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Feasibility of postural lung recruitment maneuver in children: a randomized, controlled study.

ABSTRACT: BACKGROUND:Pulmonary atelectasis in anesthetized children is easily reverted by lung recruitment maneuvers. However, the high airways pressure reached during the maneuver could negatively affect hemodynamics. The aim of this study is to assess the effect and feasibility of a postural lung recruitment maneuver (P-RM); i.e., a new maneuver that opens up the atelectatic lung areas based on changing the child's body position under constant ventilation with moderated driving pressure (12 cmH2O) and of positive end-expiratory pressure (PEEP, 10 cmH2O). Forty ASA I-II children, aged 6 months to 7 years, subjected to general anesthesia were studied. Patients were ventilated with volume control mode using standard settings with 5 cmH2O of PEEP. They were randomized into two groups: (1) control group (C group, n?=?20)-ventilation was turned to pressure control ventilation using a fixed driving pressure of 12 cmH2O. PEEP was increased from 5 to 10 cmH2O during 3 min maintaining the supine position. (2) P-RM group (n?=?20)-patients received the same increase in driving pressure and PEEP, but they were placed, respectively, in the left lateral position, in the right lateral position (90 s each), and back again into the supine position after 3 min. Then, ventilation returned to baseline settings in volume control mode. Lung ultrasound-derived aeration score and respiratory compliance were assessed before (T1) and after (T2) 10 cmH2O of PEEP was applied. RESULTS:At baseline ventilation (T1), both groups showed similar aeration score (P-RM group 9.9?±?1.9 vs C group 10.4?±?1.9; p?=?0.463) and respiratory compliance (P-RM group 15?±?6 vs C group 14?±?6 mL/cmH2O; p?=?0.517). At T2, the aeration score decreased in the P-RM group (1.5?±?1.6 vs 9.9?±?2.1; p?

SUBMITTER: Acosta CM

PROVIDER: S-EPMC7359212 | biostudies-literature | 2020 Jul

REPOSITORIES: biostudies-literature

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Feasibility of postural lung recruitment maneuver in children: a randomized, controlled study.

Acosta Cecilia M CM Volpicelli Giovanni G Rudzik Nadia N Venturin Nicolás N Gerez Sebastián S Ricci Lila L Natal Marcela M Tusman Gerardo G

The ultrasound journal 20200714 1

<h4>Background</h4>Pulmonary atelectasis in anesthetized children is easily reverted by lung recruitment maneuvers. However, the high airways pressure reached during the maneuver could negatively affect hemodynamics. The aim of this study is to assess the effect and feasibility of a postural lung recruitment maneuver (P-RM); i.e., a new maneuver that opens up the atelectatic lung areas based on changing the child's body position under constant ventilation with moderated driving pressure (12 cmH< ...[more]

PMID: 32661776

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Project description:ObjectiveGlobal lung stress varies considerably with low tidal volume ventilation for acute respiratory distress syndrome. High stress despite low tidal volumes may worsen lung injury and increase risk of death. No widely available parameter exists to assess global lung stress. We aimed to determine whether the volume delivered during a recruitment maneuver (V(RM)) is inversely associated with lung stress and mortality in acute respiratory distress syndrome.DesignSubstudy of an acute respiratory distress syndrome clinical trial on esophageal pressure-guided positive end-expiratory pressure titration.SettingU.S. academic medical center.PatientsForty-two patients with acute respiratory distress syndrome in whom airflow, airway pressure, and esophageal pressure were recorded during the recruitment maneuver.InterventionsA single recruitment maneuver was performed before initiating protocol-directed ventilator management. Recruitment maneuvers consisted of a 30-second breath hold at 40 cm H2O airway pressure under heavy sedation or paralysis. V(RM) was calculated by integrating the flow-time waveform during the maneuver. End-inspiratory stress was defined as the transpulmonary (airway minus esophageal) pressure during end-inspiratory pause of a tidal breath and tidal stress as the transpulmonary pressure difference between end-inspiratory and end-expiratory pauses.Measurements and main resultsV(RM) ranged between 7.4 and 34.7 mL/kg predicted body weight. Lower V(RM) predicted high end-inspiratory and tidal lung stress (end-inspiratory: β = -0.449; 95% CI, -0.664 to -0.234; p < 0.001; tidal: β = -0.267; 95% CI, -0.423 to -0.111; p = 0.001). After adjusting for PaO2/FIO2 and either driving pressure, tidal volume, or plateau pressure and positive end-expiratory pressure, V(RM) remained independently associated with both end-inspiratory and tidal stress. In unadjusted analysis, low V(RM) predicted increased risk of death (odds ratio, 0.85; 95% CI, 0.72-1.00; p = 0.026). V(RM) remained significantly associated with mortality after adjusting for study arm (odds ratio, 0.84; 95% CI, 0.71-1.00; p = 0.022).ConclusionsLow V(RM) independently predicts high lung stress and may predict risk of death in patients with acute respiratory distress syndrome.

