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Scharffenberg M, Mandelli M, Bluth T, Simonassi F, Wittenstein J, Teichmann R, Birr K, Kiss T, Ball L, Pelosi P, Schultz MJ, Gama de Abreu M, Huhle R. Respiratory mechanics and mechanical power during low vs. high positive end-expiratory pressure in obese surgical patients - A sub-study of the PROBESE randomized controlled trial. J Clin Anesth 2024; 92:111242. [PMID: 37833194 DOI: 10.1016/j.jclinane.2023.111242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/21/2023] [Accepted: 08/26/2023] [Indexed: 10/15/2023]
Abstract
STUDY OBJECTIVE We aimed to characterize intra-operative mechanical ventilation with low or high positive end-expiratory pressure (PEEP) and recruitment manoeuvres (RM) regarding intra-tidal recruitment/derecruitment and overdistension using non-linear respiratory mechanics, and mechanical power in obese surgical patients enrolled in the PROBESE trial. DESIGN Prospective, two-centre substudy of the international, multicentre, two-arm, randomized-controlled PROBESE trial. SETTING Operating rooms of two European University Hospitals. PATIENTS Forty-eight adult obese patients undergoing abdominal surgery. INTERVENTIONS Intra-operative protective ventilation with either PEEP of 12 cmH2O and repeated RM (HighPEEP+RM) or 4 cmH2O without RM (LowPEEP). MEASUREMENTS The index of intra-tidal recruitment/de-recruitment and overdistension (%E2) as well as airway pressure, tidal volume (VT), respiratory rate (RR), resistance, elastance, and mechanical power (MP) were calculated from respiratory signals recorded after anesthesia induction, 1 h thereafter, and end of surgery (EOS). MAIN RESULTS Twenty-four patients were analyzed in each group. PEEP was higher (mean ± SD, 11.7 ± 0.4 vs. 3.7 ± 0.6 cmH2O, P < 0.001) and driving pressure lower (12.8 ± 3.5 vs. 21.7 ± 6.8 cmH2O, P < 0.001) during HighPEEP+RM than LowPEEP, while VT and RR did not differ significantly (7.3 ± 0.6 vs. 7.4 ± 0.8 ml∙kg-1, P = 0.835; and 14.6 ± 2.5 vs. 15.7 ± 2.0 min-1, P = 0.150, respectively). %E2 was higher in HighPEEP+RM than in LowPEEP following induction (-3.1 ± 7.2 vs. -12.4 ± 10.2%; P < 0.001) and subsequent timepoints. Total resistance and elastance (13.3 ± 3.8 vs. 17.7 ± 6.8 cmH2O∙l∙s-2, P = 0.009; and 15.7 ± 5.5 vs. 28.5 ± 8.4 cmH2O∙l, P < 0.001, respectively) were lower during HighPEEP+RM than LowPEEP. Additionally, MP was lower in HighPEEP+RM than LowPEEP group (5.0 ± 2.2 vs. 10.4 ± 4.7 J∙min-1, P < 0.001). CONCLUSIONS In this sub-cohort of PROBESE, intra-operative ventilation with high PEEP and RM reduced intra-tidal recruitment/de-recruitment as well as driving pressure, elastance, resistance, and mechanical power, as compared with low PEEP. TRIAL REGISTRATION The PROBESE study was registered at www. CLINICALTRIALS gov, identifier: NCT02148692 (submission for registration on May 23, 2014).
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Affiliation(s)
- Martin Scharffenberg
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Maura Mandelli
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16131 Genoa, Italy
| | - Thomas Bluth
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Francesca Simonassi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16131 Genoa, Italy
| | - Jakob Wittenstein
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Robert Teichmann
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Katharina Birr
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Thomas Kiss
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany; Department of Anaesthesiology, Intensive-, Pain- and Palliative Care Medicine, Radebeul Hospital, Academic Hospital of the Technische Universität Dresden, Heinrich-Zille-Strasse 13, 01445 Radebeul, Germany
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16131 Genoa, Italy; Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Largo Rosanna Benzi, 10, 16132 Genoa, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16131 Genoa, Italy; Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Largo Rosanna Benzi, 10, 16132 Genoa, Italy
| | - Marcus J Schultz
- Department of Intensive Care, Laboratory of Experimental Intensive Care & Anesthesiology (L E I C A), Amsterdam University Medical Centers, location AMC, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Marcelo Gama de Abreu
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany; Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, 44195, OH, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, 44195, OH, USA.
| | - Robert Huhle
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
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Romero CS, Cortegiani A, Luedi MM. New insights in mechanical ventilation in the obese patients. J Clin Anesth 2024; 92:111268. [PMID: 37863748 DOI: 10.1016/j.jclinane.2023.111268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 09/17/2023] [Indexed: 10/22/2023]
Affiliation(s)
- Carolina S Romero
- Department of Anaesthesiology and Critical Care, Hospital General Universitario De, Valencia, Valencia, Spain; Research Methods Department, Universidad Europea de, Valencia, Valencia, Spain; Outcomes Research Consortium, Cleveland, OH, USA.
| | - Andrea Cortegiani
- Department of Surgical Oncological and Oral Science, University of Palermo. Department of Anesthesia Analgesia Intensive Care and Mergency, University Hospital Policlinico Paolo Giaccone, Palermo, Italy.
