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Posa D, Sbaraglia F, Ferrone G, Rossi M. Driving pressure: A useful tool for reducing postoperative pulmonary complications. World J Crit Care Med 2024; 13:96214. [DOI: 10.5492/wjccm.v13.i3.96214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 06/07/2024] [Accepted: 06/25/2024] [Indexed: 08/30/2024] Open
Abstract
The operating room is a unique environment where surgery exposes patients to non-physiological changes that can compromise lung mechanics. Therefore, raising clinicians’ awareness of the potential risk of ventilator-induced lung injury (VILI) is mandatory. Driving pressure is a useful tool for reducing lung complications in patients with acute respiratory distress syndrome and those undergoing elective surgery. Driving pressure has been most extensively studied in the context of single-lung ventilation during thoracic surgery. However, the awareness of association of VILI risk and patient positioning (prone, beach-chair, park-bench) and type of surgery must be raised.
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Affiliation(s)
- Domenico Posa
- Department of Emergency, Intensive Care Medicine and Anaesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Lazio, Italy
| | - Fabio Sbaraglia
- Department of Emergency, Intensive Care Medicine and Anaesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Lazio, Italy
| | - Giuliano Ferrone
- Department of Emergency, Intensive Care Medicine and Anaesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Lazio, Italy
| | - Marco Rossi
- Department of Emergency, Intensive Care Medicine and Anaesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome 00168, Lazio, Italy
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Zaidi SF, Shaikh A, Khan DA, Surani S, Ratnani I. Driving pressure in mechanical ventilation: A review. World J Crit Care Med 2024; 13:88385. [PMID: 38633474 PMCID: PMC11019631 DOI: 10.5492/wjccm.v13.i1.88385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 12/04/2023] [Accepted: 01/05/2024] [Indexed: 03/05/2024] Open
Abstract
Driving pressure (∆P) is a core therapeutic component of mechanical ventilation (MV). Varying levels of ∆P have been employed during MV depending on the type of underlying pathology and severity of injury. However, ∆P levels have also been shown to closely impact hard endpoints such as mortality. Considering this, conducting an in-depth review of ∆P as a unique, outcome-impacting therapeutic modality is extremely important. There is a need to understand the subtleties involved in making sure ∆P levels are optimized to enhance outcomes and minimize harm. We performed this narrative review to further explore the various uses of ∆P, the different parameters that can affect its use, and how outcomes vary in different patient populations at different pressure levels. To better utilize ∆P in MV-requiring patients, additional large-scale clinical studies are needed.
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Affiliation(s)
- Syeda Farheen Zaidi
- Department of Medicine, Queen Mary University, London E1 4NS, United Kingdom
| | - Asim Shaikh
- Department of Medicine, Aga Khan University, Sindh, Karachi 74500, Pakistan
| | - Daniyal Aziz Khan
- Department of Medicine, Jinnah Postgraduate Medical Center, Sindh, Karachi 75510, Pakistan
| | - Salim Surani
- Department of Medicine and Pharmacology, Texas A and M University, College Station, TX 77843, United States
| | - Iqbal Ratnani
- Department of Anesthesiology and Critical Care, Houston Methodist Hospital, Houston, TX 77030, United States
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Jing HD, Tian JY, Li W, He BL, Li HC, Jian FX, Shang C, Shen F. Predictive performance of the variation rate of the driving pressure on the outcome of invasive mechanical ventilation in patients with acute respiratory distress syndrome. Chin J Traumatol 2024; 27:107-113. [PMID: 38326140 DOI: 10.1016/j.cjtee.2024.01.004] [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: 10/07/2023] [Revised: 12/06/2023] [Accepted: 12/18/2023] [Indexed: 02/09/2024] Open
Abstract
PURPOSE To assess the value of the driving pressure variation rate (ΔP%) in predicting the outcome of weaning from invasive mechanical ventilation in patients with acute respiratory distress syndrome. METHODS In this case-control study, a total of 35 patients with moderate-severe acute respiratory distress syndrome were admitted to the intensive care unit between January 2022 and December 2022 and received invasive mechanical ventilation for at least 48 h were enrolled. Patients were divided into successful weaning group and failed weaning group depending on whether they could be removed from ventilator support within 14 days. Outcome measures including driving pressure, PaO2:FiO2, and positive end-expiratory pressure, etc. were assessed every 24 h from day 0 to day 14 until successful weaning was achieved. The measurement data of non-normal distribution were presented as median (Q1, Q3), and the differences between groups were compared by Wilcoxon rank sum test. And categorical data use the Chi-square test or Fisher's exact test to compare. The predictive value of ΔP% in predicting the outcome of weaning from the ventilator was analyzed using receiver operating characteristic curves. RESULTS Of the total 35 patients included in the study, 17 were successful vs. 18 failed in weaning from a ventilator after 14 days of mechanical ventilation. The cut-off values of the median ΔP% measured by Operator 1 vs. Operator 2 in the first 4 days were ≥ 4.17% and 4.55%, respectively (p < 0.001), with the area under curve of 0.804 (sensitivity of 88.2%, specificity of 64.7%) and 0.770 (sensitivity of 88.2%, specificity of 64.7%), respectively. There was a significant difference in mechanical ventilation duration between the successful weaning group and the failure weaning group (8 (6, 13) vs. 12 (7.5, 17.3), p = 0.043). The incidence of ventilator-associated pneumonia in the successful weaning group was significantly lower than in the failed weaning group (0.2‰ vs. 2.3‰, p = 0.001). There was a significant difference noted between these 2 groups in the 28-day mortality (11.8% vs. 66.7%, p = 0.003). CONCLUSION The median ΔP% in the first 4 days of mechanical ventilation showed good predictive performance in predicting the outcome of weaning from mechanical ventilation within 14 days. Further study is needed to confirm this finding.
