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

References

1 L. Ball, F. Costantino, G. Orefice, et al. Intraoperative mechanical ventilation: state of the art Minerva Anestesiol, 83 (2017), pp. 1075-1088

2 C.C. Young, E.M. Harris, C. Vacchiano, et al. Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations Br J Anaesth, 123 (2019), pp. 898-913

3 P. Severgnini, G. Selmo, C. Lanza, et al. Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function Anesthesiology, 118 (2013), pp. 1307-1321

4 S. Maisch, H. Reissmann, B. Fuellekrug, et al. Compliance and dead space fraction indicate an optimal level of positive end-expiratory pressure after recruitment in anesthetized patients Anesth Analg, 106 (2008), pp. 175-181

5 Y.S. Choi, M.K. Bae, S.H. Kim, et al. Effects of alveolar recruitment and positive end-expiratory pressure on oxygenation during one-lung ventilation in the supine position Yonsei Med J, 56 (2015), pp. 1421-1427

6 S. Wirth, M. Kreysing, J. Spaeth, et al. Intraoperative compliance profiles and regional lung ventilation improve with increasing positive end-expiratory pressure Acta Anaesthesiol Scand, 60 (2016), pp. 1241-1250

7 E. Östberg, A. Thorisson, M. Enlund, et al. Positive end-expiratory pressure, and postoperative atelectasis: a randomized controlled trial Anesthesiology, 131 (2019), pp. 809-817

8 iPROVE Network investigators, J Belda, C Ferrando, et al. The effects of an open-lung approach during one-lung ventilation on postoperative pulmonary complications and driving pressure: a descriptive, multicenter national study J Cardiothorac Vasc Anesth, 32 (2018), pp. 2665-2672

9 W. Karzai, K. Schwarzkopf Hypoxemia during one-lung ventilation: prediction, prevention, and treatment Anesthesiology, 110 (2009), pp. 1402-1411

10 M. Chobola, P. Homolka, M. Benej, et al. Ventilatory efficiency identifies patients prone to hypoxemia during one-lung ventilation J Cardiothorac Vasc Anesth, 33 (2019), pp. 1956-1962

11 S. Spadaro, S. Grasso, D.S. Karbing, et al. Physiologic evaluation of ventilation perfusion mismatch and respiratory mechanics at different positive end-expiratory pressure in patients undergoing protective one-lung ventilation Anesthesiology, 128 (2018), pp. 531-538

12 M. Park, H.J. Ahn, J.A. Kim, et al. Driving pressure during thoracic surgery: a randomized clinical trial Anesthesiology, 130 (2019), pp. 385-393

13 E. Östberg, A. Thorisson, M. Enlund, et al. Positive end-expiratory pressure alone minimizes atelectasis formation in nonabdominal surgery: a randomized controlled trial Anesthesiology, 128 (2018), pp. 1117-1124

14 C. Ferrando, G. Tusman, F. Suarez-Sipmann, et al. Individualized lung recruitment maneuver guided by pulse-oximetry in anesthetized patients undergoing laparoscopy: a feasibility study Acta Anaesthesiol Scand, 2 (2018), pp. 608-619

15 The PROVE Network Investigators for the Clinical Trail Network of the European Society of Anaesthesiology High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial Lancet, 384 (2014), pp. 495-503

16 K. Suehiro, R. Okutani Stroke volume variation as a predictor of fluid responsiveness in patients undergoing one-lung ventilation J Cardiothorac Vasc Anesth, 24 (2010), pp. 772-775

17 H. Xu, S.H. Shu, D. Wang, et al. Goal-directed fluid restriction using stroke volume variation and cardiac index during one-lung ventilation: a randomized controlled trial J Thorac Dis, 9 (2017), pp. 2992-3004

18 D.M. Jeong, H.J. Ahn, H.W. Park, et al. Stroke volume variation and pulse pressure variation are not useful for predicting fluid responsiveness in thoracic surgery Anesth Analg, 125 (2017), pp. 1158-1165

19 M. Lema Tome, F.A. De la Gala, P. Piñeiro, et al. Behavior of stroke volume variation in hemodynamic stable patients during thoracic surgery with one-lung ventilation periods Rev Bras Anestesiol, 68 (2018), pp. 225-230

20 A. Güldner, T. Kiss, A. Serpa Neto, et al. Intraoperative protective mechanical ventilation for prevention of postoperative pulmonary complications: a comprehensive review of the role of tidal volume, positive end-expiratory pressure, and lung recruitment maneuvers Anesthesiology, 123 (2015), pp. 692-713

21 F.J. Parrilla, I. Morán, F. Roche-Campo, et al. Ventilatory strategies in obstructive lung disease Semin Respir Crit Care Med, 35 (2014), pp. 431-440

22 A.K. Staehr-Rye, C.S. Meyhoff, F.T. Scheffenbichler, et al. High intraoperative inspiratory oxygen fraction and risk of major respiratory complications Br J Anaesth, 119 (2017), pp. 140-149

23 S. Okahara, K. Shimizu, S. Suzuki, et al. Associations between intraoperative ventilator settings during one-lung ventilation and postoperative pulmonary complications: a prospective observational study BMC Anesthesiol, 18 (2018), p. 13
 

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