Effects of Recruitment Maneuver and Positive End-expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery

Cinnella, Gilda; Grasso, Salvatore; Spadaro, Savino; Rauseo, Michela; Mirabella, Lucia; Salatto, Potito; Capraris, A. De; Nappi, Luigi; Greco, Pantaleo; Dambrosio, Michele

doi:10.1097/aln.0b013e3182746a10

Cited by 114 publications

(109 citation statements)

References 46 publications

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“…In cases of pulmonary pathology with coexisting intra-abdominal hypertension, the beneficial effects of PEEP are observed, irrespective of the method of PEEP application [19]. In patients with intra-abdominal hypertension induced by pneumoperitoneum for laparoscopic procedures, even low values of PEEP contribute to better lung elastance, and thus better compliance [20]. Comparable observations pertaining to individuals undergoing thoracic surgery with ventilation involving only one lung have been conducted [21,22].…”

Section: Discussionmentioning

confidence: 82%

Wpływ jednostronnego PEEP na biomechanikę obu płuc podczas niezależnej wentylacji u chorych znieczulanych do zabiegów torakochirurgicznych

Trela-Stachurska¹,

Nestorowicz²,

Kotlińska-Hasiec³

et al. 2015

Anaesthesiol Intensive Ther

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Background: Synchronous independent lung ventilation (ILV) is the treatment of choice for unilateral pathology of lung parenchyma. Numerous studies have documented the improved blood oxygenation and clinical efficacy of this procedure. The aim of the present study was to evaluate the effects of ILV on the selected biomechanical parameters of the lungs. Method: The study involved ASA I-II patients undergoing thoracic surgery in the lateral decubitus position under the standard conditions of general anaesthesia with the thoracic cavity closed. ILV with equal separation of the tidal volume was performed with a prototype volume separator, using incremental a PEEP of 0−15 cm H 2 O in the dependent lung. Peak pressures, dynamic compliance and airway resistance of both lungs were evaluated. Results: The study included 36 patients. In all of the patients, a PEEP of 5−15 cm H 2 O in one lung increased its peak pressures, dynamic compliance and resistances, and variably affected the biomechanical parameters of the other lung. Irrespective of patient positioning on the right or left side, the highest compliance was recorded at a PEEP of 10 cm H 2 O. Conclusions: In ILV, peak pressures and airway resistances are higher in the dependent lung compared to compliances in the non-dependent lung. ILV with a PEEP of 5−15 cm H 2 O increases the biomechanical parameters of the dependent lung while variably influencing the parameters in the non-dependent lung.

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Section: Discussionmentioning

confidence: 82%

Wpływ jednostronnego PEEP na biomechanikę obu płuc podczas niezależnej wentylacji u chorych znieczulanych do zabiegów torakochirurgicznych

Trela-Stachurska¹,

Nestorowicz²,

Kotlińska-Hasiec³

et al. 2015

Anaesthesiol Intensive Ther

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“…It has been demonstrated that both peak and plateau Paw are higher during pneumoperitoneum (13,15,16), as shown in Figure 1. It should be stressed that Paw does not allow the identification of which respiratory system mechanical component is altered.…”

Section: Alterations Of the Respiratory Systemmentioning

confidence: 81%

“…These findings have been recently confirmed by the use of a RM generated by a progressive increase in the PEEP level (under PCV) until peak pressure equaled 40 cmH2O, followed by a 5-cmH2O PEEP. Furthermore, even Ew decreases, probably because of the higher pulmonary expansion that resembles to a better extent the physiological conformation not only of the lung, but also of the chest wall (13). Additionally, PEEP can reduce Rrs because it opens and stabilizes air spaces (13,15).…”

Section: Alveolar Recruitment and Peepmentioning

confidence: 99%

Artificial ventilation during pneumoperitoneum

Comuzzi¹

2014

SOB

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the complications pertaining to pneumoperitoneum to solve them quickly, paying particular attention to the patients at higher risk, such as elderly, obese, and those with cardiopulmonary disease. KEY WORDS: pneumoperitoneum, artificial ventilation, obesity, laparoscopy, anesthesia. IntroductionLaparoscopic surgery has been increasingly employed in various surgical subspecialties because of its innumerous benefits. These are evident during the post-operative period and result from the less important organ/tissue trauma caused by laparoscopic approaches than those triggered by open surgery. The main advantages of laparoscopic surgery are: reduction of the inflammatory and metabolic responses (1-3), reduced post-operative pain and analgesic consumption (2, 3), smaller incidence of respiratory complications (2), faster resolution of post-operative ileum and recovery (1). Taken together, these outcomes reduce hospital stay, promote a quicker return to normal daily activities (2-4), and reduce the cost of the treatment (4). On the other hand, laparoscopic surgery presents some challenges regarding the intra-operative anesthesia management, since there are respiratory and hemodynamic changes pertaining to the general anesthesia itself, to the abdominal insufflation, and to the intra-operative positioning of the patient (5). These issues become even more evident in patients with cardiopulmonary disease or obesity (6). This review focuses on the intra-operative respiratory alterations caused by laparoscopy and on the ventilatory strategies that are prone to minimize the modifications evoked by the technique. Alterations of the respiratory systemIn order to allow an adequate observation of the surgical field, laparoscopic surgery requires controlled gas insufflation into the peritoneal cavity (pneumoperitoneum). For this purpose, carbon dioxide is regularly used under a pressure of 10-15 mmHg. Naturally, respiratory issues related to mechanics and CO2 overload SummaryLaparoscopic surgery has been increasingly used in many surgical subspecialties, due to its various post-operative benefits. On the other hand, it presents intra-operative challenges to the anesthesia management. The inflation of the abdominal cavity with carbon dioxide leads to hemodynamic changes, mechanical respiratory system derangements (increased elastance, resistance and airway pressure), augmented V'CO2, and alterations of the V'/Q' ratio and of the PaCO2-PetCO2 gradient. All these changes may be influenced by other factors, such as body position and baseline characteristics of the patient. To minimize the negative consequences of these modifications a protective ventilation strategy with the use of low tidal volumes and PEEP, eventually associated with recruitment maneuvers, is suggested. No ventilatory mode or anesthetic drug has been proven better than the others. It has been suggested that the use of supraglotic devices may be a safe alternative to endotracheal intubation during laparoscopic surgery. It is important that the anesthetist be aware ...

