<p>Effects of an Alveolar Recruitment Maneuver During Lung Protective Ventilation on Postoperative Pulmonary Complications in Elderly Patients Undergoing Laparoscopy</p>

Abstract

Purpose: Controversy remains over whether alveolar recruitment maneuvers (ARMs) can reduce postoperative pulmonary complications. We hypothesized that performing an ARM in addition to lung protective ventilation (LPV) could improve intraoperative arterial oxygenation and postoperative pulmonary complications (PPCs) in elderly patients undergoing laparoscopy in the Trendelenburg position. Patients and Methods: Sixty-two patients (aged 65-85) scheduled for laparoscopic low anterior resection were randomized to receive LPV only (LPV group, n = 32) or LPV with an ARM (ARM group, n = 30). LPV was set to a tidal volume of 6 mL/kg with a positive end expiratory pressure (PEEP) of 5 cmH 2 O. The ARM was performed by serially increasing the PEEP to 10 cmH 2 O for 3 breaths, 15 cmH 2 O for 3 breaths, then 20 cmH 2 O for 10 breaths, both immediately before and after abdominal insufflation. The primary end-point was the frequency of PPCs such as desaturation (SpO 2 <90%), atelectasis, and pneumonia. Secondary end-points were changes in intraoperative respiratory and gas exchange parameters and hemodynamic variables. Results: One patient in the LPV group experienced desaturation on the first postoperative day. The frequency of chest X-ray abnormalities such as atelectasis or pleural effusion was comparable between groups (6 (19%) and 5 (17%) patients, respectively, P = 0.676). Changes in other respiratory, gas exchange and hemodynamic parameters over time were not significantly different between the groups. However, vasopressor requirements during surgery were higher in the ARM than the LPV group (9 (30%) and 2 (6%) patients, respectively, P = 0.014). Conclusion: This study suggests that performing an ARM during LPV may not improve postoperative respiratory outcomes and intraoperative oxygenation compared to LPV alone in geriatric patients undergoing laparoscopy in the Trendelenburg position. In addition, since the ARM could cause a significant deterioration in hemodynamic parameters, applying ARM to elderly patients should be carefully considered.

Recruitment Maneuver to Reduce Postoperative Pulmonary Complications after Laparoscopic Abdominal Surgery: A Systematic Review and Meta-Analysis

“…The reasons for the 183 exclusions were as follows: 105 were non-RCTs, 7 were non-adult studies, 18 reported open abdominal surgery, 13 did not report PPCs, 33 were animal experiments and 7 did not compare recruitment maneuvers to conventional mechanical ventilation. Finally, 17 RCTs with a total of 3480 patients were examined [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ]. The details of the included studies are presented in Table 2 .…”

“…Due to the completeness of the outcome data and lack of selective reporting, the risks of attrition bias and reporting bias were likewise evaluated as low. Five trials did not provide information on allocation concealment [ 18 , 26 , 28 , 31 , 32 ]. Twelve studies did not report the blinding of the outcome evaluators [ 15 , 18 , 22 , 23 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ].…”

“…Five trials did not provide information on allocation concealment [ 18 , 26 , 28 , 31 , 32 ]. Twelve studies did not report the blinding of the outcome evaluators [ 15 , 18 , 22 , 23 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ]. Seven studies showed a high risk of “other bias” owing to the small sample sizes [ 16 , 18 , 24 , 26 , 28 , 30 , 31 ].…”

“… Evaluation of risk bias for included RCTs: ( a ) percentage plot of seven types of bias for the included studies; ( b ) summary of bias for each study [ 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 ]. …”

The efficacy of different alveolar recruitment maneuvers in holmium laser lithotripsy surgery under general anesthesia using a laryngeal mask

“…Nonetheless, the incidence of PPCs was lower than previously reported in the Literatures [ 14 – 17 ]. This could be attributed to the small sample size, differences in inclusion criteria, with the prior LPVS trials including patients with acute respiratory distress syndrome (ARDS) [ 18 , 19 ], elderly patients [ 20 ], and patients undergoing thoracic surgery [ 21 ], versus the healthy lung patients in this study. Additionally, it is possible that the duration of mechanical ventilation was insufficient.…”