The effect of recruitment maneuver on the development of expansion defect and atelectasis after lobectomy: A double-blind randomized controlled trial

Year 2021, Volume: 5 Issue: 9, 964 - 968, 01.09.2021

Kadir İdin

https://doi.org/10.28982/josam.1001166

Abstract

Background/Aim: In pulmonary lobectomy operations, the operation is performed with one-lung ventilation by collapsing the related lung. Postoperative expansion failure on the deflated side is a critical issue. We aimed to correct the expansion failure and atelectasis with the recruitment maneuver performed at the end of the operation.
Methods: A total of 61 cases who underwent elective lobectomy under one-lung ventilation were included in this double-blind and prospective study. They were randomized into two groups comprising thirty and thirty-one cases. The first group included patients in whom the cycling recruitment maneuver (cRM) was performed, and the second group comprised patients who underwent the manual recruitment maneuver. Both groups were ventilated similarly during the one-lung ventilation period. After switching to double-lung ventilation, a standardized cycling recruitment maneuver was performed in the first group, and a high-volume manual recruitment maneuver with an anesthetic reservoir bag was used in the second group. Preoperative and postoperative inspiratory and hemodynamic parameters, wakefulness level, pain scores, developments of complications and durations of the hospitalization were noted. Expansion failure and atelectasis were evaluated both with chest radiography and thorax computerized tomography.
Results: There was no statistically significant difference among the two groups in terms of age, smoking, duration of operation, preoperative forced expiratory volume in 1 second (FEV1), SpO2 levels, respiratory and hemodynamic parameters noted during the operation, invasive arterial pressure monitoring results, electrocardiogram (ECG) findings, modified Aldrete score (MAS), and visual analogue scores (VAS) (P>0.05 for all). The gender distribution and types of operations performed were also similar. No complications were observed. Expansion failure was seen in 23.3% and 48.8% (P=0.042) of the patients in the cRM and mRM groups, respectively. Additional procedures were needed in 4 patients (13.3%) in the cRM group and in 11 patients (35.5%) in the mRM group. The duration of hospital stay was significantly shorter in the cRM group (P=0.045). Regression analysis revealed a 3.08-times increase in the incidence of expansion failure in the mRM group compared to group cRM.
Conclusion: In pulmonary lobectomy operations, we observed that with the utilization of the recruitment maneuver which is performed after switching to double-lung ventilation, the rate of expansion failure, the need for additional procedures and duration of hospital stay decreased.

