Positive end-expiratory pressure and emergence preoxygenation after bariatric surgery: A randomised controlled trial on postoperative oxygenation.

BACKGROUND: Positive end-expiratory pressure (PEEP) is important to increase lung volume and counteract airway closure during anaesthesia, especially in obese patients. However, maintaining PEEP during emergence preoxygenation might increase postoperative atelectasis by allowing susceptible lung areas to be filled with highly absorbable oxygen that gets entrapped when small airways collapse due to the sudden loss of PEEP at extubation. OBJECTIVE: This study aimed to test the hypothesis that withdrawing PEEP just before emergence preoxygenation would better maintain postoperative oxygenation. DESIGN: Prospective, randomised controlled trial. SETTING: Single centre secondary hospital in Sweden between December 2019 and January 2023. PATIENTS: A total of 60 patients, with body mass index between 35 and 50 kg m -2 , undergoing laparoscopic bariatric surgery. INTERVENTION: Intraoperative ventilation was the same for all patients with a fixed PEEP of 12 or 14 cmH 2 O depending on body mass index. No recruitment manoeuvres were used. After surgery, patients were allocated to maintained PEEP or zero PEEP during emergence preoxygenation. MAIN OUTCOME MEASURES: The primary outcome was change in oxygenation from before awakening to 45 min postoperatively as measured by estimated venous admixture calculated from arterial blood gases. RESULTS: Both groups had impaired oxygenation postoperatively; in the group with PEEP maintained during awakening, estimated venous admixture increased by mean 9.1%, and for the group with zero PEEP during awakening, estimated venous admixture increased by mean 10.6%, difference -1.5% (95% confidence interval -4.6 to 1.7%), P  = 0.354. Throughout anaesthesia, both groups exhibited low driving pressures and superior oxygenation compared with the awake state. CONCLUSIONS: Withdrawing PEEP before emergence preoxygenation, did not alter early postoperative oxygenation in obese patients undergoing laparoscopic bariatric surgery. Intraoperative oxygenation was excellent despite using fixed PEEP and no recruitment manoeuvres, but deteriorated after extubation, indicating a need for future studies aimed at improving the emergence procedure. CLINICAL TRIAL NUMBER AND REGISTRY: www.clinicaltrials.gov , NCT04150276. Registration date: 4 November 2019. Principal investigator: Erland Östberg.

Pressure-controlled versus manual facemask ventilation for anaesthetic induction in adults: A randomised controlled non-inferiority trial.

BACKGROUND: Pressure-controlled face mask ventilation (PC-FMV) with positive end-expiratory pressure (PEEP) after apnoea following induction of general anaesthesia prolongs safe apnoea time and reduces atelectasis formation. However, depending on the set inspiratory pressure, a delayed confirmation of a patent airway might occur. We hypothesised that by lowering the peak inspiratory pressure (PIP) when using PC-FMV with PEEP, confirmation of a patent airway would not be delayed as studied by the first return of CO2 , compared with manual face mask ventilation (Manual FMV). METHODS: This was a single-centre, randomised controlled non-inferiority trial. Seventy adult patients scheduled for elective day-case surgery under general anaesthesia with body mass index between 18.5 and 29.9 kg m-2 , American Society of Anesthesiologists (ASA) classes I-III, and without anticipated difficult FMV, were included. Before the start of pre-oxygenation and induction of general anaesthesia, participants were randomly allocated to receive ventilation with either PC-FMV with PEEP, at a PIP of 11 and a PEEP of 6 cmH2 O or Manual FMV, with the adjustable pressure-limiting valve set at 11 cmH2 O. The primary outcome variable was the number of ventilatory attempts needed until confirmation of a patent airway, defined as the return of at least 1.3 kPa CO2 . RESULTS: The return of ≥1.3 kPa CO2 on the capnography curve was observed after mean ± SD, 3.6 ± 4.2 and 2.5 ± 1.9 ventilatory attempts/breaths with PC-FMV with PEEP and Manual FMV, respectively. The difference in means (1.1 ventilatory attempts/breaths) had a 99% CI of -1.0 to 3.1, within the accepted upper margin of four breaths for non-inferiority. CONCLUSION: Following induction of general anaesthesia, PC-FMV with PEEP was used without delaying a patent airway as confirmed with capnography, if moderate pressures were used.

Arterial partial pressure of oxygen as a marker of airway closure does not correlate with the efficacy of pre-oxygenation: A prospective cohort study.

