Lung Recruitment Maneuver Research Articles

Effect of visual lung recruitment manoeuvres guided by trans-oesophageal lung ultrasound on atelectasis after thoracoscopic lobectomy: a randomised, single-blind, prospective study

BackgroundAlthough the incidence of postoperative atelectasis could be reduced using lung recruitment manoeuvres, it remains high. We hypothesised that intraoperative visual lung recruitment guided by trans-oesophageal lung ultrasound would be more effective than the conventional method for managing postoperative atelectasis.MethodsIn this randomised, controlled, prospective study, 84 patients undergoing thoracoscopic lobectomy were recruited from Affiliated Chengdu Fifth People’s Hospital (teaching hospital) in China. Patients were grouped into trans-oesophageal lung ultrasound-guided (Group G, n = 42) and control (Group C, n = 42) groups.MethodsLung recruitment was performed after anaesthesia induction, before chest closure and before the endotracheal tube extubation. In Group C, recruitment pressure was controlled at 30 cm H2O for 10 s (performed thrice); in Group G, the pressure was controlled at 30 cm H2O (performed thrice), and the tidal volume did not exceed 20 ml kg−1 until no atelectasis was detected by trans-oesophageal ultrasound. The primary outcome was lung ultrasound scores measured at the post anaesthesia care unit 30 min after extubation. The secondary outcomes included the oxygenation index (30 min after extubation) and the incidence of atelectasis (30 min after extubation and 3 days after surgery).ResultsThe final analysis included 79 patients. The lung ultrasound score was significantly higher in the control group than in the ultrasound-guided group 30 min after extubation (Group C vs. Group G, 8.6 ± 2.6 vs. 6.5 ± 2.0, P < 0.001). No significant difference in the oxygenation indexes 30 min after extubation was observed between the groups (P = 0.074); however, the incidence of atelectasis 30 min after extubation significantly differed between the two groups (Group C vs. Group G, 57% vs. 33%, P = 0.031). The incidence of atelectasis 3 days after surgery did not significantly differ between the two groups (Group C vs. Group G, 45% vs. 28%, P = 0.122).ConclusionsLung recruitment guided by trans-oesophageal lung ultrasound can reduce lung ultrasound scores and the incidence of atelectasis at the post anaesthesia care unit 30 min after extubation. However, it does not significantly reduce the incidence of atelectasis 3 days after surgery.Trial registrationRegistration number: ChiCTR2200062509. Registered on 10 /8/ 2022.

Respiratory Effects of Maximal Lung Recruitment Maneuvers Using Single-Breath Estimation in ARDS.

Determining which patients with ARDS are most likely to benefit from lung recruitment maneuvers is challenging for physicians. The aim of this study was to assess whether the single-breath simplified decremental PEEP maneuver, which evaluates potential lung recruitment, may predict a subject's response to lung recruitment maneuvers, followed by PEEP titration. We conducted a pilot prospective single-center cohort study with a 3-step protocol that defined sequential measurements. First, potential lung recruitment was assessed by the single-breath maneuver in the volume controlled mode. Second, the lung recruitment maneuver was performed in the pressure controlled mode, with a fixed driving pressure of 15 cm H2O and a maximum PEEP of 30 cm H2O. Third, the lung recruitment maneuver was followed by decremental PEEP titration to determine the optimal PEEP, defined as the lowest driving pressure. Responders to the lung recruitment maneuver were defined by an improvement in PaO2 /FIO2 > 20% between the baseline state and the end of the PEEP titration phase. Forty-two subjects with moderate-to-severe ARDS were included. The mean ± SD lung recruitment was 149 ± 104 mL. A threshold lung recruitment of 195 mL (area under the receiver operator characteristic curve 0.62, 95% CI 0.43-0.80) predicted a positive response to the maximal lung recruitment maneuver. The lung recruitment maneuver, followed by PEEP titration, resulted in a modification of PEEP in 74% of the subjects. PEEP was increased in more than two thirds of the responders and decreased in almost half of the non-responders to the lung recruitment maneuver. In addition, a decrease in driving pressure and an increase in respiratory system compliance were reported in 62% and 67% of the subjects, respectively. The single-breath maneuver for evaluating lung recruitability predicted, with poor accuracy, the subjects who responded to the lung recruitment maneuver based on PaO2 /FIO2 improvement. Nevertheless, the lung recruitment maneuver, followed by PEEP titration, improved ventilator settings and respiratory mechanics in a majority of subjects.

