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Min JY, Hyung SW, Jeon JP, Chung MY, Kim CJ, Kim YH. A stepwise lung recruitment maneuver using I-gel can improve respiratory parameters: A prospective observational study. Medicine (Baltimore) 2024; 103:e38718. [PMID: 38941413 DOI: 10.1097/md.0000000000038718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2024] Open
Abstract
I-gel has been used in various clinical situations. The study investigated alterations in respiratory parameters following a stepwise lung recruitment maneuver (LRM) using the i-gel. The research involved 60 patients classified as American Society of Anesthesiologists class I-II, aged 30 to 75 years, undergoing elective urologic surgery. Various respiratory parameters, including lung compliance, airway resistance, leak volume, airway pressure, and oxygen reserve index, were recorded at different time points: before LRM, immediately after LRM, and at 5, 15, and 30 minutes after LRM, as well as at the end of the surgery. The primary outcome was to assess an improvement in lung compliance. Dynamic lung compliance (mean ± SD) was significantly increased from 49.2 ± 1.8 to 70.15 ± 3.2 mL/cmH2O (P < .05) after LRM. Static lung compliance (mean ± SD) was increased considerably from 52.4 ± 1.7 to 65.0 ± 2.5 mL/cmH2O (P < .05) after the LRM. Both parameters maintained a statistically significant increased status for a certain period compared to baseline despite a decreased degree of increment. Airway resistance (mean ± SD) was significantly reduced after the LRM from 12.05 ± 0.56 to 10.41 ± 0.64 L/cmH2O/s (P < .05). Stepwise LRM using i-gel may improve lung compliance and airway resistance. Repeated procedures could lead to prolonged improvements in respiratory parameters.
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Affiliation(s)
- Ji Young Min
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sung Woo Hyung
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joon Pyo Jeon
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Mee Young Chung
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Chang Jae Kim
- Department of Anesthesiology and Pain Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yoon Hee Kim
- Department of Anesthesiology and Pain Medicine, Chungnam National Hospital, College of Medicine, The Chungnam National University of Korea, Daejeon, Republic of Korea
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Savino S, Gaetano S. Functional Phenotyping: A New Role for Electrical Impedance Tomography. Am J Respir Crit Care Med 2024; 209:1291-1292. [PMID: 38457807 PMCID: PMC11146560 DOI: 10.1164/rccm.202402-0328ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 03/06/2024] [Indexed: 03/10/2024] Open
Affiliation(s)
- Spadaro Savino
- Department of Translational Medicine University of Ferrara Ferrara, Italy
| | - Scaramuzzo Gaetano
- Department of Translational Medicine University of Ferrara Ferrara, Italy
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Qin YJ, Zhang YQ, Chen Q, Wang Y, Li SY. Effect of high-frequency oscillation on reduction of atelectasis in perioperative patients: a prospective randomized controlled study. Ann Med 2023; 55:2272720. [PMID: 37874665 PMCID: PMC10836273 DOI: 10.1080/07853890.2023.2272720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 10/12/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Atelectasis affects approximately 90% of anaesthetized patients, with laparoscopic surgery and pneumoperitoneum reported to exacerbate this condition. High-frequency oscillation therapy applies continuous positive pressure pulses to oscillate the airway, creating a pressure difference in small airways obstructed by secretions. This process helps reduce peak airway pressure, open small airways, and decrease atelectasis incidence, while also facilitating respiratory tract clearance. This study examines the efficacy of high-frequency oscillation on reduction of atelectasis in laparoscopic cholecystectomy (LC) patients under general anaesthesia, evaluated using lung ultrasound. METHODS Sixty-four patients undergoing laparoscopic cholecystectomy were randomly divided into a control group and a high-frequency oscillation (HFO) group. Both groups underwent total intravenous anaesthesia under invasive arterial monitoring. The HFO group received a 10-minute continuous high-frequency oscillation therapy during surgery, while the control group received no intervention. Lung ultrasound evaluations were performed three times: five minutes post-intubation (T1), at the end of the surgery (T2), and before leaving the Post-Anaesthesia Care Unit (PACU; T3). Blood gas analysis was performed twice: prior to induction with no oxygen supply and before PACU discharge (oxygen supply off). RESULTS The HFO group displayed a significantly lower incidence of atelectasis at T3 (57.5% vs. 90.3%, OR 6.88, 95%CI (1.74 to 27.24)) compared to the control group. Moreover, the HFO group's PaO2 levels remained consistent with baseline levels before PACU discharge, unlike the control group. Although there was no significant difference in LUS scores between the groups at T1 (8.56 ± 0.15 vs. 8.19 ± 0.18, p = 0.1090), the HFO group had considerably lower scores at T2 (13.41 ± 0.17 vs.7.59 ± 0.17, p < 0.01) and T3 (13.72 ± 0.14 vs.7.25 ± 0.21, p < 0.01). CONCLUSION Our study indicates that high-frequency oscillation effectively reduces atelectasis in patients undergoing laparoscopic cholecystectomy. Additionally, it can mitigate the decline in oxygen partial pressure associated with atelectasis.
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Affiliation(s)
- Yuan-jun Qin
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, China
| | - Yun-qian Zhang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, China
| | - Qi Chen
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, China
| | - Yan Wang
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, China
| | - Si-yuan Li
- Department of Anesthesiology and Surgical Intensive Care Unit, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, China
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Shu B, Zhang Y, Ren Q, Zheng X, Zhang Y, Liu Q, Li S, Chen J, Chen Y, Duan G, Huang H. Optimal positive end-expiratory pressure titration of intraoperative mechanical ventilation in different operative positions of female patients under general anesthesia. Heliyon 2023; 9:e20552. [PMID: 37822628 PMCID: PMC10562915 DOI: 10.1016/j.heliyon.2023.e20552] [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: 02/06/2023] [Revised: 09/21/2023] [Accepted: 09/28/2023] [Indexed: 10/13/2023] Open
Abstract
Objective This study aimed to compare the effectiveness and safety of different titrated methods used to determine individual positive end-expiratory pressure (PEEP) for intraoperative mechanical ventilation in female patients undergoing general anesthesia in different operative positions, and provide reference ranges of optimal PEEP values based on the titration. Methods A total of 123 female patients who underwent elective open abdominal surgery under general anesthesia were included in this study. After endotracheal intubation, patients' body position was adjusted to the supine position, Trendelenburg positions at 10° and 20° respectively. PEEP was titrated from 20 cmH2O to 4 cmH2O, decreasing by 2 cmH2O every 1 min. Electrical impedance tomography (EIT), hemodynamic and respiratory mechanics parameters were continuously monitored and recorded. Optimal PEEP values and reference ranges were respectively calculated based on optimal EIT parameters, mean arterial pressure (MAP), and lung dynamic compliance (Cdyn). Results EIT-guided optimal PEEP was found to have higher values than those of the MAP-guided and Cdyn-guided methods for all three body positions (P < 0.001), and it was observed to more significantly inhibit hemodynamics (P < 0.05). The variable coefficients of EIT-guided optimal PEEP values were smaller than those of the other two methods, and this technique could provide better ventilation uniformity for dorsal/ventral lung fields and better balance for pulmonary atelectasis/collapse. The 95% reference ranges of EIT-guided optimal PEEP values were 4.6-13.8 cmH2O, 7.0-15.0 cmH2O and 8.6-17.0 cmH2O for the supine position, Trendelenburg 10°, and Trendelenburg 20° positions, respectively. Conclusion EIT-guided optimal PEEP titration was found to be a superior method for lung protective ventilation in different operative positions under general anesthesia. The calculated reference ranges of PEEP values based on the EIT-guided method can be used as a reference for intraoperative mechanical ventilation.
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Affiliation(s)
- Bin Shu
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Yang Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Qian Ren
- Department of Anesthesiology, Chongqing University Three Gorges Hospital, Chongqing, 404000, China
| | - Xuemei Zheng
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Yamei Zhang
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Qi Liu
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Shiqi Li
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Jie Chen
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Yuanjing Chen
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - Guangyou Duan
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
| | - He Huang
- Department of Anesthesiology, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, 400010, China
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Xiao L, Yu K, Yang JJ, Liu WT, Liu L, Miao HH, Li TZ. Effect of individualized positive end-expiratory pressure based on electrical impedance tomography guidance on pulmonary ventilation distribution in patients who receive abdominal thermal perfusion chemotherapy. Front Med (Lausanne) 2023; 10:1198720. [PMID: 37731718 PMCID: PMC10507689 DOI: 10.3389/fmed.2023.1198720] [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: 04/02/2023] [Accepted: 08/15/2023] [Indexed: 09/22/2023] Open
Abstract
Background Electrical impedance tomography (EIT) has been shown to be useful in guiding individual positive end-expiratory pressure titration for patients with mechanical ventilation. However, the appropriate positive end-expiratory pressure (PEEP) level and whether the individualized PEEP needs to be adjusted during long-term surgery (>6 h) were unknown. Meanwhile, the effect of individualized PEEP on the distribution of pulmonary ventilation in patients who receive abdominal thermoperfusion chemotherapy is unknown. The primary aim of this study was to observe the effect of EIT-guided PEEP on the distribution of pulmonary ventilation in patients undergoing cytoreductive surgery (CRS) combined with hot intraperitoneal chemotherapy (HIPEC). The secondary aim was to analyze their effect on postoperative pulmonary complications. Methods A total of 48 patients were recruited and randomly divided into two groups, with 24 patients in each group. For the control group (group A), PEEP was set at 5 cm H2O, while in the EIT group (group B), individual PEEP was titrated and adjusted every 2 h with EIT guidance. Ventilation distribution, respiratory/circulation parameters, and PPC incidence were compared between the two groups. Results The average individualized PEEP was 10.3 ± 1.5 cm H2O, 10.2 ± 1.6 cm H2O, 10.1 ± 1.8 cm H2O, and 9.7 ± 2.1 cm H2O at 5 min, 2 h, 4 h, and 6 h after tracheal intubation during CRS + HIPEC. Individualized PEEP was correlated with ventilation distribution in the regions of interest (ROI) 1 and ROI 3 at 4 h mechanical ventilation and ROI 1 at 6 h mechanical ventilation. The ventilation distribution under individualized PEEP was back-shifted for 6 h but moved to the control group's ventral side under PEEP 5 cm H2O. The respiratory and circulatory function indicators were both acceptable either under individualized PEEP or PEEP 5 cm H2O. The incidence of total PPCs was significantly lower under individualized PEEP (66.7%) than PEEP 5 cm H2O (37.5%) for patients with CRS + HIPEC. Conclusion The appropriate individualized PEEP was stable at approximately 10 cm H2O during 6 h for patients with CRS + HIPEC, along with better ventilation distribution and a lower total PPC incidence than the fixed PEEP of 5 cm H2O.Clinical trial registration: identifier ChiCTR1900023897.
