Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1016/j.bjane.2021.04.001
Brazilian Journal of Anesthesiology
Clinical Research

Individualized positive end-expiratory pressure in patients undergoing thoracoscopic lobectomy: a randomized controlled trial

Pressão expiratória final positiva individualizada em pacientes submetidos à lobectomia toracoscópica: um ensaio clínico randomizado

Yuying Zhang, Meng Zhang, Xu’an Wang, Gaocheng Shang, Youjing Dong

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Abstract

Background and objectives
With the intensive study of lung protective ventilation strategies, people begin to advocate the individualized application of Positive End-Expiratory Pressure (PEEP). This study investigated the optimal PEEP in patients during One-Lung Ventilation (OLV) and its effects on pulmonary mechanics and oxygenation.

Methods
Fifty-eight patients who underwent elective thoracoscopic lobectomy were randomly divided into two groups. Both groups received an Alveolar Recruitment Maneuver (ARM) after OLV. Patients in Group A received optimal PEEP followed by PEEP decremental titration, while Group B received standard 5 cm H2O PEEP until the end of OLV. Relevant indexes of respiratory mechanics, pulmonary oxygenation and hemodynamics were recorded after entering the operating room (T0), 10-minutes after intubation (T1), pre-ARM (T2), 20-minutes after the application of optimal PEEP (T3), at the end of OLV (T4) and at the end of surgery (T5). Postoperative outcomes were also assessed.

Results
The optimal PEEP obtained in Group A was 8.8 ± 2.4 cm H2O, which positively correlated with BMI and Forced Vital Capacity (FVC). Group A had a higher CPAT than Group B at T3, T4, T5 (p < 0.05) and a smaller ΔP than Group B at T3, T4 (p < 0.01). At T4, PaO2 was significantly higher in Group A (p < 0.01). At T3, stroke volume variation was higher in Group A (p < 0.01). Postoperative outcomes did not differ between the two groups.

Conclusions
Our findings suggest that the individualized PEEP can increase lung compliance, reduce driving pressure, and improve pulmonary oxygenation in patients undergoing thoracoscopic lobectomy, with little effect on hemodynamics.

Keywords

Positive end-expiratory pressure,  Respiratory mechanics,  Oxygenation,  Video assisted thoracoscopic surgery

Resumo

Justificativa e objetivos: Com o estudo intensivo das estratégias de ventilação protetora pulmonar, as pessoas começam a defender a aplicação individualizada da pressão expiratória final positiva (PEEP). Este estudo investigou a PEEP ideal em pacientes durante a ventilação monopulmonar (VMP) e seus efeitos na mecânica pulmonar e na oxigenação. Métodos: Cinquenta e oito pacientes submetidos à lobectomia toracoscópica eletiva foram divididos aleatoriamente em dois grupos. Ambos os grupos receberam uma manobra de recrutamento alveolar (MRA) após VMP. Os pacientes do Grupo A receberam PEEP ótima seguida por titulação decrescente da PEEP, enquanto o Grupo B recebeu PEEP padrão de 5 cmH2O até o final da VMP. Índices relevantes da mecânica respiratória, oxigenação pulmonar e hemodinâmica foram registrados após a entrada na sala de cirurgia (T0), 10 minutos após a intubação (T1), pré-MRA (T2), 20 minutos após a aplicação da PEEP ideal (T3), no final da VMP (T4) e ao final da cirurgia (T5). Os resultados pós-operatórios também foram avaliados. Resultados: A PEEP ótima obtida no Grupo A foi de 8,8 ± 2,4 cmH2O, que se correlacionou positivamente com o IMC e a capacidade vital forçada (CVF). O grupo A apresentou maior CPAT do que o grupo B em T3, T4, T5 (p <0,05) e menor P do que o grupo B em T3, T4 (p <0,01). Em T4, a PaO2 foi significativamente maior no Grupo A (p <0,01). No T3, a variação do volume sistólico foi maior no Grupo A (p <0,01). Os resultados pós-operatórios não diferiram entre os dois grupos. Conclusões: Nossos achados sugerem que a PEEP individualizada pode aumentar a complacência pulmonar, reduzir a pressão de direção e melhorar a oxigenação pulmonar em pacientes submetidos à lobectomia toracoscópica, com pouco efeito na hemodinâmica.

Palavras-chave

Pressão expiratória final positiva; Mecânica respiratória; Oxigenação; Cirurgia toracoscópica videoassistida

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