| | - Markus M Luedi
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Habibi AF, Ashraf A, Ghanavi Z, Shakiba M, Nemati S, Aghsaghloo V. Positive End-Expiratory Pressure in Rhinoplasty Surgery; Risks and Benefits. Indian J Otolaryngol Head Neck Surg 2023; 75:2823-2828. [PMID: 37974774 PMCID: PMC10645805 DOI: 10.1007/s12070-023-03854-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/02/2023] [Indexed: 11/19/2023] Open
Abstract
Aims The aim of this study is to evaluate the effect of Positive End Expiratory Pressure (PEEP) on surgical field bleeding and its respiratory and hemodynamic consequences in rhinoplasty surgeries. Materials and methods This single-blind clinical trial performed in Amir Al-Momenin university Hospital in 2018. Seventy cases of rhinoplasty surgery patients Enrolled and were randomized into two groups; intervention (PEEP = 5) and comparison group (PEEP = 0). Surgical field bleeding and arterial oxygen saturation pulmonary dynamics and hemodynamic parameters were evaluated during operation and in post anesthesia care unit. Data were analyzed by SPSS software using descriptive and analytical statistics. Results PEEP applying had no negative effect on surgical bleeding as well as surgeon satisfaction, heart rate and blood pressure were similar in two groups. Pulmonary dynamics and oxygenation were stable and within normal values in all cases. The mean peak airway pressure was 17.87 ± 2.24 in the PEEP group and 16.08 ± 3.37 in the ZEEP group (P = 0.029). Conclusion applying low level PEEP during anesthesia improved recovery oxygen saturation but had no negative effects on the patient`s hemodynamics, and did not aggravate bleeding and visual clarity. Supplementary Information The online version contains supplementary material available at 10.1007/s12070-023-03854-7.
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Affiliation(s)
- Ali Faghih Habibi
- Otorhinolaryngology Research Center, Department of Otolaryngology and Head and Neck Surgery, School of Medicine, Amiralmomenin Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Ali Ashraf
- Clinical Research Development Unit of Poursina Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Zahra Ghanavi
- Department of Neurosurgery, School of Advanced Medical Sciences and Technologies, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Shakiba
- Department of Biostatics & Epidemiology, School of Health, Guilan University of Medical Sciences, Rasht, Iran
| | - Shadman Nemati
- Otorhinolaryngology Research Center, Department of Otolaryngology and Head and Neck Surgery, School of Medicine, Amiralmomenin Hospital, Guilan University of Medical Sciences, Rasht, Iran
| | - Vahid Aghsaghloo
- Otorhinolaryngology Research Center, Department of Otolaryngology and Head and Neck Surgery, School of Medicine, Amiralmomenin Hospital, Guilan University of Medical Sciences, Rasht, Iran
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Luo LF, Lin YM, Liu Y, Gao XH, Li CY, Zhang XQ, Wu JH, Chen ZY. Effect of individualized PEEP titration by ultrasonography on perioperative pulmonary protection and postoperative cognitive function in patients with chronic obstructive pulmonary disease. BMC Pulm Med 2023; 23:232. [PMID: 37380978 DOI: 10.1186/s12890-023-02471-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/06/2023] [Indexed: 06/30/2023] Open
Abstract
OBJECTIVE To evaluate the effect of the individualized positive end-expiratory pressure (PEEP) lung protection ventilation strategy by combining driving pressure (ΔP) and pulmonary ultrasound (LUS)-based titration on lung function and postoperative cognitive function in patients with chronic obstructive pulmonary disease (COPD) during laparoscopic surgery. METHODS A total of 108 patients with COPD undergoing laparoscopic gastrointestinal surgery under general anesthesia were included in this study. They were randomly divided into three groups (n = 36): traditional volume ventilation group (Group C), fixed PEEP 5 cmH2O group (Group P), and ΔP combined with LUS-based PEEP titration in the resuscitation room group (Group T). All three groups were given volume ventilation mode, I:E = 1:2; In group C, VT was 10 mL/kg and PEEP was 0 cmH2O; In groups P and T, VT was 6 mL/kg and PEEP was 5 cmH2O; After mechanical ventilation for 15 min in Group T, ΔP in combination with LUS was used to titrate PEEP. The oxygenation index (PaO2/FiO2), airway platform pressure (Pplat), dynamic lung compliance (Cdyn), Montreal Cognitive Assessment (MoCA), and venous interleukin-6(IL-6) were recorded at the corresponding time points, and the final PEEP value in Group T was recorded. RESULTS The final PEEP value of Group T was (6.4 ± 1.2) cmH2O; Compared with groups C and P: PaO2/FiO2 and Cdyn in Group T were significantly increased (P < 0.05) and value of IL-6 was significantly decreased (P < 0.05) at the corresponding time points. Compared with group C, the MoCA score on day 7 after surgery in Group T was significantly higher (P < 0.05). CONCLUSION Compared with the traditional ventilation strategy, the individualized ΔP combined with LUS-based PEEP titration in patients with COPD during the perioperative period of laparoscopic surgery can play a better role in lung protection and can improve postoperative cognitive function.
