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Background Ventilator-induced lung injury caused by mechanical ventilation under general anesthesia as well as CO 2 pneumoperitoneum and special positions for laparoscopy may increase the risk of postoperative pulmonary complications (PPCs). Lung protective ventilation under general anesthesia is advised by the guidelines to lower the risk of PPCs in surgical patients. However, there is considerable controversy about the optimal level of positive end-expiratory pressure (PEEP) and how to set it. Driving pressure reflects the overall respiratory stress and high driving pressure is an independent risk factor for PPCs. The purpose of this study is to explore whether driving pressure-guided individualized PEEP ventilation can lower the incidence of postoperative atelectasis by improving respiratory mechanics during laparoscopic surgery consequently lowering the incidence of PPCs compared with the traditional fixed PEEP ventilation strategy. Methods The study will be a single-center, prospective, randomized controlled clinical study. A total of 106 adult patients with medium-to-high-risk PPCs undergoing laparoscopic surgery for more than 2 h will be randomly assigned in a 1:1 ratio to receive an individualized PEEP guided by minimum driving pressure (group D) or a fixed PEEP of 5 cmH 2 O (group C). Patients in group C will maintain a PEEP of 5 cmH 2 O throughout the whole process, and patients in group D will be administered individualized PEEP after the start of pneumoperitoneum to achieve minimum driving pressure until the end of the operation. The primary outcome is the LUS score at 24 h postoperatively. The secondary outcomes are the LUS scores at other time points, intraoperative respiratory mechanics and oxygenation index, incidence and specific types of PPCs at 7 days postoperatively. Discussion This study will better evaluate the effect of individualized PEEP application guided by driving pressure on the incidence of postoperative atelectasis based on ultrasound assessment consequently the incidence of PPCs in patients undergoing prolonged laparoscopic surgery. The results may provide a clinical evidence for optimizing perioperative lung protection strategies. Trial registration www.chictr.org.cn ChiCTR2300079041. Registered on December 25, 2023.

To evaluate the effect of negative extra-abdominal pressure (NEXAP)-based lung recruitment maneuver (LRM) for atelectasis after cardiac surgery, and compare it with stepwise positive end-expiratory pressure (PEEP)-based LRM. In this single-center randomized controlled clinical trial, patients were assigned to the NEXAP or PEEP groups. The primary outcome was the lung ultrasound score (LUSS) on global (LUSStot) and regional (LUSSp, posterior, LUSSa, anterior and LUSSl, lateral regions). 29 patients in the NEXAP group and 33 patients in the PEEP group were analyzed. The LUSStot was significantly decreased after LRM in both the NEXAP group (20.7 ± 3.2 vs. 15.6 ± 3.3; p < 0.001) and PEEP group (21.5 ± 4.2 vs. 17.1 ± 4.6; p < 0.001), and ΔLUSStot was significantly greater in the NEXAP group than PEEP group (−5.1 ± 2.3 vs. −3.8 ± 2.2, p = 0.020). Regional LUSS showed that NEXAP reduced LUSSl and LUSSp. PaO2/FiO2, PaO2, Vt, and Crs were significantly improved in the two groups. NEXAP is an effective treatment for atelectasis after cardiac surgery, which significantly reduced patients' LUSS, improved pulmonary ventilation (especially in the lateral and posterior regions). NEXAP can further reduce LUSStot than the traditional PEEP-based LRM. Regional LUSS analyses reflecting the different mechanisms between the two methods of LRMs may require further investigation. •Negative extra-abdominal pressure-based lung recruitment maneuver is effective for atelectasis after cardiac surgery.•First application of extra-abdominal pressure-based lung recruitment in a clinical population.•Negative extra-abdominal pressure-based lung recruitment can reduce the lung ultrasound score compared to traditional method.•Regional lung ultrasound analyses reflecting the different mechanisms between the two methods of recruitment maneuver.•Negative extra-abdominal pressure-based lung recruitment maneuver has less haemodynamic impact than traditional method.