Project description:BackgroundRecruiting young people for health and intervention studies by traditional methods has become increasingly challenging. The widespread access to the internet may offer new strategies for online recruitment.ObjectiveThis study aims to assess the feasibility of online recruitment for a randomized controlled trial evaluating the effectiveness of Mindhelper, an online national youth mental health promotion service. The target group was young Danes aged 15-25 in need of mental health promotion.MethodsAdvertisements for recruitment were set up on Facebook and Instagram. Browser history was collected for a subsample of participants. We compared basic characteristics of participants who completed the baseline survey and those who did not, as well as of participants who completed the follow-up survey and those who were lost to follow-up. The significance of these differences was tested with the Pearson chi-square test.ResultsA total of 560 Danes aged 15-25 were recruited within 1 month (ie, had completed the baseline survey). Among these participants, 356 (63.6%) were at risk of developing depression or stress. The average advertisement price per participant completing the baseline questionnaire was 31 DKK (approximately €4 [US $4.2]). The follow-up survey was sent to 545 participants, of whom 318 (58.3%) completed the survey. No statistically significant differences were observed in baseline characteristics of participants who completed the follow-up and those who were lost to follow-up in terms of gender (P=.45), age (P=.35), occupation (P=.17), cohabitation (P=.90), mental well-being (P=.26), mental illness (P=.44; impact of the illness, P=.05), or use of the internet when having a hard time (P=.92).ConclusionsWe conclude that it is feasible to recruit young Danes online for a large-scale randomized controlled trial assessing the effectiveness of Mindhelper.Trial registrationClinicalTrials.gov NCT04650906; https://clinicaltrials.gov/ct2/show/NCT04650906.

Project description:BackgroundA sequential change in body position from supine-to-both lateral positions under constant ventilatory settings could be used as a postural recruitment maneuver in case of acute respiratory distress syndrome (ARDS), provided that sufficient positive end-expiratory pressure (PEEP) prevents derecruitment. This study aims to evaluate the feasibility and physiological effects of a sequential postural recruitment maneuver in early mechanically ventilated COVID-19 ARDS patients.MethodsA cohort of 15 patients receiving lung-protective mechanical ventilation in volume-controlled with PEEP based on recruitability were prospectively enrolled and evaluated in five sequentially applied positions for 30 min each: Supine-baseline; Lateral-1st side; 2nd Supine; Lateral-2nd side; Supine-final. PEEP level was selected using the recruitment-to-inflation ratio (R/I ratio) based on which patients received PEEP 12 cmH2O for R/I ratio ≤ 0.5 or PEEP 15 cmH2O for R/I ratio > 0.5. At the end of each period, we measured respiratory mechanics, arterial blood gases, lung ultrasound aeration, end-expiratory lung impedance (EELI), and regional distribution of ventilation and perfusion using electric impedance tomography (EIT).ResultsComparing supine baseline and final, respiratory compliance (29 ± 9 vs 32 ± 8 mL/cmH2O; p < 0.01) and PaO2/FIO2 ratio (138 ± 36 vs 164 ± 46 mmHg; p < 0.01) increased, while driving pressure (13 ± 2 vs 11 ± 2 cmH2O; p < 0.01) and lung ultrasound consolidation score decreased [5 (4-5) vs 2 (1-4); p < 0.01]. EELI decreased ventrally (218 ± 205 mL; p < 0.01) and increased dorsally (192 ± 475 mL; p = 0.02), while regional compliance increased in both ventral (11.5 ± 0.7 vs 12.9 ± 0.8 mL/cmH2O; p < 0.01) and dorsal regions (17.1 ± 1.8 vs 18.8 ± 1.8 mL/cmH2O; p < 0.01). Dorsal distribution of perfusion increased (64.8 ± 7.3% vs 66.3 ± 7.2%; p = 0.01).ConclusionsWithout increasing airway pressure, a sequential postural recruitment maneuver improves global and regional respiratory mechanics and gas exchange along with a redistribution of EELI from ventral to dorsal lung areas and less consolidation. Trial registration ClinicalTrials.gov, NCT04475068. Registered 17 July 2020, https://clinicaltrials.gov/ct2/show/NCT04475068.

Project description:ObjectivesIntravenous (IV) access in children treated in the emergency department (ED) is frequently required and often difficult to obtain. While it has been shown that ultrasound can be useful in adults for both central and peripheral venous access, research regarding children has been limited. We sought to determine if the use of a static ultrasound technique could, a) allow clinicians to visualize peripheral veins and b) improve success rates of peripheral venous cannulation in young children in the ED.MethodsWe performed a randomized clinical trial of children < 7 years in an academic pediatric ED who required IV access and who had failed the first IV attempt. We randomized patients to either continued standard IV attempts or ultrasound-assisted attempts. Clinicians involved in the study received one hour of training in ultrasound localization of peripheral veins. In the ultrasound group, vein localization was performed by an ED physician who marked the skin overlying the target vessel. Intravenous cannulation attempts were then immediately performed by a pediatric ED nurse who relied on the skin mark for vessel location. We allowed for technique cross-over after two failed IV attempts. We recorded success rate and location of access attempts. We compared group success rates using differences in 95% confidence intervals (CI).ResultsWe enrolled 44 children over a one-year period. The median age of enrollees was 9.5 months. We visualized peripheral veins in all patients in the ultrasound group (n=23) and in those who crossed over to ultrasound after failed standard technique attempts (n= 8). Venipuncture was successful on the first attempt in the ultrasound group in 13/23 (57%, CI, 35% to 77%), versus 12/21 (57%, CI, 34% to 78%) in the standard group, difference between groups 0.6% (95% CI -30% to 29%). First attempt cannulation success in the ultrasound group was 8/23 (35%, CI, 16% to 57%), versus 6/21 (29%, CI, 11% to 52%) in the standard group, difference between groups 6% (95% CI -21% to 34%).ConclusionUltrasound allows physicians to visualize peripheral veins of young children in the ED. We were unable to demonstrate, however, a clinically important benefit to a static ultrasound aided vein cannulation technique performed by clinicians with limited ultrasound training over standard technique after one failed IV attempt in an academic pediatric ED.

Dataset Information

Feasibility of postural lung recruitment maneuver in children: a randomized, controlled study.

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Feasibility of postural lung recruitment maneuver in children: a randomized, controlled study.

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