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Affiliation(s)
- Hui-Dan Jing
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China; Department of Intensive Care Unit, Army Medical Center of PLA, Chongqing, 400042, China
| | - Jun-Ying Tian
- College of Foreign Languages, Chongqing Medical University, Chongqing, 400016, China
| | - Wei Li
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Bing-Ling He
- Department of Intensive Care Unit, Army Medical Center of PLA, Chongqing, 400042, China
| | - Hong-Chao Li
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China
| | - Fu-Xia Jian
- Department of Intensive Care Unit, Army Medical Center of PLA, Chongqing, 400042, China
| | - Cui Shang
- Department of Intensive Care Unit, Army Medical Center of PLA, Chongqing, 400042, China
| | - Feng Shen
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China.
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Piccioni F, Langiano N, Bignami E, Guarnieri M, Proto P, D'Andrea R, Mazzoli CA, Riccardi I, Bacuzzi A, Guzzetti L, Rossi I, Scolletta S, Comi D, Benigni A, Pierconti F, Coccia C, Biscari M, Murzilli A, Umari M, Peratoner C, Serra E, Baldinelli F, Accardo R, Diana F, Fasciolo A, Amodio R, Ball L, Greco M, Pelosi P, Della Rocca G. One-Lung Ventilation and Postoperative Pulmonary Complications After Major Lung Resection Surgery. A Multicenter Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2023; 37:2561-2571. [PMID: 37730455 PMCID: PMC10133024 DOI: 10.1053/j.jvca.2023.04.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 04/14/2023] [Accepted: 04/20/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVES The effect of one-lung ventilation (OLV) strategy based on low tidal volume (TV), application of positive end-expiratory pressure (PEEP), and alveolar recruitment maneuvers (ARM) to reduce postoperative acute respiratory distress syndrome (ARDS) and pulmonary complications (PPCs) compared with higher TV without PEEP and ARM strategy in adult patients undergoing lobectomy or pneumonectomy has not been well established. DESIGN Multicenter, randomized, single-blind, controlled trial. SETTING Sixteen Italian hospitals. PARTICIPANTS A total of 880 patients undergoing elective major lung resection. INTERVENTIONS Patients were randomized to receive lower tidal volume (LTV group: 4 mL/kg predicted body weight, PEEP of 5 cmH2O, and ARMs) or higher tidal volume (HTL group: 6 mL/kg predicted body weight, no PEEP, and no ARMs). After OLV, until extubation, both groups were ventilated using a tidal volume of 8 mL/kg and a PEEP value of 5 cmH2O. The primary outcome was the incidence of in-hospital ARDS. Secondary outcomes were the in-hospital rate of PPCs, major cardiovascular events, unplanned intensive care unit (ICU) admission, in-hospital mortality, ICU length of stay, and in-hospital length of stay. MEASUREMENTS AND MAIN RESULTS ARDS occurred in 3 of 438 patients (0.7%, 95% CI 0.1-2.0) and in 1 of 442 patients (0.2%, 95% CI 0-1.4) in the LTV and HTV group, respectively (Risk ratio: 3.03 95% CI 0.32-29, p = 0.372). Pulmonary complications occurred in 125 of 438 patients (28.5%, 95% CI 24.5-32.9) and in 136 of 442 patients (30.8%, 95% CI 26.6-35.2) in the LTV and HTV group, respectively (risk ratio: 0.93, 95% CI 0.76-1.14, p = 0.507). The incidence of major complications, in-hospital mortality, and unplanned ICU admission, ICU and in-hospital length of stay were comparable in both groups. CONCLUSIONS In conclusion, among adult patients undergoing elective lung resection, an OLV with lower tidal volume, PEEP 5 cmH2O, and ARMs and a higher tidal volume strategy resulted in low ARDS incidence and comparable postoperative complications, in-hospital length of stay, and mortality.
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Affiliation(s)
- Federico Piccioni
- Department of Anesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
| | - Nicola Langiano
- SOC Anesthesia and Intensive Care Medicine Clinic - Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Marcello Guarnieri
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Paolo Proto
- Department of Critical and Supportive Therapy, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Rocco D'Andrea
- Department of Anesthesia, Intensive Care Medicine and Emergency, IRRCS Policlinico di Sant' Orsola, Bologna Academic Hospital, Bologna, Italy
| | - Carlo A Mazzoli
- Department of Anesthesia, Intensive Care Medicine and Prehospital Emergency, Maggiore Hospital Carlo Alberto Pizzardi, Bologna, Italy
| | - Ilaria Riccardi
- SOC Anesthesia and Intensive Care Medicine Clinic - Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | | | - Luca Guzzetti
- ASST Settelaghi Ospedale di Circolo e Fondazione Macchi, Varese, Italy
| | - Irene Rossi
- Cardio-thoracic and vascular Department, UOC Cardio-thoracic and vascular Anesthesia and ICM, Azienda ospedaliero-universitaria Senese, Siena, Italy
| | - Sabino Scolletta
- Cardio-thoracic and vascular Department, UOC Cardio-thoracic and vascular Anesthesia and ICM, Azienda ospedaliero-universitaria Senese, Siena, Italy
| | - Daniela Comi
- Anesthesia and Intensive Care Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Alberto Benigni
- Anesthesia and Intensive Care Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Federico Pierconti
- IRCCS-IFO National Institute of Oncology - Regina Elena, DPT of Oncologic Clinic and Research, UOC Anesthesia and ICM, Rome, Italy
| | - Cecilia Coccia
- IRCCS-IFO National Institute of Oncology - Regina Elena, DPT of Oncologic Clinic and Research, UOC Anesthesia and ICM, Rome, Italy
| | - Matteo Biscari
- Arcispedale Santa Maria Nuova, IRCCS AUSL di Reggio Emilia, Italy
| | - Alice Murzilli
- Arcispedale Santa Maria Nuova, IRCCS AUSL di Reggio Emilia, Italy
| | - Marzia Umari
- SOC Anesthesia and Intensive Care Medicine - Azienda Sanitaria Universitaria Giuliana, Cattinara Hospital, Trieste, Italy
| | - Caterina Peratoner
- SOC Anesthesia and Intensive Care Medicine - Azienda Sanitaria Universitaria Giuliana, Cattinara Hospital, Trieste, Italy
| | - Eugenio Serra
- Anesthesia and Intensive Care Medicine Institute - Azienda Ospedaliera-Università of Padua, Padua, Italy
| | | | - Rosanna Accardo
- Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori Fondazione G. Pascale - IRCCS, Naples, Italy
| | - Fernanda Diana
- Anesthesia and Intensive Care Unit, Azienda Ospedaliera Brotzu - Ospedale Oncologico Businco, Cagliari, Italy
| | | | - Riccardo Amodio
