Post-extubation continuous positive airway pressure improves oxygenation after pediatric laparoscopic surgery: A randomized controlled trial.

Abstract

Effects of intraoperative recruitment maneuvers (RMs) on oxygenation and pulmonary compliance are lost during recovery if high inspired oxygen and airway suctioning are used. We investigated the effect of post-extubation noninvasive CPAP mask application on the alveolar arterial oxygen difference [(A-a) DO2 ] after pediatric laparoscopic surgery. Sixty patients (1-6years) were randomly allocated to three groups of 20 patients, to receive zero end-expiratory pressure (ZEEP group), RM with decremental PEEP titration only (RM group), or followed with post-extubation CPAP for 5minutes (RM-CPAP group). Primary outcome was [(A-a) DO2 ] at 1hour postoperatively. Secondary outcomes were respiratory mechanics, arterial blood gas analysis, hemodynamics, and adverse events. At 1hour postoperatively, mean [(A-a) DO2 ] (mmHg) was lower in the RM-CPAP group (41.5±13.2, [95% CI 37.6-45.8]) compared to (80.2±13.7 [72.6-87.5], P<0.0001] and (59.2±14.6, [54.8-62.6], P<0.001) in the ZEEP and RM groups. The mean PaO2 (mmHg) at 1hour postoperatively was higher in the RM-CPAP group (156.2±18.3 [95% CI 147.6-164.7]) compared with the ZEEP (95.9±15.9 [88.5-103.3], P<0.0001) and RM groups (129.1±15.9 [121.6-136.5], P<0.0001). At 12hours postoperatively, mean [(A-a) DO2 ] and PaO2 were (9.6±2.1 [8.4-10.8]) and (91.9±9.4 [87.5-96.3]) in the RM-CPAP group compared to (25.8±5.5 [23.6-27.6]) and (69.9±5.5 [67.4-72.5], P<0.0001) in the ZEEP group and (34.3±13.2, [28.4-40.2], P<0.0001) and (74.03 ± 9.8 [69.5-78.6], P<0.0001) in the RM group. No significant differences of perioperative adverse effects were found between groups. An RM done after pneumoperitoneum inflation followed by decremental PEEP titration improved oxygenation at 1hour postoperatively. The addition of an early post-extubation noninvasive CPAP mask ventilation improved oxygenation at 12hours postoperatively.