Lung recruitment in the prone position after cardiac surgery: a randomised controlled study

Abstract

Background: Atelectasis after cardiac surgery is common and promotes ventilation/perfusion mismatch, infection, and delayed discharge from critical care. Recruitment manoeuvres are often performed to reduce atelectasis. In severe respiratory failure, recruitment manoeuvres in the prone position may increase oxygenation, survival, or both. We compared the effects of recruitment manoeuvres in the prone vs supine position on lung aeration and oxygenation in cardiac surgical patients. Methods: Subjects were randomised to recruitment manoeuvres (40 cm H 2 O peak inspiratory pressure and 20 cm H 2 O PEEP for 30 s) in either the prone or supine position after uncomplicated cardiac surgery. The co-primary endpoints were lung aeration (end-expiratory lung volume measured by electrical impedance tomography (arbitrary units [a.u.]) and lung oxygenation (ratio of arterial oxygen partial pressure to fractional inspired oxygen [PaO 2 /FiO 2 ratio]). Secondary outcomes included postoperative oxygen requirement and adverse events. Results: Thirty subjects (27% female; age, 48e81 yr) were recruited. Dorsal lung tidal volume was higher after prone recruitment manoeuvres (363 a.u.; 95% confidence intervals [CI], 283e443; n¼15) after extubation, compared with supine recruitment manoeuvres (212 a.u.; 95% CI, 170e254; n¼15; P<0.001). Prone recruitment manoeuvres increased dorsal endexpiratory lung volume by 724 a.u. (95% CI, 456e992) after extubation, compared with 163 a.u. decrease (95% CI, 73e252) after supine recruitment manoeuvres (P<0.001). The PaO 2 /FiO 2 ratio after extubation was higher after prone recruitment manoeuvres (46.6; 95% CI, 40.7e53.0) compared with supine recruitment manoeuvres (39.3; 95% CI, 34.8e43.8; P¼0.04). Oxygen therapy after extubation was shorter after prone (33 h [13]) vs supine recruitment manoeuvres (52 h [22]; P¼0.01). No adverse events occurred. Conclusions: Recruitment manoeuvres in the prone position after cardiac surgery improve lung aeration and oxygenation. Clinical trial registration: NCT03009331.

Role of Intensified Lung Physiotherapy Bundle on the Occurrence of Pneumonia After Cardiac Surgery

“…We found that there was no significant difference in the incidence of postoperative bleeding, wound rupture or infection, and other complications between the two groups. Standardized lung physiotherapy after cardiac surgery is safe and is conducive to improving the prognosis of these patients ( 11 ).…”

Lung UltraSound Targeted Recruitment (LUSTR): A Novel Protocol to Optimize Open Lung Ventilation in Critically Ill Neonates

“…In accordance with the gravity-dependent lung physiology [ 4 , 26 ], patient position guided by LUS allowed the opening pressure to be targeted towards the most derecruited parenchyma, improving the lung reopening of the collapsed areas and reducing the risk of overdistension of the aerated segments. Although no evidence is available to suggest that a particular body position during mechanical ventilation of the neonate is effective in producing sustained and clinically relevant improvement [ 27 ], it has been described in adult patients that lung recruitment performed in prone position may obtain better results than the supine position [ 28 , 29 ]. In our population, the prone position was more frequent in the LUSTR-group, although this difference was not significant; however, the difference in the lateral or supine position between the two groups was substantial, suggesting that the prone position itself could not justify the better results obtained in the LUSTR-group, while the LUS-guided postural recruitment is likely a key feature of the LUSTR protocol.…”

Effect of Prone Positioning With Individualized Positive End-Expiratory Pressure in Acute Respiratory Distress Syndrome Using Electrical Impedance Tomography

“…But the overall effect of PP is the decrease in chest wall compliance, which results in an increase in plateau pressure during volume-controlled ventilation or a decrease in V T during pressure-controlled ventilation ( Guerin et al, 2004 ; Taccone et al, 2009 ; Gattinoni et al, 2013 ; Iftikhar et al, 2015 ; Guérin et al, 2020 ; Lai et al, 2021 ). Recent studies suggested that EIT-based optimal PEEP was significantly lower in prone than in supine position ( Kotani et al, 2018 ; Martinsson et al, 2021 ). On the contrary, a study showed that in most patients a PEEP value above commonly used settings was necessary to avoid alveolar collapse in the prone position ( Spaeth et al, 2016 ).…”