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Affiliation(s)
- Li Xiao
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Kang Yu
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Jiao-Jiao Yang
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Wen-Tao Liu
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Lei Liu
- Department of Science and Technology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Hui-Hui Miao
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Tian-Zuo Li
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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Li X, Liu H, Wang J, Ni ZL, Liu ZX, Jiao JL, Han Y, Cao JL. Individualized Positive End-expiratory Pressure on Postoperative Atelectasis in Patients with Obesity: A Randomized Controlled Clinical Trial. Anesthesiology 2023; 139:262-273. [PMID: 37440205 DOI: 10.1097/aln.0000000000004603] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
BACKGROUND Individualized positive end-expiratory pressure (PEEP) guided by dynamic compliance improves oxygenation and reduces postoperative atelectasis in nonobese patients. The authors hypothesized that dynamic compliance-guided PEEP could also reduce postoperative atelectasis in patients undergoing bariatric surgery. METHODS Patients scheduled to undergo laparoscopic bariatric surgery were eligible. Dynamic compliance-guided PEEP titration was conducted in all patients using a downward approach. A recruitment maneuver (PEEP from 10 to 25 cm H2O at 5-cm H2O step every 30 s, with 15-cm H2O driving pressure) was conducted both before and after the titration. Patients were then randomized (1:1) to undergo surgery under dynamic compliance-guided PEEP (PEEP with highest dynamic compliance plus 2 cm H2O) or PEEP of 8 cm H2O. The primary outcome was postoperative atelectasis, as assessed with computed tomography at 60 to 90 min after extubation, and expressed as percentage to total lung tissue volume. Secondary outcomes included Pao2/inspiratory oxygen fraction (Fio2) and postoperative pulmonary complications. RESULTS Forty patients (mean ± SD; 28 ± 7 yr of age; 25 females; average body mass index, 41.0 ± 4.7 kg/m2) were enrolled. Median PEEP with highest dynamic compliance during titration was 15 cm H2O (interquartile range, 13 to 17; range, 8 to 19) in the entire sample of 40 patients. The primary outcome of postoperative atelectasis (available in 19 patients in each group) was 13.1 ± 5.3% and 9.5 ± 4.3% in the PEEP of 8 cm H2O and dynamic compliance-guided PEEP groups, respectively (intergroup difference, 3.7%; 95% CI, 0.5 to 6.8%; P = 0.025). Pao2/Fio2 at 1 h after pneumoperitoneum was higher in the dynamic compliance-guided PEEP group (397 vs. 337 mmHg; group difference, 60; 95% CI, 9 to 111; P = 0.017) but did not differ between the two groups 30 min after extubation (359 vs. 375 mmHg; group difference, -17; 95% CI, -53 to 21; P = 0.183). The incidence of postoperative pulmonary complications was 4 of 20 in both groups. CONCLUSIONS Postoperative atelectasis was lower in patients undergoing laparoscopic bariatric surgery under dynamic compliance-guided PEEP versus PEEP of 8 cm H2O. Postoperative Pao2/Fio2 did not differ between the two groups. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Xiang Li
- Department of Anesthesiology, Eye & Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China; Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - He Liu
- Department of Anesthesiology, Huzhou Central Hospital, Huzhou, China
| | - Jun Wang
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhi-Lin Ni
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China; Department of Anesthesiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Zhong-Xiao Liu
- Department of Radiology, Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Jia-Li Jiao
- Institute of Translational Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuan Han
- Department of Anesthesiology, Eye & Ear, Nose, and Throat Hospital of Fudan University, Shanghai, China; Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China
| | - Jun-Li Cao
- Jiangsu Province Key Laboratory of Anesthesiology, Xuzhou Medical University, Xuzhou, China.; NMPA Key Laboratory for Research and Evaluation of Narcotic and Psychotropic Drugs, Xuzhou Medical University, Xuzhou, China
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Fogagnolo A, Spadaro S, Karbing DS, Scaramuzzo G, Mari M, Guirrini S, Ragazzi R, Al-Husinat L, Greco P, Rees SE, Volta CA. Effect of expiratory flow limitation on ventilation/perfusion mismatch and perioperative lung function during pneumoperitoneum and Trendelenburg position. Minerva Anestesiol 2023; 89:733-743. [PMID: 36748283 DOI: 10.23736/s0375-9393.22.17006-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Laparoscopic surgery and Trendelenburg position may affect the respiratory function and alter the gas exchange. Further the reduction of the lung volumes may contribute to the development of expiratory flow limitation (EFL). The latter is associated with an increased risk of postoperative pulmonary complications. Our aim was to investigate the incidence of EFL and to evaluate its effect on pulmonary function and intraoperative V/Q mismatch. METHODS This is a prospective study on patients undergoing elective laparoscopic gynecological surgery. We evaluated respiratory mechanics, V/Q mismatch and presence of EFL after anesthesia induction, during pneumoperitoneum and Trendelenburg position and at the end of surgery. Intraoperative gas exchange and hemodynamic were also recorded. Clinical data were collected until seven days after surgery to evaluate the onset of pulmonary postoperative complications (PPCs). RESULTS Among the 66 patients enrolled, 25/66 (38%) exhibited EFL during surgery, of whom 10/66 (15%) after anesthesia induction, and the remaining 15 patients after pneumoperitoneum and Trendelenburg position. Median PEEP able to reverse flow limitation was 7 [7-10] cmH2O after anesthesia induction and 9 [8-15] cmH2O after pneumoperitoneum and Trendelenburg position. Patients with EFL had significantly higher shunt (17 [2-25] vs. 9 [1-19]; P=0.05), low V̇/Q̇ (27 [20-70] vs. 15 [10-22]; P=0.05) and high V̇/Q̇ (10 [7-14] vs. 6 [4-7]; P=0.024). At the end of surgery, only high V/Q was significantly higher in EFL patients. Further, they exhibited higher incidence of postoperative pulmonary complication (48% (12/25) vs. 15% (6/41), P=0.005), hypoxemia and hypercapnia (80% [20/25] vs. 32% [13/41]; P<0.001). CONCLUSIONS Expiratory flow limitation is a common phenomenon during gynecological laparoscopic surgery associated with worsen gas exchange, increased V/Q mismatch and altered lung mechanics. Our study showed that patients experiencing EFL during surgery showed a higher risk for PPCs.
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Affiliation(s)
| | - Savino Spadaro
- Anesthesia and Intensive Care Unit, AOU Sant'Anna, Ferrara, Italy -
- Department of Translational Medicine and for Romagna, University of Ferrara, AOU Ferrara, Ferrara, Italy
| | - Dan S Karbing
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Gaetano Scaramuzzo
- Anesthesia and Intensive Care Unit, AOU Sant'Anna, Ferrara, Italy
- Department of Translational Medicine and for Romagna, University of Ferrara, AOU Ferrara, Ferrara, Italy
| | - Matilde Mari
- Department of Translational Medicine and for Romagna, University of Ferrara, AOU Ferrara, Ferrara, Italy
| | - Silvia Guirrini
- Department of Translational Medicine and for Romagna, University of Ferrara, AOU Ferrara, Ferrara, Italy
| | - Riccardo Ragazzi
- Anesthesia and Intensive Care Unit, AOU Sant'Anna, Ferrara, Italy
- Department of Translational Medicine and for Romagna, University of Ferrara, AOU Ferrara, Ferrara, Italy
| | - Lou'i Al-Husinat
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid, Jordan
| | - Pantaleo Greco
- Section of Obstetrics and Gynecology, Department of Surgical Sciences, AOU Ferrara, Ferrara, Italy
| | - Stephen E Rees
- Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Carlo A Volta
- Anesthesia and Intensive Care Unit, AOU Sant'Anna, Ferrara, Italy
- Department of Translational Medicine and for Romagna, University of Ferrara, AOU Ferrara, Ferrara, Italy
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Cheng M, Ni L, Huang L, Zhou Y, Wang K. Effect of positive end-expiratory pressure on pulmonary compliance and pulmonary complications in patients undergoing robot-assisted laparoscopic radical prostatectomy: a randomized control trial. BMC Anesthesiol 2022; 22:347. [DOI: 10.1186/s12871-022-01869-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 10/18/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
To observe the effects of different positive end-expiratory pressure (PEEP) ventilation strategies on pulmonary compliance and complications in patients undergoing robotic-assisted laparoscopic prostate surgery.
Methods
A total of 120 patients with the American Society of Anesthesiologists Physical Status Class I or II who underwent elective robotic-assisted laparoscopic prostatectomy were enrolled. We randomized the patients divided into divided into three groups of 40 patients each: PEEP0, PEEP5, or PEEP10. Master Anesthetist used volume control ventilation intraoperatively with an intraoperative deep muscle relaxation strategy. Respiratory mechanics indexes were recorded at six time-points: 10 mimuts after anaesthesia induction, immediately after pneumoperitoneum establishment, 30 min, 60 min, 90 min, and at the end of pneumoperitoneum. Arterial blood gas analysis and oxygenation index calculation were performed 10 mimuts after anaesthesia induction, 60 mimuts after pneumoperitoneum, and after tracheal extubation. Postoperative pulmonary complications were also recorded.
Results
After pneumoperitoneum, peak inspiratory pressure (Ppeak), plateau pressure (Pplat), mean pressure (Pmean), driving pressure (ΔP), and airway resistance (Raw) increased significantly, and pulmonary compliance (Crs) decreased, persisting during pneumoperitoneum in all groups. Between immediately after pneumoperitoneum establishment, 30 min, 60 min, and 90 min, pulmonary compliance in the 10cmH2OPEEP group was higher than in the 5cmH2OPEEP (P < 0.05) and 0cmH2OPEEP groups(P < 0.05). The driving pressure (ΔP) immediately after pneumoperitoneum establishment, at 30 min, 60 min, and 90 min in the 10cmH2OPEEP group was lower than in the 5cmH2OPEEP (P < 0.05) and 0cmH2OPEEP groups (P < 0.05). Sixty min after pneumoperitoneum and tracheal extubation, the PaCO2 did not differ significantly among the three groups (P > 0.05). The oxygenation index (PaO2/FiO2) was higher in the PEEP5 group than in the PEEP0 and PEEP10 groups 60 min after pneumoperitoneum and after tracheal extubation, with a statistically significant difference (P < 0.05). In postoperative pulmonary complications, the incidence of atelectasis was higher in the PEEP0 group than in the PEEP5 and PEEP10 groups, with a statistically significant difference (p < 0.05).
