs with large lower lobe atelectasis (≥40%) were divided into 2 groups: manual resuscitation (n = 5) and selective recruitment (n = 12). Transplant suitability was then evaluated in cellular EVLP. In the manual resuscitation group, following bronchoscopy, if the conventional recruitment maneuver was not successful, a bagging technique was utilized to resolve atelectasis in EVLP. In the selective recruitment group, a pediatric endotracheal tube was introduced to the lower lobe bronchus on the back table of the donor hospital. Selective recruitment of the lower lobe was accomplished while keeping peak inspiratory pressure <30 cm H2O for 30 seconds. Results The average atelectasis size and lung weight in 17 donor lungs was 75.4 ± 20.6% and 960 ± 221 g, respectively. There were no significant differences between the 2 groups in all donor variables, except cold ischemic time (P = 0.001, 5.2 ± 0.5 versus 6.4 ± 0.7 hours). The selective recruitment group was associated with better transplant suitability (P = 0.035, 75% versus 20%), better PO2/FiO2 ratio (P = 0.186, 324 ± 89 versus 258 ± 87 mm Hg), lower lung weight (P = 0.057, 997.9 ± 229.2 versus 1377.2 ± 452.9 g), and better pathological score (P < 0.05, 1.0 ± 1.3 versus 2.8 ± 0.8) than the manual resuscitation group. Conclusion A selective recruitment procedure is a safe and effective method of eliminating large atelectasis before EVLP.
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Nestler C, Simon P, Petroff D, Hammermüller S, Kamrath D, Wolf S, Dietrich A, Camilo LM, Beda A, Carvalho AR, Giannella-Neto A, Reske AW, Wrigge H. Individualized positive end-expiratory pressure in obese patients during general anaesthesia: a randomized controlled clinical trial using electrical impedance tomography. Br J Anaesth 2019; 119:1194-1205. [PMID: 29045567 DOI: 10.1093/bja/aex192] [Citation(s) in RCA: 126] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2017] [Indexed: 11/14/2022] Open
Abstract
Background General anaesthesia leads to atelectasis, reduced end-expiratory lung volume (EELV), and diminished arterial oxygenation in obese patients. We hypothesized that a combination of a recruitment manoeuvre (RM) and individualized positive end-expiratory pressure (PEEP) can avoid these effects. Methods Patients with a BMI ≥35 kg m -2 undergoing elective laparoscopic surgery were randomly allocated to mechanical ventilation with a tidal volume of 8 ml kg -1 predicted body weight and (i) an RM followed by individualized PEEP titrated using electrical impedance tomography (PEEP IND ) or (ii) no RM and PEEP of 5 cm H 2 O (PEEP 5 ). Gas exchange, regional ventilation distribution, and EELV (multiple breath nitrogen washout method) were determined before, during, and after anaesthesia. The primary end point was the ratio of arterial partial pressure of oxygen to inspiratory oxygen fraction ( P aO 2 / F iO 2 ). Results For PEEP IND ( n =25) and PEEP 5 ( n =25) arms together, P aO 2 / F iO 2 and EELV decreased by 15 kPa [95% confidence interval (CI) 11-20 kPa, P <0.001] and 1.2 litres (95% CI 0.9-1.6 litres, P <0.001), respectively, after intubation. Mean ( sd ) PEEP IND was 18.5 (5.6) cm H 2 O. In the PEEP IND arm, P aO 2 / F iO 2 before extubation was 23 kPa higher (95% CI 16-29 kPa; P <0.001), EELV was 1.8 litres larger (95% CI 1.5-2.2 litres; P <0.001), driving pressure was 6.7 cm H 2 O lower (95% CI 5.4-7.9 cm H 2 O; P <0.001), and regional ventilation was more equally distributed than for PEEP 5 . After extubation, however, these differences between the arms vanished. Conclusions In obese patients, an RM and higher PEEP IND restored EELV, regional ventilation distribution, and oxygenation during anaesthesia, but these differences did not persist after extubation. Therefore, lung protection strategies should include the postoperative period. Clinical trial registration German clinical trials register DRKS00004199, www.who.int/ictrp/network/drks2/en/ .
