Lung Recruitment Strategies in Anesthesia Intraoperative ventilatory management to prevent Post-operative Pulmonary Complications Kook-Hyun Lee, MD, PhD Department of Anesthesiology Seoul National University College of Medicine leekh@snu.ac.kr
Han River Olympic Stadium
Seoul National University H. (SNUH)
Outline Post-op. Pulmonary Complication (PPC) Open lung approach - PEEP (Positive End-exp. Pressure) - Lung recruitment Clinical application
Post-operative Pulmonary Complication (PPC) Respiratory center depression: anesthetics Airway abnormality: laryngeal edema, secretion Lung mechanics: pneumothorax, bronchospasm Respiratory failure: atelectasis, pneumonia, edema Pulmonary circulation: embolism
Risks of PPC COPD Age over 60 years ASA grade II or greater, Duration of surgery over 3 hours Upper abd./ thoracic surgery: atelectasis Anaesthesia and Intensive Care Medicine 2011;12:12
Patient factors with PPC in Noncardiothoracic Surgery Smetana GW. (Annals of Internal Medicine 2006: 144; 583)
Procedure, Laboratory factors with PPC Smetana GW. (Annals of Internal Medicine 2006: 144; 583)
Influence of Anesthetics Disruption of central regulation of breathing Hypoventilation Positional dependence Pain: limitation of respiratory movement Disruption of diaphragmatic function Neuromuscular blocker
under General Anesthesia (GA)
Post-op Complications in Cardiac Surgery (Ferguson, Chest 1999; Hess & Kacmarek, 1996) Generalized respiratory dysfunction Alteration in motion of the diaphragm and lung : 20-30% in FRC post thoracic or cardiac surgery 60-80% of atelectasis within 24 h of surgery Phrenic Nerve paralysis with slush ice use Pneumonitis, bronchospasm or lobar collapse in 40%, Nosocomial infection
Factors prone to Atelectasis Patient Position Operation Anesthesia Obesity Lithotomy Laparoscopy Unilateral Ventilation Airway secretion Head-down Long surgery High FIO2 Pleurisy, Ascites Supine Bypass Volume overload Cardiac enlargement Lateral Apnea Tracheal suction Lung edema Compliance Alveolar lavage Pregnancy Hypoventilation Inflammation
Atelectasis With induction of G/A & causes shunts Mechanism - Gas resorption - Compression atelectasis - Surfactant
Prevention of Atelectasis Avoidance of high FIO2 - Pure O2 results in atelectasis Recruitment maneuver - Airway pressure 30cmH2O atelectasis PEEP reduces renewed lung collapse
ARDSnet study: Tidal volume (VT 6 ml/kg) with ARDS N Engl J Med 2000; 342:1301 8
VT vs. Inflammatory mediators (CPB) VT 10-12ml/kg PEEP 2-3 cmh20 VT 8 ml/kg PEEP 10 cmh20 J Thorac Cardiovasc Surg 2005;130:378 High Pressure Ventilation Am J Respir Crit Care Med 1998;157:294 323
Ventilation at low airway pressures can augment lung injury. Ventilation with large and high PIP VT can result in pulmonary barotrauma. Ventilation at very low lung volumes can repeatedly open and close airway and alveolar duct units as ventilation occurs from below to above the infection point (Pinf) Am J Respir Crit Care Med 1994;149:1327-34
Alveolar Recruitment on Acute Lung Injury V Recruitment P Pelosi et al. Critical Care 2010, 14:210
Respir Care 2015 ;60:1688-1704
Open Lung Approach Hess DR, RESPIRATORY CARE 2015 ;60:1688-1704
Alveolar Recruitment(AR) under General Anesthesia (GA) Study Control group Intervention Group Almarakbi (2009) Pang (2003) Severgnini (2013) Sprung (2009) Weingarten (2010) Whalen (2006) PEEP 10 cm/h2o (n=15) VT 10 ml/kg, PEEP 0 (n=12) VT 9 ml/kg, PEEP 0 (n=27) VT 8 ml/kg, PEEP 4 (n=9) VT 10 ml/kg, PEEP 0(n= 20) VT 8 ml/kg, PEEP 4(n=10) PIP 40 cm/h2o for 15 s PIP 40 for 15 s, PEEP 10 cm/h2o PIP 40 for 15 s, PEEP 10/ every 10 min PIP 40 for 10 breaths for 1 min, then on ventilator with PEEP 5 and VT 10 ml/kg VT 7 ml/kg, PEEP 10, AR; PIP at 45, I:E 3:1, plateau pressure 30, 3 breaths, then to baseline PEEP 10 for 3 breaths, 15 for 3 breaths, 20 for 10 breaths, PIP 50; PEEP 12; AR at 30, 60 min VT 6 ml/kg, PEEP 4, AR VT 8 ml/kg, PEEP 4, AR Respir Care 2015;60(4):609 620
Protective mechanical ventilation during GA for open abdominal surgery improves postop. pulmonary function. Control: VT 9 ml/kg, PEEP 0 (n=27) PV: VT 7 ml/kg, PEEP 10 cm/h2o Recruitment: PIP at 45, I:E 3:1, Pr. 30, 3 breaths Protective ventilation improved respiratory function and reduced the modified Clinical Pulmonary Infection Score without affecting length of hospital stay. Anesthesiology 2013;118:1307-21
A trial of intraoperative low-tidal-volume ventilation in abdominal surgery Lung-protective ventilation in intermediate and high-risk patients was associated with improved clinical outcomes. NEJM 2013;369:428-37
Korean GA Cases of Recruitment Hypoxemia in Brain-dead Donor Acute lung injury after femoral nailing Laparoscope: with PEEP One-lung ventilation Thoracic and major abdominal surgery Robot assisted laparoscopic surgery Hemoptysis
Lung recruitment during small tidal volume ventilation allows minimal PEEP without augmenting lung injury. Critical Care Medicine 1999;27:1940-5
Ventilatory Strategy under General Anesthesia Lower PPC Oxygenation, Infection score Ventilatory support, Hospital days Lung protective ventilation: Low VT Limitation of FIO2 Open Lung approach; Recruitment, PEEP
O2 inhalation Incentive Spirometry
Laparoscopic Surgery
Fast-track ERAS protocol : 術後回復力増強 by Pf. Henrik Kehlet fast-track surgery Slim K. Colorectal Dis 2011; 13: 478-80.
Multidisciplinary Study and Collaboration : Surgeon, Nurse, Respiratory therapist Anesthesiologist Physical therapist
Korean Association for Respiratory Care (KARC) Founded on July 31, 1999 Hosted the 9th APARC on July 30, 2000, Seoul, Korea Workshop and congress
Urumuqi 烏魯木齊 2018. 8. 5
August 23~24, 2019 KARC for 20 th Anniversary https://www.seouldragoncity.com
August 23~24, 2019 KARC in Seoul for 20 th Anniversary at Seoul Dragoncity
谢谢! Thank you!