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Bignami E, Spadaro S, Saglietti F, Di Lullo A, Corte FD, Guarnieri M, de Simone G, Giambuzzi I, Zangrillo A, Volta CA. Positive end-expiratory pressure (PEEP) level to prevent expiratory flow limitation during cardiac surgery: study protocol for a randomized clinical trial (EFLcore study). Trials 2018; 19:654. [PMID: 30477541 PMCID: PMC6258414 DOI: 10.1186/s13063-018-3046-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 11/11/2018] [Indexed: 11/11/2022] Open
Abstract
Background Lung dysfunction commonly occurs after cardiopulmonary bypass (CPB). Randomized evidence suggests that the presence of expiratory flow limitation (EFL) in major abdominal surgery is associated with postoperative pulmonary complications. Appropriate lung recruitment and a correctly set positive end-expiratory pressure (PEEP) level may prevent EFL. According to the available data in the literature, an adequate ventilation strategy during cardiac surgery is not provided. The aim of this study is to assess whether a mechanical ventilation strategy based on optimal lung recruitment with a best PEEP before and after CPB and with a continuous positive airway pressure (CPAP) during CPB would reduce the incidence of respiratory complications after cardiac surgery. Methods/design This will be a single-center, single-blind, parallel-group, randomized controlled trial. Using a 2-by-2 factorial design, high-risk adult patients undergoing elective cardiac surgery will be randomly assigned to receive either a best PEEP (calculated with a PEEP test) or zero PEEP before and after CPB and CPAP (equal to the best PEEP) or no ventilation (patient disconnected from the circuit) during CPB. The primary endpoint will be a composite endpoint of the incidence of EFL after the weaning from CPB and postoperative pulmonary complications. Discussion This study will help to establish a correct ventilatory strategy before, after, and during CPB. The main purpose is to establish if a ventilation based on a simple and feasible respiratory test may preserve lung function in cardiac surgery. Trial registration ClinicalTrials.gov, ID: NCT02633423. Registered on 6 December 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-3046-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Elena Bignami
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy. .,Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Viale Gramsci 14, 43126, Parma, Italy.
| | - Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Via Aldo Moro 8, 44121, Ferrara, Italy
| | - Francesco Saglietti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Antonio Di Lullo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Francesca Dalla Corte
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Via Aldo Moro 8, 44121, Ferrara, Italy
| | - Marcello Guarnieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Giulio de Simone
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Ilaria Giambuzzi
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Carlo Alberto Volta
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Via Aldo Moro 8, 44121, Ferrara, Italy
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Gao W, Li N, Jin ZH, Lv XQ, Cui XG. Effect of preoperative inhaled budesonide on pulmonary injury after cardiopulmonary bypass: A randomized pilot study. J Thorac Cardiovasc Surg 2018; 157:272-284. [PMID: 30396739 DOI: 10.1016/j.jtcvs.2018.09.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 08/23/2018] [Accepted: 09/04/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Cardiopulmonary bypass can result in lung injury. This prospective, double-blinded, randomized trial aimed to evaluate the protective effect of inhaled budesonide on lung injury after cardiopulmonary bypass. METHODS Sixty patients, aged 25 to 65 years, requiring cardiopulmonary bypass were randomized to groups treated with saline or budesonide inhalation preoperatively. The respiratory mechanics were recorded. Bronchoalveolar lavage fluid was collected before cardiopulmonary bypass and after sternal closure. Serum and bronchoalveolar lavage fluid levels of proinflammatory and anti-inflammatory factors were analyzed. The primary end point was the lowest ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen after cardiopulmonary bypass. The durations of ventilation and postoperative recovery time were noted. RESULTS Budesonide significantly improved respiratory mechanics after cardiopulmonary bypass. Budesonide improved the partial pressure of arterial oxygen to the fraction of inspired oxygen ratio from 8 to 48 hours after the operation. Budesonide shortened the durations of mechanical ventilation and postoperative recovery time. Budesonide decreased the levels of proinflammatory factors while increasing the levels of anti-inflammatory factors in bronchoalveolar lavage fluid and serum (all P < .05). The macrophage and neutrophil counts, and protein and elastase concentrations were decreased by budesonide treatment. CONCLUSIONS Budesonide treatment shortened the durations of mechanical ventilation, inhibited local and systemic inflammation, and improved respiratory function after cardiopulmonary bypass.
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Affiliation(s)
- Wei Gao
- Department of Anesthesiology, the Second Affiliated Hospital of the Harbin Medical University, Harbin 150081, Heilongjiang Province, China
| | - Na Li
- Department of Anesthesiology, the Second Affiliated Hospital of the Harbin Medical University, Harbin 150081, Heilongjiang Province, China
| | - Zhe-Hao Jin
- Department of Anesthesiology, the Second Affiliated Hospital of the Harbin Medical University, Harbin 150081, Heilongjiang Province, China
| | - Xiang-Qi Lv
- Department of Anesthesiology, the Second Affiliated Hospital of the Harbin Medical University, Harbin 150081, Heilongjiang Province, China
| | - Xiao-Guang Cui
- Department of Anesthesiology, the Second Affiliated Hospital of the Harbin Medical University, Harbin 150081, Heilongjiang Province, China.
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