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Affiliation(s)
- C Nestler
- Department of Anaesthesia and Intensive Care Medicine, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - P Simon
- Department of Anaesthesia and Intensive Care Medicine, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.,Integrated Research and Treatment Centre (IFB) AdiposityDiseases
| | - D Petroff
- Integrated Research and Treatment Centre (IFB) AdiposityDiseases.,Clinical Trial Centre
| | - S Hammermüller
- Department of Anaesthesia and Intensive Care Medicine, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - D Kamrath
- Department of Anaesthesia and Intensive Care Medicine, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - S Wolf
- Department of Anaesthesia and Intensive Care Medicine, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany
| | - A Dietrich
- Integrated Research and Treatment Centre (IFB) AdiposityDiseases.,Department of Surgery, University of Leipzig, Leipzig, Germany
| | - L M Camilo
- Laboratory of Pulmonary Engineering, Biomedical Engineering Program, Alberto Luis Coimbra Institute of Post-Graduation and Research in Engineering, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - A Beda
- Department of Electronic Engineering and Postgraduate Program of Electrical Engineering, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - A R Carvalho
- Laboratory of Pulmonary Engineering, Biomedical Engineering Program, Alberto Luis Coimbra Institute of Post-Graduation and Research in Engineering, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Laboratory of Respiration Physiology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - A Giannella-Neto
- Department of Anaesthesia and Intensive Care Medicine, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.,Laboratory of Pulmonary Engineering, Biomedical Engineering Program, Alberto Luis Coimbra Institute of Post-Graduation and Research in Engineering, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - A W Reske
- Department of Anaesthesia and Intensive Care Medicine, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.,Integrated Research and Treatment Centre (IFB) AdiposityDiseases
| | - H Wrigge
- Department of Anaesthesia and Intensive Care Medicine, University of Leipzig, Liebigstraße 20, 04103 Leipzig, Germany.,Integrated Research and Treatment Centre (IFB) AdiposityDiseases
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Application of Positive End-Expiratory Pressure (PEEP) in Patients During Prolonged Gynecological Surgery. ACTA MEDICA BULGARICA 2019. [DOI: 10.2478/amb-2019-0005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Introduction: A lot of clinical studies have shown that during prolonged surgery protective ventilation strategy, including low tidal volume, PEEP and recruitment maneuvers (RM) can reduce the rate of postoperative pulmonary complications, which are the second most common cause for postoperative mortality. Therefore, it is important to investigate clinical methods for preventing them. The strategy of protective ventilation is easy and safe for the patients and inexpensive for application during prolonged surgery.
Aims: The objective of this trial was to study whether application of PEEP in patients during prolonged gynecological surgery could decrease the postoperative complications.
Material and Methods: We compared the rates of postoperative complications in patients after prolonged open gynecological surgery, who were divided into 2 groups – group A, which was the control group on non-protective ventilation (35 patients) and group B on protective ventilation (35 patients). The patients in the control group were ventilated with tidal volume (VT) of 8-10 ml/kg without PEEP and RM; the patients in group B were ventilated with VT = 6-8 ml/kg according to their Predicted Body Weight, with a PEEP of 6 cm H2O and RM, which consisted of applying continuous positive airway pressure of 30 cm H2O for 30 seconds. RM was performed after intubation, after every disconnection from ventilator and before extubation. The study was successfully performed without a need for a change in the type of ventilation strategy because of hypoxia or hemodynamic instability. Statistical nonparametric test (e.g. chi-square) was applied.
Results: Total rate of all postoperative complications observed in both groups was 27,1%. We found a significant relationship between application of PEEP and lower rates of postoperative pulmonary complications in group A (39,4%) compared to group B (12,1%), lower rate of respiratory failure (33,3% in group A vs. 9,1% in group B -) and atelectasis (21,2% in group A vs. 0% in group B).