Conclusion
The use of PEEP at 5cmH2O during RARP increases lung compliance, improves intraoperative oxygenation index and reduces postoperative atelectasis.
Trial registration
This study was registered in the China Clinical Trials Registry on May 30, 2020 (Registration No. ChiCTR2000033380).
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Peták F, Fodor GH, Schranc Á, Südy R, Balogh ÁL, Babik B, Dos Santos Rocha A, Bayat S, Bizzotto D, Dellacà RL, Habre W. Expiratory high-frequency percussive ventilation: a novel concept for improving gas exchange. Respir Res 2022; 23:283. [PMID: 36243752 PMCID: PMC9569091 DOI: 10.1186/s12931-022-02215-2] [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: 06/02/2022] [Accepted: 10/06/2022] [Indexed: 11/25/2022] Open
Abstract
Background Although high-frequency percussive ventilation (HFPV) improves gas exchange, concerns remain about tissue overdistension caused by the oscillations and consequent lung damage. We compared a modified percussive ventilation modality created by superimposing high-frequency oscillations to the conventional ventilation waveform during expiration only (eHFPV) with conventional mechanical ventilation (CMV) and standard HFPV. Methods Hypoxia and hypercapnia were induced by decreasing the frequency of CMV in New Zealand White rabbits (n = 10). Following steady-state CMV periods, percussive modalities with oscillations randomly introduced to the entire breathing cycle (HFPV) or to the expiratory phase alone (eHFPV) with varying amplitudes (2 or 4 cmH2O) and frequencies were used (5 or 10 Hz). The arterial partial pressures of oxygen (PaO2) and carbon dioxide (PaCO2) were determined. Volumetric capnography was used to evaluate the ventilation dead space fraction, phase 2 slope, and minute elimination of CO2. Respiratory mechanics were characterized by forced oscillations. Results The use of eHFPV with 5 Hz superimposed oscillation frequency and an amplitude of 4 cmH2O enhanced gas exchange similar to those observed after HFPV. These improvements in PaO2 (47.3 ± 5.5 vs. 58.6 ± 7.2 mmHg) and PaCO2 (54.7 ± 2.3 vs. 50.1 ± 2.9 mmHg) were associated with lower ventilation dead space and capnogram phase 2 slope, as well as enhanced minute CO2 elimination without altering respiratory mechanics. Conclusions These findings demonstrated improved gas exchange using eHFPV as a novel mechanical ventilation modality that combines the benefits of conventional and small-amplitude high-frequency oscillatory ventilation, owing to improved longitudinal gas transport rather than increased lung surface area available for gas exchange. Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-02215-2.
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Affiliation(s)
- Ferenc Peták
- Department of Medical Physics and Informatics, University of Szeged, 9, Korányi fasor, Szeged, 6720, Hungary.
| | - Gergely H Fodor
- Department of Medical Physics and Informatics, University of Szeged, 9, Korányi fasor, Szeged, 6720, Hungary
| | - Álmos Schranc
- Department of Medical Physics and Informatics, University of Szeged, 9, Korányi fasor, Szeged, 6720, Hungary
| | - Roberta Südy
- Department of Medical Physics and Informatics, University of Szeged, 9, Korányi fasor, Szeged, 6720, Hungary.,Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - Ádám L Balogh
- Unit for Anaesthesiological Investigations, Department of Acute Medicine, University of Geneva, Geneva, Switzerland
| | - Barna Babik
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
| | - André Dos Santos Rocha
- Unit for Anaesthesiological Investigations, Department of Acute Medicine, University of Geneva, Geneva, Switzerland
| | - Sam Bayat
- Univ. Grenoble Alpes, Inserm UA07 STROBE Laboratory & Department of Pneumology and Clinical Physiology, Grenoble University Hospital, Grenoble, France
| | - Davide Bizzotto
- Dipartimento Di Elettronica, Informazione E Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Raffaele L Dellacà
- Dipartimento Di Elettronica, Informazione E Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Walid Habre
- Unit for Anaesthesiological Investigations, Department of Acute Medicine, University of Geneva, Geneva, Switzerland.,Paediatric Anaesthesia Unit, Department of Acute Medicine, University Hospitals of Geneva, Geneva, Switzerland
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10
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Rauseo M, Spinelli E, Sella N, Slobod D, Spadaro S, Longhini F, Giarratano A, Gilda C, Mauri T, Navalesi P. Expert opinion document: "Electrical impedance tomography: applications from the intensive care unit and beyond". JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:28. [PMID: 37386674 DOI: 10.1186/s44158-022-00055-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/01/2022] [Indexed: 07/01/2023]
Abstract
Mechanical ventilation is a life-saving technology, but it can also inadvertently induce lung injury and increase morbidity and mortality. Currently, there is no easy method of assessing the impact that ventilator settings have on the degree of lung inssflation. Computed tomography (CT), the gold standard for visually monitoring lung function, can provide detailed regional information of the lung. Unfortunately, it necessitates moving critically ill patients to a special diagnostic room and involves exposure to radiation. A technique introduced in the 1980s, electrical impedance tomography (EIT) can non-invasively provide similar monitoring of lung function. However, while CT provides information on the air content, EIT monitors ventilation-related changes of lung volume and changes of end expiratory lung volume (EELV). Over the past several decades, EIT has moved from the research lab to commercially available devices that are used at the bedside. Being complementary to well-established radiological techniques and conventional pulmonary monitoring, EIT can be used to continuously visualize the lung function at the bedside and to instantly assess the effects of therapeutic maneuvers on regional ventilation distribution. EIT provides a means of visualizing the regional distribution of ventilation and changes of lung volume. This ability is particularly useful when therapy changes are intended to achieve a more homogenous gas distribution in mechanically ventilated patients. Besides the unique information provided by EIT, its convenience and safety contribute to the increasing perception expressed by various authors that EIT has the potential to be used as a valuable tool for optimizing PEEP and other ventilator settings, either in the operative room and in the intensive care unit. The effects of various therapeutic interventions and applications on ventilation distribution have already been assessed with the help of EIT, and this document gives an overview of the literature that has been published in this context.
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Affiliation(s)
- Michela Rauseo
- Department of Anesthesia and Intensive Care Medicine, University of Foggia, Policlinico Riuniti di Foggia, Foggia, Italy.
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico Milan, Milano, Italy
| | - Nicolò Sella
- Instiute of Anesthesia and Intensive Care, Padua University Hospital, Padova, Italy
| | - Douglas Slobod
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico Milan, Milano, Italy
- Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada
| | - Savino Spadaro
- Anesthesia and Intensive Care Unit, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care Unit, Department of Medical and Surgical Sciences, "Magna Graecia" University, "Mater Domini" University Hospital, Catanzaro, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral Science (Di.Chir.On.S.), Section of Anaesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Cinnella Gilda
- Department of Anesthesia and Intensive Care Medicine, University of Foggia, Policlinico Riuniti di Foggia, Foggia, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico Milan, Milano, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Paolo Navalesi
- Instiute of Anesthesia and Intensive Care, Padua University Hospital, Padova, Italy
- Department of Medicine - DIMED, University of Padua, Padova, Italy
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11
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Patel B, Mumby S, Johnson N, Falaschetti E, Hansen J, Adcock I, McAuley D, Takata M, Karbing DS, Jabaudon M, Schellengowski P, Rees SE. Decision support system to evaluate ventilation in the acute respiratory distress syndrome (DeVENT study)-trial protocol. Trials 2022; 23:47. [PMID: 35039050 PMCID: PMC8762446 DOI: 10.1186/s13063-021-05967-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/23/2021] [Indexed: 12/16/2022] Open
Abstract
Background The acute respiratory distress syndrome (ARDS) occurs in response to a variety of insults, and mechanical ventilation is life-saving in this setting, but ventilator-induced lung injury can also contribute to the morbidity and mortality in the condition. The Beacon Caresystem is a model-based bedside decision support system using mathematical models tuned to the individual patient’s physiology to advise on appropriate ventilator settings. Personalised approaches using individual patient description may be particularly advantageous in complex patients, including those who are difficult to mechanically ventilate and wean, in particular ARDS. Methods We will conduct a multi-centre international randomised, controlled, allocation concealed, open, pragmatic clinical trial to compare mechanical ventilation in ARDS patients following application of the Beacon Caresystem to that of standard routine care to investigate whether use of the system results in a reduction in driving pressure across all severities and phases of ARDS. Discussion Despite 20 years of clinical trial data showing significant improvements in ARDS mortality through mitigation of ventilator-induced lung injury, there remains a gap in its personalised application at the bedside. Importantly, the protective effects of higher positive end-expiratory pressure (PEEP) were noted only when there were associated decreases in driving pressure. Hence, the pressures set on the ventilator should be determined by the diseased lungs’ pressure-volume relationship which is often unknown or difficult to determine. Knowledge of extent of recruitable lung could improve the ventilator driving pressure. Hence, personalised management demands the application of mechanical ventilation according to the physiological state of the diseased lung at that time. Hence, there is significant rationale for the development of point-of-care clinical decision support systems which help personalise ventilatory strategy according to the current physiology. Furthermore, the potential for the application of the Beacon Caresystem to facilitate local and remote management of large numbers of ventilated patients (as seen during this COVID-19 pandemic) could change the outcome of mechanically ventilated patients during the course of this and future pandemics. Trial registration ClinicalTrials.gov identifier NCT04115709. Registered on 4 October 2019, version 4.0 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05967-2.