Keywords

Atelectasis, Cycling recruitment management, Expansion defect, Lobectomy

References

• 1. Tusman G, Böhm SH, Warner DO, Sprung J. Atelectasis and perioperative pulmonary complications in high-risk patients. Curr Opin Anaesthesiol. 2012 Feb;25(1):1-10.
• 2. Handy JR Jr, Denniston K, Grunkemeier GL, Wu YX. What is the inpatient cost of hospital complications or death after lobectomy or pneumonectomy? Ann Thorac Surg. 2011 Jan;91(1):234-8.
• 3. Canet J, Gallart L, Gomar C, Paluzie G, Vallès J, Castillo J, et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology. 2010;113:1338-50.
• 4. Stolz AJ, Lischke R, Schutzner J, Petrik E, Harustiak T, Pafko P. Predisposing factors of atelectasis following pulmonary lobectomy. Acta Chir Belg. 2009 Jan-Feb;109(1):81-5.
• 5. Uramoto H, Nakanishi R, Fujino Y, Imoto H, Takenoyama M, Yoshimatsu T, et al. Prediction of pulmonary complications after a lobectomy in patients with non-small cell lung cancer. Thorax. 2001 Jan;56(1):59-61.
• 6. Uzieblo M, Welsh R, Pursel SE, Chmielewski GW. Incidence and significance of lobular atelectasis in thoracic surgical patients. Am Surg. 2000 May;66(5):476-80.
• 7. Abholda A, Liu D, Brooks A, Burt M. Prolonged air leak following radical upper lobectomy. Chest. 1998 Jun;113(6):1507-10.
• 8. Akkaş Y, Yazıcı Ü. Postoperative Complications In: Yüksel M, Balci AE, editors. Thoracic Surgery. Istanbul: Nobel Medical Bookstores; 2015. p. 203-11
• 9. Toker A, Dilege S, Bostancı K, Kalaycı G. Perioperative Pneumoperitoneum to Prevent Space and Air Leak after Lobectomy Operations. Thorac Cardiovasc Surg. 2003 Apr;51(2):93-6.
• 10. Rice TW, Kirby TJ. Prolonged air leak. Chest Surg Clin North Am 1992 Feb;23(2):803-11.
• 11. Handy JR, Judson MA, Zellner JL. Pneumoperitoneum to treat air leaks and spaces after lung volume reduction operations. Ann Thorac Surg. 1997 Dec;64(6):1803-5.
• 12. Tusman G, Böhm SH, Sipmann FS, Maisch S. Lung recruitment improves the efficiency of ventilation and gas exchange during one-lung ventilation anesthesia. Anesth Analg. 2004 Jun;98(6):1604-9.
• 13. Tusman G, Böhm SH, Suarez-Sipmann F, Turchetto E. Alveolar recruitment improves ventilatory efficiency of the lungs during anesthesia. Can J Anaesth. 2004 Aug-Sep;51(7):723-7.
• 14. Kilpatrick B, Slinger P. Lung protective strategies in anaesthesia. Br J Anaesth. 2010 Dec;105 Suppl 1:i108-16.
• 15. Inomata S, Nishikawa T, Saito S, Kihara S. "Best" PEEP during one-lung ventilation. Br J Anaesth. 1997 Jun;78(6):754-6.
• 16. Tusman G, Böhm SH, Vazquez de Anda GF, do Campo JL, Lachmann B. The 'alveolar recruitment strategy' improves arterial oxygenation during general anaesthesia. Br J Anaesth. 1999 Jan;82(1):8-13.
• 17. Lumb AB, Greenhill SJ, Simpson MP, Stewart J. Lung recruitment and positive airway pressure before extension does not improve oxygenation in the post-anaesthesia care unit: a randomized clinical trial. Br J Anaesth. 2010. May;104(5):643-7.
• 18. Stock MC, Downs JB, Gauer PK, Alster JM, Imrey PB. Prevention of postoperative pulmonary complications with CPAP, incentive spirometry, and conservative therapy. Chest. 1985 Feb;87(2):151-7.
• 19. Sentürk NM, Dilek A, Camci E, Senturk E, Orhan M, Tugrul M, et al. Effects of positive end-expiratory pressure on ventilatory and oxygenation parameters during pressure-controlled one-lung ventilation. J Cardiothorac Vasc Anaesth. 2005 Feb;19(1):71-5.
• 20. Hoftman N, Canales C, Leduc M, Mahajan A. Positive end expiratory pressure during one-lung ventilation: selecting ideal patients and ventilator settings with the aim of improving arterial oxygenation. Ann Card Anaesth. 2011 Sep-Dec;14(3):183-7.
• 21. Tusman G, Böhm SH, Melkun F, Staltari D, Quinzio C, Nador C, et al. Alveolar recruitment strategy increases arterial oxygenation during one-lung ventilation. Ann Thorac Surg. 2002 Apr;73(4):1204-9.
• 22. Carbognani P, Spaggiani L, Solli P, Rusca M. Pneumoperitoneum for prolonged air leaks after lower lobectomies. Ann Thorac Surg. 1998 Aug;66(2):604-5.
• 23. Jung JD, Kim SH, Yu BS, Kim HJ. Effects of a preemptive alveolar recruitment strategy on arterial oxygenation during one-lung ventilation with different tidal volumes in patients with normal pulmonary function test. Korean J Anesthesiol. 2014 Aug;67(2):96-102.
• 24. Unzueta C, Tusman G, Suarez-Sipmann F, Böhm S, Moral V. Alveolar recruitment improves ventilation during thoracic surgery: a randomized controlled trial. Br J Anaesth. 2012 Mar;108(3):517-24.
• 25. Park SH, Jeon YT, Hwang JW, Do SH, Kim JH, Park HP. A preemptive alveolar recruitment strategy before one-lung ventilation improves arterial oxygenation in patients undergoing thoracic surgery: a prospective randomised study. Eur J Anaesthesiol. 2011 Apr;28(4):298-302.