Conclusion: The protective ventilation strategy (low VT, PEEP and RM) in patients during prolonged gynecological surgery can reduce the rate of postoperative pulmonary complications such as respiratory failure and atelectasis.
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Reinius H, Borges JB, Engström J, Ahlgren O, Lennmyr F, Larsson A, Fredén F. Optimal PEEP during one-lung ventilation with capnothorax: An experimental study. Acta Anaesthesiol Scand 2019; 63:222-231. [PMID: 30132806 DOI: 10.1111/aas.13247] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 07/12/2018] [Accepted: 07/24/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND One-lung ventilation (OLV) with induced capnothorax carries the risk of severely impaired ventilation and circulation. Optimal PEEP may mitigate the physiological perturbations during these conditions. METHODS Right-sided OLV with capnothorax (16 cm H2 O) on the left side was initiated in eight anesthetized, muscle-relaxed piglets. A recruitment maneuver and a decremental PEEP titration from PEEP 20 cm H2 O to zero end-expiratory pressure (ZEEP) was performed. Regional ventilation and perfusion were studied with electrical impedance tomography and computer tomography of the chest was used. End-expiratory lung volume and hemodynamics were recorded and. RESULTS PaO2 peaked at PEEP 12 cm H2 O (49 ± 14 kPa) and decreased to 11 ± 5 kPa at ZEEP (P < 0.001). PaCO2 was 9.5 ± 1.3 kPa at 20 cm H2 O PEEP and did not change when PEEP step-wise was reduced to 12 cm H2 O PaCO2. At lower PEEP, PaCO2 increased markedly. The ventilatory driving pressure was lowest at PEEP 14 cm H2 O (19.6 ± 5.8 cm H2 O) and increased to 38.3 ± 6.1 cm H2 O at ZEEP (P < 0.001). When reducing PEEP below 12-14 cm H2 O ventilation shifted from the dependent to the nondependent regions of the ventilated lung (P = 0.003), and perfusion shifted from the ventilated to the nonventilated lung (P = 0.02). CONCLUSION Optimal PEEP was 12-18 cm H2 O and probably relates to capnothorax insufflation pressure. With suboptimal PEEP, ventilation/perfusion mismatch in the ventilated lung and redistribution of blood flow to the nonventilated lung occurred.
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Affiliation(s)
- Henrik Reinius
- Department of Surgical Sciences; Hedenstierna laboratory; Section of Anesthesiology and Intensive Care; Uppsala University; Uppsala Sweden
| | - Joao Batista Borges
- Department of Surgical Sciences; Hedenstierna laboratory; Section of Anesthesiology and Intensive Care; Uppsala University; Uppsala Sweden
- Laboratório de Pneumologia LIM-09; Disciplina de Pneumologia; Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo; São Paulo Brazil
| | - Joakim Engström
- Department of Surgical Sciences; Hedenstierna laboratory; Section of Anesthesiology and Intensive Care; Uppsala University; Uppsala Sweden
| | - Oskar Ahlgren
- Department of Surgical Sciences; Hedenstierna laboratory; Section of Anesthesiology and Intensive Care; Uppsala University; Uppsala Sweden
| | - Fredrik Lennmyr
- Department of Surgical Sciences; Hedenstierna laboratory; Section of Anesthesiology and Intensive Care; Uppsala University; Uppsala Sweden
- Department of Cardiothoracic Anesthesia; Uppsala University Hospital; Uppsala Sweden
| | - Anders Larsson
- Department of Surgical Sciences; Hedenstierna laboratory; Section of Anesthesiology and Intensive Care; Uppsala University; Uppsala Sweden
| | - Filip Fredén
- Department of Surgical Sciences; Hedenstierna laboratory; Section of Anesthesiology and Intensive Care; Uppsala University; Uppsala Sweden