Lung Recruitment Before Surfactant Administration in Extremely Preterm Neonates

A multicenter randomized clinical trial (RCT) showed a lung recruitment maneuver using high-frequency oscillatory ventilation just before surfactant administration (ie, intubate-recruit-surfactant-extubate [IN-REC-SUR-E]) improved the efficacy of treatment compared with the standard intubate-surfactant-extubate (IN-SUR-E) technique without increasing the risk of adverse neonatal outcomes. To examine follow-up outcomes at corrected postnatal age (cPNA) 2 years of preterm infants previously enrolled in an RCT and treated with IN-REC-SUR-E or IN-SUR-E in 35 tertiary neonatal intensive care units. This was a follow-up study of infants recruited into the primary RCT from 2015 to 2018 at 35 tertiary neonatal intensive care units (NICUs) in Italy. Follow-up examinations included neurodevelopmental, growth, and respiratory outcomes of these children at cPNA 2 years. Participants included spontaneously breathing extremely preterm neonates (24 0/7 to 27 6/7 weeks' gestation) reaching failure criteria for continuous positive airway pressure within the first 24 hours of life. Data were analyzed from April 2023 to January 2024. Infants were randomly assigned (1:1) to IN-REC-SUR-E or IN-SUR-E and then followed up. The primary outcome was the occurrence of death after discharge or major disability at cPNA 2 years. Secondary outcomes were neurodevelopmental outcomes (major disability, cerebral palsy, cognitive impairment, visual deficit, or auditory deficit), anthropometric measurements (weight, length, and head circumference), and recurrent respiratory infections and hospitalizations because of respiratory causes at 2y cPNA. A total of 137 extremely preterm infants (median [IQR] gestational age, 26.5 [25.3-27.5] weeks and 75 [54.7%] female), initially enrolled in the original RCT, were followed up at cPNA 2 years, including 64 infants in the IN-SUR-E group and 73 infants in the IN-REC-SUR-E group. There were no significant differences in the occurrence of death after discharge or major disability at cPNA 2 years (IN-SUR-E: 13 children [20.3%] vs IN-REC-SUR-E: 10 children [13.7%]; P = .36). There were no significant differences in incidence of disability, cerebral palsy, or cognitive impairment in the IN-REC-SUR-E group compared with the IN-SUR-E group. There were no significant differences in anthropometric measurements (weight, length, and head circumference) between groups. There were no significant differences in the incidence of recurrent respiratory infections or in hospitalizations because of respiratory causes between groups. In this RCT of lung recruitment before surfactant vs standard care there were no significant differences between the 2 groups in death, neurodevelopmental outcomes, anthropometric measurements, or recurrent respiratory infections at the 2-year follow-up. These findings can aid clinicians in decision-making for the best strategy to administer surfactant, considering long-term outcomes.

The effect of lung-recruitment maneuver on postoperative shoulder pain in patients undergoing laparoscopic cholecystectomy: a randomized controlled trial.

Lung-recruitment maneuvers (LRM) have been shown to reduce postoperative pain after laparoscopic surgery. This study aimed to investigate the association of LRM with the incidence of shoulder pain after laparoscopic cholecystectomy. A randomized controlled study was conducted with 110 patients undergoing elective laparoscopic cholecystectomy from July 2022 to March 2023. Participants were randomized to receive either routine exsufflation or LRM at pneumoperitoneum release. The postoperative shoulder pain and abdominal pain were assessed at 1, 4, 6, 12, and 24h after surgery using a numeric rating scale. Analgesic consumption and postoperative nausea or vomiting (PONV) were evaluated during the first 24h after surgery. The incidence of shoulder pain during the first 24h after surgery was significantly lower in the LRM group compared to the control group (26.9 vs. 59.3%; P = 0.001). The median [interquartile range] score of worst shoulder pain was significantly lower compared to the control group (3 [2-3] vs 4 [3-5.5]; P = 0.003). Participants in the LRM group showed reduced abdominal pain at rest at 4 and 24h after surgery, and experienced significantly lower intensities of abdominal pain during mobilization at all time points over 24h after surgery. There were no significant differences in opioid consumption or the incidence of PONV between the groups. LRM reduces both the incidence and intensity of shoulder pain during 24h after laparoscopic cholecystectomy. Additionally, LRM was associated with reduced intensity of abdominal pain during mobilization over the study period.