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Affiliation(s)
- Lai-Feng Luo
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, No.950 of Donghai street, Fengze District, Quanzhou, 362000, China
- Department of Anesthesiology, The Second Hospital of Sanming, Sanming City, 366000, Fujian Province, China
| | - Yu-Mei Lin
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, No.950 of Donghai street, Fengze District, Quanzhou, 362000, China
| | - Ying Liu
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, No.950 of Donghai street, Fengze District, Quanzhou, 362000, China
| | - Xiao-Hua Gao
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, No.950 of Donghai street, Fengze District, Quanzhou, 362000, China
| | - Chui-Yu Li
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, No.950 of Donghai street, Fengze District, Quanzhou, 362000, China
| | - Xiao-Qi Zhang
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, No.950 of Donghai street, Fengze District, Quanzhou, 362000, China
| | - Jian-Hua Wu
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, No.950 of Donghai street, Fengze District, Quanzhou, 362000, China.
| | - Zhi-Yuan Chen
- Department of Anesthesiology, the Second Affiliated Hospital of Fujian Medical University, No.950 of Donghai street, Fengze District, Quanzhou, 362000, China.
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Grieco DL, Russo A, Anzellotti GM, Romanò B, Bongiovanni F, Dell'Anna AM, Mauti L, Cascarano L, Gallotta V, Rosà T, Varone F, Menga LS, Polidori L, D'Indinosante M, Cappuccio S, Galletta C, Tortorella L, Costantini B, Gueli Alletti S, Sollazzi L, Scambia G, Antonelli M. Lung-protective ventilation during Trendelenburg pneumoperitoneum surgery: A randomized clinical trial. J Clin Anesth 2023; 85:111037. [PMID: 36495775 DOI: 10.1016/j.jclinane.2022.111037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/31/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
Study objective To assess the effects of a protective ventilation strategy during Trendelenburg pneumoperitoneum surgery on postoperative oxygenation. DESIGNS Parallel-group, randomized trial. SETTING Operating room of a university hospital, Italy. PATIENTS Morbidly obese patients undergoing Trendelenburg pneumoperitoneum gynaecological surgery. INTERVENTIONS Participants were randomized to standard (SV: tidal volume = 10 ml/kg of predicted body weight, PEEP = 5 cmH2O) or protective (PV: tidal volume = 6 ml/kg of predicted body weight, PEEP = 10 cmH2O, recruitment maneuvers) ventilation during anesthesia. MEASUREMENTS Primary outcome was PaO2/FiO2 one hour after extubation. Secondary outcomes included day-1 PaO2/FiO2, day-2 respiratory function and intraoperative respiratory/lung mechanics, assessed through esophageal manometry, end-expiratory lung volume (EELV) measurement and pressure-volume curves. MAIN RESULTS Sixty patients were analyzed (31 in SV group, 29 in PV group). Median [IqR] tidal volume was 350 ml [300-360] in PV group and 525 [500-575] in SV group. Median PaO2/FiO2 one hour after extubation was 280 mmHg [246-364] in PV group vs. 298 [250-343] in SV group (p = 0.64). Day-1 PaO2/FiO2, day-2 forced vital capacity, FEV-1 and Tiffenau Index were not different between groups (all p > 0.10). Intraoperatively, 59% of patients showed complete airway closure during pneumoperitoneum, without difference between groups: median airway opening pressure was 17 cmH2O. In PV group, airway and transpulmonary driving pressure were lower (12 ± 5 cmH2O vs. 17 ± 7, p < 0.001; 9 ± 4 vs. 13 ± 7, p < 0.001), PaCO2 and respiratory rate were higher (48 ± 8 mmHg vs. 42 ± 12, p < 0.001; 23 ± 5 breaths/min vs. 16 ± 4, p < 0.001). Intraoperative EELV was similar between PV and SV group (1193 ± 258 ml vs. 1207 ± 368, p = 0.80); ratio of tidal volume to EELV was lower in PV group (0.45 ± 0.12 vs. 0.32 ± 0.09, p < 0.001). CONCLUSIONS In obese patients undergoing Trendelenburg pneumoperitoneum surgery, PV did not improve postoperative oxygenation nor day-2 respiratory function. PV was associated with intraoperative respiratory mechanics indicating less injurious ventilation. The high prevalence of complete airway closure may have affected study results. TRIAL REGISTRATION Prospectively registered on http://clinicaltrials.govNCT03157479 on May 17th, 2017.
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Affiliation(s)
- Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Andrea Russo
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gian Marco Anzellotti
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Bruno Romanò
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Bongiovanni
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio M Dell'Anna
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Mauti
- Department of Internal medicine, Catholic University of The Sacred Heart, Rome, Italy; Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Laura Cascarano
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valerio Gallotta
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Rosà
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Varone
- Department of Internal medicine, Catholic University of The Sacred Heart, Rome, Italy; Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca S Menga
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lorenzo Polidori
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco D'Indinosante
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Serena Cappuccio
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudia Galletta
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lucia Tortorella
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Barbara Costantini
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Salvatore Gueli Alletti
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Liliana Sollazzi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Non-invasive over-distension measurements: data driven vs model-based. J Clin Monit Comput 2022; 37:389-398. [PMID: 35920951 DOI: 10.1007/s10877-022-00900-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 07/22/2022] [Indexed: 10/16/2022]
Abstract
Clinical measurements offer bedside monitoring aiming to minimise unintended over-distension, but have limitations and cannot be predicted for changes in mechanical ventilation (MV) settings and are only available in certain MV modes. This study introduces a non-invasive, real-time over-distension measurement, which is robust, predictable, and more intuitive than current methods. The proposed over-distension measurement, denoted as OD, is compared with the clinically proven stress index (SI). Correlation is analysed via R2 and Spearman rs. The OD safe range corresponding to the unit-less SI safe range (0.95-1.05) is calibrated by sensitivity and specificity test. Validation is fulfilled with 19 acute respiratory distress syndrome (ARDS) patients data (196 cases), including assessment across ARDS severity. Overall correlation between OD and SI yielded R2 = 0.76 and Spearman rs = 0.89. Correlation is higher considering only moderate and severe ARDS patients. Calibration of OD to SI yields a safe range defined: 0 ≤ OD ≤ 0.8 cmH2O. The proposed OD offers an efficient, general, real-time measurement of patient-specific lung mechanics, which is more intuitive and robust than SI. OD eliminates the limitations of SI in MV mode and its less intuitive lung status value. Finally, OD can be accurately predicted for new ventilator settings via its foundation in a validated predictive personalized lung mechanics model. Therefore, OD offers potential clinical value over current clinical methods.