BACKGROUND: The prerequisites for the early formation of anaesthesia-related atelectasis are pre-oxygenation with its resulting high alveolar oxygen content, and airway closure. Airway closure increases with age, so it seems counterintuitive that atelectasis formation during anaesthesia does not. One proposed explanation is that pre-oxygenation is impaired in the elderly by airway closure present in the waking state. The extent of airway closure cannot be assessed at the bedside, but arterial partial pressure of oxygen ( Pa O 2 ) as a surrogate variable of the resulting ventilation to perfusion mismatch can. OBJECTIVE: The primary aim was to test the hypothesis that a decreased efficacy of pre-oxygenation, measured as the fraction of end-tidal oxygen (F E' O 2 ) after 3 min of pre-oxygenation, correlates with decreased Pa O 2 on room air. We also re-investigated the influence on F E' O 2 by age. DESIGN: Prospective observational study. SETTING: Two regional hospitals, Västerås and Köping County Hospitals, Västmanland, Sweden, between 30 October 2018 and 17 September 2021. PARTICIPANTS: We included 120 adults aged 40 to 79 years presenting for elective noncardiac surgery. INTERVENTION: An arterial blood gas was sampled before commencing pre-oxygenation. RESULTS: No linear correlation was found between F E' O 2 at 3 min and Pa O 2 or age (Pearson's r  = -0.038, P  = 0.684; and Pearson's r  = -0.113, P  = 0.223, respectively). The mean ±â€ŠSD F E' O 2 at 3 min for the population studied was 0.87 ±â€Š0.05. CONCLUSION: The lack of correlation between F E' O 2 at 3 min and Pa O 2 or age during pre-oxygenation has implications for further studies concerning the interaction between airway closure and atelectasis. After 3 min of pre-oxygenation, F E' O 2 , even in the elderly, indicated a high enough alveolar oxygen concentration to promote atelectasis after induction, therefore, it is still unclear why atelectasis formation diminishes after middle age. TRIAL REGISTRATION: ClinicalTrials.gov NCT03395782.

Oxygenation Impairment during Anesthesia: Influence of Age and Body Weight.

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: During anesthesia oxygenation is impaired, especially in the elderly or obese, but the mechanisms are uncertain. WHAT THIS ARTICLE TELLS US THAT IS NEW: Pooled data were examined from 80 patients studied with multiple inert gas elimination technique and computed tomography. Oxygenation was impaired by anesthesia, more so with greater age or body mass index. The key contributors were low ventilation/perfusion ratio (likely airway closure) in the elderly and shunt (atelectasis) in the obese. BACKGROUND: Anesthesia is increasingly common in elderly and overweight patients and prompted the current study to explore mechanisms of age- and weight-dependent worsening of arterial oxygen tension (PaO2). METHODS: This is a primary analysis of pooled data in patients with (1) American Society of Anesthesiologists (ASA) classification of 1; (2) normal forced vital capacity; (3) preoxygenation with an inspired oxygen fraction (FIO2) more than 0.8 and ventilated with FIO2 0.3 to 0.4; (4) measurements done during anesthesia before surgery. Eighty patients (21 women and 59 men, aged 19 to 69 yr, body mass index up to 30 kg/m2) were studied with multiple inert gas elimination technique to assess shunt and perfusion of poorly ventilated regions (low ventilation/perfusion ratio [(Equation is included in full-text article.)]) and computed tomography to assess atelectasis. RESULTS: PaO2/FIO2 was lower during anesthesia than awake (368; 291 to 470 [median; quartiles] vs. 441; 397 to 462 mm Hg; P = 0.003) and fell with increasing age and body mass index. Log shunt was best related to a quadratic function of age with largest shunt at 45 yr (r2 =0.17, P = 0.001). Log shunt was linearly related to body mass index (r2 = 0.15, P < 0.001). A multiple regression analysis including age, age2, and body mass index strengthened the association further (r2 = 0.27). Shunt was highly associated to atelectasis (r2 = 0.58, P < 0.001). Log low (Equation is included in full-text article.)showed a linear relation to age (r2 = 0.14, P = 0.001). CONCLUSIONS: PaO2/FIO2 ratio was impaired during anesthesia, and the impairment increased with age and body mass index. Shunt was related to atelectasis and was a more important cause of oxygenation impairment in middle-aged patients, whereas low(Equation is included in full-text article.), likely caused by airway closure, was more important in elderly patients. Shunt but not low(Equation is included in full-text article.)increased with increasing body mass index. Thus, increasing age and body mass index impaired gas exchange by different mechanisms during anesthesia.

Positive End-expiratory Pressure and Postoperative Atelectasis: A Randomized Controlled Trial.

