EFFICACY AND SAFETY OF THREE ALVEOLAR RECRUITMENT MANOEUVRES AFTER OFF-PUMP CORONARY ARTERY BYPASS GRAFTING
Keywords:
alveolar recruitment, mechanical ventilation, coronary artery bypass graftingAbstract
Background. The significance of alveolar recruitment manoeuvre (RM) after coronary artery surgery is still unsettled. Objective. The aim of this study was to compare three methods of RM after off-pump coronary artery bypass grafting (OPCAB). Materials and methods. 80 adult patients undergoing OPCAB were enrolled into a prospective randomized trial. Six patients were excluded from the analysis due to deviation from the study protocol. Four groups: СPAP-40 group was exposed to RM by changing the ventilator mode to continuous positive airway pressure of 40 cm H2O for 40 sec (n=19); in a Peak-40 group (n=20), RM was achieved by inflating the lungs at constant flow until a peak inspiratory pressure of 40 cm H2O was reached and held for 40 sec; the PEEP-15 (n=19) group received RM by raising the positive end-expiratory pressure to 15 cm H2O for 5 min; the control group (n=16) received no RM. PEEP level was defined as 5 cm H2O in all groups. The primary end-point of the study was the decrease in duration of postoperative respiratory support. Blood gases, respiratory and haemodynamic parameters were registered before RM, 10 min after RM, after a spontaneous breathing trial, at 1, 6, and 12 hrs after tracheal extubation. Results. Arterial oxygenation and dynamic compliance increased in all groups receiving RM (P<0.017). In the CPAP-40 group, mean arterial pressure decreased significantly during RM (P=0.01). In the PEEP-15 group, the duration of respiratory support was shortened by 1 hr as compared with the control group (P=0.012). Conclusion. Alveolar RM Peak-40 and PEEP-15 after OPCAB improved the oxygenation without negative influence on the haemodynamics, whereas CPAP-40 was accompanied by arterial hypotension. Application of a PEEP of 15 cm H2O for five minutes reduced the time to tracheal extubation.
References
Intraoperative ventilatory strategies for prevention of pulmonary atelectasis in obese patients undergoing laparoscopic bariatric surgery / H. F. Talab, I. A. Zabani, H. S. Abdelrahman // Anesth. Analg. – 2009. – Vol. 109, № 5. – P. 1511–1516.
Atelectases during anaesthesia and in the postoperative period / A. Strandberg, L. Tokics, B. Brismar [et al.] // Acta Anaesthesiol. Scand. – 1986. – Vol. 30, № 2. – P. 154–158.
Pulmonary densities during anesthesia with muscular relaxation — a proposal of atelectasis / B. Brismar, G. Hedenstierna, H. Lundquist [et al.] // Anesthesiology. – 1985. – Vol. 62, № 4. – P. 422–430.
Effects of off-pump coronary surgery on the mechanics of the respiratory system, lung, and chest wall: comparison with extracorporeal circulation / C. Roosens, J. Heerman, F. De Somer [et al.] // Crit. Care Med. – 2002. – Vol. 30, № 11. – P. 2430–2437.
Padovani C. Alveolar recruitment in the immediate postoperative period of cardiac surgery / C. Padovani, O. M. Cavenaqhi // Rev. Bras. Cir. Cardiovasc. – 2011. – Vol. 26, № 1. – P. 116–121.
Hedenstierna G. Atelectasis formation during anesthesia: causes and measures to prevent it / G. Hedenstierna, H. U. Rothen // J. Clin. Monit. Comput. – 2000. – Vol. 16. – P. 329–335.
Tusman G. How to open the Lung? The unsolved question / G. Tusman, E. Turchetto, A. Rodriguez // Anesthesiology. – 2000. – Vol. 93, № 4. – P. 1154–1159.
Hess D. R. Lung recruitment: the role of recruitment maneuvers / D. R. Hess, L. M. Bigatello // Respir. Care. – 2002. – Vol. 47, № 3. – P. 308–317.
Effects of alveolar recruitment on arterial oxygenation in patients after cardiac surgery: a prospective, randomized, controlled clinical trial / L. Minkovich, G. Djaiani, R. Katznelson [et al.] // J. Cardiothorac. Vasc. Anesth. – 2007. – Vol. 21, № 3. – P. 375–383.
Lung recruitment maneuver depresses central hemodynamics in patients following cardiac surgery / J. Nielsen, M. Østergaard, J. Kjaergaard [et al.] // Intensive Care Med. – 2005. – Vol. 31, № 9. – P. 1189–1194.
Clinical review: The implication of experimental and clinical studies of recruitment maneuvers in acute lung injury / E. Piacentini, A. Villagra, J. Lopez-Aguilar, L. Blanch // Crit. Care. – 2004. – Vol. 8, № 2. – P. 115–121.
Rama-Maceiras P. Peri-operative atelectasis and alveolar recruitment manoeuvres / P. Rama-Maceiras // Arch. Bronconeumonal. – 2010. – Vol. 46, № 6. – P. 317–324.
Alveolar recruitment strategy during cardiopulmonary bypass does not improve postoperative gas exchange and lung function / M. Scherer, S. Dettmer, D. Meininger [et al.] // Cardiovasc. Eng. – 2009. – Vol. 9, № 1. – P. 1–5.
Single transpulmonary thermodilution and continuous monitoring of central venous oxygen saturation during off-pump coronary surgery / A. A. Smetkin, M. Y. Kirov, V. V. Kuzkov [et al.] // Acta Anaesthesiol Scand. – 2009. – Vol. 53. – P. 506–514.