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Affiliation(s)
- Brijesh Patel
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College, London, UK.
| | - Sharon Mumby
- Airway Disease, National, Heart & Lung Institute, Imperial College, London, UK
| | - Nicholas Johnson
- Imperial Clinical Trials Unit, Stadium House, 68 Wood Lane, London, W12 7RH, UK
| | | | | | - Ian Adcock
- Airway Disease, National, Heart & Lung Institute, Imperial College, London, UK
| | - Danny McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | - Masao Takata
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College, London, UK
| | - Dan S Karbing
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, University Hospital of Clermont-Ferrand, GReD, Université Clermont Auvergne, CNRS, INSERM, Clermont-Ferrand, France
| | - Peter Schellengowski
- Medical University of Vienna, Department of Medicine I, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Stephen E Rees
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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12
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Lagier D, Zeng C, Fernandez-Bustamante A, Melo MFV. Perioperative Pulmonary Atelectasis: Part II. Clinical Implications. Anesthesiology 2022; 136:206-236. [PMID: 34710217 PMCID: PMC9885487 DOI: 10.1097/aln.0000000000004009] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.
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Affiliation(s)
- David Lagier
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Congli Zeng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Marcos F. Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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13
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Garfield B, Handslip R, Patel BV. Ventilator-Associated Lung Injury. ENCYCLOPEDIA OF RESPIRATORY MEDICINE 2022. [PMCID: PMC8128668 DOI: 10.1016/b978-0-08-102723-3.00237-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ventilatory support, while life saving, can also cause or aggravate lung injury through several mechanisms which are encompassed within ventilator-associated lung injury (VALI). The important realizationin the acute respiratory distress syndrome that the “baby” lung resided in non-dependent areas led to the conceptualization of “lung rest” to reduce stress and strain to exposed alveolar units. We discuss concepts and mechanisms within VALI that ultimately induce maladaptive lung responses, as well as, current and future management strategies to detect and mitigate VALI at the bedside.
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14
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Positive end-expiratory pressure individualization guided by continuous end-expiratory lung volume monitoring during laparoscopic surgery. J Clin Monit Comput 2021; 36:1557-1567. [PMID: 34966951 DOI: 10.1007/s10877-021-00800-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/24/2021] [Indexed: 10/19/2022]
Abstract
To determine whether end-expiratory lung volume measured with volumetric capnography (EELVCO2) can individualize positive end-expiratory pressure (PEEP) setting during laparoscopic surgery. We studied patients undergoing laparoscopic surgery subjected to Fowler (F-group; n = 20) or Trendelenburg (T-group; n = 20) positions. EELVCO2 was measured at 0° supine (baseline), during capnoperitoneum (CP) at 0° supine, during CP with Fowler (head up + 20°) or Trendelenburg (head down - 30°) positions and after CP back to 0° supine. PEEP was adjusted to preserve baseline EELVCO2 during and after CP. Baseline EELVCO2 was statistically similar to predicted FRC in both groups. At supine and CP, EELVCO2 decreased from baseline values in F-group [median and IQR 2079 (768) to 1545 (725) mL; p = 0.0001] and in T-group [2164 (789) to 1870 (940) mL; p = 0.0001]. Change in body position maintained EELVCO2 unchanged in both groups. PEEP adjustments from 5.6 (1.1) to 10.0 (2.5) cmH2O in the F-group (p = 0.0001) and from 5.6 (0.9) to 10.0 (2.6) cmH2O in T-group (p = 0.0001) were necessary to reach baseline EELVCO2 values. EELVCO2 increased close to baseline with PEEP in the F-group [1984 (600) mL; p = 0.073] and in the T-group [2175 (703) mL; p = 0.167]. After capnoperitoneum and back to 0° supine, PEEP needed to maintain EELVCO2 was similar to baseline PEEP in F-group [5.9 (1.8) cmH2O; p = 0.179] but slightly higher in the T-group [6.5 (2.2) cmH2O; p = 0.006]. Those new PEEP values gave EELVCO2 similar to baseline in the F-group [2039 (980) mL; p = 0.370] and in the T-group [2150 (715) mL; p = 0.881]. Breath-by-breath noninvasive EELVCO2 detected changes in lung volume induced by capnoperitoneum and body position and was useful to individualize the level of PEEP during laparoscopy.Trial registry: Clinicaltrials.gov NCT03693352. Protocol started 1st October 2018.
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15
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Li P, Kang X, Miao M, Zhang J. Individualized positive end-expiratory pressure (PEEP) during one-lung ventilation for prevention of postoperative pulmonary complications in patients undergoing thoracic surgery: A meta-analysis. Medicine (Baltimore) 2021; 100:e26638. [PMID: 34260559 PMCID: PMC8284741 DOI: 10.1097/md.0000000000026638] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Accepted: 06/24/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Positive end-expiratory pressure (PEEP) is an important part of the lung protection strategies for one-lung ventilation (OLV). However, a fixed PEEP value is not suitable for all patients. Our objective was to determine the prevention of individualized PEEP on postoperative complications in patients undergoing one-lung ventilation. METHOD We searched the PubMed, Embase, and Cochrane and performed a meta-analysis to compare the effect of individual PEEP vs fixed PEEP during single lung ventilation on postoperative pulmonary complications. Our primary outcome was the occurrence of postoperative pulmonary complications during follow-up. Secondary outcomes included the partial pressure of arterial oxygen and oxygenation index during one-lung ventilation. RESULT Eight studies examining 849 patients were included in this review. The rate of postoperative pulmonary complications was reduced in the individualized PEEP group with a risk ratio of 0.52 (95% CI:0.37-0.73; P = .0001). The partial pressure of arterial oxygen during the OLV in the individualized PEEP group was higher with a mean difference 34.20 mm Hg (95% CI: 8.92-59.48; P = .0004). Similarly, the individualized PEEP group had a higher oxygenation index, MD: 49.07mmHg, (95% CI: 27.21-70.92; P < .0001). CONCLUSIONS Individualized PEEP setting during one-lung ventilation in patients undergoing thoracic surgery was associated with fewer postoperative pulmonary complications and better perioperative oxygenation.
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16
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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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Zhang C, Xu F, Li W, Tong X, Xia R, Wang W, Du J, Shi X. Driving Pressure-Guided Individualized Positive End-Expiratory Pressure in Abdominal Surgery: A Randomized Controlled Trial. Anesth Analg 2021; 133:1197-1205. [PMID: 34125080 DOI: 10.1213/ane.0000000000005575] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The optimal positive end-expiratory pressure (PEEP) to prevent postoperative pulmonary complications (PPCs) remains unclear. Recent evidence showed that driving pressure was closely related to PPCs. In this study, we tested the hypothesis that an individualized PEEP guided by minimum driving pressure during abdominal surgery would reduce the incidence of PPCs. METHODS This single-centered, randomized controlled trial included a total of 148 patients scheduled for open upper abdominal surgery. Patients were randomly assigned to receive an individualized PEEP guided by minimum driving pressure or an empiric fixed PEEP of 6 cm H2O. The primary outcome was the incidence of clinically significant PPCs within the first 7 days after surgery, using a χ2 test. Secondary outcomes were the severity of PPCs, the area of atelectasis, and pleural effusion. Other outcomes, such as the incidence of different types of PPCs (including hypoxemia, atelectasis, pleural effusion, dyspnea, pneumonia, pneumothorax, and acute respiratory distress syndrome), intensive care unit (ICU) admission rate, length of hospital stay, and 30-day mortality were also explored. RESULTS The median value of PEEP in the individualized group was 10 cm H2O. The incidence of clinically significant PPCs was significantly lower in the individualized PEEP group compared with that in the fixed PEEP group (26 of 67 [38.8%] vs 42 of 67 [62.7%], relative risk = 0.619, 95% confidence intervals, 0.435-0.881; P = .006). The overall severity of PPCs and the area of atelectasis were also significantly diminished in the individualized PEEP group. Higher respiratory compliance during surgery and improved intra- and postoperative oxygenation was observed in the individualized group. No significant differences were found in other outcomes between the 2 groups, such as ICU admission rate or 30-day mortality. CONCLUSIONS The application of individualized PEEP based on minimum driving pressure may effectively decrease the severity of atelectasis, improve oxygenation, and reduce the incidence of clinically significant PPCs after open upper abdominal surgery.
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Affiliation(s)
- Chengmi Zhang
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fengying Xu
- Department of Anesthesiology, No. 971 Hospital of People's Liberation Army Navy, Qingdao, China
| | - Weiwei Li
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xingyu Tong
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ran Xia
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wei Wang
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jianer Du
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xueyin Shi
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
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Park JH, Lee HM, Kang CM, Kim KS, Jang CH, Hwang HK, Lee JR. Correlation of Intraoperative End-Tidal Carbon Dioxide Concentration on Postoperative Hospital Stay in Patients Undergoing Pylorus-Preserving Pancreaticoduodenectomy. World J Surg 2021; 45:1860-1867. [PMID: 33591427 PMCID: PMC7885757 DOI: 10.1007/s00268-021-05984-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2021] [Indexed: 11/29/2022]
Abstract
Background Hypocapnia has been traditionally advocated during general anesthesia, even though it may induce deleterious physiological effects that result in unfavorable outcomes in patients. This study investigated the association between intraoperative end-tidal carbon dioxide (EtCO2) and length of hospital stay (LOS) in patients who underwent pylorus-preserving pancreaticoduodenectomy (PPPD). Methods The medical records of 759 patients from 2006 to 2015 were reviewed. The patients were divided into two groups based on the mean EtCO2 value during general anesthesia: the hypocapnia group (< 35 mmHg) and the normocapnia group (≥ 35 mmHg). The primary outcome was LOS between the groups. Secondary outcomes included the length of intensive care unit (ICU) stay, postoperative 30-day, 1-year, and 2-year mortality, and perioperative factors associated with LOS. Results A total of 727 patients were finally analyzed. The median LOS of the hypocapnia group was significantly longer than that of the normocapnia group (22 days vs. 18 days, respectively; p < 0.001). Postoperative mortality did not differ between the groups. Cox regression analysis revealed that hypocapnia was an independent risk factor for longer LOS (hazard ratio [HR], 1.61; 95% confidence interval [CI], 1.37–1.89; p < 0.001). Age and postoperative pancreatic fistula were also risk factors for a longer LOS. Conclusions It was concluded that low levels of intraoperative EtCO2 during general anesthesia were associated with an increased LOS for patients undergoing PPPD.
