Individualised flow-controlled ventilation versus pressure-controlled ventilation in a porcine model of thoracic surgery requiring one-lung ventilation

Canbaz

et al. 2023

Preprint

Background While actual figures are still lacking, this incidence of laryngotracheal stenosis (LTS) is expected to increase because of the high COVID-19 patient numbers requiring (prolonged) invasive mechanical ventilation. While prolonged intubation is a known risk factor of LTS, LTS related to COVID-19 may be result in a different phenotype: pronation affects the location of stenosis and COVID-19 pneumonia can decline lung mechanics. Therefore, airway management in patients with COVID-19 related LTS has unique challenges for both anesthesiologists and surgeons for its location and severity. This prospective observational feasibility trial aims to evaluate the use of a novel thin, cuffed, endotracheal tube (Tritube) in combination with flow_controlled ventilation (FCV) in the management of patients with LTS secondary to COVID-19 related LTS undergoing laryngeal surgery. Methods 20 patients suffering from COVID-19 related LTS, as diagnosed by CT, requiring endolaryngeal surgery were included. Ultrathin endotracheal tube Tritube, together with FCV was used for airway management and ventilation. Feasibility, ventilation efficiency and surgical exposure were evaluated. Results Median duration of mechanical ventilation during their ICU stay was 17 days, [range (7-27] and the prone position was used in all patients. In 18/20 patients endoscopic diagnosis, confirmed the initial CT diagnosis: posterior subglottic stenosis. Visual Analogue Scale (VAS) score was 9 out of 10 (range 7-10). FCV ventilation was performed with or without CO2 laser. All hemodynamic and respiratory variables were within the normal clinical range. In 1 patient a respiratory complication occurred, meaning that the SpO2 temporarily dropped to 89 %. Note that this patient had SpO2 of 90 % before induction of anesthesia. Conclusion This study shows that it is feasible to use Tritube with FCV in patients with unusual location of tracheal stenosis, namely a subglottic posterior location, undergoing laryngotracheal surgery. Tritube provides a good surgical field and FCV provided highly adequate ventilation especially in patients with compromised lung mechanics. Trial registration Clinical trial registration was done prospectively (NCT05317923) on 08/04/2022.

Section: Discussionsupporting

confidence: 60%

Airway management during unusual tracheal stenosis: A Clinical Feasibility Trial

Canbaz

et al. 2023

Preprint

Laryngoscope Investig Oto

“…We show that FCV ventilation via cuffed Tritube ensures an efficient ventilation in the narrowed airway. Moreover, the highly efficient ventilation, as described before in various patients, allowed an extended apneic period for the surgical procedure 35,39–42 . Our respiratory and hemodynamic data show that FCV was able to maintain stable respiratory and hemodynamic levels for almost 80 min, without having to accept periods of hypercapnia.…”

Section: Discussionsupporting

confidence: 58%

“…Moreover, the highly efficient ventilation, as described before in various patients, allowed an extended apneic period for the surgical procedure. 35 , 39 , 40 , 41 , 42 Our respiratory and hemodynamic data show that FCV was able to maintain stable respiratory and hemodynamic levels for almost 80 min, without having to accept periods of hypercapnia. Another benefit of using Tritube with FCV is the continuous PetCO 2 monitoring, while only intermittent capnometry is possible with HFJV.…”

Section: Discussionmentioning

confidence: 70%

“…Primary outcome parameters PO 2 and PaCO 2 (Table 2), showed a stable and adequate gas exchange throughout the procedure. Before In line with the blood gas analyses, PetCO 2 was within the normal range in all patients throughout the procedure (Table 3) and showed a stable but slow decline (from 53 [48-58] mmHg after induction to 42.5 [36][37][38][39][40][41][42][43][44][45][46][47][48] mmHg at the end of surgery) indicating adequate ventilation with FCV. SpO 2 was stable in all patients starting at 95 [90-97] % and slowly increasing to 98 [94-100] % at the end of surgery.…”

Section: Procedure Respiratory and Hemodynamic Datamentioning

confidence: 71%

See 1 more Smart Citation

Airway management during unusual tracheal stenosis: A clinical feasibility trial

Altun,

Canbaz,

Altun

et al. 2023

ObjectivesProlonged intubation is a known risk factor of LTS. LTS related to COVID‐19 may result in a different phenotype: pronation affects the location of stenosis and COVID‐19 pneumonia can decline lung mechanics. Therefore, airway management in these patients may carry unique challenges for both anesthesiologists and surgeons.This prospective observational feasibility trial aims to evaluate the use of a novel thin, cuffed, endotracheal tube (Tritube) in combination with flow‐controlled ventilation (FCV) in the management of patients with COVID‐19‐related LTS undergoing laryngeal surgery.Methods20 patients suffering from COVID‐19‐related LTS, as diagnosed by CT, requiring endolaryngeal surgery, with or without CO2 laser, were included. Ultrathin endotracheal tube Tritube, together with FCV was used for airway management and ventilation. Feasibility, ventilation efficiency, and surgical exposure were evaluated.ResultsMedian duration of mechanical ventilation during their ICU stay was 17 days, (range, 7–27), and all patients had been pronated. In 18/20 patients, endoscopic diagnosis confirmed the initial CT diagnosis: posterior subglottic stenosis. Surgeons’ satisfaction on the view was rated 9 out of 10 (range 7–10), where 0 was the worst view and 10 was the best view. Hemodynamic and respiratory variables were within the normal clinical range during the surgical procedure. One patient that had a SpO2 of 90% before induction of anesthesia, a temporal drop to 89%, caused meeting the predefined requirement of “respiratory complication.”ConclusionThis study demonstrates the feasibility of using Tritube with FCV in patients with relatively unusual subglottic posterior location tracheal stenosis, undergoing laryngotracheal surgery. Tritube provides a good surgical field and FCV provides highly adequate ventilation especially in patients with compromised lung mechanics.Level of EvidenceIV, non‐comparitive prospective clinical trial with 20 patients.

“…PCV allows the ventilator to maintain pressure at the airway opening for a specified period of time (14)(15)(16)(17). As such, the final tidal volume and flow rate are affected by compliance, airway resistance, and spontaneous breathing.…”

Section: Discussionmentioning

confidence: 99%

Effect of target-controlled pressure-controlled ventilation on percutaneous nephrolithotripsy patients under general anesthesia: a retrospective study

Tao¹,

Ma²,

Sun³

et al. 2023

Transl Androl Urol

Background: Prone position surgery tends to limit chest wall mobility with decreased compliance and increased airway pressure, which can increase the incidence of postoperative pulmonary complications, including atelectasis, pneumonia, and respiratory failure. There is a lack of guidelines recommending mechanical ventilation parameters in prone position surgery. The present study aimed to investigate the effect of pressure-controlled ventilation (PCV) with end-inspiratory flow rate as the target on percutaneous nephrolithotripsy patients under general anesthesia in the prone position.