Compared the Effectiveness of Intraperitoneal Bupivacaine with Lung Recruitment Maneuver Versus Normal Saline with Lung Recruitment Maneuver in Reducing Shoulder Pain After Laparoscopic Surgery: A Double-Blind Randomized Controlled Trial.

Postoperative shoulder pain is one of the most common complications following laparoscopic surgery. Various interventions have been proposed to control this pain. The main objective of this comparative study was to determine the effects of intraperitoneal bupivacaine and normal saline infusion, in combination with lung recruitment maneuver (LRM), on shoulder pain following laparoscopic surgery. The present randomized controlled trial was conducted on 105 candidates for laparoscopic cholecystectomy referred to Imam Ali Hospital in Bojnurd, Iran, from November 2021 to June 2022. The patients were assigned to three groups using block randomization: BR (receiving 50 cc of 0.25% diluted intraperitoneal bupivacaine + LRM), NR (receiving 50 cc of intraperitoneal normal saline + LRM), and N (receiving 50 cc of intraperitoneal normal saline). Postoperative shoulder pain and surgical incision site pain were assessed using the Visual Analogue Scale (VAS) at recovery intervals of 4, 12, 24, and 48 hours after surgery. Additionally, the prevalence of nausea and vomiting, the first time of need for sedation, and the incidence of sedation overdose in the first 24 hours after surgery were investigated. The data were analyzed using one-way analyzed by one-way analysis of variance (ANOVA) with SPSS software at a significance level of 0.05. The findings showed no significant differences in demographic variables between the three groups. The range and mean score of shoulder pain based on VAS was 0 - 1 (0.3) in the BR group, 0 - 2 (1.4) in the NR group, and 1 - 3 (2.1) in the N group at 4 hours after surgery. The mean score of shoulder pain intensity in the BR group was lower compared to the NR and N groups during recovery time intervals at 4, 12, and 24 hours after surgery. This difference between groups was significant. There was also a statistically significant difference in the mean score of surgical incision site pain intensity and the first time of need for sedation between the three groups. The occurrence of side effects was not significant between the groups. Itching, bradycardia, and hypotension were not observed in any of the groups. The findings of this study showed that bupivacaine, along with LRM, is a safe method effective in relieving postoperative shoulder pain. It prolonged the first time of need for sedation and significantly reduced the incidence of shoulder pain.

A stepwise lung recruitment maneuver using I-gel can improve respiratory parameters: A prospective observational study.

I-gel has been used in various clinical situations. The study investigated alterations in respiratory parameters following a stepwise lung recruitment maneuver (LRM) using the i-gel. The research involved 60 patients classified as American Society of Anesthesiologists class I-II, aged 30 to 75 years, undergoing elective urologic surgery. Various respiratory parameters, including lung compliance, airway resistance, leak volume, airway pressure, and oxygen reserve index, were recorded at different time points: before LRM, immediately after LRM, and at 5, 15, and 30 minutes after LRM, as well as at the end of the surgery. The primary outcome was to assess an improvement in lung compliance. Dynamic lung compliance (mean ± SD) was significantly increased from 49.2 ± 1.8 to 70.15 ± 3.2 mL/cmH2O (P < .05) after LRM. Static lung compliance (mean ± SD) was increased considerably from 52.4 ± 1.7 to 65.0 ± 2.5 mL/cmH2O (P < .05) after the LRM. Both parameters maintained a statistically significant increased status for a certain period compared to baseline despite a decreased degree of increment. Airway resistance (mean ± SD) was significantly reduced after the LRM from 12.05 ± 0.56 to 10.41 ± 0.64 L/cmH2O/s (P < .05). Stepwise LRM using i-gel may improve lung compliance and airway resistance. Repeated procedures could lead to prolonged improvements in respiratory parameters.

The Hemodynamic Changes Induced by Lung Recruitment Maneuver to Predict Fluid Responsiveness in Children during One Lung Ventilation-A Prospective Observational Study.