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Almgren B, Wickerts CJ, Hogman M. Post–suction Recruitment Manoeuvre Restores Lung Function in Healthy, Anaesthetized Pigs. Anaesth Intensive Care 2019; 32:339-45. [PMID: 15264727 DOI: 10.1177/0310057x0403200306] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endotracheal suction can cause partial lung collapse and hypoxia and alter lung mechanics. We investigated the effects of adding a recruitment manoeuvre directly after endotracheal suction to restore lung volume in volume-controlled ventilation and pressure-controlled ventilation modes. Five anaesthetized pigs were investigated. The effects of endotracheal suction with or without a recruitment manoeuvre were compared in random order. In volume-controlled ventilation, compliance decreased after suction from 33±5 to 26±6 ml.cmH2O–1 (P<0.05), and 30 minutes later it remained decreased at 25±6 ml.cmH2O–1. Venous admixture increased after suction from 5±2 to 8±4% (P<0.05), but had recovered at 30 minutes. In pressure-controlled ventilation, compliance decreased after suction from 34±3 to 25±7 ml.cmH2O–1 (P<0.05), and 30 minutes later it remained decreased at 25±7 ml.cmH2O–1. Venous admixture increased after suction from 5±2 to 13±7% (P<0.05), and had not recovered after 30 minutes, 10±4%. When a recruitment manoeuvre was applied directly after suction, no negative side-effects were registered in volume-controlled ventilation or pressure-controlled ventilation. We conclude that the impairment of lung mechanics and gas exchange induced by endotracheal suction can be prevented by a simple post-suction recruitment manoeuvre. Further studies are needed to identify a suitable suction recruitment manoeuvre in patients with diseased lungs.
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Affiliation(s)
- B Almgren
- Department of Medical Cell Biology, Section of Integrative Physiology, Uppsala University, Uppsala, Sweden
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Chino K, Ganzberg S, Mendoza K. Office-Based Sedation/General Anesthesia for COPD Patients, Part II. Anesth Prog 2019; 66:44-51. [PMID: 30883229 PMCID: PMC6424168 DOI: 10.2344/anpr-66-02-05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 10/10/2018] [Indexed: 11/11/2022] Open
Abstract
The safe treatment of patients with chronic obstructive pulmonary disease (COPD) in dental office office-based settings can be quite complex without a current understanding of the etiology, course, severity, and current treatment modalities of the disease. The additional concerns of providing sedation and/or general anesthesia to patients with COPD in settings outside of a hospital demand thorough investigation of individual patient presentation and realistic development of planned treatment that patients suffering from this respiratory condition can tolerate. Along with other co-morbidities, such as advanced age and potential significant cardiovascular compromise, the dental practitioner providing sedation or general anesthesia must tailor any treatment plan to address multiple organ systems and mitigate risks of precipitating acute respiratory failure from inadequate pain and/or anxiety control. Part I of this article covered the epidemiology, etiology, and pathophysiology of COPD. Patient considerations in the preoperative period were also reviewed. Part II will cover which patients are acceptable for sedation/general anesthesia in the dental office-based setting as well as sedation/general anesthesia techniques that may be considered. Postoperative care will also be reviewed.
