Open lung approach versus standard protective strategies: Effects on driving pressure and ventilatory efficiency during anesthesia - A pilot, randomized controlled trial

Carlos Ferrando, Fernando Suarez-Sipmann, Gerardo Tusman, Irene León, Esther Romero, Estefania Gracia, Ana Mugarra, Blanca Arocas, Natividad Pozo, Marina Soro, Francisco J Belda, Carlos Ferrando, Fernando Suarez-Sipmann, Gerardo Tusman, Irene León, Esther Romero, Estefania Gracia, Ana Mugarra, Blanca Arocas, Natividad Pozo, Marina Soro, Francisco J Belda

Abstract

Background: Low tidal volume (VT) during anesthesia minimizes lung injury but may be associated to a decrease in functional lung volume impairing lung mechanics and efficiency. Lung recruitment (RM) can restore lung volume but this may critically depend on the post-RM selected PEEP. This study was a randomized, two parallel arm, open study whose primary outcome was to compare the effects on driving pressure of adding a RM to low-VT ventilation, with or without an individualized post-RM PEEP in patients without known previous lung disease during anesthesia.

Methods: Consecutive patients scheduled for major abdominal surgery were submitted to low-VT ventilation (6 ml·kg-1) and standard PEEP of 5 cmH2O (pre-RM, n = 36). After 30 min estabilization all patients received a RM and were randomly allocated to either continue with the same PEEP (RM-5 group, n = 18) or to an individualized open-lung PEEP (OL-PEEP) (Open Lung Approach, OLA group, n = 18) defined as the level resulting in maximal Cdyn during a decremental PEEP trial. We compared the effects on driving pressure and lung efficiency measured by volumetric capnography.

Results: OL-PEEP was found at 8±2 cmH2O. 36 patients were included in the final analysis. When compared with pre-RM, OLA resulted in a 22% increase in compliance and a 28% decrease in driving pressure when compared to pre-RM. These parameters did not improve in the RM-5. The trend of the DP was significantly different between the OLA and RM-5 groups (p = 0.002). VDalv/VTalv was significantly lower in the OLA group after the RM (p = 0.035).

Conclusions: Lung recruitment applied during low-VT ventilation improves driving pressure and lung efficiency only when applied as an open-lung strategy with an individualized PEEP in patients without lung diseases undergoing major abdominal surgery.

Trial registration: ClinicalTrials.gov NCT02798133.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1. CONSORT flow diagram.
Fig 1. CONSORT flow diagram.
COPD: chronic obstructive pulmonary disease, ASA: American Society of Anesthesiology physical status, RM: recruitment maneuver, OLA: open-lung approach.
Fig 2. Respiratory system mechanics and ventilatory…
Fig 2. Respiratory system mechanics and ventilatory efficiency study variables.
a) DP, driving pressure; b) Cdyn, respiratory system compliance; c) Pplat, plateau pressure; d) VTalv/VDalv, alveolar dead space to alveolar tidal volume. Values are shown as median and standard deviation. preRM and postRM represent values before and after the recruitment maneuver was performed. OLA represent values of the patients randomized to open-lung approach (OLA) and RM-5 represent values of the patients randomized to a post-RM PEEP of 5 cmH2O. * when P<0.05 and ** P<0.001.

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