The prediction of fluid responsiveness in critical patients helps clinicians in decision making to avoid either under- or overloading of fluid. This study was designed to determine whether lung recruitment maneuver (LRM) would have an effect on the predictability of fluid responsiveness by the changes of hemodynamic parameters in pediatric patients who were receiving lung-protective ventilation and one-lung ventilation (OLV). A total of 34 children, aged 1-6 years old, scheduled for heart surgeries via right thoracotomy were enrolled. Patients were anesthetized and OLV with lung-protection ventilation settings was established, and then, positioned on left lateral decubitus. LRM and volume expansion (VE) were performed in sequence. Heart rate (HR), systolic arterial pressure (SAP), mean arterial pressure (MAP) diastolic arterial pressure (DAP), stroke volume (SV), stroke volume variation (SVV), and pulse pressure variation (PPV) were recorded via an A-line based monitor system at the following time points: before and after LRM (T1 and T2) and before and after VE (T3 and T4). An increase in stroke volume (SV) or mean arterial pressure (MAP) of ≥10% following fluid loading identified fluid responders. The predictability of fluid responsiveness by the changes of SV (ΔSVLRM) and MAP (ΔMAPLRM) after LRM and VE were statistically evaluated by receiver operating characteristic curves [area under the curves (AUC)]. SVs in all patients were significantly decreased after LRM (p < 0.01) and then, increased and returned to baseline after VE (p < 0.01). In total, 16 out of 34 patients who were fluid responders had significantly lower SV after LRM compared to that in fluid non-responders. The area under the receiver operating characteristic curves for ΔSVLRM was 0.828 (95% confidence interval [CI], 0.660 to 0.935; p < 0.001) and it indicated that ΔSVLRM was able to predict the fluid responsiveness of pediatric patients. MAPs in all patients were also decreased significantly after LRM, and 12 of them fell into the category of fluid responders after VE. Statistically, ΔMAPLRM did not predict fluid responsiveness when LRM was considered as an influential factor (p = 0.07). ΔSVLRM, but not ΔMAPLRM, showed great reliability in the prediction of the fluid responsiveness following VE in children during one-lung ventilation with lung-protective settings. ChiCTR2300070690.

Use of stepwise lung recruitment maneuver to predict fluid responsiveness under lung protective ventilation in the operating room

Recent research has revealed that hemodynamic changes caused by lung recruitment maneuvers (LRM) with continuous positive airway pressure can be used to identify fluid responders. We investigated the usefulness of stepwise LRM with increasing positive end-expiratory pressure and constant driving pressure for predicting fluid responsiveness in patients under lung protective ventilation (LPV). Forty-one patients under LPV were enrolled when PPV values were in a priori considered gray zone (4% to 17%). The FloTrac-Vigileo device measured stroke volume variation (SVV) and stroke volume (SV), while the patient monitor measured pulse pressure variation (PPV) before and at the end of stepwise LRM and before and 5 min after fluid challenge (6 ml/kg). Fluid responsiveness was defined as a ≥ 15% increase in the SV or SV index. Seventeen were fluid responders. The areas under the curve for the augmented values of PPV and SVV, as well as the decrease in SV by stepwise LRM to identify fluid responders, were 0.76 (95% confidence interval, 0.61–0.88), 0.78 (0.62–0.89), and 0.69 (0.53–0.82), respectively. The optimal cut-offs for the augmented values of PPV and SVV were > 18% and > 13%, respectively. Stepwise LRM -generated augmented PPV and SVV predicted fluid responsiveness under LPV.

Successful management of pulmonary edema secondary to accidental electrocution in a young dog

BackgroundHuman records describe pulmonary edema as a life-threatening complication of electric shock. Successful management requires prompt recognition and intensive care. However, in companion animals, electrocutions are rarely reported, even though domestic environments are full of electrical devices and there is always the possibility of accidental injury. Therefore, it is important for veterinarians to know more about this condition in order to achieve successful patient outcomes.Case presentationA 3-month-old male Labrador Retriever was presented with a history of transient loss of consciousness after chewing on a household electrical cord. On admission, the puppy showed an orthopneic position with moderate respiratory distress. Supplemental oxygen via nasal catheter was provided, but the patient showed marked worsening of respiratory status. Point-of-care ultrasound exams suggested neurogenic pulmonary edema due to electrical shock close to the central nervous system and increased B-lines without evidence of cardiac abnormalities. Mechanical ventilation of the patient was initiated using volume-controlled mode with a tidal volume of 9 to 15 ml/kg until reaching an end-tidal carbon dioxide ≤ 40 mm Hg, followed by a stepwise lung-recruitment maneuver in pressure-controlled mode with increases of the peak inspiratory pressure (15 to 20 cm H2O) and positive end-expiratory pressure (3 to 10 cm H2O) for 30 min, and return to volume-controlled mode with a tidal volume of 15 ml/kg until reaching a peripheral oxygen saturation ≥ 96%. Weaning from the ventilator was achieved in six hours, and the patient was discharged two days after admission without neurological or respiratory deficits.ConclusionsWe present a rather unusual case of a neurogenic pulmonary edema subsequent to accidental electrocution in a dog. Timely diagnosis by ultrasound and mechanical ventilation settings are described. Our case highlights that pulmonary edema should be considered a potentially life-threatening complication of electrical shock in small animal emergency and critical care medicine.

