Effect of regular alveolar recruitment on intraoperative atelectasis in paediatric patients ventilated in the prone position: a randomised controlled trial

Abstract

Background: Desaturation frequently occurs in infants after general anaesthesia in the prone position. We aimed to evaluate the effect of regular alveolar recruitment in preventing atelectasis in infants and children after general anaesthesia in the prone position. Methods: Children (<3 yr) undergoing general anaesthesia (>2 h) in the prone position were randomised to either receive regular alveolar recruitment or standardised care without recruitment. Ultrasound-guided alveolar recruitment was performed for both groups, and mechanical ventilation was started with a tidal volume of 6 ml kg À1 and PEEP of 7 cm H 2 O. During mechanical ventilation, the intervention (regular recruitment) group received alveolar recruitment once per hour. Lung ultrasound was performed after inducing anaesthesia and each position change. The primary outcome was the incidence of significant atelectasis (defined by consolidation score !2 in any region) before extubation, as evaluated by lung ultrasound undertaken by an investigator masked to trial allocation. Results: Seventy-three children (regular recruitment: 37; standardised care: 36) were included in the analysis. Before the hourly intervention, atelectasis was similar between children randomised to regular alveolar recruitment or standardised care in both supine (83.3%, both groups; P>0.99) and prone positions (88.9% vs 91.9%; P¼0.970). The incidence of atelectasis before extubation was lower in children receiving regular alveolar recruitment (8.1%), compared with 47.2% in children randomised to standardised care (absolute risk reduction: 39.1% [95% confidence interval: 20.6e57.6%); P<0.001). Conclusions: Regular alveolar recruitment reduced the incidence of atelectasis at the end of surgery in infants and children <3 yr undergoing general anaesthesia in the prone position. Clinical trial registration: NCT03486847.

Successful lung transplantation after prone positioning in an ineligible donor: a case report

“…In this case, the donor’s hypoxemia was not corrected by the conventional recruitment maneuver. It returned to a viable state after the donor was in the prone position for 12 h. Traditionally, the prone position has been used for acute respiratory distress syndrome [ 12 ]. It allows the alveoli to open and participate in gas exchange, which increases PaO 2 [ 8 ].…”

“…The reaction to prone positioning started to occur after four hours, and a significant improvement in oxygenation was observed after 12 h, as seen in this case [ 7 ]. The improved oxygenation due to prone positioning is likely mediated by rapid positional improvements in the V/Q mismatch, enhanced postural drainage of secretions, and sustained improvements in atelectasis and shunting [ 7 , 8 , 12 ]. In this case, we confirmed the reversal of the non-aerated region with EIT instead of CT. As EIT is a non-invasive monitoring method that makes cross-sectional images of the chest through the analysis of transthoracic electrical conductivity, this technique is radiation-free and applicable at the bedside.…”

Effect of oxygen concentration on atelectasis formation during induction of general anesthesia in children: A prospective randomized controlled trial—A Comment

“…The authors conclude that lower oxygen concentration (60%) Secondly, in our opinion, the fraction of oxygen and PEEP administered intraoperatively, and the fraction of oxygen used at extubation can potentially influence the incidence and severity of postoperative atelectasis. [3][4][5] Therefore, a uniform protocolization or a comment upon the above-mentioned factors seems mandatory when evaluating postoperative atelectasis in a group of patients.…”

Atelectasis and lung recruitment in pediatric anesthesia: An educational review

“…12,13 It most commonly affects the dependent areas of the lungs where the transpulmonary pressure is lowest. [10][11][12]14,15 Initially, loss of muscle tone associated with general anesthesia results in a reduction in functional residual capacity (FRC), with resultant small airway closure. 16,17 In addition, changes in chest and diaphragm position while supine result in further compression of lung tissue by transmitting intra-abdominal pressure.…”