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Qian M, Yang F, Zhao L, Shen J, Xie Y. Individualized positive end-expiratory pressure titration on respiration and circulation in elderly patients undergoing spinal surgery in prone position under general anesthesia. Am J Transl Res 2021; 13:13835-13844. [PMID: 35035723 PMCID: PMC8748121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/11/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVE To investigate the effect of individualized positive end-expiratory pressure (PEEP) titration on intraoperative respiration and circulation in elderly patients undergoing spinal surgery in prone position under general anesthesia. METHODS We prospectively selected 80 elderly patients (39 males and 41 females) aged over 65 years old, at American Society of Anesthesiologists (ASA) grade II or III, who underwent elective prone spinal surgery under general anesthesia, for this study. These patients were randomly divided into titration group and control group, with 40 cases in each group. PEEP of the titration group was increased from 0 to 20 cmH2O by steps of 2 cmH2O. For the control group, PEEP was constantly at 5 cmH2O and ventilation was maintained throughout the surgery. Dynamic pulmonary compliance (Cdyn) measurements were recorded when each PEEP level was kept for 1 min during titration, and individualized PEEP was determined by maximal Cdyn. MAP (mean arterial pressure), heart rate (HR), and CVP (Central venous pressure) were recorded at the set of prone position (T0), PEEP ventilation for 10 min (T1), 30 min (T2), 60 min (T3), end of surgery (T4), and 20 min after extubation (T5). Mean airway pressure (Pmean) and Cdyn were recorded from T0 to T4. Blood gas analysis was performed from T0 to T5 to calculate intrapulmonary shunt fraction (Qs/Qt) and OI (PaO2/FiO2). The rate of phenylephrine use during mechanical ventilation and the incidence of postoperative pulmonary complications were also recorded. RESULTS The individualized PEEP obtained by titration for 1 min in the titration group was (12.38±2.67) cmH2O, which was significantly higher than the 5 cmH2O in constant PEEP of the control group (P<0.05). There was no significant difference in MAP, HR, and CVP between the two groups at different time points, and no significant difference was noted in Pmean between the two groups from T0 to T4 (all P>0.05). From T2 to T4, Cdyn was significantly higher, and Qs/Qt was lower in the titration group than those in the control group (all P<0.05). From T2 to T5, the OI in the titration group was significantly higher than that in the control group (P<0.05). The rate of phenylephrine use was significantly higher in the titration group than that in the control group (10 patients (25%) vs. 3 patients (8%), P<0.05). The incidence of postoperative pulmonary complications in the titration group was significantly lower than that in the control group (2 cases (5%) vs. 8 cases (20%), P<0.05). CONCLUSION Compared with a constant PEEP of 5 cmH2O, intraoperative individualized PEEP titration in elderly patients undergoing spinal surgery in prone position can improve oxygenation, reduce intrapulmonary shunt and postoperative pulmonary complications. (Chinese Clinical Trial Registry, registration number ChiCTR2000040722, https://www.chictr.org.cn).
