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Heath C, Hauser N. Is there a role for lung-protective ventilation in healthy children? Paediatr Anaesth 2022; 32:278-285. [PMID: 34839569 DOI: 10.1111/pan.14345] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 12/27/2022]
Abstract
Lung-protective ventilation (LPV) has been adopted in the theater environment as a strategy to reduce pulmonary complications under anesthesia. Postoperative pulmonary complications are not infrequent and may have significant implications on the postoperative length of stay as well as the morbidity and mortality of pediatric patients. There is evidence in the adult literature to suggest that intraoperative LPV strategies may reduce the risk of such complications. The utility of LPV strategies in healthy children is not well researched, and the data from critical care studies appear to be conflicting. To ascertain the value of intraoperative LPV in pediatric patients, it is important to understand the pathophysiology of pediatric ventilator-induced lung injury and the basis of LPV strategies. The current evidence in adult and pediatric populations, including pediatric intensive care, is reviewed to gain insight into the role and value of intraoperative LPV for pediatric patients.
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Affiliation(s)
- Chloe Heath
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia
| | - Neil Hauser
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, WA, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Nedlands, WA, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, the University of Western Australia, Perth, WA, Australia
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2
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Cagle LA, Franzi LM, Linderholm AL, Last JA, Adams JY, Harper RW, Kenyon NJ. Effects of positive end-expiratory pressure and recruitment maneuvers in a ventilator-induced injury mouse model. PLoS One 2017; 12:e0187419. [PMID: 29112971 PMCID: PMC5675408 DOI: 10.1371/journal.pone.0187419] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Accepted: 10/19/2017] [Indexed: 12/26/2022] Open
Abstract
Background Positive-pressure mechanical ventilation is an essential therapeutic intervention, yet it causes the clinical syndrome known as ventilator-induced lung injury. Various lung protective mechanical ventilation strategies have attempted to reduce or prevent ventilator-induced lung injury but few modalities have proven effective. A model that isolates the contribution of mechanical ventilation on the development of acute lung injury is needed to better understand biologic mechanisms that lead to ventilator-induced lung injury. Objectives To evaluate the effects of positive end-expiratory pressure and recruitment maneuvers in reducing lung injury in a ventilator-induced lung injury murine model in short- and longer-term ventilation. Methods 5–12 week-old female BALB/c mice (n = 85) were anesthetized, placed on mechanical ventilation for either 2 hrs or 4 hrs with either low tidal volume (8 ml/kg) or high tidal volume (15 ml/kg) with or without positive end-expiratory pressure and recruitment maneuvers. Results Alteration of the alveolar-capillary barrier was noted at 2 hrs of high tidal volume ventilation. Standardized histology scores, influx of bronchoalveolar lavage albumin, proinflammatory cytokines, and absolute neutrophils were significantly higher in the high-tidal volume ventilation group at 4 hours of ventilation. Application of positive end-expiratory pressure resulted in significantly decreased standardized histology scores and bronchoalveolar absolute neutrophil counts at low- and high-tidal volume ventilation, respectively. Recruitment maneuvers were essential to maintain pulmonary compliance at both 2 and 4 hrs of ventilation. Conclusions Signs of ventilator-induced lung injury are evident soon after high tidal volume ventilation (as early as 2 hours) and lung injury worsens with longer-term ventilation (4 hrs). Application of positive end-expiratory pressure and recruitment maneuvers are protective against worsening VILI across all time points. Dynamic compliance can be used guide the frequency of recruitment maneuvers to help ameloriate ventilator-induced lung injury.
