Post‐extubation continuous positive airway pressure improves oxygenation after pediatric laparoscopic surgery: A randomized controlled trial

Abstract

Background: Effects of intraoperative recruitment maneuvers (RMs) on oxygenation and pulmonary compliance are lost during recovery if high inspired oxygen and airway suctioning are used. We investigated the effect of post-extubation noninvasive CPAP mask application on the alveolar arterial oxygen difference [(A-a) DO 2 ] after pediatric laparoscopic surgery. Methods: Sixty patients (1-6 years) were randomly allocated to three groups of 20 patients, to receive zero end-expiratory pressure (ZEEP group), RM with decremental PEEP titration only (RM group), or followed with post-extubation CPAP for 5 minutes (RM-CPAP group). Primary outcome was [(A-a) DO 2 ] at 1 hour postoperatively. Secondary outcomes were respiratory mechanics, arterial blood gas analysis, hemodynamics, and adverse events. Results: At 1 hour postoperatively, mean [(A-a) DO 2 ] (mm Hg) was lower in the RM-CPAP group (41.5 ± 13.2, [95% CI 37.6-45.8]) compared to (80.2 ± 13.7 [72.6-87.5], P < 0.0001] and (59.2 ± 14.6, [54.8-62.6], P < 0.001) in the ZEEP and RM groups. The mean PaO 2 (mm Hg) at 1 hour postoperatively was higher in the RM-CPAP group (156.2 ± 18.3 [95% CI 147.6-164.7]) compared with the ZEEP (95.9 ± 15.9 [88.5-103.3], P < 0.0001) and RM groups (129.1 ± 15.9 [121.6-136.5], P < 0.0001). At 12 hours postoperatively, mean [(A-a) DO 2 ] and PaO 2 were (9.6 ± 2.1 [8.4-10.8]) and (91.9 ± 9.4[87.5-96.3]) in the RM-CPAP group compared to (25.8 ± 5.5 [23.6-27.6]) and (69.9 ± 5.5 [67.4-72.5], P < 0.0001) in the ZEEP group and (34.3 ± 13.2, [28.4-40.2], P < 0.0001) and (74.03 ± 9.8 [69.5-78.6], P < 0.0001) in the RM group. No significant differences of perioperative adverse effects were found between groups. Conclusions:An RM done after pneumoperitoneum inflation followed by decremental PEEP titration improved oxygenation at 1 hour postoperatively. The addition of an early post-extubation noninvasive CPAP mask ventilation improved oxygenation at 12 hours postoperatively.

S2k-Leitlinie Nichtinvasive Beatmung als Therapie der akuten respiratorischen Insuffizienz

“…Insbesondere bei Kindern mit chronischen Atemwegs-und Lungenerkrankungen, angeborenen Herzfehlern oder mit neuromuskulären Erkrankungen kann nach großen Operationen, wie z. B. Wirbelsäulenoperationen, NIV hilfreich sein [506,560,561,598]. Bei Letzteren speziell ist die NIV am besten präoperativ zu beginnen, um perioperative Komplikationen zu vermeiden [598].…”

Slow PEEP Titration During General Anesthesia with Muscle Paralysis Improves Lung Function Without Compromising Hemodynamic Stability in Preschool Children: A Randomized Control Clinical Trial

“…Ambrosio et al observed decrease in P(A-a)O 2 with increasing PEEP from 5 -20 cmH 2 O (4). In pediatric patients, titration of PEEP decreased P(A-a)O 2 1 hour after laparscopic surgery compered to children ventilated without PEEP (17). Positive pressure ventilation with PEEP 10 cmH 2 O also caused a Results are presented as mean and CI 95%.…”

Comparison of Postextubation Complications Between Positive-Pressure and Suctioning Techniques: A Systematic Review

“…After the screening process, 18 of the 4,267 identified studies were considered potential candidates for inclusion in the systematic review. 7,10,11,[19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] Five studies were excluded because they were surveys on extubation techniques or airway management. 10,11,[19][20][21] In addition, 6 studies were excluded because they did not compare positive-pressure and suctioning techniques.…”

“…10,11,[19][20][21] In addition, 6 studies were excluded because they did not compare positive-pressure and suctioning techniques. [22][23][24][25][26][27] A total of 7 studies, 6 RCTs 7,28-32 and 1 non-randomized controlled study, 33 were finally included in the systematic review.…”