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Affiliation(s)
- Meijuan Qian
- Department of Anesthesiology, Gusu School, Nanjing Medical University, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal HospitalSuzhou 215002, Jiangsu Province, China
| | - Fen Yang
- Department of Anesthesiology, Gusu School, Nanjing Medical University, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal HospitalSuzhou 215002, Jiangsu Province, China
| | - Lihong Zhao
- Department of Anesthesiology, Gusu School, Nanjing Medical University, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal HospitalSuzhou 215002, Jiangsu Province, China
| | - Jun Shen
- Department of Orthopaedic Surgery, Gusu School, Nanjing Medical University, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal HospitalSuzhou 215002, Jiangsu Province, China
| | - Yang Xie
- Department of Anesthesiology, Gusu School, Nanjing Medical University, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal HospitalSuzhou 215002, Jiangsu Province, China
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Postoperative pulmonale Komplikationen nach chirurgischen Eingriffen. ANÄSTHESIE NACHRICHTEN 2021. [PMCID: PMC8720644 DOI: 10.1007/s44179-021-0039-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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García-Sanz V, Aguado D, Gómez de Segura IA, Canfrán S. Individualized positive end-expiratory pressure following alveolar recruitment manoeuvres in lung-healthy anaesthetized dogs: a randomized clinical trial on early postoperative arterial oxygenation. Vet Anaesth Analg 2021; 48:841-853. [PMID: 34391669 DOI: 10.1016/j.vaa.2021.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 01/26/2021] [Accepted: 03/27/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To assess and compare the effect of intraoperative stepwise alveolar recruitment manoeuvres (ARMs), followed by individualized positive end-expiratory pressure (PEEP), defined as PEEP at maximal respiratory system compliance + 2 cmH2O (PEEPmaxCrs+2), with that of spontaneous ventilation (SV) and controlled mechanical ventilation (CMV) without ARM or PEEP on early postoperative arterial oxygenation in anaesthetized healthy dogs. STUDY DESIGN Prospective, randomized, nonblinded clinical study. ANIMALS A total of 32 healthy client-owned dogs undergoing surgery in dorsal recumbency. METHODS Dogs were ventilated intraoperatively (inspired oxygen fraction: 0.5) with one of the following strategies: SV, CMV alone, and CMV with PEEPmaxCrs+2 following a single ARM (ARM1) or two ARMs (ARM2, the second ARM at the end of surgery). Arterial blood gas analyses were performed before starting the ventilatory strategy, at the end of surgery, and at 5, 10, 15, 30 and 60 minutes after extubation while breathing room air. Data were analysed using Kruskal-Wallis and Friedman tests (p < 0.050). RESULTS At any time point after extubation, PaO2 was not significantly different between groups. At 5 minutes after extubation, PaO2 was 95.1 (78.1-104.0), 93.8 (88.3-104.0), 96.9 (86.6-115.0) and 89.1 (87.6-102.0) mmHg in the SV, CMV, ARM1 and ARM2 groups, respectively. PaO2 decreased at 30 minutes after extubation in the CMV, ARM1 and ARM2 groups (p < 0.050), but it did not decrease after 30 minutes in the SV group. Moderate hypoxaemia (PaO2, 60-80 mmHg) was observed in one dog in the ARM1 group and two dogs each in the SV and ARM2 groups. CONCLUSIONS AND CLINICAL RELEVANCE Intraoperative ARMs, followed by PEEPmaxCrs+2, did not improve early postoperative arterial oxygenation compared with SV or CMV alone in healthy anaesthetized dogs. Therefore, this ventilatory strategy might not be clinically advantageous for improving postoperative arterial oxygenation in healthy dogs undergoing surgery when positioned in dorsal recumbency.
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Affiliation(s)
- Virginia García-Sanz
- Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Madrid, Spain
| | - Delia Aguado
- Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Madrid, Spain.
| | - Ignacio A Gómez de Segura
- Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Madrid, Spain
| | - Susana Canfrán
- Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Madrid, Spain
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Effects of two stepwise lung recruitment strategies on respiratory function and haemodynamics in anaesthetised pigs: A randomised crossover study. Eur J Anaesthesiol 2021; 38:634-643. [PMID: 33967255 DOI: 10.1097/eja.0000000000001480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Lung recruitment manoeuvres and positive end-expiratory pressure (PEEP) can improve lung function during general anaesthesia. Different recruitment manoeuvre strategies have been described in large international trials: in the protective ventilation using high vs. low PEEP (PROVHILO) strategy, tidal volume (VT) was increased during volume-controlled ventilation; in the individualised peri-operative open-lung approach vs. standard protective ventilation in abdominal surgery (iPROVE) strategy, PEEP was increased during pressure-controlled ventilation. OBJECTIVES To compare the effects of the PROVHILO strategy and the iPROVE strategy on respiratory and haemodynamic variables. DESIGN Randomised crossover study. SETTING University hospital research facility. ANIMALS A total of 20 juvenile anaesthetised pigs. INTERVENTIONS Animals were assigned randomly to one of two sequences: PROVHILO strategy followed by iPROVE strategy or vice-versa (n = 10/sequence). In the PROVHILO strategy, VT was increased stepwise by 4 ml kg-1 at a fixed PEEP of 12 cmH2O until a plateau pressure of 30 to 35 cmH2O was reached. In the iPROVE strategy, at fixed driving pressure of 20 cmH2O, PEEP was increased up to 20 cmH2O followed by PEEP titration according to the lowest elastance of the respiratory system (ERS). MAIN OUTCOME MEASURES We assessed regional transpulmonary pressure (Ptrans), respiratory system mechanics, gas exchange and haemodynamics, as well as the centre of ventilation (CoV) by electrical impedance tomography. RESULTS During recruitment manoeuvres with the PROVHILO strategy compared with the iPROV strategy, dorsal Ptrans was lower at end-inspiration (16.3 ± 2.7 vs. 18.6 ± 3.1 cmH2O, P = 0.001) and end-expiration (4.8 ± 2.6 vs. 8.8 ± 3.4 cmH2O, P < 0.001), and mean arterial pressure (MAP) was higher (77 ± 11 vs. 60 ± 14 mmHg, P < 0.001). At 1 and 15 min after recruitment manoeuvres, ERS was higher in the PROVHILO strategy than the iPROVE strategy (24.6 ± 3.9 vs. 21.5 ± 3.4 and 26.7 ± 4.3 vs. 24.0 ± 3.8 cmH2O l-1; P < 0.001, respectively). At 1 min, PaO2 was lower in PROVHILO compared with iPROVE strategy (57.1 ± 6.1 vs. 59.3 ± 5.1 kPa, P = 0.013), but at 15 min, values did not differ. CoV did not differ between strategies. CONCLUSION In anaesthetised pigs, the iPROVE strategy compared with the PROVHILO strategy increased dorsal Ptrans at the cost of lower MAP during recruitment manoeuvres, and decreased ERS thereafter, without consistent improvement of oxygenation or shift of the CoV. TRIAL REGISTRATION This study was registered and approved by the Landesdirektion Dresden, Germany (DD24-5131/338/28).