Ultrasound guided lung recruitment maneuvers and prevention of postoperative atelectasis after pediatric laparoscopic abdominal surgery

Ultrasound guided lung recruitment maneuvers and prevention of postoperative atelectasis after pediatric laparoscopic abdominal surgery

Effect of ultrasound-guided lung recruitment to reduce pulmonary atelectasis after non-cardiac surgery under general anesthesia: a systematic review and meta-analysis of randomized controlled trials

BackgroundAt present, the application of bedside lung ultrasound is increasing gradually, but there is no relevant expert consensus or guidance for its evaluation in the field of perioperative anesthesia. Through this meta-analysis, we tried to determine the impact of ultrasound-guided lung recruitment maneuvers (LRM) on perioperative patients.MethodsWe searched PubMed, Cochrane Library database, Embase, and Clinical Trials gov for the randomized controlled trials (RCTs) published up to December 31, 2022. The primary outcome was the incidence of postoperative atelectasis. Secondary outcomes included lung ultrasound score (LUS) and LUS of each part. A total of 443 patients were examined in nine randomized controlled trials.ResultsThe incidence of atelectasis after surgery in patients with ultrasound-guided LRM was less (RR 0.31; 95% CI 0.25–0.40; p < 0.05). The LUS (WMD − 6.24; 95% CI − 6.90–5.59; p < 0.05) and the LUS of each part (LUS in front lung region (WMD − 2.00; 95% CI − 2.49 to − 1.51; p < 0.05); LUS in lateral lung region (WMD − 2.50; 95% CI − 3.20 to − 1.80; p < 0.05); LUS in posterior lung region (WMD − 3.24; 95% CI − 4.23 to − 2.24; p < 0.05)) in patients with ultrasound-guided LRM were lower.ConclusionUltrasound-guided lung recruitment maneuvers have been shown to be a promising approach for improving perioperative lung ventilation by increasing aeration while mitigating the development of atelectasis. In comparison to non-ultrasound-guided methods, this technique has exhibited superior effects.

Ultrasound-guided versus conventional lung recruitment manoeuvres in thoracic surgery: a randomised controlled study.

Lung recruitment manoeuvres (RMs) during mechanical ventilation may reduce atelectasis, however, the optimal recruitment strategy for patients undergoing thoracic surgery remains unknown. Our study was designed to investigate whether ultrasound-guided lung RMs is superior to conventional RMs in reducing perioperative atelectasis during thoracic surgery with one-lung ventilation. We conducted a randomised controlled clinical trial from August 2022 to September 2022. Sixty patients scheduled for video-assisted thoracoscopic surgery (VATS) under general anaesthesia were enrolled. Subjects were randomly divided into the ultrasound-guided RMs group (manual inflation guided by lung ultrasound) or conventional RMs group (manual inflation with 30 cmH2O pressure). Lung ultrasound were performed at three predefined time points (1min after anaesthetic induction; after RMs at the end of surgery; before discharge from postanesthesia care unit [PACU]). The primary outcome was lung ultrasound score before discharge from the PACU after extubation. In the early postoperative period, lung aeration deteriorated in both groups even after lung RMs. However, ultrasound-guided lung RMs had significantly lower lung ultrasound scores when compared with conventional RMs in bilateral lungs (2.0 [0.8-4.0] vs. 8.0 [3.8-10.3], P < 0.01) at the end of surgery, which remained before patients discharged from the PACU. Accordingly, the lower incidence of atelectasis was found in ultrasound-guided RMs group than in conventional RMs group (7% vs. 53%; P < 0.01) at the end of surgery. Ultrasound-guided RMs is superior to conventional RMs in improving lung aeration and reducing the incidence of lung atelectasis at early postoperative period in patients undergoing VATS. The study protocol was approved by the Institutional Review Board of the Fudan University Shanghai Cancer Center (No. 220,825,810; date of approval: August 5, 2022) and registered on Chinese Clinical Trial Registry (registration number: ChiCTR2200062761).