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Affiliation(s)
- Ji-Hoon Park
- Department of Anesthesiology and Pain Medicine, Keimyung University Dongsan Medical Center, 1095 Dalgubeol-daero, Dalseo-gu, Daegu, 42601, Korea
| | - Hye-Mi Lee
- Department of Anaesthesiology and Pain Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Chang Moo Kang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea.,Yonsei Cancer Center, Pancreatobiliary Cancer Clinic, Severance Hospital, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea
| | - Kyung Sub Kim
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Korea
| | - Chul Ho Jang
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Gangnam Severance Hospital, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Korea
| | - Ho Kyoung Hwang
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea. .,Yonsei Cancer Center, Pancreatobiliary Cancer Clinic, Severance Hospital, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.
| | - Jeong-Rim Lee
- Department of Anaesthesiology and Pain Medicine, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Republic of Korea. .,Anesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, Korea.
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19
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Spadaro S, Fogagnolo A. How much positive end expiratory pressure during one lung ventilation? An unresolvable question. Minerva Anestesiol 2021; 87:153-155. [PMID: 33432801 DOI: 10.23736/s0375-9393.20.15428-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Savino Spadaro
- Section of Anesthesia and Intensive Care, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy -
| | - Alberto Fogagnolo
- Section of Anesthesia and Intensive Care, Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, Ferrara, Italy
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20
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Fu Y, Zhang YW, Gao J, Fu HM, Si L, Gao YT. Effects of lung-protective ventilation strategy on lung aeration loss and postoperative pulmonary complications in moderate-risk patients undergoing abdominal surgery. Minerva Anestesiol 2020; 87:655-662. [PMID: 33325216 DOI: 10.23736/s0375-9393.20.14951-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND There is a controversy about whether the use of a lung-protective ventilation strategy(LPVS) can reduce the incidence of postoperative pulmonary complications (PPCs) and improve the clinical outcomes in moderate-risk patients were assessed by the Assess Respiratory Risk in Surgical Patients in Catalonia(ARISCAT). METHODS One hundred moderate-risk patients predicted by the ARISCAT, scheduled to undergo abdominal surgery were randomized into two groups: conventional ventilation strategy group (G<inf>0</inf>) and lung-protective ventilation strategy group (G<inf>1</inf>). Lung ultrasonography (LUS) and the LUS score were performed before induction of anesthesia (T<inf>0</inf>), 30min after extubation (T<inf>1</inf>), and 24h (T<inf>2</inf>), 72h (T<inf>3</inf>) after surgery. The incidence and severity of PPCs within the postoperative 7 days, the duration of postoperative oxygen supplementation, and postoperative hospital stay (PHS) were recorded. RESULTS The LUS score of both groups at T<inf>1-3</inf> was higher than those at T<inf>0</inf> (P<0.05), moreover, the LUS score of G<inf>1</inf> was lower than that of G<inf>0</inf> at T<inf>1-3</inf>. The incidence of PPCs of G<inf>1</inf> (10.9%) was lower than that of G<inf>0</inf> (29.8%) (relative risk, 0.37; 95% confidence interval [CI], 0.14 to 0.93; P=0.02) and the severity of PPCs of G<inf>1</inf> were lower than those of G<inf>0</inf> (P<0.05). The PHS of G<inf>1</inf> was less than that of G<inf>0</inf> (8[7-10] vs. 9[8-11], P<0.05). CONCLUSIONS The LPVS can decrease lung aeration loss assessed by LUS and reduce the incidence of PPCs in moderate-risk patients.
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Affiliation(s)
- Yu Fu
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Yan-Wei Zhang
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Jie Gao
- Medical College of Nantong University, Nantong, China
| | - Hui-Min Fu
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Ling Si
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Yong-Tao Gao
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, China -
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21
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Peel JK, Funk DJ, Slinger P, Srinathan S, Kidane B. Positive end-expiratory pressure and recruitment maneuvers during one-lung ventilation: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2020; 160:1112-1122.e3. [DOI: 10.1016/j.jtcvs.2020.02.077] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 02/13/2020] [Accepted: 02/15/2020] [Indexed: 01/09/2023]
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22
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Spadaro S, Grasso S, Karbing DS, Santoro G, Cavallesco G, Maniscalco P, Murgolo F, Di Mussi R, Ragazzi R, Rees SE, Volta CA, Fogagnolo A. Physiological effects of two driving pressure-based methods to set positive end-expiratory pressure during one lung ventilation. J Clin Monit Comput 2020; 35:1149-1157. [PMID: 32816177 PMCID: PMC7439797 DOI: 10.1007/s10877-020-00582-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/17/2020] [Indexed: 12/14/2022]
Abstract
During one-lung ventilation (OLV), titrating the positive end-expiratory pressure (PEEP) to target a low driving pressure (∆P) could reduce postoperative pulmonary complications. However, it is unclear how to conduct PEEP titration: by stepwise increase starting from zero PEEP (PEEPINCREMENTAL) or by stepwise decrease after a lung recruiting manoeuvre (PEEPDECREMENTAL). In this randomized trial, we compared the physiological effects of these two PEEP titration strategies on respiratory mechanics, ventilation/perfusion mismatch and gas exchange. Patients undergoing video-assisted thoracoscopic surgery in OLV were randomly assigned to a PEEPINCREMENTAL or PEEPDECREMENTAL strategy to match the lowest ∆P. In the PEEPINCREMENTAL group, PEEP was stepwise titrated from ZEEP up to 16 cm H2O, whereas in the PEEPDECREMENTAL group PEEP was decrementally titrated, starting from 16 cm H2O, immediately after a lung recruiting manoeuvre. Respiratory mechanics, ventilation/perfusion mismatch and blood gas analyses were recorded at baseline, after PEEP titration and at the end of surgery. Sixty patients were included in the study. After PEEP titration, shunt decreased similarly in both groups, from 50 [39-55]% to 35 [28-42]% in the PEEPINCREMENTAL and from 45 [37-58]% to 33 [25-45]% in the PEEPDECREMENTAL group (both p < 0.001 vs baseline). The resulting ∆P, however, was lower in the PEEPDECREMENTAL than in the PEEPINCREMENTAL group (8 [7-11] vs 10 [9-11] cm H2O; p = 0.03). In the PEEPDECREMENTAL group the PaO2/ FIO2 ratio increased significantly after intervention (from 140 [99-176] to 186 [152-243], p < 0.001). Both the PEEPINCREMENTAL and the PEEPDECREMENTAL strategies were able to decrease intraoperative shunt, but only PEEPDECREMENTAL improved oxygenation and lowered intraoperative ΔP.Clinical trial number NCT03635281; August 2018; "retrospectively registered".
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Affiliation(s)
- Savino Spadaro
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy.
| | - Salvatore Grasso
- Department of Emergency and Organ Transplant (DETO), "Aldo Moro" University of Bari, Bari, Italy
| | - Dan Stieper Karbing
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Giuseppe Santoro
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
| | - Giorgio Cavallesco
- Department of Morphology, Experimental Medicine and Surgery, Thoracic Surgery, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, Ferrara, Italy
| | - Pio Maniscalco
- Department of Morphology, Experimental Medicine and Surgery, Thoracic Surgery, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, Ferrara, Italy
| | - Francesca Murgolo
- Department of Emergency and Organ Transplant (DETO), "Aldo Moro" University of Bari, Bari, Italy
| | - Rosa Di Mussi
- Department of Emergency and Organ Transplant (DETO), "Aldo Moro" University of Bari, Bari, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
| | - Stephen Edward Rees
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Carlo Alberto Volta
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
| | - Alberto Fogagnolo
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
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23
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Zhu SJ, Zhang XL, Xie Q, Zhou YF, Wang KR. Comparison of the effects of deep and moderate neuromuscular block on respiratory system compliance and surgical space conditions during robot-assisted laparoscopic radical prostatectomy: a randomized clinical study. J Zhejiang Univ Sci B 2020; 21:637-645. [PMID: 32748579 DOI: 10.1631/jzus.b2000193] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Robot-assisted radical prostatectomy (RARP) requires pneumoperitoneum (Pnp) and a steep head-down position that may disturb respiratory system compliance (Crs) during surgery. Our aim was to compare the effects of different degrees of neuromuscular block (NMB) on Crs with the same Pnp pressure during RARP. METHODS One hundred patients who underwent RARP were enrolled and randomly allocated to a deep or moderate NMB group with 50 patients in each group. Rocuronium was administered to both groups: in the moderate NMB group to maintain 1-2 responses to train-of-four (TOF) stimulation; and in the deep NMB group to maintain no response to TOF stimulation and 1-2 responses in the post-tetanic count. Pnp pressure in both groups was 10 mmHg (1 mmHg=133.3 Pa). Peak inspiratory pressure (Ppeak), mean pressure (Pmean), Crs, and airway resistance (Raw) were recorded after anesthesia induction and at 0, 30, 60, and 90 min of Pnp and post-Pnp. Surgical space conditions were evaluated after the procedure on a 4-point scale. RESULTS Immediately after the Pnp, Ppeak, Pmean, and Raw significantly increased, while Crs decreased and persisted during Pnp in both groups. The results did not significantly differ between the two groups at any of the time points. There was no difference in surgical space conditions between groups. Body movements occurred in 14 cases in the moderate NMB group and in one case in the deep NMB group, and all occurred during obturator lymphadenectomy. A significant difference between the two groups was observed. CONCLUSIONS Under the same Pnp pressure in RARP, deep and moderate NMBs resulted in similar changes in Crs, and in other respiratory mechanics and surgical space conditions. However, deep NMB significantly reduced body movements during surgery.