- Department of Anesthesia, Intensive Care and Pain Medicine, IRCCS Centro di Riferimento Oncologico della Basilicata/OECI Clinical Cancer Center - Rionero in Vulture, Potenza, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino-IST, University of Genoa, Genoa, Italy
| | - Massimiliano Greco
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Anaesthesiology and Intensive Care, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS AOU San Martino-IST, University of Genoa, Genoa, Italy
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Wilson MG, Adams CN, Turnbull MD, Falyar CR, Harris EM, Thompson JA, Simmons VC. Improving Certified Registered Nurse Anesthetists' Adherence to a Standardized Intraoperative Lung Protective Ventilation Protocol. J Perianesth Nurs 2023; 38:845-850. [PMID: 37589630 DOI: 10.1016/j.jopan.2022.12.005] [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: 08/26/2022] [Revised: 12/08/2022] [Accepted: 12/11/2022] [Indexed: 08/18/2023]
Abstract
PURPOSE The use of lung protective ventilation (LPV) during general anesthesia is an effective strategy among certified registered nurse anesthetists (CRNAs) to reduce and prevent the incidence of postoperative pulmonary complications. The purpose of this project was to implement a LPV protocol, assess CRNA provider adherence, and investigate differences in ventilation parameters and postoperative oxygen requirements. DESIGN This quality improvement project was conducted using a pre- and postimplementation design. METHODS Sixty patients undergoing robotic laparoscopic abdominal surgery and 35 CRNAs at a community hospital participated. An evidence-based intraoperative LPV protocol was developed, CRNA education was provided, and the protocol was implemented. Pre- and postimplementation, CRNA knowledge, and confidence were assessed. Ventilation data were collected at 1-minute intervals intraoperatively and oxygen requirements were recorded in the postanesthesia care unit (PACU). FINDINGS Use of intraoperative LPV strategies increased 2.4%. Overall CRNA knowledge (P = .588), confidence (P = .031), and practice (P < .001) improved from pre- to postimplementation. Driving pressures decreased from pre- to postimplementation (P < .001). Supplemental oxygen use on admission to the PACU decreased from 93.3% to 70.0%. CONCLUSIONS Educational interventions and implementation of a standardized protocol can improve the use of intraoperative LPV strategies and patient outcomes.
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Affiliation(s)
- Megan G Wilson
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Cara N Adams
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Matthew D Turnbull
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Christian R Falyar
- Middle Tennesee Acute Surgical Pain Management Fellowship, Middle Tennesee School of Anesthesia, Madison, TN
| | - Erica M Harris
- Duke University Anesthesia Department, Duke University Medical Center, Durham, NC
| | - Julie A Thompson
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC
| | - Virginia C Simmons
- Duke University Nurse Anesthesia Program, Duke University School of Nursing, Durham, NC.
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Li XF, Jiang RJ, Mao WJ, Yu H, Xin J, Yu H. The effect of driving pressure-guided versus conventional mechanical ventilation strategy on pulmonary complications following on-pump cardiac surgery: A randomized clinical trial. J Clin Anesth 2023; 89:111150. [PMID: 37307653 DOI: 10.1016/j.jclinane.2023.111150] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 04/28/2023] [Accepted: 05/14/2023] [Indexed: 06/14/2023]
Abstract
STUDY OBJECTIVE Postoperative pulmonary complications occur frequently and are associated with worse postoperative outcomes in cardiac surgical patients. The advantage of driving pressure-guided ventilation strategy in decreasing pulmonary complications remains to be definitively established. We aimed to investigate the effect of intraoperative driving pressure-guided ventilation strategy compared with conventional lung-protective ventilation on pulmonary complications following on-pump cardiac surgery. DESIGN Prospective, two-arm, randomized controlled trial. SETTING The West China university hospital in Sichuan, China. PATIENTS Adult patients who were scheduled for elective on-pump cardiac surgery were enrolled in the study. INTERVENTIONS Patients undergoing on-pump cardiac surgery were randomized to receive driving pressure-guided ventilation strategy based on positive end-expiratory pressure (PEEP) titration or conventional lung-protective ventilation strategy with fixed 5 cmH2O of PEEP. MEASUREMENTS The primary outcome of pulmonary complications (including acute respiratory distress syndrome, atelectasis, pneumonia, pleural effusion, and pneumothorax) within the first 7 postoperative days were prospectively identified. Secondary outcomes included pulmonary complication severity, ICU length of stay, and in-hospital and 30-day mortality. MAIN RESULTS Between August 2020 and July 2021, we enrolled 694 eligible patients who were included in the final analysis. Postoperative pulmonary complications occurred in 140 (40.3%) patients in the driving pressure group and 142 (40.9%) in the conventional group (relative risk, 0.99; 95% confidence interval, 0.82-1.18; P = 0.877). Intention-to-treat analysis showed no significant difference between study groups regarding the incidence of primary outcome. The driving pressure group had less atelectasis than the conventional group (11.5% vs 17.0%; relative risk, 0.68; 95% confidence interval, 0.47-0.98; P = 0.039). Secondary outcomes did not differ between groups. CONCLUSION Among patients who underwent on-pump cardiac surgery, the use of driving pressure-guided ventilation strategy did not reduce the risk of postoperative pulmonary complications when compared with conventional lung-protective ventilation strategy.
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Affiliation(s)
- Xue-Fei Li
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Rong-Juan Jiang
- Department of Anesthesiology, Chengdu Second People's Hospital, Chengdu 610041, China
| | - Wen-Jie Mao
- Department of Anesthesiology, Jianyang People's Hospital, Jianyang 641400, China
| | - Hong Yu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Juan Xin
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Hai Yu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu 610041, China.