Successful application of airway pressure release ventilation in a child with severe acute respiratory distress syndrome induced by trauma: a case report

BackgroundTrauma has been identified as one of the risk factors for acute respiratory distress syndrome. Respiratory support can be further complicated by comorbidities of trauma such as primary or secondary lung injury. Conventional ventilation strategies may not be suitable for all trauma-related acute respiratory distress syndrome. Airway pressure release ventilation has emerged as a potential rescue method for patients with acute respiratory distress syndrome and hypoxemia refractory to conventional mechanical ventilation. However, there is a lack of research on the use of airway pressure release ventilation in children with trauma-related acute respiratory distress syndrome. We report a case of airway pressure release ventilation applied to a child with falling injury, severe acute respiratory distress syndrome, hemorrhagic shock, and bilateral hemopneumothorax. We hope this case report presents a potential option for trauma-related acute respiratory distress syndrome and serves as a basis for future research.Case presentationA 15-year-old female with falling injury who developed severe acute respiratory distress syndrome, hemorrhagic shock, and bilateral hemopneumothorax was admitted to the surgical intensive care unit. She presented refractory hypoxemia despite the treatment of conventional ventilation with deep analgesia, sedation, and muscular relaxation. Lung recruitment was ineffective and prone positioning was contraindicated. Her oxygenation significantly improved after the use of airway pressure release ventilation. She was eventually extubated after 12 days of admission and discharged after 42 days of hospitalization.ConclusionAirway pressure release ventilation may be considered early in the management of trauma patients with severe acute respiratory distress syndrome when prone position ventilation cannot be performed and refractory hypoxemia persists despite conventional ventilation and lung recruitment maneuvers.

PEEP-Induced Lung Recruitment Maneuver Combined with Prone Position for ARDS: A Single-Center, Prospective, Randomized Clinical Trial

Background: Prone position (PP) and the positive end-expiratory pressure (PEEP)-induced lung recruitment maneuver (LRM) are both efficient in improving oxygenation and prognosis in patients with ARDS. The synergistic effect of PP combined with PEEP-induced LRM in patients with ARDS remains unclear. We aim to explore the effects of PP combined with PEEP-induced LRM on prognosis in patients with moderate to severe ARDS and the predicting role of lung recruitablity. Methods: Patients with moderate to severe ARDS were consecutively enrolled. The patients were prospectively assigned to either the intervention (PP with PEEP-induced LRM) or control groups (PP). The clinical outcomes, respiratory mechanics, and electric impedance tomography (EIT) monitoring results for the two groups were compared. Lung recruitablity (recruitment-to-inflation ratio: R/I) was measured during the PEEP-induced LRM procedure and was used for predicting the response to LRM. Results: Fifty-eight patients were included in the final analysis, among which 28 patients (48.2%) received PEEP-induced LRM combined with PP. PEEP-induced LRM enhanced the effect of PP by a significant improvement in oxygenation (∆PaO2/FiO2 75.8 mmHg vs. 4.75 mmHg, p &lt; 0.001) and the compliance of respiratory system (∆Crs, 2 mL/cmH2O vs. −1 mL/cmH2O, p = 0.02) among ARDS patients. Based on the EIT measurement, PP combined with PEEP-induced LRM increased the ventilation distribution mainly in the dorsal region (5.0% vs. 2.0%, p = 0.015). The R/I ratio was measured in 28 subjects. The higher R/I ratio was related to greater oxygenation improvement after LRM (Pearson’s r = 0.4; p = 0.034). Conclusions: In patients with moderate to severe ARDS, PEEP-induced LRM combined with PP can improve oxygenation and dorsal ventilation distribution. R/I can be useful to predict responses to LRM.

Clinical validation of the Air-Test for the non-invasive detection of perioperative atelectasis in children.