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Affiliation(s)
- Kristin Chino
- Private Practice, Anesthesia for Dentistry, Las Vegas, Nevada
| | - Steven Ganzberg
- Clinical Professor of Anesthesiology, UCLA School of Dentistry, Los Angeles, California
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Hopster K, Duffee LR, Hopster-Iversen CCS, Driessen B. Efficacy of an alveolar recruitment maneuver for improving gas exchange and pulmonary mechanics in anesthetized horses ventilated with oxygen or a helium-oxygen mixture. Am J Vet Res 2018; 79:1021-1027. [DOI: 10.2460/ajvr.79.10.1021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Fernandez-Bustamante A, Vidal Melo MF. Bedside assessment of lung aeration and stretch. Br J Anaesth 2018; 121:1001-1004. [PMID: 30336843 PMCID: PMC8604375 DOI: 10.1016/j.bja.2018.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 08/06/2018] [Accepted: 08/09/2018] [Indexed: 11/18/2022] Open
Affiliation(s)
- A Fernandez-Bustamante
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Webb Waring Center, University of Colorado School of Medicine, Aurora, CO, USA
| | - M F Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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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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Choi ES, Oh AY, In CB, Ryu JH, Jeon YT, Kim HG. Effects of recruitment manoeuvre on perioperative pulmonary complications in patients undergoing robotic assisted radical prostatectomy: A randomised single-blinded trial. PLoS One 2017; 12:e0183311. [PMID: 28877238 PMCID: PMC5587235 DOI: 10.1371/journal.pone.0183311] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 07/20/2017] [Indexed: 01/28/2023] Open
Abstract
Robotic-assisted laparoscopic radical prostatectomy (RARP) needs a steep Trendelenburg position and a relatively high CO2 insufflation pressure, and patients undergoing RARP are usually elderly. These factors make intraoperative ventilatory care difficult and increase the risk of perioperative pulmonary complications. The aim was to determine the efficacy of recruitment manoeuvre (RM) on perioperative pulmonary complications in elderly patients undergoing RARP. A total of 60 elderly patients scheduled for elective RARP were randomly allocated to two groups after induction of anaesthesia; positive end expiratory pressure (PEEP) was applied during the operation without RM in the control group (group C) and after RM in the recruitment group (group R). The total number of patients who developed intraoperative desaturation or postoperative atelectasis was significantly higher in group C compared to group R (43.3% vs. 17.8%, P = 0.034). Intraoperative respiratory mechanics, perioperative blood gas analysis, and pulmonary function testing did not show differences between the groups. Adding RM to PEEP compared to PEEP alone significantly reduced perioperative pulmonary complications in elderly patients undergoing RARP.
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Affiliation(s)
- Eun-Su Choi
- Department of Anesthesiology and Pain Medicine, Nowon Eulji Medical Center, Eulji University, Seoul, Republic of Korea
| | - Ah-Young Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Chi-Bum In
- Department of Anesthesiology and Pain Medicine, Konyang University Hospital, Daejeon, Republic of Korea
| | - Jung-Hee Ryu
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Young-Tae Jeon
- Department of Anesthesiology and Pain Medicine, Seoul National University Bundang Hospital, Seongnam, Republic of Korea
| | - Hyoung-Gyun Kim
- Department of Anesthesiology and Pain Medicine, Nowon Eulji Medical Center, Eulji University, Seoul, Republic of Korea
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Effect of Preoperative Inspiratory Muscle Training on Alveolar-Arterial Oxygen Gradients After Coronary Artery Bypass Surgery. J Cardiopulm Rehabil Prev 2017; 37:290-294. [DOI: 10.1097/hcr.0000000000000234] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Högman M. Innovative exhaled breath analysis with old breathing manoeuvres-is there a problem or an advantage? J Breath Res 2017; 11:031001. [PMID: 28660856 DOI: 10.1088/1752-7163/aa720b] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
As the field of exhaled breath research is expanding, the question that arises is can the old usual method of spirometry be used in all cases? The answer is yes for some analysation methods and definitely not for others: it all depends on the result you are looking for. Exhaled breath condensate collection can be accomplished with silent tidal breathing, but not in the analysation of the amount of exhaled particles, as they become very low during tidal breathing. There are gases that are exhalation flow dependent, e.g. nitric oxide, acetone and ethanol, that require a special breathing manoeuvre with flow control. Physiological changes of the lung, i.e. inhalation to total lung capacity or forced exhalation such as during spirometry, will affect the result of exhaled biomarkers. The standardisation of exhaled breath requires further development, and there are many aspects to consider.
