Brazilian Journal of Anesthesiology
https://bjan-sba.org/article/doi/10.1590/S0034-70942010000300004
Brazilian Journal of Anesthesiology
Scientific Article

Avaliação do impacto da aplicação de manobra de hiperinsuflação pulmonar sobre a resposta inflamatória sistêmica e colapso pulmonar em pacientes submetidos a procedimentos cirúrgicos sob ventilação espontânea

Assessing the impact of lung hyperinflation maneuver on systemic inflammatory response and lung collapse in patients undergoing surgeries under spontaneous ventilation

Luiz Marcelo Sá Malbouisson; Elton Lúcio Silva de Souza; Larissa Barbalho; Cristina de Oliveira Massoco; Maria José Carvalho Carmona; José Otávio Costa Auler Jr

Downloads: 0
Views: 702

Resumo

JUSTIFICATIVA E OBJETIVOS: O uso de manobras de hiperinsuflação pulmonar (MHP) reverte atelectasias intraoperatórias. Contudo, pode induzir resposta inflamatória sistêmica de origem pulmonar. O objetivo deste estudo foi testar o impacto da aplicação de MHP sobre a resposta inflamatória sistêmica e sobre a estrutura pulmonar em pacientes submetidos à anestesia subaracnoidea. MÉTODO: Após aprovação do Comitê de Ética institucional e obtenção do consentimento escrito pós-informado, 20 pacientes submetidos a procedimentos cirúrgicos de pequeno e médio porte foram alea torizados em dois grupos: 1) Controle (GC) e 2) MHP (GMHP). Uma hora após a instalação do bloqueio espinhal, foi realizada MHP no GMHP aplicando-se pressão positiva nas vias aéreas em dois níveis (BIPAP) com pressão expiratória de 20 cmH2O e pressão inspiratória de 20 cmH2O durante 1 a 2 minutos. TNFα, IL-1, IL-6, IL-8, IL-10 e IL-12 foram medidos no sangue através de técnica de citometria de fluxo nos momentos basal, 90, 180 e 780 minutos. Os volumes e peso pulmonares foram computados a partir de tomografias computadorizadas obtidas imediatamente após a cirurgia. RESULTADOS: A aplicação de MHP resultou em redução da fração de parênquima pulmonar não aerado (7,5 ± 4,3% no Grupo Controle versus 4 ± 2,1% no Grupo MHP, p = 0,02), sem alterações nos volumes pulmonares. Foi observada elevação progressiva nos valores plasmáticos das interleucinas IL-1, IL-6, IL-8 e IL-10, similar nos dois grupos. Os níveis plasmáticos de TNFα e IL-12 foram indetectáveis durante o estudo. CONCLUSÕES: A aplicação de MHP única reduziu a fração de atelectasias, porém não amplificou a resposta inflamatória observada em pacientes com pulmões normais submetidos a cirurgias de pequeno e médio portes sob anestesia subaracnoidea.

Palavras-chave

COMPLICAÇÕES, METABOLISMO, TÉCNICA ANESTÉSICA, TÉCNICA ANESTÉSICA, VENTILAÇÃO, VENTILAÇÃO, manobra de hiperinsuflação pulmonar

Abstract

BACKGROUND AND OBJECTIVES: Lung hyperinflation maneuvers (LHM) reverse intraoperative atelectasis; however, they can lead to pulmonary-induced systemic inflammatory response. The objective of this study was to determine the impact of LHM on systemic inflammatory response and lung structure in patients undergoing subarachnoid block. METHODS: After approval by the Ethics Committee of the institution and signing the informed consent, 20 patients undergoing small and medium surgical procedures were randomly separated into two groups: 1) control (CG), and 2) LHM (LHMG). One hour after the spinal anesthesia, LHM was performed in LHMG by applying bilevel positive pressure in the airways (BIPAP) with an expiratory pressure of 20 cmH2O and inspiratory pressure of 20 cmH2O for 1 to 2 minutes. Blood levels of TNFα, IL-1, IL-6, IL-8, IL-10, and IL-12 were determined by flow cytometry at baseline and at 90, 180, and 780 minutes. Lung volumes and weights were determined using CT scans obtained immediately after the surgery. RESULTS: The use of LHM resulted in a reduction in the fraction of non-aerated pulmonary parenchyma (7.5 ± 4.3%, in the Control Group, vs. 4 ± 2.1%, in the LHM Group, p = 0.02) without changing pulmonary volumes. A progressive increase in plasma levels of IL-1, IL-6, IL-8, and IL-10, similar in both groups, was observed. Plasma levels of TNFα and IL-12 were undetectable during the study. CONCLUSIONS: The use of LHM reduced the incidence of atelectasis, but it did not amplify the inflammatory response in patients with normal lungs undergoing small and medium surgeries under subarachnoid block.