The incidence of anesthesia-induced atelectasis in children is high and closely related to episodes of hypoxemia. The Air-Test is a simple maneuver to detect lung collapse. By a step-reduction in FiO<inf>2</inf> to 0.21, a fall in pulse-oximetry hemoglobin saturation <97% unmasks the presence of collapse-related shunt in healthy lungs. The aim of this study was to validate the Air-Test as a diagnostic tool to detect perioperative atelectasis in children using lung ultrasound as a reference. We first assessed the Air-Test in a retrospective cohort of 88 anesthetized children (Retrospective study) followed by a prospective study performed in 72 children (45 postconceptional weeks to 16 years old) using a similar protocol (Validation study). We analyzed the performance of the Air-Test to detect atelectasis by an operating characteristic curve (ROC) analysis, using lung ultrasound consolidation score as reference. Preoperative SpO<inf>2</inf> was normal in both studies (retrospective 98.7±0.6%, validation 99.0±0.9%). The Air-Test, with a SpO<inf>2</inf> cut point <97%, resulted positive in 67 patients in the retrospective study (SpO<inf>2</inf> 93.3±2.1%) and in 59 in the validation study (SpO<inf>2</inf> 94.9±1.8%); both P<0.0001. In the validation study, the Air-Test showed a sensitivity of 0.91 (95% CI 0.85-0.92), specificity of 1.00 (95% CI 0.84-1) and an area under the curve (AUC) of 0.98 (95% CI 0.97-1.00). AUC between both studies was similar (P=0.16). The Air-Test is a noninvasive and accurate method to detect atelectasis in healthy anesthetized children. It can be used as a screening tool to individualize patients that can benefit from lung recruitment maneuvers.

Oscillometry for personalizing continuous distending pressure maneuvers: an observational study in extremely preterm infants

RationaleLung recruitment and continuous distending pressure (CDP) titration are critical for assuring the efficacy of high-frequency ventilation (HFOV) in preterm infants. The limitation of oxygenation (peripheral oxygen saturation, SpO2) in optimizing CDP calls for evaluating other non-invasive bedside measurements. Respiratory reactance (Xrs) at 10 Hz measured by oscillometry reflects lung volume recruitment and tissue strain. In particular, lung volume recruitment and decreased tissue strain result in increased Xrs values.ObjectivesIn extremely preterm infants treated with HFOV as first intention, we aimed to measure the relationship between CDP and Xrs during SpO2-driven CDP optimization.MethodsIn this prospective observational study, extremely preterm infants born before 28 weeks of gestation undergoing SpO2-guided lung recruitment maneuvers were included in the study. SpO2 and Xrs were recorded at each CDP step. The optimal CDP identified by oxygenation (CDPOpt_SpO2) was compared to the CDP providing maximal Xrs on the deflation limb of the recruitment maneuver (CDPXrs).ResultsWe studied 40 infants (gestational age at birth = 22+ 6-27+ 5 wk; postnatal age = 1–23 days). Measurements were well tolerated and provided reliable results in 96% of cases. On average, Xrs decreased during the inflation limb and increased during the deflation limb. Xrs changes were heterogeneous among the infants for the amount of decrease with increasing CDP, the decrease at the lowest CDP of the deflation limb, and the hysteresis of the Xrs vs. CDP curve. In all but five infants, the hysteresis of the Xrs vs. CDP curve suggested effective lung recruitment. CDPOpt_SpO2 and CDPXrs were highly correlated (ρ = 0.71, p < 0.001) and not statistically different (median difference [range] = -1 [-3; 9] cmH2O). However, CDPXrs were equal to CDPOpt_SpO2 in only 6 infants, greater than CDPOpt_SpO2 in 10, and lower in 24 infants.ConclusionsThe Xrs changes described provide complementary information to oxygenation. Further investigation is warranted to refine recruitment maneuvers and CPD settings in preterm infants.

An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline.

Background: This document updates previously published Clinical Practice Guidelines for the management of patients with acute respiratory distress syndrome (ARDS), incorporating new evidence addressing the use of corticosteroids, venovenous extracorporeal membrane oxygenation, neuromuscular blocking agents, and positive end-expiratory pressure (PEEP). Methods: We summarized evidence addressing four "PICO questions" (patient, intervention, comparison, and outcome). A multidisciplinary panel with expertise in ARDS used the Grading of Recommendations, Assessment, Development, and Evaluation framework to develop clinical recommendations. Results: We suggest the use of: 1) corticosteroids for patients with ARDS (conditional recommendation, moderate certainty of evidence), 2) venovenous extracorporeal membrane oxygenation in selected patients with severe ARDS (conditional recommendation, low certainty of evidence), 3) neuromuscular blockers in patients with early severe ARDS (conditional recommendation, low certainty of evidence), and 4) higher PEEP without lung recruitment maneuvers as opposed to lower PEEP in patients with moderate to severe ARDS (conditional recommendation, low to moderate certainty), and 5) we recommend against using prolonged lung recruitment maneuvers in patients with moderate to severe ARDS (strong recommendation, moderate certainty). Conclusions: We provide updated evidence-based recommendations for the management of ARDS. Individual patient and illness characteristics should be factored into clinical decision making and implementation of these recommendations while additional evidence is generated from much-needed clinical trials.