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“…The importance of PEEP application for maintaining adequate gas exchange while preventing ventilator-induced lung injury is especially emphasized (7,10,22,23). Many studies suggested that PEEP and the alveolar recruitment maneuver application improved ventilation-perfusion and gas exchange (7,24,25). In a clinical trial it was demonstrated that a PEEP of 10 cmH 2 O produced beneficial effects on the impaired elastance of the respiratory system caused by pneumoperitoneum in patients undergoing laparoscopic cholecystectomy (5).…”

Section: Discussionmentioning

confidence: 99%

“…Studies reported that PEEP applied during laparoscopy improved oxygenation and respiratory compliance (5)(6)(7). However, PEEP application causes a subsequent elevation of intrathoracic pressure, decreases cerebral venous return, increases intracranial blood volume and pressure, and possibly impairs cerebral blood flow.…”

Section: Introductionmentioning

confidence: 99%

Effects of positive end-expiratory pressure on intracranial pressure during pneumoperitoneum and Trendelenburg position in a porcine model*

Bedirli¹,

Emmez²,

Ünal³

et al. 2017

Turk J Med Sci

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IntroductionRobot-assisted laparoscopic surgery has developed greatly and is becoming a standard technique for radical prostatectomy. It is widely preferred for pelvic surgeries because of its important advantages that minimize postoperative morbidity and mortality. Robotic surgeries in the pelvic region, including radical prostatectomy, rectum resection, and gynecologic procedures, usually require a steep Trendelenburg position and carbon dioxide pneumoperitoneum to secure the surgical field. Pneumoperitoneum combined with steep Trendelenburg position may cause significant changes in cardiovascular, respiratory, and neurophysiological parameters (1,2). Both the increase in abdominal pressure as a result of carbon dioxide insufflation and the head-down position have been shown to impair respiratory functions during the procedure by pushing the diaphragm upward and reducing lung volume and respiratory compliance, thus inducing atelectasis formation (3,4).Background/aim: This study was undertaken to evaluate the effects of positive end-expiratory pressure (PEEP) levels on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) and to determine the appropriate PEEP level during steep Trendelenburg position combined with pneumoperitoneum. Materials and methods:Ten pigs were included in this study. Pneumoperitoneum and Trendelenburg position were maintained and PEEP titration was initiated. Arterial pressure, heart rate, arterial blood gas, ICP, and CPP were recorded at the following time points: baseline (T0), 30 min after positioning and pneumoperitoneum (T1), PEEP 5 (T2), PEEP 10 (T3), PEEP 15 (T4), and PEEP 20 (T5).Results: MAP significantly increased at T1 compared to T0 and decreased at T4 and T5 compared to T1. ICP was 9.5 mmHg and CPP was 69.3 mmHg at T0. CO 2 insufflation and steep Trendelenburg position did not cause any significant difference in ICP and CPP. ICP increased and CPP decreased significantly at T4 and T5 compared to both T0 and T1. PaO 2 and PaO 2 /FiO 2 decreased significantly at T1 and T2 compared to T0, while both increased significantly at T3, T4, and T5 compared to T1. Conclusion:PEEP of 10 cmH 2 O was effective for providing oxygenation while preserving hemodynamic stability, ICP, and CPP in this model.

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Effects of Recruitment Maneuver and Positive End-expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery

Cited by 114 publications

References 46 publications

Wpływ jednostronnego PEEP na biomechanikę obu płuc podczas niezależnej wentylacji u chorych znieczulanych do zabiegów torakochirurgicznych

Wpływ jednostronnego PEEP na biomechanikę obu płuc podczas niezależnej wentylacji u chorych znieczulanych do zabiegów torakochirurgicznych

Artificial ventilation during pneumoperitoneum

Effects of positive end-expiratory pressure on intracranial pressure during pneumoperitoneum and Trendelenburg position in a porcine model*

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