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Affiliation(s)
- Shao-Jun Zhu
- Department of Anesthesiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Xiao-Lin Zhang
- Department of Anesthesiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Qing Xie
- Department of Anesthesiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Yan-Feng Zhou
- Department of Anesthesiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
| | - Kui-Rong Wang
- Department of Anesthesiology, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
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24
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Bar S, Santarelli D, de Broca B, Abou Arab O, Leviel F, Miclo M, Dupont H, Guinot PG, Lorne E. Predictive value of the respiratory exchange ratio for the occurrence of postoperative complications in laparoscopic surgery: a prospective and observational study. J Clin Monit Comput 2020; 35:849-858. [PMID: 32533528 DOI: 10.1007/s10877-020-00544-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 06/06/2020] [Indexed: 11/28/2022]
Abstract
Indirect measurement of the respiratory exchange ratio (RER) has been shown to predict the occurrence of postoperative complications after major open non-cardiac surgery. Our main objective was to demonstrate the ability of the RER, indirectly measured by the anaesthesia respirator, to predict the occurrence of postoperative complications following laparoscopic surgery. We performed an observational, prospective and monocentric study. Haemodynamic and respiratory parameters were collected at several timepoints to calculate the RER by a non-volumetric method: RER = (FetCO2-FiCO2)/(FiO2-FetO2). Fifty patients were prospectively included. Nine patients (18%) had at least one postoperative complication. The mean RER was significantly higher for the subgroup of patients with complications than the subgroup without (1.04 ± 0.27 vs 0.88 ± 0.13, p < 0.05). The RER could predict the occurrence of post-operative complications with an area under the ROC curve of 0.73 (95% CI 0.59-0.85, p = 0.021). The best cut off was 0.98, with a sensitivity of 56% and a specificity of 88%. One hour after insufflation, the FiO2-FetO2 difference was significantly lower and the RER was significantly higher in the complications subgroup than in the subgroup without complications (4.4/- 1.6% vs 5.8/- 1.2%, p = 0.001 and 0.95 [0.85-1.04] vs 0.83 [0.75-0.92], p = 0.04, respectively). The RER measured during laparoscopic surgery can predict the occurrence of postoperative complications.Trial registration The objectives and procedures of the study was registered at Clinicaltrials.gov (NCT03751579); date: November 23, 2018.
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Affiliation(s)
- Stéphane Bar
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Rond-Point Fernand Leger, 80054, Amiens, France. .,Research Unit Simplification of Care for Complex Patients, UR 7518, University of Picardy Jules Verne, 80000, Amiens, France.
| | - Dimitri Santarelli
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Rond-Point Fernand Leger, 80054, Amiens, France
| | - Bruno de Broca
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Rond-Point Fernand Leger, 80054, Amiens, France
| | - Osama Abou Arab
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Rond-Point Fernand Leger, 80054, Amiens, France
| | - Florent Leviel
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Rond-Point Fernand Leger, 80054, Amiens, France
| | - Matthieu Miclo
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Rond-Point Fernand Leger, 80054, Amiens, France
| | - Hervé Dupont
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Rond-Point Fernand Leger, 80054, Amiens, France
| | - Pierre-Grégroire Guinot
- Anaesthesiology and Critical Care Department, Dijon University Hospital, 2 Bd Maréchal de Lattre de Tassigny, 21000, Dijon, France
| | - Emmanuel Lorne
- Anaesthesiology and Critical Care Department, Amiens University Hospital, Rond-Point Fernand Leger, 80054, Amiens, France
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Ferrero C, Borland K. Anaesthetic complications and management of a great dane presenting with acute respiratory distress. VETERINARY RECORD CASE REPORTS 2020. [DOI: 10.1136/vetreccr-2019-001048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Camilla Ferrero
- Anaesthesia DepartmentAnderson Moores Veterinary SpecialistsWinchesterUK
| | - Karla Borland
- Anaesthesia DepartmentAnderson Moores Veterinary SpecialistsWinchesterUK
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26
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Ruszkai Z, Kiss E, László I, Bokrétás GP, Vizserálek D, Vámossy I, Surány E, Buzogány I, Bajory Z, Molnár Z. Effects of intraoperative positive end-expiratory pressure optimization on respiratory mechanics and the inflammatory response: a randomized controlled trial. J Clin Monit Comput 2020; 35:469-482. [PMID: 32388650 PMCID: PMC7222900 DOI: 10.1007/s10877-020-00519-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 05/04/2020] [Indexed: 12/18/2022]
Abstract
Applying lung protective mechanical ventilation (LPV) during general anaesthesia even in patients with non-injured lungs is recommended. However, the effects of an individual PEEP-optimisation on respiratory mechanics, oxygenation and their potential correlation with the inflammatory response and postoperative complications have not been evaluated have not been compared to standard LPV in patients undergoing major abdominal surgery. Thirty-nine patients undergoing open radical cystectomy were enrolled in this study. In the study group (SG) optimal PEEP was determined by a decremental titration procedure and defined as the PEEP value resulting the highest static pulmonary compliance. In the control group (CG) PEEP was set to 6 cmH2O. Primary endpoints were intraoperative respiratory mechanics and gas exchange parameters. Secondary outcomes were perioperative procalcitonin kinetics and postoperative pulmonary complications. Optimal PEEP levels (median = 10, range: 8–14 cmH2O), PaO2/FiO2 (451.24 ± 121.78 mmHg vs. 404.15 ± 115.87 mmHg, P = 0.005) and static pulmonary compliance (52.54 ± 13.59 ml cmH2O-1 vs. 45.22 ± 9.13 ml cmH2O-1, P < 0.0001) were significantly higher, while driving pressure (8.26 ± 1.74 cmH2O vs. 9.73 ± 4.02 cmH2O, P < 0.0001) was significantly lower in the SG as compared to the CG. No significant intergroup differences were found in procalcitonin kinetics (P = 0.076). Composite outcome results indicated a non-significant reduction of postoperative complications in the SG. Intraoperative PEEP-optimization resulted in significant improvement in gas exchange and pulmonary mechanics as compared to standard LPV. Whether these have any effect on short and long term outcomes require further investigations. Trial registration: Clinicaltrials.gov, identifier: NCT02931409.
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Affiliation(s)
- Zoltán Ruszkai
- Department of Anaesthesiology and Intensive Therapy, Pest Megyei Flór Ferenc Hospital, Semmelweis Square 1, Kistarcsa, 2143, Hungary.
| | - Erika Kiss
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Semmelweis Street 6, Szeged, 6725, Hungary
| | - Ildikó László
- Department of Anaesthesiology and Intensive Therapy, University of Szeged, Semmelweis Street 6, Szeged, 6725, Hungary
| | - Gergely Péter Bokrétás
- Department of Anaesthesiology and Intensive Therapy, Péterfy Sándor Hospital, Péterfy Sándor Street 8-20, Budapest, 1076, Hungary
| | - Dóra Vizserálek
- Department of Anaesthesiology and Intensive Therapy, Péterfy Sándor Hospital, Péterfy Sándor Street 8-20, Budapest, 1076, Hungary
| | - Ildikó Vámossy
- Department of Anaesthesiology and Intensive Therapy, Péterfy Sándor Hospital, Péterfy Sándor Street 8-20, Budapest, 1076, Hungary
| | - Erika Surány
- Department of Anaesthesiology and Intensive Therapy, Péterfy Sándor Hospital, Péterfy Sándor Street 8-20, Budapest, 1076, Hungary
| | - István Buzogány
- Department of Urology, Péterfy Sándor Hospital, Péterfy Sándor Street 8-20, Budapest, 1076, Hungary
| | - Zoltán Bajory
- Department of Urology, University of Szeged, Kálvária Avenue 57, Szeged, 6725, Hungary
| | - Zsolt Molnár
- Centre for Translational Medicine, University of Pécs, Szigeti Street 12, Pécs, 7624, Hungary
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27
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Effects of intra-operative positive end-expiratory pressure setting guided by oesophageal pressure measurement on oxygenation and respiratory mechanics during laparoscopic gynaecological surgery: A randomised controlled trial. Eur J Anaesthesiol 2020; 37:1032-1039. [PMID: 32371830 DOI: 10.1097/eja.0000000000001204] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The creation of pneumoperitoneum during laparoscopic surgery can lead to adverse effects on the respiratory system. Positive end-expiratory pressure (PEEP) plays an important role in mechanical ventilation during laparoscopic surgery. OBJECTIVE To evaluate whether PEEP setting guided by oesophageal pressure (Poeso) measurement would affect oxygenation and respiratory mechanics during laparoscopic gynaecological surgery. DESIGN A randomised controlled study. SETTING A single-centre trial from March 2018 to June 2018. PATIENTS Forty-four adult patients undergoing laparoscopic gynaecological surgery with anticipated duration of surgery more than 2 h. INTERVENTION PEEP set according to Poeso measurement (intervention group) versus PEEP constantly set at 5 cmH2O (control group). MAIN OUTCOME MEASURES Gas exchange and respiratory mechanics after induction and intubation (T0) and at 15 and 60 min after initiation of pneumoperitoneum (T1 and T2, respectively). RESULTS PEEP during pneumoperitoneum was significantly higher in the intervention group than in the control group (T1, 12.5 ± 1.9 vs. 5.0 ± 0.0 cmH2O and T2, 12.4 ± 1.9 vs. 5.0 ± 0.0 cmH2O, both P < 0.001). Partial pressures of oxygen decreased significantly from baseline during pneumoperitoneum in the control group but not in the intervention group. Nevertheless, the changes in partial pressures of oxygen did not differ between groups. Compliance of the respiratory system (CRS) significantly decreased and driving pressure significantly increased during pneumoperitoneum in both groups. However, the changes in CRS and driving pressure were significantly less in the intervention group. Transpulmonary pressure during expiration was maintained in the intervention group while it decreased significantly in the control group. CONCLUSION PEEP setting guided by Poeso measurement showed no beneficial effects in terms of oxygenation but respiratory mechanics were better during laparoscopic gynaecological surgery. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03256396.
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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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Karbing DS, Panigada M, Bottino N, Spinelli E, Protti A, Rees SE, Gattinoni L. Changes in shunt, ventilation/perfusion mismatch, and lung aeration with PEEP in patients with ARDS: a prospective single-arm interventional study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:111. [PMID: 32293506 PMCID: PMC7092565 DOI: 10.1186/s13054-020-2834-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 03/13/2020] [Indexed: 11/10/2022]
Abstract
Background Several studies have found only a weak to moderate correlation between oxygenation and lung aeration in response to changes in PEEP. This study aimed to investigate the association between changes in shunt, low and high ventilation/perfusion (V/Q) mismatch, and computed tomography-measured lung aeration following an increase in PEEP in patients with ARDS. Methods In this preliminary study, 12 ARDS patients were subjected to recruitment maneuvers followed by setting PEEP at 5 and then either 15 or 20 cmH2O. Lung aeration was measured by computed tomography. Values of pulmonary shunt and low and high V/Q mismatch were calculated by a model-based method from measurements of oxygenation, ventilation, and metabolism taken at different inspired oxygen levels and an arterial blood gas sample. Results Increasing PEEP resulted in reduced values of pulmonary shunt and the percentage of non-aerated tissue, and an increased percentage of normally aerated tissue (p < 0.05). Changes in shunt and normally aerated tissue were significantly correlated (r = − 0.665, p = 0.018). Three distinct responses to increase in PEEP were observed in values of shunt and V/Q mismatch: a beneficial response in seven patients, where shunt decreased without increasing high V/Q; a detrimental response in four patients where both shunt and high V/Q increased; and a detrimental response in a patient with reduced shunt but increased high V/Q mismatch. Non-aerated tissue decreased with increased PEEP in all patients, and hyperinflated tissue increased only in patients with a detrimental response in shunt and V/Q mismatch. Conclusions The results show that improved lung aeration following an increase in PEEP is not always consistent with reduced shunt and V/Q mismatch. Poorly matched redistribution of ventilation and perfusion, between dependent and non-dependent regions of the lung, may explain why patients showed detrimental changes in shunt and V/Q mismatch on increase in PEEP, despite improved aeration. Trial registration ClinicalTrails.gov, NCT04067154. Retrospectively registered on August 26, 2019.