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Affiliation(s)
- Laura A. Cagle
- Center for Comparative Respiratory Biology and Medicine, University of California, Davis, Davis, CA, United States of America
- * E-mail:
| | - Lisa M. Franzi
- Center for Comparative Respiratory Biology and Medicine, University of California, Davis, Davis, CA, United States of America
| | - Angela L. Linderholm
- Center for Comparative Respiratory Biology and Medicine, University of California, Davis, Davis, CA, United States of America
| | - Jerold A. Last
- Center for Comparative Respiratory Biology and Medicine, University of California, Davis, Davis, CA, United States of America
| | - Jason Y. Adams
- Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, University of California, Davis, Davis, CA, United States of America
| | - Richart W. Harper
- Center for Comparative Respiratory Biology and Medicine, University of California, Davis, Davis, CA, United States of America
- Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, University of California, Davis, Davis, CA, United States of America
| | - Nicholas J. Kenyon
- Center for Comparative Respiratory Biology and Medicine, University of California, Davis, Davis, CA, United States of America
- Division of Pulmonary, Critical Care, and Sleep Medicine, School of Medicine, University of California, Davis, Davis, CA, United States of America
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Jauncey-Cooke J, East CE, Bogossian F. Paediatric lung recruitment: a review of the clinical evidence. Paediatr Respir Rev 2015; 16:127-32. [PMID: 24680638 DOI: 10.1016/j.prrv.2014.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2012] [Revised: 02/13/2014] [Accepted: 02/15/2014] [Indexed: 12/21/2022]
Abstract
Lung recruitment is used as an adjunct to lung protective ventilation strategies. Lung recruitment is a brief, deliberate elevation of transpulmonary pressures beyond what is achieved during tidal ventilation levels. The aim of lung recruitment is to maximise the number of alveoli participating in gas exchange particularly in distal and dependant regions of the lung. This may improve oxygenation and end expiratory levels. Restoration of end expiratory levels and stabilisation of the alveoli may reduce the incidence of ventilator induced lung injury (VILI). Various methods of lung recruitment have been studied in adult and experimental populations. This review aims to establish the evidence for lung recruitment in the pediatric population.
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Affiliation(s)
- Jacqui Jauncey-Cooke
- School of Nursing & Midwifery, The University of Queensland, Australia; Paediatric Critical Care Research Group, PICU, Mater Children's Hospital, Brisbane, Australia.
| | - Chris E East
- School of Nursing and Midwifery/Maternity Services, Monash University/Southern Health, Clayton, Victoria and the School of Nursing & Midwifery, The University of Queensland, Australia.
| | - Fiona Bogossian
- School of Nursing & Midwifery, The University of Queensland, Australia.
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Jauncey-Cooke JI, Bogossian F, East CE. Lung recruitment--a guide for clinicians. Aust Crit Care 2009; 22:155-62. [PMID: 19679490 DOI: 10.1016/j.aucc.2009.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Revised: 05/12/2009] [Accepted: 06/04/2009] [Indexed: 12/31/2022] Open
Abstract
Recruitment manoeuvres play an important role in minimising ventilator associated lung injury (VALI) particularly when lung protective ventilation strategies are employed and as such clinicians should consider their application. This paper provides evidence-based recommendations for clinical practice with regard to alveolar recruitment. It includes recommendations for timing of recruitment, strategies of recruitment and methods of measuring the efficacy of recruitment manoeuvres and contributes to knowledge about the risks associated with recruitment manoeuvres. There are a range of methods for recruiting alveoli, most notably by manipulating positive end expiratory pressure (PEEP) and peak inspiratory pressure (PIP) with consensus as to the most effective not yet determined. A number of studies have demonstrated that improvement in oxygenation is rarely sustained following a recruitment manoeuvre and it is questionable whether improved oxygenation should be the clinician's goal. Transient haemodynamic compromise has been noted in a number of studies with a few studies reporting persistent, harmful sequelae to recruitment manoeuvres. No studies have been located that assess the impact of recruitment manoeuvres on length of ventilation, length of stay, morbidity or mortality. Recruitment manoeuvres restore end expiratory lung volume by overcoming threshold opening pressures and are most effective when applied after circuit disconnection and airway suction. Whether this ultimately improves outcomes in adult or paediatric populations is unknown.
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