Effects of positive end-expiratory

pressure/recruitment manoeuvres compared

with zero end-expiratory pressure on
atelectasis during open gynaecological
surgery as assessed by ultrasonography: A
Randomised controlled trial

Guide: Dr. Karthik Raj, MD

Dr. Jelliffe. J
Post Graduate
British Journal of Anaesthesia Dept. of Anaesthesiology
January 2020
Vol. 124 Issue 1
GTMCH, Theni
 Introduction
• Post-operative pulmonary complications (PPCs) are associated with

increased mortality, morbidity and healthcare costs.

• PPCs may include atelectasis, pneumonia, ARDS and pulmonary aspiration.

• Atelectasis is seen in ¾ patients receiving general anaesthesia.

• Perioperative atelectasis is a key contributor to the development of most

PPCs.
 Introduction
• Many clinical trials have investigated the use of intraoperative

protective mechanical ventilation to prevent PPCs.

• But, none of the trials have visually confirmed if the protective

measures led to any decrease in intra-operative atelectasis.

• Thoracic CT is gold-standard to assess atelectasis.

• Ultrasonography is easy to use, portable and without risk of ionizing

radiation.
 Study Design

• Single center, double blinded, randomized controlled trial

• Department of Anaesthesiology, University of Montreal,

Canada.
 Inclusion Criteria

• Women > 18 years of age

• Elective laprotomy for oncologic gynaecological surgery

• Duration of surgery > 2 hours

 Exclusion Criteria

• Patient refusal

• BMI > 40 kg/m2

• ASA IV, V

• Previous intra-thoracic surgery

• Severe COPD
 Anaesthesia Protocol
• Pre-oxygenation with 100% of O2 for 3 minutes.

• Induction with Propofol and Fentanyl

• Rocuronium for tracheal intubation and to maintain muscle relaxation during

surgery

• Desflurane/Sevoflurane

• Volume controlled ventilation; tidal volume 8ml/kg ; frequency 12 bpm ; EtCO2 30-

40mmHg

• Reversal with Neostigmine 0.05mg/kg and glycopyrrolate 0.007mg/kg

 Ventilation Protocol

• Patients were randomly assigned to one of two groups:

• PEEP/RM group

• Zero end-expiratory pressure (ZEEP) group

 Ventilation Protocol
• PEEP Group:

• Recruitment manouever 30 cm H20 for 30 sec every 30 minutes

• PEEP of 7 cm H2O

• ZEEP Group:

• No recruitment manouver/PEEP
 Lung Ultrasound
• Performed with GE Logic e ultrasound machine using curvilinear

probe (2-5MHz)

• Ultrasonographic assessment of anterior, lateral and posterior

zones separated by anterior and posterior axillary lines were done.

• Each zone was divided into upper and lower portion leading to a

total of 12 quadrants.

• Intercostal spaces of each quadrant were scanned

Study Protocol
 Primary Outcome: Lung
Ultrasonography Score (LUS)
• LUS was calculated at each time point for all subjects.
• LUS scoring:
• 0 – normal lung sliding with < 3 B lines
• 1 – More than 3 B lines
• 2 – Coalescent B lines
• 3 – Consolidated lung

• LUS was calculated for each quadrant and then was added up
for all 12 quadrants for every patient.
B - Lines
Coalesced B Lines
 Secondary Outcomes
• At each time point:

• Vital signs (PR, BP, SpO2)

• FiO2

• Arterial blood gas analysis

• Mechanical ventilation parameters (Vt, f, PEEP)

• Total number of recruitment manouevers (PEEP Group)

 Explanatory Variables
• Induction:

– Induction duration

– Number of laryngoscopy attempts

• Maintenance:

– Mechanical ventilation duration

– Operating table angulation

– Fluid balance
 Explanatory Variables

• Emergence:

– Spontaneous ventilation duration

– Postoperative pain

– Cough severity
Results
 Results
• Mean LUS was similar in both groups before induction of GA.

• After induction, lung aeration deteriorated in both groups.

• Before emergence, LUS was lower in PEEP group compared to ZEEP

group

• No difference in LUS between the two groups after extubation and

arrival in PACU.
 Results
• Secondary Outcomes:

• In PEEP group:

– PaO2 and FiO2 ratio increased with the use of PEEP and RM during GA

– Driving pressure decreased

• In ZEEP group:

– PaO2 and FiO2 ratio remained unchanged during GA

– Driving pressure increased

 Results

• Explanatory Analyses:

• Increased BMI in ZEEP group – associated with increased

aeration loss during GA in maintenance.

• Longer duration of spontaneous ventilation at emergence

in PEEP group was also associated with increased aeration

loss.
 Discussion
• Combination of PEEP and recruitment manouver improves lung aeration
during GA lasting for more than 2 hours.

• Higher PaO2:FiO2 ratio and lower driving pressure was also achieved with
PEEP and RM.

• Inter-patient variability was seen post induction.

• Minimising atelectasis in the perioperative period decreases post-

operative pulmonary complications (PPCs).

• Use of PEEP at emergence and CPAP post-operatively might benefit in

preserving lung aeration.
 Positive End-Expiratory Pressure

• PEEP increases end expiratory pressure to a value that is

greater than atmospheric pressure.

• Used to improve patient’s oxygenation status

• PEEP is applied in conjunction with other ventilator modes

• In spontaneously breathing patients, PEEP is called CPAP

 Indications for PEEP

• 3 major indications:

1. Intrapulmonary shunt and refractory hypoxemia

2. Decreased FRC and lung compliance

3. Auto-PEEP not responding to adjustments of

ventilator settings
 Physiology of PEEP

• Reinflates collapsed alveoli

• Maintains alveolar inflation during exhalation

• Decreases the threshold for alveolar opening

• Thereby facilitates gas diffusion and oxygenation

 Complications of PEEP

• 1. Decreased venous return and CO

• 2. Barotrauma

• 3. Increased intracranial pressure

• 4. Alterations of renal functions and water

metabolism
 Recruitment Manoeuvres

• Sustained increase in pressure in the lungs

• Goal is to open as many collapsed lung units as

possible
 Recruitment Manoeuvres
• Sigmoid curve - Different areas of
lungs open at different pressures
• Opening pressure can range from
few cm H2O to as high as 55-60cm
H2O
• Compression atelectasis / loose
atelectasis - seen after induction in
GA
• Opening pressure for compression
atelectasis: Around 20cm H2O
• Most RMs are performed with
pressure sustained for 40 sec or
more.
 Complications of Recruitment
Manoeuvres
1. Hypotension

2. Hypoxemia

3. Barotrauma

4. Pneumothorax

5. Subcutaneous emphysema

6. Pneumomediastinum
 Conclusion
• PEEP and RM prevent intra-operative atelectasis significantly.

• But aeration loss increases after extubation and in the PACU.

• PEEP during emergence and CPAP post-operatively.

• Serial lung ultrasonography can be used to deliver patient-specific

pulmonary protective efforts peri-operatively.

Thank you