Feasibility of postural lung recruitment maneuver in children: a randomized, controlled study

Abstract

Background: Pulmonary atelectasis in anesthetized children is easily reverted by lung recruitment maneuvers. However, the high airways pressure reached during the maneuver could negatively affect hemodynamics. The aim of this study is to assess the effect and feasibility of a postural lung recruitment maneuver (P-RM); i.e., a new maneuver that opens up the atelectatic lung areas based on changing the child's body position under constant ventilation with moderated driving pressure (12 cmH 2 O) and of positive end-expiratory pressure (PEEP, 10 cmH 2 O). Forty ASA I-II children, aged 6 months to 7 years, subjected to general anesthesia were studied. Patients were ventilated with volume control mode using standard settings with 5 cmH 2 O of PEEP. They were randomized into two groups: (1) control group (C group, n = 20)-ventilation was turned to pressure control ventilation using a fixed driving pressure of 12 cmH 2 O. PEEP was increased from 5 to 10 cmH 2 O during 3 min maintaining the supine position. (2) P-RM group (n = 20)-patients received the same increase in driving pressure and PEEP, but they were placed, respectively, in the left lateral position, in the right lateral position (90 s each), and back again into the supine position after 3 min. Then, ventilation returned to baseline settings in volume control mode. Lung ultrasound-derived aeration score and respiratory compliance were assessed before (T1) and after (T2) 10 cmH 2 O of PEEP was applied. Results: At baseline ventilation (T1), both groups showed similar aeration score (P-RM group 9.9 ± 1.9 vs C group 10.4 ± 1.9; p = 0.463) and respiratory compliance (P-RM group 15 ± 6 vs C group 14 ± 6 mL/cmH 2 O; p = 0.517). At T2, the aeration score decreased in the P-RM group (1.5 ± 1.6 vs 9.9 ± 2.1; p < 0.001), but remained without changes in the C group (9.9 ± 2.1; p = 0.221). Compliance was higher in the P-RM group (18 ± 6 mL/cmH 2 O) when compared with the C group (14 ± 5 mL/cmH 2 O; p = 0.001). Conclusion: Lung aeration and compliance improved only in the group in which a posture change strategy was applied.

Ultrasound assessment of pulmonary fibroproliferative changes in severe COVID-19: a quantitative correlation study with histopathological findings

“…We are not aware of any study that has compared pre-mortem with post-mortem LUS findings, and pre-mortem LUS was not performed on our patients. Therefore, for the post-mortem analysis, we used LUS parameters previously established in vivo [ 2 , 3 , 5 , 7 , 26 ]. To our knowledge, this is the first study to correlate ultrasound imaging with histological injury in COVID-19 patients; our results provide additional information to the previous in vivo imaging studies and reinforce the concept that LUS is accurate enough to track the extent of fibroproliferative alveolar damage in severe COVID-19.…”

“…We defined for each of the eight sites of study a binary indicator (0 = absence; 1 = presence) of LUS parameters previously described in several studies dedicated to assess the severity of pulmonary COVID-19 [ 2 , 5 , 26 ], as follows: normal pleural line, irregular pleural line, fragmented pleural line, A lines, spaced B lines, confluent B lines (sometimes giving the appearance of a white lung), peripheral consolidation, and pulmonary consolidation. For each patient, values of LUS parameters were calculated as the sum of the scores obtained at the eight examined sites (therefore, the value of each LUS parameter varied from 0 to 8 for each patient).…”

Targeted Lateral Positioning Decreases Lung Collapse and Overdistension in COVID-19-Associated ARDS

“…This is the rst description of using EIT with targeted lateral positioning to personalize PEEP in adult patients with COVID-19-associated ARDS. A randomized and controlled trial demonstrated the feasibility and e cacy of a postural recruitment maneuver in children with anesthesia-induced atelectasis [7]. Besides being applied in children with healthy lungs, another difference between the Acosta et al and our study is the lack of PEEP titrations.…”

“…Very recently, Zhao et al reported the use of EIT for individualized ventilation strategy in one patient with COVID-19 [8]. Similarly to the study in children with anesthesia-induced atelectasis [7], a key difference between the Zhao et al case report and our case series is the lack of a strategy to personalize PEEP during the lateral positioning.…”

Targeted lateral positioning decreases lung collapse and overdistension in COVID-19-associated ARDS

“…This is the first description of using EIT with targeted lateral positioning to personalize PEEP in adult patients with COVID-19-associated ARDS. A randomized and controlled trial demonstrated the feasibility and efficacy of a postural recruitment maneuver in children with anesthesia-induced atelectasis [ 10 ]. Besides being applied in children with healthy lungs, another difference between the Acosta et al and our study is the lack of PEEP titrations.…”