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Perioperative Open-lung Approach, Regional Ventilation, and Lung Injury in Cardiac Surgery. Anesthesiology 2020; 133:1029-1045. [PMID: 32902561 DOI: 10.1097/aln.0000000000003539] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND In the Protective Ventilation in Cardiac Surgery (PROVECS) randomized, controlled trial, an open-lung ventilation strategy did not improve postoperative respiratory outcomes after on-pump cardiac surgery. In this prespecified subanalysis, the authors aimed to assess the regional distribution of ventilation and plasma biomarkers of lung epithelial and endothelial injury produced by that strategy. METHODS Perioperative open-lung ventilation consisted of recruitment maneuvers, positive end-expiratory pressure (PEEP) = 8 cm H2O, and low-tidal volume ventilation including during cardiopulmonary bypass. Control ventilation strategy was a low-PEEP (2 cm H2O) low-tidal volume approach. Electrical impedance tomography was used serially throughout the perioperative period (n = 56) to compute the dorsal fraction of ventilation (defined as the ratio of dorsal tidal impedance variation to global tidal impedance variation). Lung injury was assessed serially using biomarkers of epithelial (soluble form of the receptor for advanced glycation end-products, sRAGE) and endothelial (angiopoietin-2) lung injury (n = 30). RESULTS Eighty-six patients (age = 64 ± 12 yr; EuroSCORE II = 1.65 ± 1.57%) undergoing elective on-pump cardiac surgery were studied. Induction of general anesthesia was associated with ventral redistribution of tidal volumes and higher dorsal fraction of ventilation in the open-lung than the control strategy (0.38 ± 0.07 vs. 0.30 ± 0.10; P = 0.004). No effect of the open-lung strategy on the dorsal fraction of ventilation was noted at the end of surgery after median sternotomy closure (open-lung = 0.37 ± 0.09 vs. control = 0.34 ± 0.11; P = 0.743) or in extubated patients at postoperative day 2 (open-lung = 0.63 ± 0.18 vs. control = 0.59 ± 0.11; P > 0.999). Open-lung ventilation was associated with increased intraoperative plasma sRAGE (7,677 ± 3,097 pg/ml vs. 6,125 ± 1,400 pg/ml; P = 0.037) and had no effect on angiopoietin-2 (P > 0.999). CONCLUSIONS In cardiac surgery patients, open-lung ventilation provided larger dorsal lung ventilation early during surgery without a maintained benefit as compared with controls at the end of surgery and postoperative day 2 and was associated with higher intraoperative plasma concentration of sRAGE suggesting lung overdistension. EDITOR’S PERSPECTIVE
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Schumann S, Feth A, Borgmann S, Wirth S. Dependency of respiratory system mechanics on positive end-expiratory pressure and recruitment maneuvers in lung healthy pediatric patients-A randomized crossover study. Paediatr Anaesth 2020; 30:905-911. [PMID: 32445609 DOI: 10.1111/pan.13927] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/07/2020] [Accepted: 05/14/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The lungs of pediatric patients are subjected to tidal derecruitment during mechanical ventilation and in contrast to adult patients this unfavorable condition cannot be resolved with small c increases. This raises the question if higher end-expiratory pressure increases or recruitment maneuvers may resolve tidal derecruitment in pediatric patients. AIMS We hypothesized that higher PEEP resolves tidal derecruitment in pediatric patients and that recruitment maneuvers between the pressure changes support the improvement of respiratory system mechanics. METHODS The effects of end-expiratory pressure changes from 3 to 7 cmH2 O and vice versa without and with intermediate recruitment maneuvers on respiratory system mechanics and regional ventilation were investigated in 57 mechanically ventilated pediatric patients. The intratidal respiratory system compliance was determined from volume and pressure data before and after PEEP changes and categorized to indicate tidal derecruitment. RESULTS Tidal derecruitment occurred comparably frequently at PEEP 3 cmH2 O without (13 out of 14 cases) and with recruitment maneuver (14 out of 14 cases) and at PEEP 7 cmH2 O without (13 out of 14 cases) and with recruitment maneuver (13 out of 15 cases). CONCLUSIONS We conclude that contrary to our hypothesis, PEEP up to 7 cmH2 O is not sufficient to resolve tidal derecruitment and that recruitment maneuvers may be dispensable in mechanically ventilated pediatric patients.