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Affiliation(s)
- Marieann Högman
- Dept. of Medical Sciences, Respiratory, Allergy & Sleep Research, Uppsala University, Uppsala, Sweden
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Kachulis B, Mitrev L, Jordan D. Intraoperative anesthetic management of lung transplantation patients. Best Pract Res Clin Anaesthesiol 2017; 31:261-272. [DOI: 10.1016/j.bpa.2017.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 04/26/2017] [Indexed: 11/15/2022]
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Review of hypoxaemia in anaesthetized horses: predisposing factors, consequences and management. Vet Anaesth Analg 2017; 44:397-408. [DOI: 10.1016/j.vaa.2016.06.001] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 05/18/2016] [Accepted: 06/02/2016] [Indexed: 11/24/2022]
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[Does intraoperative lung-protective ventilation reduce postoperative pulmonary complications?]. Anaesthesist 2017; 65:573-9. [PMID: 27392439 DOI: 10.1007/s00101-016-0198-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Recent studies show that intraoperative protective ventilation is able to reduce postoperative pulmonary complications (PPC). OBJECTIVES This article provides an overview of the definition and ways to predict PPC. We present different factors that lead to ventilator-induced lung injury and explain the concepts of stress and strain as well as driving pressure. Different strategies of mechanical ventilation to avoid PPC are discussed in light of clinical evidence. MATERIALS AND METHODS The Medline database was used to selectively search for randomized controlled trials dealing with intraoperative mechanical ventilation and outcomes. RESULTS Low tidal volumes (VT) and high levels of positive end-expiratory pressure (PEEP), combined with recruitment maneuvers, are able to prevent PPC. Non-obese patients undergoing open abdominal surgery show better lung function with the use of higher PEEP levels and recruitment maneuvers, however such strategy can lead to hemodynamic impairment, while not reducing the incidence of PPC, hospital length of stay and mortality. An increase in the level of PEEP that results in an increase in driving pressure is associated with a greater risk of PPC. CONCLUSIONS The use of intraoperative VT ranging from 6 to 8 ml/kg based on ideal body weight is strongly recommended. Currently, a recommendation regarding the level of PEEP during surgery is not possible. However, a PEEP increase that leads to a rise in driving pressure should be avoided.
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Brander L, Moerer O, Hedenstierna G, Beck J, Takala J, Slutsky AS, Sinderby C. Neural control of ventilation prevents both over-distension and de-recruitment of experimentally injured lungs. Respir Physiol Neurobiol 2016; 237:57-67. [PMID: 28013057 DOI: 10.1016/j.resp.2016.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 10/25/2016] [Accepted: 12/20/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND Endogenous pulmonary reflexes may protect the lungs during mechanical ventilation. We aimed to assess integration of continuous neurally adjusted ventilatory assist (cNAVA), delivering assist in proportion to diaphragm's electrical activity during inspiration and expiration, and Hering-Breuer inflation and deflation reflexes on lung recruitment, distension, and aeration before and after acute lung injury (ALI). METHODS In 7 anesthetised rabbits with bilateral pneumothoraces, we identified adequate cNAVA level (cNAVAAL) at the plateau in peak ventilator pressure during titration procedures before (healthy lungs with endotracheal tube, [HLETT]) and after ALI (endotracheal tube [ALIETT] and during non-invasive ventilation [ALINIV]). Following titration, cNAVAAL was maintained for 5min. In 2 rabbits, procedures were repeated after vagotomy (ALIETT+VAG). In 3 rabbits delivery of assist was temporarily modulated to provide assist on inspiration only. Computed tomography was performed before intubation, before ALI, during cNAVA titration, and after maintenance at cNAVAAL. RESULTS During ALIETT and ALINIV, normally aerated lung-regions doubled and poorly aerated lung-regions decreased to less than a third (p<0.05) compared to HLETT; no over-distension was observed. Tidal volumes were<5ml/kg throughout. Removing assist during expiration resulted in lung de-recruitment during ALIETT, but not during ALINIV. During ALIETT+VAG the expiratory portion of EAdi disappeared, resulting in cyclic lung collapse and recruitment. CONCLUSIONS When using cNAVA in ALI, vagally mediated reflexes regulated lung recruitment preventing both lung over-distension and atelectasis. During non-invasive cNAVA the upper airway muscles play a role in preventing atelectasis. Future studies should be performed to compare these findings with conventional lung-protective approaches.