Alveolar recruitment strategy improves arterial oxygenation after cardiopulmonary bypass / B. A. Claxton, P. Morgan, H. McKeague [et al.] // Anaesthesia. – 2003. – Vol. 58, № 2. – P. 111–117.
Matthay M. A. The acute respiratory distress syndrome: pathogenesis and treatment / M. A. Matthay, R. L. Zemans // Ann. Rev. Pathology. – 2011. – № 6. – P. 147–163.
Effects of periodic lung recruitment maneuvers on gas exchange and respiratory mechanics in mechanically ventilated acute respiratory distress syndrome (ARDS) patients / G. Foti, M. Cereda, M. E. Sparacino [et al.] // Intensive Care Med. – 2000. – Vol. 26, № 5. – P. 501–507.
Dynamic of re-expansion of atelectasis during general anaesthesia / H. U. Rothen, P. Neumann, J. E. Berglund // Br. J. Anaesth. – 1999. – Vol. 82, № 4. – P. 551–556.
The effect of open lung ventilation on right ventricular and left ventricular function in lung-lavaged pigs / D. R. Miranda, L. Klompe, F. Cademartiri [et al.] // Crit Care. – 2006. – Vol. 10, № 3. – P. R86.
Effect of alveolar recruitment maneuver in early acute respiratory distress syndrome according to anti-derecruitment strategy, etiological category of diffuse lung injury, and body position of the patient / C. M. Lim, H. Jung, Y. Koh [et al.] // Crit. Care Med. – 2003. – Vol. 31, № 2. – P. 411–418.
Intercomparison of recruitment maneuver efficacy in three models of acute lung injury / S. C. Lim, A. B. Adams, D. Simonson [et al.] // Crit. Care Med. – 2004. – Vol. 32, № 12. – P. 2371–2377.
Comparison of two ventilatory strategies in elderly patients undergoing major abdominal surgery / T. N. Weingarten, F. X. Whalen, D. O. Warner [et al.] // Br. J. Anaesth. – 2010. – Vol. 104, № 1. – P. 16–22.
Lapinsky S. E. Bench-to-bedside review: Recruitment and recruiting maneuvers / S. E. Lapinsky, S. Mehta // Crit. Care. – 2005. – Vol. 9, № 1. – P. 60–65.
“Alveolar recruitment strategy” improves arterial oxygenation during general anaesthesia / G. Tusman, S. H. Bohm, G. F. Vsquez de Anda [et al.] // Br. J. Anaesth. – 1999. – Vol. 82, № 1. – P. 8–13.
Hajjar L. Effect of alveolar recruitment in patients after cardiac surgery: a prospective, randomized, controlled clinical trial / L. Hajjar, F. Galos, E. Nozawa // Crit. Care. – 2008. – Vol. 12, Suppl. 2. – P. 314.
Pressure support improves oxygenation and lung protection compared to pressure-controlled ventilation and is further improved by random variation of pressure support / P. M. Spieth, A. R. Carvalho, A. Güldner [et al.] // Crit. Care Med. – 2011. – Vol. 39, № 4. – P. 746–755.
Varelman D. Cardiorespiratory effects of spontaneous breathing in two different models of experimental lung injury: a randomized controlled trial / D. Varelman, T. Muders, J. Zinserling // Crit. Care. – 2008. – № 12. – R 135.
Haemodynamic stability and pulmonary shunt during spontaneous breathing and mechanical ventilation in porcine lung collapse / L. Vimláti, A. Larsson, G. Hedenstierna, M. Lichtwarck-Aschoff // Acta Anaesthesiol. Scand. – 2012. – Vol. 56, № 6. – P. 748–754.
Lung collapse and gas exchange during general anesthesia: effects of spontaneous breathing, muscle paralysis and positive end-expiratory pressure / L. Tokics, G. Hedenstierna, A. Strandberg [et al.] // Anesthesiology. – 1987. – Vol. 66, № 2. – P. 157–167.
Recruitment maneuvers for acute lung injury: a systematic review / E. Fan, M. E. Wilcox, R. G. Brower [et al.] // Am. J. Respir. Crit. Care Med. – 2008. – Vol. 178, № 11. – P. 1156–1163.
Van den Berg P. C. Effect of positive pressure on venous return in volume-loaded cardiac surgical patients / P. C. Van den Berg, J. R. Jansen, M. R. Pinsky // J. Appl. Physiol. – 2002. – Vol. 92, № 3. – P. 1223–1231.
Respiratory and hemodynamic changes during decremental open lung positive end-expiratory pressure titration in patients with acute respiratory distress syndrome / C. Gernoth, G. Wagner, P. Pelosi, T. Luecke // Crit. Care. – 2009. – Vol. 13, № 2. – P. R59.
How far can we go with positive end-expiratory pressure (PEEP) in liver transplant patients? / F. H. Saner, S. W. Olde Daminik, G. Pavlkovic [et al.] // Clin. Anesth. – 2010. – Vol. 22, № 2. – P. 104–109.
The pulmonary and hemodynamic effects of two different recruitment maneuvers after cardiac surgery / S. Celebi, O. Köner, F. Menda [et al.] // Anesth. Analg. – 2007. – Vol. 104, № 2. – P. 384–390.
Different patterns of lung recruitment maneuvers in acute respiratory distress syndrome: effect on oxygenation and central hemodinamics / M. Iannuzzi, A. De Sio, E. De Robertis [et al.] / / Minerva Anestesiol. – 2010. – Vol. 76, № 9. – P. 692–698.
Hemodynamic and respiratory changes during lung recruitment and descending optimal positive end-expiratory pressure titration in patients with acute respiratory distress syndrome / I. Toth, T. Leiner, A. Mikor [et al.] // Crit Care Med. – 2007. – Vol. 35, № 3. – P. 787–793.