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Affiliation(s)
- Stefan Schumann
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Arne Feth
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Silke Borgmann
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Steffen Wirth
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Freiburg, Germany
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Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations. Br J Anaesth 2019; 123:898-913. [DOI: 10.1016/j.bja.2019.08.017] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 07/22/2019] [Accepted: 08/04/2019] [Indexed: 12/16/2022] Open
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García-Sanz V, Aguado D, Gómez de Segura IA, Canfrán S. Comparative effects of open-lung positive end-expiratory pressure (PEEP) and fixed PEEP on respiratory system compliance in the isoflurane anaesthetised healthy dog. Res Vet Sci 2019; 127:91-98. [PMID: 31683197 DOI: 10.1016/j.rvsc.2019.10.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 12/18/2022]
Abstract
This study was performed to assess the effects of open-lung positive end-expiratory pressure (OL-PEEP) following stepwise recruitment manoeuvre (RM) and those of a fixed PEEP of 5 cm H2O without previous RM on respiratory system compliance (Crs) and selected cardiovascular variables in healthy dogs under general anaesthesia. Forty-five healthy client-owned dogs undergoing surgery were anaesthetised and mechanically ventilated (tidal volume, VT = 10-12 mL/kg; PEEP = 0 cm H2O) for 1 min (baseline) and randomly allocated into zero positive end-expiratory pressure (ZEEP), PEEP (5 cm H2O) and OL-PEEP treatment groups. In the OL-PEEP group, a stepwise RM was performed and the individual OL-PEEP was subsequently applied. The Crs, heart rate (HR) and non-invasive mean arterial pressure (NIMAP) were registered at baseline and then every 10 min during 60 min. In the ZEEP group, Crs decreased from baseline. In the PEEP group, Crs was not different from either baseline or ZEEP group values. In the OL-PEEP group, Crs was higher than both baseline and ZEEP group values at all time points as well as of those in the PEEP group during at least 20 min after RM. There were no differences for HR and NIMAP between groups. A clinically relevant hypotension following RM was observed in 40% of dogs. Therefore, an individually set OL-PEEP following stepwise RM improved Crs in anaesthetised healthy dogs, although transient but clinically relevant hypotension was observed during RM in some dogs. Fixed PEEP of 5 cm H2O without previous RM did not improve Crs, although it prevented it from decreasing.
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Affiliation(s)
- Virginia García-Sanz
- Anaesthesiology Service, Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Avda. Puerta de Hierro s/n, 28040 Madrid, Spain.
| | - Delia Aguado
- Anaesthesiology Service, Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Avda. Puerta de Hierro s/n, 28040 Madrid, Spain.
| | - Ignacio A Gómez de Segura
- Anaesthesiology Service, Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Avda. Puerta de Hierro s/n, 28040 Madrid, Spain.
| | - Susana Canfrán
- Anaesthesiology Service, Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Avda. Puerta de Hierro s/n, 28040 Madrid, Spain.
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Effect of open-lung vs conventional perioperative ventilation strategies on postoperative pulmonary complications after on-pump cardiac surgery: the PROVECS randomized clinical trial. Intensive Care Med 2019; 45:1401-1412. [PMID: 31576435 PMCID: PMC9889189 DOI: 10.1007/s00134-019-05741-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/09/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate whether a perioperative open-lung ventilation strategy prevents postoperative pulmonary complications after elective on-pump cardiac surgery. METHODS In a pragmatic, randomized, multicenter, controlled trial, we assigned patients planned for on-pump cardiac surgery to either a conventional ventilation strategy with no ventilation during cardiopulmonary bypass (CPB) and lower perioperative positive end-expiratory pressure (PEEP) levels (2 cm H2O) or an open-lung ventilation strategy that included maintaining ventilation during CPB along with perioperative recruitment maneuvers and higher PEEP levels (8 cm H2O). All study patients were ventilated with low-tidal volumes before and after CPB (6 to 8 ml/kg of predicted body weight). The primary end point was a composite of pulmonary complications occurring within the first 7 postoperative days. RESULTS Among 493 randomized patients, 488 completed the study (mean age, 65.7 years; 360 (73.7%) men; 230 (47.1%) underwent isolated valve surgery). Postoperative pulmonary complications occurred in 133 of 243 patients (54.7%) assigned to open-lung ventilation and in 145 of 245 patients (59.2%) assigned to conventional ventilation (p = 0.32). Open-lung ventilation did not significantly reduce the use of high-flow nasal oxygenotherapy (8.6% vs 9.4%; p = 0.77), non-invasive ventilation (13.2% vs 15.5%; p = 0.46) or new invasive mechanical ventilation (0.8% vs 2.4%, p = 0.28). Mean alive ICU-free days at postoperative day 7 was 4.4 ± 1.3 days in the open-lung group vs 4.3 ± 1.3 days in the conventional group (mean difference, 0.1 ± 0.1 day, p = 0.51). Extra-pulmonary complications and adverse events did not significantly differ between groups. CONCLUSIONS A perioperative open-lung ventilation including ventilation during CPB does not reduce the incidence of postoperative pulmonary complications as compared with usual care. This finding does not support the use of such a strategy in patients undergoing on-pump cardiac surgery. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT02866578. https://clinicaltrials.gov/ct2/show/NCT02866578.
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16
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Cereda M, Xin Y, Goffi A, Herrmann J, Kaczka DW, Kavanagh BP, Perchiazzi G, Yoshida T, Rizi RR. Imaging the Injured Lung: Mechanisms of Action and Clinical Use. Anesthesiology 2019; 131:716-749. [PMID: 30664057 PMCID: PMC6692186 DOI: 10.1097/aln.0000000000002583] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Acute respiratory distress syndrome (ARDS) consists of acute hypoxemic respiratory failure characterized by massive and heterogeneously distributed loss of lung aeration caused by diffuse inflammation and edema present in interstitial and alveolar spaces. It is defined by consensus criteria, which include diffuse infiltrates on chest imaging-either plain radiography or computed tomography. This review will summarize how imaging sciences can inform modern respiratory management of ARDS and continue to increase the understanding of the acutely injured lung. This review also describes newer imaging methodologies that are likely to inform future clinical decision-making and potentially improve outcome. For each imaging modality, this review systematically describes the underlying principles, technology involved, measurements obtained, insights gained by the technique, emerging approaches, limitations, and future developments. Finally, integrated approaches are considered whereby multimodal imaging may impact management of ARDS.