BACKGROUND: Positive end-expiratory pressure (PEEP) increases lung volume and protects against alveolar collapse during anesthesia. During emergence, safety preoxygenation preparatory to extubation makes the lung susceptible to gas absorption and alveolar collapse, especially in dependent regions being kept open by PEEP. We hypothesized that withdrawing PEEP before starting emergence preoxygenation would limit postoperative atelectasis formation. METHODS: This was a randomized controlled evaluator-blinded trial in 30 healthy patients undergoing nonabdominal surgery under general anesthesia and mechanical ventilation with PEEP 7 or 9 cm H2O depending on body mass index. A computed tomography scan at the end of surgery assessed baseline atelectasis. The study subjects were thereafter allocated to either maintained PEEP (n = 16) or zero PEEP (n = 14) during emergence preoxygenation. The primary outcome was change in atelectasis area as evaluated by a second computed tomography scan 30 min after extubation. Oxygenation was assessed by arterial blood gases. RESULTS: Baseline atelectasis was small and increased modestly during awakening, with no statistically significant difference between groups. With PEEP applied during awakening, the increase in atelectasis area was median (range) 1.6 (-1.1 to 12.3) cm and without PEEP 2.3 (-1.6 to 7.8) cm. The difference was 0.7 cm (95% CI, -0.8 to 2.9 cm; P = 0.400). Postoperative atelectasis for all patients was median 5.2 cm (95% CI, 4.3 to 5.7 cm), corresponding to median 2.5% of the total lung area (95% CI, 2.0 to 3.0%). Postoperative oxygenation was unchanged in both groups when compared to oxygenation in the preoperative awake state. CONCLUSIONS: Withdrawing PEEP before emergence preoxygenation does not reduce atelectasis formation after nonabdominal surgery. Despite using 100% oxygen during awakening, postoperative atelectasis is small and does not affect oxygenation, possibly conditional on an open lung during anesthesia, as achieved by intraoperative PEEP.

Effect of positive end-expiratory pressure on gastric insufflation during induction of anaesthesia when using pressure-controlled ventilation via a face mask: A randomised controlled trial.

BACKGROUND: Face mask ventilation (FMV) during induction of anaesthesia is associated with risk of gastric insufflation that may lead to gastric regurgitation and pulmonary aspiration. A continuous positive airway pressure (CPAP) has been shown to reduce gastric regurgitation. We therefore hypothesised that CPAP followed by FMV with positive end-expiratory pressure (PEEP) during induction of anaesthesia would reduce the risk of gastric insufflation. OBJECTIVE: The primary aim was to compare the incidence of gastric insufflation during FMV with a fixed PEEP level or zero PEEP (ZEEP) after anaesthesia induction. A secondary aim was to investigate the effects of FMV with or without PEEP on upper oesophageal sphincter (UES), oesophageal body and lower oesophageal sphincter (LES) pressures. DESIGN: A randomised controlled trial. SETTING: Single centre, Department of Anaesthesia and Intensive Care, Örebro University Hospital, Sweden. PARTICIPANTS: Thirty healthy volunteers. INTERVENTIONS: Pre-oxygenation without or with CPAP 10 cmH2O, followed by pressure-controlled FMV with either ZEEP or PEEP 10 cmH2O after anaesthesia induction. MAIN OUTCOME MEASURES: A combined impedance/manometry catheter was used to detect the presence of gas and to measure oesophageal pressures. The primary outcome measure was the cumulative incidence of gastric insufflation, defined as a sudden anterograde increase in impedance of more than 1 kΩ over the LES. Secondary outcome measures were UES, oesophageal body and LES pressures. RESULTS: The cumulative incidence of gastric insufflation related to peak inspiratory pressure (PIP), was significantly higher in the PEEP group compared with the ZEEP group (log-rank test P < 0.01). When PIP reached 30 cmH2O, 13 out of 15 in the PEEP group compared with five out of 15 had shown gastric insufflation. There was a significant reduction of oesophageal sphincter pressures within groups comparing pre-oxygenation to after anaesthesia induction, but there were no significant differences in oesophageal sphincter pressures related to the level of PEEP. CONCLUSION: Contrary to the primary hypothesis, with increasing PIP the tested PEEP level did not protect against but facilitated gastric insufflation during FMV. This result suggests that PEEP should be used with caution after anaesthesia induction during FMV, whereas CPAP during pre-oxygenation seems to be safe. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT02238691.

Positive End-expiratory Pressure Alone Minimizes Atelectasis Formation in Nonabdominal Surgery: A Randomized Controlled Trial.