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Yang G, Zhang P, Li L, Wang J, Jiao P, Wang J, Chu Q. Driving Pressure-Guided Ventilation in Obese Patients Undergoing Laparoscopic Sleeve Gastrectomy: A Randomized Controlled Trial. Diabetes Metab Syndr Obes 2023; 16:1515-1523. [PMID: 37252007 PMCID: PMC10225129 DOI: 10.2147/dmso.s405804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 05/19/2023] [Indexed: 05/31/2023] Open
Abstract
Purpose This study aims to compare the conventional lung protective ventilation strategy (LPVS) with driving pressure-guided ventilation in obese patients undergoing laparoscopic sleeve gastrectomy (LSG). Methods Forty-five patients undergoing elective LSG under general anesthesia were randomly assigned to the conventional LPVS group (group L) or the driving pressure-guided ventilation group (group D) using random numbers generated by Excel. The primary outcome was the driving pressure of both groups 90 min after pneumoperitoneum. Results After 30 min of pneumoperitoneum, 90 min of pneumoperitoneum, 10 min of closing the pneumoperitoneum, and restoring the supine position, the driving pressure of group L and group D were 20.0 ± 2.9 cm H2O vs 16.6 ± 3.0 cm H2O (P < 0.001), 20.7 ± 3.2 cm H2O vs 17.3 ± 2.8 cm H2O (P < 0.001), and 16.3 ± 3.1 cm H2O vs 13.3 ± 2.5 cm H2O (P = 0.001), respectively; the respiratory compliance of groups L and D were 23.4 ± 3.7 mL/cm H2O vs 27.6 ± 5.1 mL/cm H2O (P = 0.003), 22.7 ± 3.8 mL/cm H2O vs 26.4 ± 3.5 mL/cm H2O (P = 0.005), and 29.6 ± 6.8 mL/cm H2O vs 34.7 ± 5.3 mL/cm H2O (P = 0.007), respectively. The intraoperative PEEP in groups L and group D was 5 (5-5) cm H2O vs 10 (9-11) cm H2O (P < 0.001). Conclusion An individualized peep-based driving pressure-guided ventilation strategy can reduce intraoperative driving pressure and increase respiratory compliance in obese patients undergoing LSG.
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Affiliation(s)
- Guanyu Yang
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital, Zhengzhou, Henan, People’s Republic of China
| | - Pin Zhang
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital, Zhengzhou, Henan, People’s Republic of China
| | - Liumei Li
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital, Zhengzhou, Henan, People’s Republic of China
| | - Jingjing Wang
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital, Zhengzhou, Henan, People’s Republic of China
| | - Pengfei Jiao
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital, Zhengzhou, Henan, People’s Republic of China
| | - Jie Wang
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital, Zhengzhou, Henan, People’s Republic of China
| | - Qinjun Chu
- Department of Anesthesiology and Perioperative Medicine, Zhengzhou Central Hospital, Zhengzhou, Henan, People’s Republic of China
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Liu F, Zhang W, Zhao Z, Xu X, Jian M, Han R. Effect of driving pressure on early postoperative lung gas distribution in supratentorial craniotomy: a randomized controlled trial. BMC Anesthesiol 2023; 23:176. [PMID: 37217882 DOI: 10.1186/s12871-023-02144-7] [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: 11/13/2022] [Accepted: 05/17/2023] [Indexed: 05/24/2023] Open
Abstract
BACKGROUND Neurosurgical patients represent a high-risk population for postoperative pulmonary complications (PPCs). A lower intraoperative driving pressure (DP) is related to a reduction in postoperative pulmonary complications. We hypothesized that driving pressure-guided ventilation during supratentorial craniotomy might lead to a more homogeneous gas distribution in the lung postoperatively. METHODS This was a randomized trial conducted between June 2020 and July 2021 at Beijing Tiantan Hospital. Fifty-three patients undergoing supratentorial craniotomy were randomly divided into the titration group or control group at a ratio of 1 to 1. The control group received 5 cmH2O PEEP, and the titration group received individualized PEEP targeting the lowest DP. The primary outcome was the global inhomogeneity index (GI) immediately after extubation obtained by electrical impedance tomography (EIT). The secondary outcomes were lung ultrasonography scores (LUSs), respiratory system compliance, the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) and PPCs within 3 days postoperatively. RESULTS Fifty-one patients were included in the analysis. The median (IQR [range]) DP in the titration group versus the control group was 10 (9-12 [7-13]) cmH2O vs. 11 (10-12 [7-13]) cmH2O, respectively (P = 0.040). The GI tract did not differ between groups immediately after extubation (P = 0.080). The LUSS was significantly lower in the titration group than in the control group immediately after tracheal extubation (1 [0-3] vs. 3 [1-6], P = 0.045). The compliance in the titration group was higher than that in the control group at 1 h after intubation (48 [42-54] vs. 41 [37-46] ml·cmH2O-1, P = 0.011) and at the end of surgery (46 [42-51] vs. 41 [37-44] ml·cmH2O-1, P = 0.029). The PaO2/FiO2 ratio was not significantly different between groups in terms of the ventilation protocol (P = 0.117). At the 3-day follow-up, no postoperative pulmonary complications occurred in either group. CONCLUSIONS Driving pressure-guided ventilation during supratentorial craniotomy did not contribute to postoperative homogeneous aeration, but it may lead to improved respiratory compliance and lower lung ultrasonography scores. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT04421976.
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Affiliation(s)
- Feifei Liu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, China
- Department of Anesthesiology, Beijing Fangshan Liangxiang Hospital, Beijing, China
| | - Wei Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, China
| | - Zhanqi Zhao
- Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
| | - Xin Xu
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, China
| | - Minyu Jian
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, China
| | - Ruquan Han
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, No. 119, Southwest 4th Ring Road, Fengtai District, Beijing, 100070, China.