The physiological effect of prone positioning and lateral decubitus in non-intubated patients with severe COVID-19: a prospective cohort study

Introduction: Prone positioning is one type of postural lung recruitment manoeuvre that has been widely studied regarding the benefits and physiological changes of the cardiorespiratory system. However, prone positioning is not very comfortable for the patients because they have to lie on their stomachs for a while when the oxygen therapy and other monitoring devices are still attached. Based on patient observations, some patients will change to more comfortable positions, namely using the right/left lateral decubitus position. The purpose of this research was to examine the physiological impact of prone and lateral decubitus position in non-intubated patients who were diagnosed with severe COVID-19. Methods: It was a prospective cohort study in subsequent people with severe COVID-19 who obtained a non-rebreathing mask or high-flow nasal cannula at a University Hospital between 1 June and 10 September 2021. The study lasted for a total of 2021 days and involved 48 patients. The patients assumed the prone positioning or lateral decubitus every morning and afternoon for 4 h and were measured for cardiorespiratory parameters and blood gas analysis. It has been reported in line with the STROCSS criteria. Results: Dynamic changes based on cardiorespiratory parameters and blood gas analysis parameters in patients with prone and lateral decubitus position in patients with severe COVID-19 receiving conventional oxygen therapy (via non-rebreathing mask) or high-flow nasal cannula did not show any significant difference. Conclusion: The physiological effect of prone positioning and lateral decubitus in non-intubated patients with severe COVID-19 are similar. Accordingly, lateral decubitus can be an alternative for postural lung recruitment manoeuvres and warrants further randomized trials.

EFFICACY OF ULTRASOUND MONITORING OF RECRUITMENT MANEUVER IN NEWBORNS WITH PULMONARY ATELECTASIS: A CLINICAL CASE STUDY

Real-time, routine bedside diagnosis of treatment effi cacy without radiation exposure is the greatest challenge facing intensive care medicine in respiratory disease, including neonates. Ultrasound for lung monitoring is a major step forward in the timely diagnosis of respiratory disease. The use of a recruitment maneuver has been shown to be eff ective in the treatment of atelectasis and safe while monitoring lung status. This article presents the experience of using an ultrasound- guided lung recruitment maneuver and a clinical case to demonstrate it.A child with respiratory distress syndrome was diagnosed with pulmonary atelectasis on day 3. A lung ultrasound- guided recruitment maneuver was performed using the method of controlled gradual increase of PEEP from 5 cm to 8 cm H2O for 2 minutes and then to 10-11 cm H2O for the next 2 minutes in PCV mode (pressure- controlled ventilation). PEEP was then titrated (decreased) to the minimum inspiratory pressure (5 cm H2O). SpO2 and capnography were closely monitored, and lung ultrasound was performed every 2 minutes during pressure increase to monitor status. Ultrasound imaging showed improvement of lung ventilation in the aff ected area during the recruitment maneuver (fi rst reduction of B-lines, then normal pattern with A-lines on the background of B-lines, normalization of respiratory movement of the pleura). Chest x-ray confi rmed resolution of atelectasis.The Bioethics Committee of ME «Regional Medical Center of Family Health» DRC» has approved the publication of materials.All anamnestic data, examination results and photographic materials were published with the written informed consent of the parents of the newborn.Conclusions. Ultrasound examination is a valid and appropriate diagnostic method that allows clinicians to obtain non-invasive, rapid, bedside information about the lung status of newborns with pulmonary atelectasis during the recruitment maneuver, avoiding the risks associated with radiography.

A meta-analysis of conventional assisted ventilation versus continuous lung recruitment maneuver in preterm infants.

A meta-analysis of conventional assisted ventilation versus continuous lung recruitment maneuver in preterm infants.