BACKGROUND: Various methods for protective ventilation are increasingly being recommended for patients undergoing general anesthesia. However, the importance of each individual component is still unclear. In particular, the perioperative use of positive end-expiratory pressure (PEEP) remains controversial. The authors tested the hypothesis that PEEP alone would be sufficient to limit atelectasis formation during nonabdominal surgery. METHODS: This was a randomized controlled evaluator-blinded study. Twenty-four healthy patients undergoing general anesthesia were randomized to receive either mechanical ventilation with PEEP 7 or 9 cm H2O depending on body mass index (n = 12) or zero PEEP (n = 12). No recruitment maneuvers were used. The primary outcome was atelectasis area as studied by computed tomography in a transverse scan near the diaphragm, at the end of surgery, before emergence. Oxygenation was evaluated by measuring blood gases and calculating the ratio of arterial oxygen partial pressure to inspired oxygen fraction (PaO2/FIO2 ratio). RESULTS: At the end of surgery, the median (range) atelectasis area, expressed as percentage of the total lung area, was 1.8 (0.3 to 9.9) in the PEEP group and 4.6 (1.0 to 10.2) in the zero PEEP group. The difference in medians was 2.8% (95% CI, 1.7 to 5.7%; P = 0.002). Oxygenation and carbon dioxide elimination were maintained in the PEEP group, but both deteriorated in the zero PEEP group. CONCLUSIONS: During nonabdominal surgery, adequate PEEP is sufficient to minimize atelectasis in healthy lungs and thereby maintain oxygenation. Thus, routine recruitment maneuvers seem unnecessary, and the authors suggest that they should only be utilized when clearly indicated. VISUAL ABSTRACT: An online visual overview is available for this article at http://links.lww.com/ALN/B728.

[Atelectasis during general anaesthesia - mechanisms and importance]. / Atelektaser under anestesi ­ uppkomst och betydelse.

In 1985, Dr. Göran Hedenstierna pioneered in the transition of atelectases during anaesthesia from a concept to a clinical entity, using computed tomography to detect "pulmonary densities". These densities were soon to be fully recognized as atelectasis. Most of the conclusions in the original paper are almost 40 years later still scientifically intact: the immediate appearance of atelectasis after induction of anaesthesia in the majority of adult patients, that atelectasis impedes arterial oxygenation by shunting deoxygenated blood, and the efficacy of a positive end-expiratory pressure to oppose atelectasis. The importance of atelectasis in the development of postoperative pulmonary complications is still obscure, as is the concept of protective ventilation. A common denominator in several studies on protective ventilation during anaesthesia is the lack of recognising the importance of the oxygen concentration. The pivotal role of oxygen in the development of atelectasis, and the impact of oxygen in relation to different conditions in the lungs, needs further studies.

Using trigger tools to identify triage errors by ambulance dispatch nurses in Sweden: an observational study.

OBJECTIVES: This study aimed to assess whether trigger tools were useful identifying triage errors among patients referred to non-emergency care by emergency medical dispatch nurses, and to describe the characteristics of these patients. DESIGN: An observational study of patients referred by dispatch nurses to non-emergency care. SETTING: Dispatch centres in two Swedish regions. PARTICIPANTS: A total of 1089 adult patients directed to non-emergency care by dispatch nurses between October 2016 and February 2017. 53% were female and the median age was 61 years. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was a visit to an emergency department within 7 days of contact with the dispatch centre. Secondary outcomes were (1) visits related to the primary contact with the dispatch centre, (2) provision of care above the primary level (ie, interventions not available at a typical local primary care centre) and (3) admission to hospital in-patient care. RESULTS: Of 1089 included patients, 260 (24%) visited an emergency department within 7 days. Of these, 209 (80%) were related to the dispatch centre contact, 143 (55%) received interventions above the primary care level and 99 (38%) were admitted to in-patient care. Elderly (65+) patients (OR 1.45, 95% CI 1.05 to 1.98) and patients referred onwards to other healthcare providers (OR 1.58, 95% CI 1.15 to 2.19) had higher likelihoods of visiting an emergency department. Six avoidable patient harms were identified, none of which were captured by existing incident reporting systems, and all of which would have received an ambulance if the decision support system had been strictly adhered to. CONCLUSION: The use of these patient outcomes in the framework of a Global Trigger Tool-based review can identify patient harms missed by incident reporting systems in the context of emergency medical dispatching. Increased compliance with the decision support system has the potential to improve patient safety.

Minimizing atelectasis formation during general anaesthesia-oxygen washout is a non-essential supplement to PEEP.