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Min WK, Jin S, Choi YJ, Won YJ, Lee K, Lim CH. Lung ultrasound score-based assessment of postoperative atelectasis in obese patients according to inspired oxygen concentration: A prospective, randomized-controlled study. Medicine (Baltimore) 2023; 102:e32990. [PMID: 36800571 PMCID: PMC9936007 DOI: 10.1097/md.0000000000032990] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND According to a recent meta-analysis, in patients with a body mass index (BMI) ≥ 30, a high fraction of inhaled oxygen (FiO2) did not increase postoperative atelectasis. However, a high FiO2 generally increases the risk of postoperative atelectasis. Therefore, this study aimed to evaluate the effect of FiO2 on the development of atelectasis in obese patients using the modified lung ultrasound score (LUSS). METHODS Patients were assigned to 4 groups: BMI ≥ 30: group A (n = 21) and group B (n = 20) and normal BMI: group C (n = 22) and group D (n = 21). Groups A and C were administered 100% O2 during preinduction and emergence and 50% O2 during anesthesia. Groups B and D received 40% O2 for anesthesia. The modified LUSS was assessed before and 20 min after arrival to the postanesthesia care unit (PACU). RESULTS The difference between the modified LUSS preinduction and PACU was significantly higher in group A with a BMI ≥ 30 (P = .006); however, there was an insignificant difference between groups C and D in the normal BMI group (P = .076). CONCLUSION High FiO2 had a greater effect on the development of atelectasis in obese patients than did low FiO2; however, in normal-weight individuals, FiO2 did not have a significant effect on postoperative atelectasis.
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Affiliation(s)
- Won Kee Min
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Gyeonggi- do, Republic of Korea
| | - Sejong Jin
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Gyeonggi- do, Republic of Korea
- Department of Neuroscience, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yoon Ji Choi
- Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, Gyeonggi- do, Republic of Korea
- * Correspondence: Yoon Ji Choi, Department of Anesthesiology and Pain Medicine, Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan-si, Gyeonggi-do 15355, Republic of Korea (e-mail: )
| | - Young Ju Won
- Department of Anesthesiology and Pain Medicine, Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Kaehong Lee
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Choon-Hak Lim
- Department of Anesthesiology and Pain Medicine, Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
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10
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Jo YY, Chang YJ, Lee D, Kim YB, Jung J, Kwak HJ. Comparisons of Mechanical Power and Respiratory Mechanics in Pressure-Controlled Ventilation and Volume-Controlled Ventilation during Laparoscopic Cholecystectomy in Elderly Patients. J Pers Med 2023; 13:jpm13020201. [PMID: 36836435 PMCID: PMC9967818 DOI: 10.3390/jpm13020201] [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: 12/18/2022] [Revised: 01/18/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
We compared the effects of pressure-controlled volume-guaranteed ventilation (PCV) and volume-controlled ventilation (VCV) on respiratory mechanics and mechanical power (MP) in elderly patients undergoing laparoscopy. Fifty patients aged 65-80 years scheduled for laparoscopic cholecystectomy were randomly assigned to either the VCV group (n = 25) or the PCV group (n = 25). The ventilator had the same settings in both modes. The change in MP over time was insignificant between the groups (p = 0.911). MP significantly increased during pneumoperitoneum in both groups compared with anesthesia induction (IND). The increase in MP from IND to 30 min after pneumoperitoneum (PP30) was not different between the VCV and PCV groups. The change in driving pressure (DP) over time were significantly different between the groups during surgery, and the increase in DP from IND to PP30 was significantly higher in the VCV group than in the PCV group (both p = 0.001). Changes in MP during PCV and VCV were similar in elderly patients, and MP increased significantly during pneumoperitoneum in both groups. However, MP did not reach clinical significance (≥12 J/min). In contrast, the PCV group had a significantly lower increase in DP after pneumoperitoneum than the VCV group.
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Affiliation(s)
| | | | | | | | | | - Hyun Jeong Kwak
- Correspondence: ; Tel.: +82-32-460-3637; Fax: +82-32-469-6319
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11
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Zhou L, Li H, Li M, Liu L. Individualized positive end-expiratory pressure guided by respiratory mechanics during anesthesia for the prevention of postoperative pulmonary complications: a systematic review and meta-analysis. J Clin Monit Comput 2023; 37:365-377. [PMID: 36607532 DOI: 10.1007/s10877-022-00960-9] [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: 06/22/2022] [Accepted: 12/01/2022] [Indexed: 01/07/2023]
Abstract
The optimization of positive end-expiratory pressure (PEEP) according to respiratory mechanics [driving pressure or respiratory system compliance (Crs)] is a simple and straightforward strategy. However, its validity to prevent postoperative pulmonary complications (PPCs) remains unclear. Here, we performed a meta-analysis to assess such efficacy. We searched PubMed, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) that compared personalized PEEP based on respiratory mechanics and constant PEEP to prevent PPCs in adults. The primary outcome was PPCs. Fourteen studies with 1105 patients were included. Compared with those who received constant PEEP, patients who received optimized PEEP exhibited a significant reduction in the incidence of PPCs (RR = 0.54, 95% CI 0.42 to 0.69). The results of commonly happened PPCs (pulmonary infections, hypoxemia, and atelectasis but not pleural effusion) also supported individualized PEEP group. Moreover, the application of PEEP based on respiratory mechanics improved intraoperative respiratory mechanics (driving pressure and Crs) and oxygenation. The PEEP titration method based on respiratory mechanics seems to work positively for lung protection in surgical patients undergoing general anesthesia.
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Affiliation(s)
- Li Zhou
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, No. 25 Taiping St, Jiangyang District, Luzhou, 646000, China
| | - Hongmei Li
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, No. 25 Taiping St, Jiangyang District, Luzhou, 646000, China
| | - Mingjuan Li
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, No. 25 Taiping St, Jiangyang District, Luzhou, 646000, China
| | - Li Liu
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, No. 25 Taiping St, Jiangyang District, Luzhou, 646000, China.