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Affiliation(s)
- Lukas Brander
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada; Department of Intensive Care Medicine, Cantonal Hospital of Lucerne, Switzerland.
| | - Onnen Moerer
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada; Department of Anaesthesiology, Emergency and Critical Care Medicine, University of Göttingen, Germany
| | - Göran Hedenstierna
- Department of Medical Sciences, Clinical Physiology, University of Uppsala, Uppsala, Sweden
| | - Jennifer Beck
- Department of Pediatrics, University of Toronto, Toronto, Canada; Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada; Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St. Michael's Hospital, Toronto, Canada
| | - Jukka Takala
- Department of Intensive Care Medicine, Bern University Hospital - Inselspital, and University of Bern, Switzerland
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada; Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada
| | - Christer Sinderby
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada; Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada; Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St. Michael's Hospital, Toronto, Canada
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Affiliation(s)
- Göran Hedenstierna
- Hedenstierna Laboratory, Department of Medical Sciences, Clinical Physiology, Uppsala University Hospital, Sweden
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Preoxygenation and intraoperative ventilation strategies in obese patients: a comprehensive review. Curr Opin Anaesthesiol 2016; 29:109-18. [PMID: 26545146 DOI: 10.1097/aco.0000000000000267] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Obesity along with its pathophysiological changes increases risk of intraoperative and perioperative respiratory complications. The aim of this review is to highlight recent updates in preoxygenation techniques and intraoperative ventilation strategies in obese patients to optimize gas exchange and pulmonary mechanics and reduce pulmonary complications. RECENT FINDINGS There is no gold standard in preoxygenation or intraoperative ventilatory management protocol for obese patients. Preoxygenation in head up or sitting position has been shown to be superior to supine position. Apneic oxygenation and use of continuous positive airway pressure increases safe apnea duration. Recent evidence encourages the intraoperative use of low tidal volume to improve oxygenation and lung compliance without adverse effects. Contrary to nonobese patients, some studies have reported the beneficial effect of recruitment maneuvers and positive end-expiratory pressure in obese patients. No difference has been observed between volume controlled and pressure controlled ventilation. SUMMARY The ideal ventilatory plan for obese patients is indeterminate. A multimodal preoxygenation and intraoperative ventilation plan is helpful in obese patients to reduce perioperative respiratory complications. More studies are needed to identify the role of low tidal volume, positive end-expiratory pressure, and recruitment maneuvers in obese patients undergoing general anesthesia.
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Ahn S, Byun SH, Chang H, Koo YB, Kim JC. Effect of recruitment maneuver on arterial oxygenation in patients undergoing robot-assisted laparoscopic prostatectomy with intraoperative 15 cmH 2O positive end expiratory pressure. Korean J Anesthesiol 2016; 69:592-598. [PMID: 27924200 PMCID: PMC5133231 DOI: 10.4097/kjae.2016.69.6.592] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 07/30/2016] [Accepted: 08/02/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND This randomized, controlled study was designed to compare the effects of recruitment maneuvers (RMs) with a 15 cmH2O positive end-expiratory pressure (PEEP) on the systemic oxygenation and lung compliance of patients with healthy lungs following robot-assisted laparoscopic prostatectomy (RALP). METHODS Sixty patients undergoing a RALP with an intraoperative 15 cmH2O PEEP were randomly allocated to an RM or a Control group. The patients in the RM group received a single RM through the application of a continuous positive airway pressure of 40 cmH2O for 40 s 15 min after being placed in the Trendelenburg position. The arterial oxygen tension (PaO2, primary endpoint) and the pulmonary dynamic and static compliances (secondary endpoints) were measured 10 min after the anesthetic induction (T1), 10 min after establishment of the pneumoperitoneum (T2), 10 min after establishment of the Trendelenburg position (T3), 10 min after the RM (T4), 60 min after the RM (T5), and 10 min after deflation of the pneumoperitoneum in the supine position (T6). RESULTS The intergroup comparisons of the PaO2 showed significantly higher values in the RM group than in the Control group at T4 and T5 (193 ± 35 mmHg vs. 219 ± 33 mmHg, P = 0.015, 188 ± 41 mmHg vs. 214 ± 42 mmHg, P = 0.005, respectively). However, the PaO2 at T6 was similar in the two groups (211 ± 39 mmHg vs. 224 ± 41 mmHg, P = 0.442). Moreover, there were no statistical differences between the groups in the dynamic and static compliances of the lungs at any time point. CONCLUSIONS The arterial oxygenation of the patients with a healthy lung function who had undergone a RALP with intraoperative 15 cmH2O PEEP was improved by a single RM. However, this benefit did not last long, and it did not lead to an amelioration of the lung mechanics.