BACKGROUND: Following preoxygenation and induction of anaesthesia, most patients develop atelectasis. We hypothesized that an immediate restoration to a low oxygen level in the alveoli would prevent atelectasis formation and improve oxygenation during the ensuing anaesthesia. METHODS: We randomly assigned 24 patients to either a control group (n = 12) or an intervention group (n = 12) receiving an oxygen washout procedure directly after intubation. Both groups were, depending on body mass index, ventilated with a positive end-expiratory pressure (PEEP) of 6-8 cmH2O during surgery. The atelectasis area was studied by computed tomography before emergence. Oxygenation levels were evaluated by measuring blood gases and calculating estimated venous admixture (EVA). RESULTS: The atelectasis areas expressed as percentages of the total lung area were 2.0 (1.5-2.7) (median [interquartile range]) and 1.8 (1.4-3.3) in the intervention and control groups, respectively. The difference was non-significant, and also oxygenation was similar between the two groups. Compared to oxygenation before the start of anaesthesia, oxygenation at the end of surgery was improved in the intervention group, mean (SD) EVA from 7.6% (6.6%) to 3.9% (2.9%) (P = .019) and preserved in the control group, mean (SD) EVA from 5.0% (5.3%) to 5.6% (7.1%) (P = .59). CONCLUSION: Although the oxygen washout restored a low pulmonary oxygen level within minutes, it did not further reduce atelectasis size. Both study groups had small atelectasis and good oxygenation. These results suggest that a moderate PEEP alone is sufficient to minimize atelectasis and maintain oxygenation in healthy patients.

The effects of anesthesia and muscle paralysis on the respiratory system.

BACKGROUND: Oxygenation is impaired in almost all subjects during anesthesia, and hypoxemia for shorter or longer periods is a common finding. Moreover, postoperative lung complications occur in 3-10% after elective abdominal surgery and more in emergency operations. DISCUSSION: Rapid collapse of alveoli on induction of anesthesia and more widespread closure of airways seem to explain the oxygenation impairment and may also contribute to postoperative pulmonary infection. Causative mechanisms to atelectasis and airway closure seem to be loss of respiratory muscle tone and gas resorption. CONCLUSION: Avoiding high inspired oxygen fractions during both induction and maintenance of anesthesia prevents or reduces atelectasis, while intermittent "vital capacity" maneuvers recruit atelectatic lung regions.

Effects of anesthesia on the respiratory system.

Most anesthetics cause a loss of muscle tone that is accompanied by a fall in the resting lung volume. The lowered lung volume promotes cyclic (tidal) or continuous airway closure. High inspired oxygen fractions cause rapid absorption of gas behind closed airways, resulting in atelectasis. This chapter deals with these mechanisms in more detail, and it addresses possible measures to keep the lung open with the use of recruitment maneuvers, continuous and/or end-expiratory positive pressure, as well as the interaction with different oxygen concentrations. The effects on ventilation/perfusion matching and pulmonary gas exchange are also discussed.

A ventilation strategy during general anaesthesia to reduce postoperative atelectasis.

BACKGROUND: Atelectasis is common during and after general anaesthesia. We hypothesized that a ventilation strategy, without recruitment manoeuvres, using a combination of continuous positive airway pressure (CPAP) or positive end-expiratory pressure (PEEP) and a reduced end-expiratory oxygen fraction (FETO2) before ending mask ventilation with CPAP after extubation would reduce the area of postoperative atelectasis. METHODS: Thirty patients were randomized into three groups. During induction and emergence, inspiratory oxygen fractions (FIO2) were 1.0 in the control group and 1.0 or 0.8 in the intervention groups. No CPAP/PEEP was used in the control group, whereas CPAP/PEEP of 6 cmH2O was used in the intervention groups. After extubation, FIO2 was set to 0.30 in the intervention groups and CPAP was applied, aiming at FETO2 < 0.30. Atelectasis was studied by computed tomography 25 min postoperatively. RESULTS: The median area of atelectasis was 5.2 cm(2) (range 1.6-12.2 cm(2)) and 8.5 cm(2) (3-23.1 cm(2)) in the groups given FIO2 1.0 with or without CPAP/PEEP, respectively. After correction for body mass index the difference between medians (2.9 cm(2)) was statistically significant (confidence interval 0.2-7.6 cm(2), p = 0.04). In the group given FIO2 0.8, in which seven patients were ex- or current smokers, the median area of atelectasis was 8.2 cm(2) (1.8-14.7 cm(2)). CONCLUSION: Compared with conventional ventilation, after correction for obesity, this ventilation strategy reduced the area of postoperative atelectasis in one of the intervention groups but not in the other group, which included a higher proportion of smokers.