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12
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Driving pressure-guided ventilation improves homogeneity in lung gas distribution for gynecological laparoscopy: a randomized controlled trial. Sci Rep 2022; 12:21687. [PMID: 36522433 PMCID: PMC9755264 DOI: 10.1038/s41598-022-26144-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022] Open
Abstract
To investigate whether driving pressure-guided ventilation could contribute to a more homogeneous distribution in the lung for gynecological laparoscopy. Chinese patients were randomized, after pneumoperitoneum, to receive either positive end expiratory pressure (PEEP) of 5 cm H2O (control group), or individualized PEEP producing the lowest driving pressure (titration group). Ventilation homogeneity is quantified as the global inhomogeneity (GI) index based on electrical impedance tomography, with a lower index implying more homogeneous ventilation. The perioperative arterial oxygenation index and respiratory system mechanics were also recorded. Blood samples were collected for lung injury biomarkers including interleukin-10, neutrophil elastase, and Clara Cell protein-16. A total of 48 patients were included for analysis. We observed a significant increase in the GI index immediately after tracheal extubation compared to preinduction in the control group (p = 0.040) but not in the titration group (p = 0.279). Furthermore, the GI index was obviously lower in the titration group than in the control group [0.390 (0.066) vs 0.460 (0.074), p = 0.0012]. The oxygenation index and respiratory compliance were significantly higher in the titration group than in the control group. No significant differences in biomarkers or hemodynamics were detected between the two groups. Driving pressure-guided PEEP led to more homogeneous ventilation, as well as improved gas exchange and respiratory compliance for patients undergoing gynecological laparoscopy.Trial Registration: ClinicalTrials.gov NCT04374162; first registration on 05/05/2020.
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13
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Jeon K. Critical Care Management Following Lung Transplantation. J Chest Surg 2022; 55:325-331. [PMID: 35924541 PMCID: PMC9358155 DOI: 10.5090/jcs.22.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 07/18/2022] [Indexed: 11/16/2022] Open
Abstract
Postoperative critical care management for lung transplant recipients in the intensive care unit (ICU) has expanded in recent years due to its complexity and impact on clinical outcomes. The practical aspects of post-transplant critical care management, especially regarding ventilation and hemodynamic management during the early postoperative period in the ICU, are discussed in this brief review. Monitoring in the ICU provides information on the patient’s clinical status, diagnostic assessment of complications, and future management plans since lung transplantation involves unique pathophysiological conditions and risk factors for complications. After lung transplantation, the grafts should be appropriately ventilated with lung protective strategies to prevent ventilator-induced lung injury, as well as to promote graft function and maintain adequate gas exchange. Hypotension and varying degrees of pulmonary edema are common in the immediate postoperative lung transplantation setting. Ventricular dysfunction in lung transplant recipients should also be considered. Therefore, adequate volume and hemodynamic management with vasoactive agents based on their physiological effects and patient response are critical in the early postoperative lung transplantation period. Integrated management provided by a professional multidisciplinary team is essential for the critical care management of lung transplant recipients in the ICU.
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Affiliation(s)
- Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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14
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Xu Q, Guo X, Liu J, Li SX, Ma HR, Wang FX, Lin JY. Effects of dynamic individualized PEEP guided by driving pressure in laparoscopic surgery on postoperative atelectasis in elderly patients: a prospective randomized controlled trial. BMC Anesthesiol 2022; 22:72. [PMID: 35296253 PMCID: PMC8925066 DOI: 10.1186/s12871-022-01613-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 03/07/2022] [Indexed: 11/16/2022] Open
Abstract
Background Driving pressure (ΔP = Plateau pressure-PEEP) is highly correlated with postoperative pulmonary complications (PPCs) and appears to be a promising indicator for optimizing ventilator settings. We hypothesized that dynamic, individualized positive end-expiratory pressure (PEEP) guided by ΔP could reduce postoperative atelectasis and improve intraoperative oxygenation, respiratory mechanics, and reduce the incidence of PPCs on elderly patients undergoing laparoscopic surgery. Methods Fifty-one elderly patients who were subject to laparoscopic surgery participated in this randomized trial. In the PEEP titration group (DV group), the PEEP titration was decremented to the lowest ΔP and repeated every 1 h. Additional procedures were also performed when performing predefined events that may be associated with lung collapse. In the constant PEEP group (PV group), a PEEP of 6 cmH2O was used throughout the surgery. Moreover, zero PEEP was applied during the entire procedure in the conventional ventilation group (CV group). The primary objective of this study was lung ultrasound score noted at the end of surgery and 15 min after admission to the post-anesthesia care unit (PACU) at 12 lung areas bilaterally. The secondary endpoints were perioperative oxygenation function, expiratory mechanics, and the incidence of the PPCs. Results The lung ultrasound scores of the DV group were significantly lower than those in the PV group and CV group (P < 0.05), whereas there was no significant difference between the PV group and CV group (P > 0.05). The lung static compliance (Cstat) and ΔP at all the intraoperative time points in the DV group were significantly better compared to the PV group and the CV group (p < 0.05). Conclusions Intraoperative titrated PEEP reduced postoperative lung atelectasis and improved respiratory mechanics in elderly patients undergoing laparoscopic surgery. Meanwhile, standard PEEP strategy is not superior to conventional ventilation in reducing postoperative pulmonary atelectasis in laparoscopic surgery.
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Affiliation(s)
- Qi Xu
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Xiao Guo
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Jiang Liu
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Si-Xun Li
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Hai-Rui Ma
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Fei-Xiang Wang
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Jing-Yan Lin
- Department of Anesthesiology, Affiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China. .,Department of Anesthesiology, North Sichuan Medical College, Nanchong, 637000, Sichuan, China.
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15
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Ogbuka I, Avera S, Ivonye C, Henriques King M. Saved by the PEEP: Resolution of Complete Unilateral Lung Collapse Secondary to Mucus Plugging With Ventilator Technique. J Investig Med High Impact Case Rep 2022; 10:23247096221121412. [PMID: 36121295 PMCID: PMC9490456 DOI: 10.1177/23247096221121412] [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] [Indexed: 11/15/2022] Open
Abstract
Bronchoscopy can be used to resolve respiratory failure caused by tenacious mucus plugs. However, emergent bronchoscopy to resolve mucus plugging is not always available in small rural hospitals around the country. We present a case in which increasing the positive end-expiratory pressure settings on the ventilator resulted in immediate improvement in patient oxygenation and imaging findings during a respiratory emergency caused by mucus plugging.