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Affiliation(s)
- Dan Stieper Karbing
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Fredrik Bajer Vej 7E, DK-9220, Aalborg East, Denmark.
| | - Mauro Panigada
- Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Nicola Bottino
- Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Spinelli
- Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alessandro Protti
- Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Stephen Edward Rees
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Fredrik Bajer Vej 7E, DK-9220, Aalborg East, Denmark
| | - Luciano Gattinoni
- Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy.,Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Gӧttingen, Gӧttingen, Germany
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Alvey NJ, Hlaing M, Piccoli J, Kukreja N, Tran TT. Positive end-expiratory pressure titration via esophageal balloon monitoring in a morbidly obese patient undergoing laparoscopic nephrectomy. Can J Anaesth 2020; 67:1086-1087. [PMID: 32128724 PMCID: PMC7223554 DOI: 10.1007/s12630-020-01606-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 02/12/2020] [Accepted: 02/12/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Nicholas J Alvey
- Department of Anesthesiology, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Maung Hlaing
- Department of Anesthesiology, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Jerome Piccoli
- Division of Pulmonary Medicine, UCHealth, Aurora, CO, USA
| | - Naveen Kukreja
- Department of Anesthesiology, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA
| | - Timothy T Tran
- Department of Anesthesiology, University of Colorado - Anschutz Medical Campus, Aurora, CO, USA.
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31
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Mari GM, Crippa J, Achilli P, Miranda A, Santurro L, Riggio V, Gerosa M, Ascheri P, Cordaro G, Costanzi AT, Maggioni D. 4K ultra HD technology reduces operative time and intraoperative blood loss in colorectal laparoscopic surgery. F1000Res 2020; 9:106. [PMID: 32789007 PMCID: PMC7400694 DOI: 10.12688/f1000research.21297.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/15/2020] [Indexed: 12/26/2022] Open
Abstract
Background: HD systems are routinely used in laparoscopic surgery, 4K ultra HD monitors are mainly available within specialized, high-volume laparoscopic centers. The higher resolution of 4K ultra HD video could upgrade the surgical performance improving intraoperative and post-operative outcomes. Methods: We performed a retrospective comparative analysis of intraoperative parameters and post-operative outcomes in a cohort of patients operated on for elective laparoscopic procedures for colo-rectal cancer during two different time frames: 2017 procedures performed using the Visera Elite full HD technology (® Olympus America, Medical) and the 2018 procedures performed the Visera 4K Ultra HD System (® Olympus America, Medical). Results: There was a statistically significant reduction in operative time in patients operated on with the 4K ultra HD technology compared to HD technology (p < 0.05). Intraoperative blood loss was significantly reduced in patients operated in 2018 (p < 0.05). There were no statistically significant differences in complication rate and postoperative outcomes between the two groups.
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Affiliation(s)
- Giulio M. Mari
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
| | - Jacopo Crippa
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Pietro Achilli
- General Surgery Residency Program, University of Milan, Milan, Italy
| | - Angelo Miranda
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
| | - Letizia Santurro
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
| | - Valentina Riggio
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
| | - Martino Gerosa
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
| | - Pietro Ascheri
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
| | - Giuseppe Cordaro
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
| | | | - Dario Maggioni
- General Surgery Department, Desio Hospital, ASST Monza, Desio, MB, Italy
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Généreux V, Chassé M, Girard F, Massicotte N, Chartrand-Lefebvre C, Girard M. Effects of positive end-expiratory pressure/recruitment manoeuvres compared with zero end-expiratory pressure on atelectasis during open gynaecological surgery as assessed by ultrasonography: a randomised controlled trial. Br J Anaesth 2020; 124:101-109. [DOI: 10.1016/j.bja.2019.09.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 09/17/2019] [Accepted: 09/23/2019] [Indexed: 12/22/2022] Open
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Spinelli E, Mauri T, Fogagnolo A, Scaramuzzo G, Rundo A, Grieco DL, Grasselli G, Volta CA, Spadaro S. Electrical impedance tomography in perioperative medicine: careful respiratory monitoring for tailored interventions. BMC Anesthesiol 2019; 19:140. [PMID: 31390977 PMCID: PMC6686519 DOI: 10.1186/s12871-019-0814-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/29/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Electrical impedance tomography (EIT) is a non-invasive radiation-free monitoring technique that provides images based on tissue electrical conductivity of the chest. Several investigations applied EIT in the context of perioperative medicine, which is not confined to the intraoperative period but begins with the preoperative assessment and extends to postoperative follow-up. MAIN BODY EIT could provide careful respiratory monitoring in the preoperative assessment to improve preparation for surgery, during anaesthesia to guide optimal ventilation strategies and to monitor the hemodynamic status and in the postoperative period for early detection of respiratory complications. Moreover, EIT could further enhance care of patients undergoing perioperative diagnostic procedures. This narrative review summarizes the latest evidence on the application of this technique to the surgical patient, focusing also on possible future perspectives. CONCLUSIONS EIT is a promising technique for the perioperative assessment of surgical patients, providing tailored adaptive respiratory and haemodynamic monitoring. Further studies are needed to address the current technological limitations, confirm the findings and evaluate which patients can benefit more from this technology.
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Affiliation(s)
- Elena Spinelli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli studi di Milano, Milan, Italy
| | - Tommaso Mauri
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli studi di Milano, Milan, Italy
| | - Alberto Fogagnolo
- Department Morphology, Surgery and Experimental medicine, Anesthesia and Intensive care section, University of Ferrara, Azienda Ospedaliera- Universitaria Sant'Anna, 8, Aldo Moro, Ferrara, Italy
| | - Gaetano Scaramuzzo
- Department Morphology, Surgery and Experimental medicine, Anesthesia and Intensive care section, University of Ferrara, Azienda Ospedaliera- Universitaria Sant'Anna, 8, Aldo Moro, Ferrara, Italy
| | - Annalisa Rundo
- UOC Anestesia e Rianimazione, Polo ospedaliero Belcolle ASL, Viterbo, Italy
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - Giacomo Grasselli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università degli studi di Milano, Milan, Italy
| | - Carlo Alberto Volta
- Department Morphology, Surgery and Experimental medicine, Anesthesia and Intensive care section, University of Ferrara, Azienda Ospedaliera- Universitaria Sant'Anna, 8, Aldo Moro, Ferrara, Italy
| | - Savino Spadaro
- Department Morphology, Surgery and Experimental medicine, Anesthesia and Intensive care section, University of Ferrara, Azienda Ospedaliera- Universitaria Sant'Anna, 8, Aldo Moro, Ferrara, Italy.
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Physiologic Evaluation of Ventilation Perfusion Mismatch and Respiratory Mechanics at Different Positive End-expiratory Pressure in Patients Undergoing Protective One-lung Ventilation. Anesthesiology 2019; 128:531-538. [PMID: 29215365 DOI: 10.1097/aln.0000000000002011] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Arterial oxygenation is often impaired during one-lung ventilation, due to both pulmonary shunt and atelectasis. The use of low tidal volume (VT) (5 ml/kg predicted body weight) in the context of a lung-protective approach exacerbates atelectasis. This study sought to determine the combined physiologic effects of positive end-expiratory pressure and low VT during one-lung ventilation. METHODS Data from 41 patients studied during general anesthesia for thoracic surgery were collected and analyzed. Shunt fraction, high V/Q and respiratory mechanics were measured at positive end-expiratory pressure 0 cm H2O during bilateral lung ventilation and one-lung ventilation and, subsequently, during one-lung ventilation at 5 or 10 cm H2O of positive end-expiratory pressure. Shunt fraction and high V/Q were measured using variation of inspired oxygen fraction and measurement of respiratory gas concentration and arterial blood gas. The level of positive end-expiratory pressure was applied in random order and maintained for 15 min before measurements. RESULTS During one-lung ventilation, increasing positive end-expiratory pressure from 0 cm H2O to 5 cm H2O and 10 cm H2O resulted in a shunt fraction decrease of 5% (0 to 11) and 11% (5 to 16), respectively (P < 0.001). The PaO2/FIO2 ratio increased significantly only at a positive end-expiratory pressure of 10 cm H2O (P < 0.001). Driving pressure decreased from 16 ± 3 cm H2O at a positive end-expiratory pressure of 0 cm H2O to 12 ± 3 cm H2O at a positive end-expiratory pressure of 10 cm H2O (P < 0.001). The high V/Q ratio did not change. CONCLUSIONS During low VT one-lung ventilation, high positive end-expiratory pressure levels improve pulmonary function without increasing high V/Q and reduce driving pressure.