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Affiliation(s)
- Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, ON, Canada
| | - Jacob Herrmann
- Departments of Anesthesia and Biomedical Engineering, University of Iowa, IA
| | - David W. Kaczka
- Departments of Anesthesia, Radiology, and Biomedical Engineering, University of Iowa, IA
| | | | - Gaetano Perchiazzi
- Hedenstierna Laboratory and Uppsala University Hospital, Uppsala University, Sweden
| | - Takeshi Yoshida
- Hospital for Sick Children, University of Toronto, ON, Canada
| | - Rahim R. Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
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Spaeth J, Schmidt J, Wirth S, Schumann S. Intratidal Analysis of Intraoperative Respiratory System Mechanics. Anesth Analg 2018; 126:724-725. [PMID: 29346211 DOI: 10.1213/ane.0000000000002555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Johannes Spaeth
- Department of Anesthesiology and Critical Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany,
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Pelosi P, Ball L. Should we titrate ventilation based on driving pressure? Maybe not in the way we would expect. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:389. [PMID: 30460263 DOI: 10.21037/atm.2018.09.48] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Mechanical ventilation maintains adequate gas exchange in patients during general anaesthesia, as well as in critically ill patients without and with acute respiratory distress syndrome (ARDS). Optimization of mechanical ventilation is important to minimize ventilator induced lung injury and improve outcome. Tidal volume (VT), positive end-expiratory pressure (PEEP), respiratory rate (RR), plateau pressures as well as inspiratory oxygen are the main parameters to set mechanical ventilation. Recently, the driving pressure (∆P), i.e., the difference of the plateau pressure and end-expiratory pressure of the respiratory system or of the lung, has been proposed as a key role parameter to optimize mechanical ventilation parameters. The ∆P depends on the VT as well as on the relative balance between the amount of aerated and/or overinflated lung at end-expiration and end-inspiration at different levels of PEEP. During surgery, higher ∆P, mainly due to VT, was progressively associated with an increased risk to develop post-operative pulmonary complications; in two large randomized controlled trials the reduction in ∆P by PEEP did not result in better outcome. In non-ARDS patients, ∆P was not found even associated with morbidity and mortality. In ARDS patients, an association between ∆P (higher than 13-15 cmH2O) and mortality has been reported. In several randomized controlled trials, when ∆P was minimized by the use of higher PEEP with or without recruitment manoeuvres, this strategy resulted in equal or even higher mortality. No clear data are currently available about the interpretation and clinical use of ∆P during assisted ventilation. In conclusion, ∆P is an indicator of severity of the lung disease, is related to VT size and associated with complications and mortality. We advocate the use of ∆P to optimize individually VT but not PEEP in mechanically ventilated patients with and without ARDS.
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Affiliation(s)
- Paolo Pelosi
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy.,Policlinico San Martino, IRCCS per l'Oncologia, Genova, Italy
| | - Lorenzo Ball
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy.,Policlinico San Martino, IRCCS per l'Oncologia, Genova, Italy
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Ball L, Costantino F, Fiorito M, Amodio S, Pelosi P. Respiratory mechanics during general anaesthesia. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:379. [PMID: 30460253 DOI: 10.21037/atm.2018.09.50] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intraoperative mechanical ventilation is mandatory during many surgical procedures. Knowledge in this field has been widely derived from the experience in the treatment of patients with acute respiratory distress syndrome in the intensive care unit. However, also in surgical patients without lung injury, mechanical ventilation settings affect the clinical outcome, and in particular the occurrence of postoperative pulmonary complications (PPCs). A deep understanding of respiratory physiology is mandatory for the clinician, in order to tailor ventilation settings based on the specific characteristics of each patient. In this paper we will discuss the basis of lung physiology applied to the mechanical ventilation in the operating room. The role of compliance, tidal volume, positive end-expiratory pressure (PEEP), plateau pressure, driving pressure, stress index, mechanical power and other ventilator-derived parameters will be discussed. The above-mentioned physiological parameters are easy to measure and can guide the clinician to assess and titrate mechanical ventilation parameters, but the clinical impact of guiding mechanical ventilation based on these parameters has yet to be determined.
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Affiliation(s)
- Lorenzo Ball
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Federico Costantino
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Martina Fiorito
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Sara Amodio
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Paolo Pelosi
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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20
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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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Soares JHN, Carvalho AR, Bergamini BC, Gress MAK, Jandre FC, Zin WA, Giannella-Neto A. Alveolar Tidal recruitment/derecruitment and Overdistension During Four Levels of End-Expiratory Pressure with Protective Tidal Volume During Anesthesia in a Murine Lung-Healthy Model. Lung 2018; 196:335-342. [DOI: 10.1007/s00408-018-0096-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 02/05/2018] [Indexed: 12/16/2022]
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Huhle R, D’Antini D, Herrmann J, Raimondo P, Mirabella L, Hemmes SNT, Schultz MJ, Pelosi P, Kaczka DW, Cinnella G, Gama de Abreu M. Intratidal Analysis of Intraoperative Respiratory System Mechanics. Anesth Analg 2018; 126:725-726. [DOI: 10.1213/ane.0000000000002556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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