Keywords

ANESTHETIC TECHNIQUE, ANESTHETIC TECHNIQUE, COMPLICATIONS, METABOLISM, VENTILATION, VENTILATION, lung hyperinflation maneuver

References

Hachenberg T, Lundquist H, Tokics L. Analysis of lung density by computed tomography before and during general anaesthesia. Acta Anaesthesiol Scand. 1993;37:549-555.

Bendixen HH, Hedley-Whyte J, Laver MB. Impaired oxygenation in surgical patients during general anesthesia with controlled ventilation: A concept of atelectasis. N Engl J Med. 1963;269:991-996.

Rothen HU, Neumann P, Berglund JE. Dynamics of re-expansion of atelectasis during general anaesthesia. Br J Anaesth. 1999;82:551-556.

Tremblay L, Valenza F, Ribeiro SP. Injurious ventilatory strategies increase cytokines and c-fos m-RNA expression in an isolated rat lung model. J Clin Invest. 1997;99:944-952.

Chiumello D, Pristine G, Slutsky AS. Mechanical ventilation affects local and systemic cytokines in an animal model of acute respiratory distress syndrome. Am J Respir Crit Care Med. 1999;160:109-116.

Wilson MR, Choudhury S, Takata M. Pulmonary inflammation induced by high-stretch ventilation is mediated by tumor necrosis factor signaling in mice. Am J Physiol Lung Cell Mol Physiol. 2005;288:L599-607.

Wilson MR, Choudhury S, Goddard ME. High tidal volume upregulates intrapulmonary cytokines in an in vivo mouse model of ventilator-induced lung injury. J Appl Physiol. 2003;95:1385-1393.

Ranieri VM, Suter PM, Tortorella C. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. Jama. 1999;282:54-61.

Malbouisson LM, Szeles TF, Barbalho L. Lung hyperinflation stimulates the release of inflammatory mediators in spontaneously breathing subjects. Braz J Med Biol Res. 2010;43:201-205.

Meier T, Lange A, Papenberg H. Pulmonary cytokine responses during mechanical ventilation of noninjured lungs with and without end-expiratory pressure. Anesth Analg. 2008;107:1265-1275.

Wolthuis EK, Choi G, Dessing MC. Mechanical ventilation with lower tidal volumes and positive end-expiratory pressure prevents pulmonary inflammation in patients without preexisting lung injury. Anesthesiology. 2008;108:46-54.

Tenling A, Hachenberg T, Tyden H. Atelectasis and gas exchange after cardiac surgery. Anesthesiology. 1998;89:371-378.

Tusman G, Bohm SH, Suarez-Sipmann F. Alveolar recruitment improves ventilatory efficiency of the lungs during anesthesia. Can J Anaesth. 2004;51:723-727.

Tusman G, Bohm SH, Sipmann FS. Lung recruitment improves the efficiency of ventilation and gas exchange during one-lung ventilation anesthesia. Anesth Analg. 2004;98:1604-1609.

Ingber DE. Cellular mechanotransduction: putting all the pieces together again. FASEB J. 2006;20:811-827.

Stamenovic D. Micromechanical foundations of pulmonary elasticity. Physiol Rev. 1990;70:1117-1134.

Copland IB, Kavanagh BP, Engelberts D. Early changes in lung gene expression due to high tidal volume. Am J Respir Crit Care Med. 2003;168:1051-1059.

Vlahakis NE, Schroeder MA, Limper AH. Stretch induces cytokine release by alveolar epithelial cells in vitro. Am J Physiol. 1999;277:L167-173.

von Bethmann AN, Brasch F, Nusing R. Hyperventilation induces release of cytokines from perfused mouse lung. Am J Respir Crit Care Med. 1998;157:263-272.

Duggan M, McCaul CL, McNamara PJ. Atelectasis causes vascular leak and lethal right ventricular failure in uninjured rat lungs. Am J Respir Crit Care Med. 2003;167:1633-1640.

Moriondo A, Pelosi P, Passi A. Proteoglycan fragmentation and respiratory mechanics in mechanically ventilated healthy rats. J Appl Physiol. 2007;103:747-756.

Terragni PP, Rosboch G, Tealdi A. Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome. Am J Respir Crit Care Med. 2007;175:160-166.

Puls A, Pollok-Kopp B, Wrigge H. Effects of a single-lung recruitment maneuver on the systemic release of inflammatory mediators. Intensive Care Med. 2006;32:1080-1085.

5dd2db650e88250308c63494 rba Articles
Links & Downloads

Braz J Anesthesiol

Share this page
Page Sections