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Abdel‐Ghaffar HS, Youseff HA, Abdelal FA, Osman MA, Sayed JA, Riad MAF, Abdel‐Rady MM. Post-extubation continuous positive airway pressure improves oxygenation after pediatric laparoscopic surgery: A randomized controlled trial. Acta Anaesthesiol Scand 2019; 63:620-629. [PMID: 30761530 DOI: 10.1111/aas.13324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 08/28/2018] [Accepted: 09/05/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Effects of intraoperative recruitment maneuvers (RMs) on oxygenation and pulmonary compliance are lost during recovery if high inspired oxygen and airway suctioning are used. We investigated the effect of post-extubation noninvasive CPAP mask application on the alveolar arterial oxygen difference [(A-a) DO2 ] after pediatric laparoscopic surgery. METHODS Sixty patients (1-6 years) were randomly allocated to three groups of 20 patients, to receive zero end-expiratory pressure (ZEEP group), RM with decremental PEEP titration only (RM group), or followed with post-extubation CPAP for 5 minutes (RM-CPAP group). Primary outcome was [(A-a) DO2 ] at 1 hour postoperatively. Secondary outcomes were respiratory mechanics, arterial blood gas analysis, hemodynamics, and adverse events. RESULTS At 1 hour postoperatively, mean [(A-a) DO2 ] (mm Hg) was lower in the RM-CPAP group (41.5 ± 13.2, [95% CI 37.6-45.8]) compared to (80.2 ± 13.7 [72.6-87.5], P < 0.0001] and (59.2 ± 14.6, [54.8-62.6], P < 0.001) in the ZEEP and RM groups. The mean PaO2 (mm Hg) at 1 hour postoperatively was higher in the RM-CPAP group (156.2 ± 18.3 [95% CI 147.6-164.7]) compared with the ZEEP (95.9 ± 15.9 [88.5-103.3], P < 0.0001) and RM groups (129.1 ± 15.9 [121.6-136.5], P < 0.0001). At 12 hours postoperatively, mean [(A-a) DO2 ] and PaO2 were (9.6 ± 2.1 [8.4-10.8]) and (91.9 ± 9.4 [87.5-96.3]) in the RM-CPAP group compared to (25.8 ± 5.5 [23.6-27.6]) and (69.9 ± 5.5 [67.4-72.5], P < 0.0001) in the ZEEP group and (34.3 ± 13.2, [28.4-40.2], P < 0.0001) and (74.03 ± 9.8 [69.5-78.6], P < 0.0001) in the RM group. No significant differences of perioperative adverse effects were found between groups. CONCLUSIONS An RM done after pneumoperitoneum inflation followed by decremental PEEP titration improved oxygenation at 1 hour postoperatively. The addition of an early post-extubation noninvasive CPAP mask ventilation improved oxygenation at 12 hours postoperatively.
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Affiliation(s)
- Hala S. Abdel‐Ghaffar
- Anesthesia and Intensive Care Department, Faculty of Medicine Assiut University Assiut Egypt
| | - Hamdy A. Youseff
- Anesthesia and Intensive Care Department, Faculty of Medicine Assiut University Assiut Egypt
| | - Fatma A. Abdelal
- Anesthesia and Intensive Care Department, Faculty of Medicine Assiut University Assiut Egypt
| | - Mohamed A. Osman
- Pediatric Surgery Department, Faculty of Medicine Assiut University Assiut Egypt
| | - Jehan A. Sayed
- Anesthesia and Intensive Care Department, Faculty of Medicine Assiut University Assiut Egypt
| | | | - Marwa M. Abdel‐Rady
- Anesthesia and Intensive Care Department, Faculty of Medicine Assiut University Assiut Egypt
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Positive end-expiratory pressure increases arterial oxygenation in elderly patients undergoing urological surgery using laryngeal mask airway in lithotomy position. J Clin Monit Comput 2019; 34:161-169. [DOI: 10.1007/s10877-019-00281-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 02/13/2019] [Indexed: 10/27/2022]
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Kim K, Jang DM, Park JY, Yoo H, Kim HS, Choi WJ. Changes of diaphragmatic excursion and lung compliance during major laparoscopic pelvic surgery: A prospective observational study. PLoS One 2018; 13:e0207841. [PMID: 30496318 PMCID: PMC6264802 DOI: 10.1371/journal.pone.0207841] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 11/07/2018] [Indexed: 11/18/2022] Open
Abstract
Major laparoscopic pelvic surgery requires steep Trendelenburg position with pneumoperitoneum for a long time. We investigated the effect of Trendelenburg position with pneumoperitoneum on diaphragmatic excursion and lung compliance during major laparoscopic pelvic surgery using M-mode sonography. Twenty patients undergoing elective pelviscopic radical hysterectomy were included in this study. Diaphragmatic excursion was measured at the following time points; after sedation, after intubation, 90 minutes after Trendelenburg position with pneumoperitoneum, and after operation with recovery of muscle relaxation. And lung compliance was measured using anesthetic machine under general anesthesia; after the intubation, 90 minutes after Trendelenburg position with pneumoperitoneum and after operation with recovery of muscle relaxation. In order to detect postoperative pulmonary complication, postoperative chest radiography was checked. Static lung compliance, dynamic lung compliance and diaphragmatic excursion were decreased during operation (P < 0.001, respectively). At the end of the operation with recovery of muscle relaxation, reduced diaphragmatic movement was not recovered as its excursion after sedation (P < 0.001). In conclusion, lung compliance was decreased following transiently decreased diaphragmatic excursion during major laparoscopic pelvic surgery.
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Affiliation(s)
- Kyungmi Kim
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Dong-Min Jang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jong-Yeon Park
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hwanhee Yoo
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Hong Soon Kim
- Department of Anesthesiology and Pain Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Woo-Jong Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
- * E-mail:
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Grieco D, Anzellotti G, Dell’Anna A, Russo A, Bongiovanni F, Antonelli M. PEEP-induced changes in lung volume to estimate transpulmonary pressure: the role of alveolar recruitment. Br J Anaesth 2018; 121:101-103. [DOI: 10.1016/j.bja.2018.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 03/29/2018] [Accepted: 04/01/2018] [Indexed: 10/17/2022] Open
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De Monte V, Bufalari A, Grasso S, Ferrulli F, Crovace AM, Lacitignola L, Staffieri F. Respiratory effects of low versus high tidal volume with or without positive end-expiratory pressure in anesthetized dogs with healthy lungs. Am J Vet Res 2018; 79:496-504. [DOI: 10.2460/ajvr.79.5.496] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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40
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Grieco DL, Russo A, Romanò B, Anzellotti GM, Ciocchetti P, Torrini F, Barelli R, Eleuteri D, Perilli V, Dell'Anna AM, Bongiovanni F, Sollazzi L, Antonelli M. Lung volumes, respiratory mechanics and dynamic strain during general anaesthesia. Br J Anaesth 2018; 121:1156-1165. [PMID: 30336861 DOI: 10.1016/j.bja.2018.03.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/11/2018] [Accepted: 03/28/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Driving pressure (ΔP) represents tidal volume normalised to respiratory system compliance (CRS) and is a novel parameter to target ventilator settings. We conducted a study to determine whether CRS and ΔP reflect aerated lung volume and dynamic strain during general anaesthesia. METHODS Twenty non-obese patients undergoing open abdominal surgery received three PEEP levels (2, 7, or 12 cm H2O) in random order with constant tidal volume ventilation. Respiratory mechanics, lung volumes, and alveolar recruitment were measured to assess end-expiratory aerated volume, which was compared with the patient's individual predicted functional residual capacity in supine position (FRCp). RESULTS CRS was linearly related to aerated volume and ΔP to dynamic strain at PEEP of 2 cm H2O (intraoperative FRC) (r=0.72 and r=0.73, both P<0.001). These relationships were maintained with higher PEEP only when aerated volume did not overcome FRCp (r=0.73, P<0.001; r=0.54, P=0.004), with 100 ml lung volume increases accompanied by 1.8 ml cm H2O-1 (95% confidence interval [1.1-2.5]) increases in CRS. When aerated volume was greater or equal to FRCp (35% of patients at PEEP 2 cm H2O, 55% at PEEP 7 cm H2O, and 75% at PEEP 12 cm H2O), CRS and ΔP were independent from aerated volume and dynamic strain, with CRS weakly but significantly inversely related to alveolar dead space fraction (r=-0.47, P=0.001). PEEP-induced alveolar recruitment yielded higher CRS and reduced ΔP only at aerated volumes below FRCp (P=0.015 and 0.008, respectively). CONCLUSIONS During general anaesthesia, respiratory system compliance and driving pressure reflect aerated lung volume and dynamic strain, respectively, only if aerated volume does not exceed functional residual capacity in supine position, which is a frequent event when PEEP is used in this setting.
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Affiliation(s)
- D L Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy.
| | - A Russo
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - B Romanò
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - G M Anzellotti
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - P Ciocchetti
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - F Torrini
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - R Barelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - D Eleuteri
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - V Perilli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - A M Dell'Anna
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - F Bongiovanni
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - L Sollazzi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - M Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
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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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Wirth S, Artner L, Broß T, Lozano-Zahonero S, Spaeth J, Schumann S. Intratidal recruitment/derecruitment persists at low and moderate positive end-expiratory pressure in paediatric patients. Respir Physiol Neurobiol 2016; 234:9-13. [PMID: 27585545 DOI: 10.1016/j.resp.2016.08.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/04/2016] [Accepted: 08/23/2016] [Indexed: 11/25/2022]
Abstract
In paediatric patients positive end-expiratory pressure (PEEP) is traditionally set lower than in adults. We investigated whether moderately higher PEEP improves respiratory mechanics and regional ventilation. Therefore, 40 children were mechanically ventilated with PEEP 2 and 5cmH2O. Volume-dependent compliance profiles were analysed as a measure of intratidal recruitment/derecruitment. Regional ventilation was assessed using electrical impedance tomography. Mean compliance was 17.9±9.9mLcmH2O-1 (PEEP 2cmH2O), and 19.0±10.9mLcmH2O-1 (PEEP 5 cmH2O, p<0.001). Strong intratidal recruitment/derecruitment occurred in 40% of children at PEEP 2 cmH2O, and 36% at PEEP 5 cmH2O. Children showing strong recruitment/derecruitment were 33 (PEEP 2 cmH20) and 20 (PEEP 5 cmH20) months younger than children showing moderate recruitment/derecruitment. A higher PEEP improved peripheral ventilation. In conclusion, mechanically ventilated paediatric patients undergo intratidal recruitment/derecruitment which occurs more prominently in younger than in older children. A PEEP of 5cmH2O does not fully prevent intratidal recruitment/derecruitment but homogenizes regional ventilation in comparison to 2cmH2O.
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Affiliation(s)
- Steffen Wirth
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg, Germany.
| | - Lisa Artner
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Tobias Broß
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Sara Lozano-Zahonero
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Johannes Spaeth
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, Medical Center-University of Freiburg, Faculty of Medicine, Freiburg, Germany
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