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16
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Lee YY, Han JI, Kang BK, Jeong K, Lee JW, Kim DY. Assessment of Perioperative Atelectasis Using Lung Ultrasonography in Patients Undergoing Pneumoperitoneum Surgery in the Trendelenburg Position: Aspects of Differences according to Ventilatory Mode. J Korean Med Sci 2021; 36:e334. [PMID: 34962110 PMCID: PMC8728588 DOI: 10.3346/jkms.2021.36.e334] [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: 08/08/2021] [Accepted: 10/28/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND During robotic gynecologic pneumoperitoneum surgery in the Trendelenburg position, aeration loss leads to perioperative atelectasis. Recently developed ventilator mode pressure-controlled ventilation volume-guaranteed (PCV-VG) mode could provide adequate ventilation with lower inspiratory pressure compared to volume-controlled ventilation (VCV); we hypothesized that PCV-VG mode may be beneficial in reducing perioperative atelectasis via low tidal volume (VT) of 6 mL/kg ventilation during robotic gynecologic pneumoperitoneum surgery in the Trendelenburg position. We applied lung ultrasound score (LUS) for detecting perioperative atelectasis. We aimed to compare perioperative atelectasis between VCV and PCV-VG with a low VT of 6 mL/kg during pneumoperitoneum surgery in the Trendelenburg position using LUS. METHODS Patients scheduled for robotic gynecologic surgery were randomly allocated to the VCV (n = 41) or PCV-VG group (n = 41). LUS, ventilatory, and hemodynamic parameters were evaluated at T1 (before induction), T2 (10 minutes after induction in the supine position), T3 (10 minutes after desufflation of CO2 in the supine position), and T4 (30 minutes after emergence from anesthesia in the recovery room). RESULTS Eighty patients (40 with PCV-VG and 40 with VCV) were included. Demographic data showed no significant differences between the groups. The total LUS has changed from baseline to T4, 0.63 (95% confidence interval [CI], 0.32, 0.94) to 1.77 (95% CI, 1.42, 2.21) in the VCV group and 0.86 (95% CI, 0.56, 1.16) to 1.43 (95% CI, 1.08, 1.78) in the PCV-VG group (P = 0.170). In both groups, total LUS increased significantly compared to the baseline values. CONCLUSION Using a low VT of 6 mL/kg during pneumoperitoneum surgery in the Trendelenburg position, our study showed no evidence that PCV-VG ventilation was superior to VCV in terms of perioperative atelectasis. TRIAL REGISTRATION Clinical Research Information Service Identifier: KCT0006404.
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Affiliation(s)
- Youn Young Lee
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Jong In Han
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, Korea.
| | - Bo Kyung Kang
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Kyungah Jeong
- Department of Obstetrics and Gynecology, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Jong Wha Lee
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
| | - Dong Yeon Kim
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, Korea
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Lee JH, Kang P, Song IS, Ji SH, Lee HC, Jang YE, Kim EH, Kim HS, Kim JT. Determining optimal positive end-expiratory pressure and tidal volume in children by intratidal compliance: a prospective observational study. Br J Anaesth 2021; 128:214-221. [PMID: 34686309 DOI: 10.1016/j.bja.2021.09.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/30/2021] [Accepted: 09/10/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Limited data exist regarding optimal intraoperative ventilation strategies for the paediatric population. This study aimed to determine the optimal combination of PEEP and tidal volume (VT) based on intratidal compliance profiles in healthy young children undergoing general anaesthesia. METHODS During anaesthesia, infants (1 month-1 yr), toddlers (1-3 yr), and children (3-6 yr) were assigned serially to four ventilator settings: PEEP 8 cm H2O/VT 8 ml kg-1 (PEEP8/VT8), PEEP 10 cm H2O/VT 5 ml kg-1 (PEEP10/VT5), PEEP 10 cm H2O/VT 8 ml kg-1 (PEEP10/VT8), and PEEP 12 cm H2O/VT 5 ml kg-1 (PEEP12/VT5). The primary outcome was intratidal compliance profile, classified at each ventilator setting as horizontal (indicative of optimal alveolar ventilatory conditions), increasing, decreasing, or combinations of increasing/decreasing/horizontal compliance. Secondary outcomes were peak inspiratory, plateau, and driving pressures. RESULTS Intratidal compliance was measured in 15 infants, 13 toddlers, and 15 children (15/43 [35%] females). A horizontal compliance profile was most frequently observed with PEEP10/VT5 (60.5%), compared with PEEP10/VT8, PEEP8/VT8, and PEEP12/VT5 (23.3-34.9%; P<0.001). Decreasing compliance profiles were most frequent when VT increased to 8 ml kg-1, PEEP increased to 12 cm H2O, or both. Plateau airway pressures were lower at PEEP8/VT8 (16.9 cm H2O [2.2]) and PEEP10/VT5 (16.7 cm H2O [1.7]), compared with PEEP10/VT8 (19.5 cm H2O [2.1]) and PEEP12/VT5 (19.0 cm H2O [2.0]; P<0.001). Driving pressure was lowest with PEEP10/VT5 (4.6 cm H2O), compared with other combinations (7.0 cm H2O [2.0]-9.5 cm H2O [2.1]; P<0.001). CONCLUSIONS VT 5 ml kg-1 combined with 10 cm H2O PEEP may reduce atelectasis and overdistension, and minimise driving pressure in the majority of mechanically ventilated children <6 yr. The effect of these PEEP and VT settings on postoperative pulmonary complications in children undergoing surgery requires further study. CLINICAL TRIAL REGISTRATION NCT04633720.