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Affiliation(s)
- Sowoon Ahn
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Sung Hye Byun
- Department of Anesthesiology and Pain Medicine, School of Medicine, Catholic University of Daegu, Daegu, Korea
| | - Haeyoon Chang
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Young Bin Koo
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jong Chan Kim
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Freitas CRDC, Malbouisson LMS, Benicio A, Negri EM, Bini FM, Massoco CO, Otsuki DA, Melo MFV, Carmona MJC. Lung Perfusion and Ventilation During Cardiopulmonary Bypass Reduces Early Structural Damage to Pulmonary Parenchyma. Anesth Analg 2016; 122:943-52. [PMID: 26991612 DOI: 10.1213/ane.0000000000001118] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND It is unclear whether maintaining pulmonary perfusion and ventilation during cardiopulmonary bypass (CPB) reduces pulmonary inflammatory tissue injury compared with standard CPB where the lungs are not ventilated and are minimally perfused. In this study, we tested the hypothesis that maintenance of lung perfusion and ventilation during CPB decreases regional lung inflammation, which may result in less pulmonary structural damage. METHODS Twenty-seven pigs were randomly allocated into a control group only submitted to sternotomy (n = 8), a standard CPB group (n = 9), or a lung perfusion group (n = 10), in which lung perfusion and ventilation were maintained during CPB. Hemodynamics, gas exchanges, respiratory mechanics, and systemic interleukins (ILs) were determined at baseline (T0), at the end of 90 minutes of CPB (T90), and 180 minutes after CPB (T180). Bronchoalveolar lavage (BAL) ILs were obtained at T0 and T180. Dorsal and ventral left lung tissue samples were examined for optical and electron microscopy. RESULTS At T90, there was a transient reduction in PaO2/FIO2 in CPB (126 ± 64 mm Hg) compared with the control and lung perfusion groups (296 ± 46 and 244 ± 57 mm Hg; P < 0.001), returning to baseline at T180. Serum ILs were not different among the groups throughout the study, whereas there were significant increases in BAL IL-6 (P < 0.001), IL-8 (P < 0.001), and IL-10 (P < 0.001) in both CPB and lung perfusion groups compared with the control group. Polymorphonuclear counts within the lung tissue were smaller in the lung perfusion group than in the CPB group (P = 0.006). Electron microscopy demonstrated extrusion of surfactant vesicles into the alveolar spaces and thickening of the alveolar septa in the CPB group, whereas alveolar and capillary histoarchitecture was better preserved in the lung perfusion group. CONCLUSIONS Maintenance of lung perfusion and ventilation during CPB attenuated early histologic signs of pulmonary inflammation and injury compared with standard CPB. Although increased compared with control animals, there were no differences in serum or BAL IL in animals receiving lung ventilation and perfusion during CPB compared with standard CPB.
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Affiliation(s)
- Claudia Regina da Costa Freitas
- From the *Discipline of Anesthesiology, LIM 8 - Laboratory of Anesthesiology, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil; †Department of Cardiothoracic Surgery, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; ‡Department of Pathology, Faculdade de Medicina da Universidade de Sao Paulo, São Paulo, Brazil; §Department of Veterinary Pathology, Faculdade de Medicina Veterinária da Universidade de Sao Paulo, São Paulo, Brazil; and ‖Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
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