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Affiliation(s)
- Ji-Hyun Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Pyoyoon Kang
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - In Sun Song
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang-Hwan Ji
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyung-Chul Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Eun Jang
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun-Hee Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
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Yin H, Cao L, Zhao H, Yang Y. Effects of dexmedetomide, propofol and remifentanil on perioperative inflammatory response and lung function during lung cancer surgery. Am J Transl Res 2021; 13:2537-2545. [PMID: 34017412 PMCID: PMC8129352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/04/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To investigate the effects of combined anesthesia with dexmedetomide, propofol and remifentanil on perioperative inflammatory response and pulmonary function in patients with lung cancer. METHODS 90 patients with lung cancer admitted to our hospital from April 2017 to April 2019 were selected. According to different anesthesia schemes, patients undergoing combined anesthesia with propofol and remifentanil were included in group A (GA), and patients receiving combined anesthesia with dexmedetomidine, propofol and remifentanil were included in group B (GB). The blood gas, pulmonary function index, inflammatory factor level in serum, anesthetic effect and complications were compared between the two groups. RESULTS HR indexes at T1 and T2 in GB were significantly lower than those in GA (P<0.001). There was no significant fluctuation in PaCO2 and PaO2 indexes in the two groups at different time points (P>0.05). At T0, T1 and T2, RV/TLC levels in serum increased significantly in the two groups. (MVV-VE)/FEV1 and MVV/FEV levels were significantly decreased (all P<0.05). The fluctuation levels of RV/TLC, (MVV-VE)/FEV1 and MVV/FEV levels in serum of GB were significantly lower than those of GA at T1 and T2 (P<0.05). At T0, T1 and T2, the levels of inflammatory factors in serum were significantly decreased in the two groups (P<0.05), but the levels of inflammatory factors in serum of GB were significantly lower than those of GA at T1 and T2 (P<0.05). The VAS scores of GB were significantly lower than those of GA at 1 hour and 4 hours after operation (P<0.05). Ramsay scores of GB were significantly higher than those of GA at 1 hour and 4 hours after operation (P<0.05). The restlessness score and choking cough score in GB were lower than those in GA (P<0.05). Perioperative complications in GB were better than those in GA (P<0.05). CONCLUSION On the basis of propofol and remifentanil anesthesia, the combination of dexmedetomidine for anesthesia induction can achieve satisfactory anesthesia effect. On the basis of propofol and remifentanil anesthesia combined with dexmedetomidine for anesthesia induction, it can significantly inhibit the inflammatory response of lung cancer patients during perioperative period and it can more effectively stabilize the blood gas microcirculation and lung function of patients.
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Affiliation(s)
- Hengming Yin
- Department of Anesthesiology, Qinghai Provincial People’s HospitalXining 810001, Qinghai Province, China
| | - Lin Cao
- Department of Anesthesiology, Eastern Theater General Hospital, Qinhuai District Medical AreaNanjing 210002, Jiangsu Province, China
| | - Hongyu Zhao
- Department of Anesthesiology, Jinan Central Hospital Affiliated to Shandong UniversityJinan 250014, Shandong Province, China
| | - Yongjian Yang
- Department of Anesthesiology, Jinan Central Hospital Affiliated to Shandong UniversityJinan 250014, Shandong Province, China
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Nguyen TK, Mai DH, Le AN, Nguyen QH, Nguyen CT, Vu TA. A review of intraoperative lung-protective mechanical ventilation strategy. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2020.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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20
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Cho S, Oh HW, Choi MH, Lee HJ, Woo JH. Effects of Intraoperative Ventilation Strategy on Perioperative Atelectasis Assessed by Lung Ultrasonography in Patients Undergoing Open Abdominal Surgery: a Prospective Randomized Controlled Study. J Korean Med Sci 2020; 35:e327. [PMID: 33045769 PMCID: PMC7550238 DOI: 10.3346/jkms.2020.35.e327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/29/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Protective mechanical ventilation using low tidal volume has been introduced to surgical patients to reduce the incidence of postoperative pulmonary complications. We investigated the effects of protective ventilation (PV) techniques on anesthesia-induced atelectasis identified via lung ultrasonography in patients undergoing abdominal surgery. METHODS A total of 42 adult patients who were scheduled for open abdominal surgery with an expected duration > 2 hours were included in the study. Patients were randomized to receive either conventional ventilation (CV; tidal volume of 9-10 mL/kg predicted body weight [PBW] with no positive end-expiratory pressure [PEEP]) or PV (tidal volume of 6-8 mL/kg PBW and 5 cmH₂O PEEP) via pressure-controlled ventilation with volume guaranteed. Lung ultrasonography was performed at four predefined time points to assess perioperative atelectasis by dividing each hemithorax into six quadrants based on a modified lung ultrasound (LUS) scoring system. RESULTS The tidal volume delivered to patients was 9.65 ± 1.65 mL/kg PBW in the CV group and 6.31 ± 0.62 mL/kg PBW in the PV group. Ventilation using low tidal volume led to similar LUS scores in all lung areas and at all time points compared to ventilation using high tidal volume. There was no significant difference between the groups in the number of patients requiring recruitment maneuvers at the end of surgery. CONCLUSION Ventilation with low tidal volume combined with 5 cmH₂O PEEP did not cause further loss of aeration compared to ventilation with high tidal volume. Low tidal volume ventilation can be used in patients without lung injury based on lung assessment by bedside lung ultrasonography. TRIAL REGISTRATION Clinical Research Information Service Identifier: KCT0003746.
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Affiliation(s)
- Sooyoung Cho
- Department of Anesthesiology and Pain Medicine, Ewha Womans University, School of Medicine, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Hye Won Oh
- Department of Anesthesiology and Pain Medicine, Ewha Womans University, School of Medicine, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Min Hee Choi
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Mokdong Hospital, Seoul, Korea
| | - Hyun Jung Lee
- Department of Anesthesiology and Pain Medicine, Ewha Womans University, School of Medicine, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea
| | - Jae Hee Woo
- Department of Anesthesiology and Pain Medicine, Ewha Womans University, School of Medicine, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Seoul Hospital, Seoul, Korea.
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