Background Although the incidence of postoperative atelectasis could be reduced using lung recruitment manoeuvres, it remains high. We hypothesised that intraoperative visual lung recruitment guided by trans-oesophageal lung ultrasound would be more effective than the conventional method for managing postoperative atelectasis. Methods In this randomised , controlled, prospective study, 84 patients undergoing thoracoscopic lobectomy were recruited from Affiliated Chengdu Fifth People ’ s Hospital (teaching hospital) in China. Patients were grouped into trans-oesophageal lung ultrasound-guided (Group G, n  = 42) and control (Group C, n  = 42) groups. Methods Lung recruitment was performed after anaesthesia induction, before chest closure and before the endotracheal tube extubation. In Group C, recruitment pressure was controlled at 30 cm H 2 O for 10 s (performed thrice); in Group G, the pressure was controlled at 30 cm H 2 O (performed thrice), and the tidal volume did not exceed 20 ml kg −1 until no atelectasis was detected by trans-oesophageal ultrasound. The primary outcome was lung ultrasound scores measured at the post anaesthesia care unit 30 min after extubation. The secondary outcomes included the oxygenation index (30 min after extubation) and the incidence of atelectasis (30 min after extubation and 3 days after surgery). Results The final analysis included 79 patients. The lung ultrasound score was significantly higher in the control group than in the ultrasound-guided group 30 min after extubation (Group C vs. Group G, 8.6 ± 2.6 vs. 6.5 ± 2.0, P  < 0.001). No significant difference in the oxygenation indexes 30 min after extubation was observed between the groups ( P  = 0.074); however, the incidence of atelectasis 30 min after extubation significantly differed between the two groups (Group C vs. Group G, 57% vs. 33%, P  = 0.031). The incidence of atelectasis 3 days after surgery did not significantly differ between the two groups (Group C vs. Group G, 45% vs. 28%, P  = 0.122). Conclusions Lung recruitment guided by trans-oesophageal lung ultrasound can reduce lung ultrasound scores and the incidence of atelectasis at the post anaesthesia care unit 30 min after extubation. However, it does not significantly reduce the incidence of atelectasis 3 days after surgery. Trial registration Registration number: ChiCTR2200062509. Registered on 10 /8/ 2022.

Older patients undergoing laparoscopic radical rectal cancer surgery under general anesthesia with mechanical ventilation face an increased risk of postoperative pulmonary atelectasis due to the Trendelenburg position and pneumoperitoneum. This study aims to assess whether lung ultrasound-guided individualized positive end-expiratory pressure(PEEP) ventilation can reduce postoperative atelectasis in older patients. Forty patients aged > 65 years scheduled for elective laparoscopic radical rectal cancer surgery were randomly assigned to two groups: the ultrasound-guided group (Group P) received individualized PEEP titrated by lung ultrasound, and the control group (Group C) maintained a fixed PEEP of 5 cmH 2 O. PEEP was maintained until extubation in both groups. Post-extubation, lung ultrasound assessed 12 regions in both lungs. Ultrasound-guided individualized PEEP values varied significantly between individuals [median (IQR): 11 (7-11.75) ]. Compared with the PEEP with a fixed 5 cmH 2 O, the incidence of postoperative pulmonary atelectasis (postoperative day 1: 0 vs. 25%; P  = 0.047) and severity [lung ultrasound score (LUS):8.5 (6-9.75) vs. 12.5 (10-13.75); P  < 0.001)] were lower in the patients undergoing the lung ultrasound PEEP titration strategy. Meanwhile, the intraoperative drive pressure(ΔP) (6.5 ± 2.8 vs. 10.4 ± 5.8; P  = 0.01) and the incidence of postoperative pulmonary complications(PPCs) (5% vs. 35%; P  = 0.044) were lower in the ultrasound-guided group, and intraoperative oxygenation index(OI) (461.5 ± 39.5 vs. 415.7 ± 69.1; P  = 0.014) and dynamic compliance(Cdyn) (36.4 ± 8.2 vs. 25.8 ± 8.9; P  < 0.001) were elevated. The perioperative hemodynamic characteristics were comparable between the two groups. Lung ultrasound-guided individualized PEEP decreased the incidence and severity of postoperative atelectasis in older patients undergoing laparoscopic rectal cancer surgery. This strategy improved intraoperative respiratory mechanics (Cdyn, ΔP, OI) and reduced PPCs without hemodynamic compromise. Trial registration This clinical trial was registered at the Chinese Clinical Trial Registry (Registration No.:ChiCTR2300078385, 07/12/2023, www.chictr.org.cn ).

Postoperative pulmonary complications (PPCs) are common in patients undergoing general anesthesia, with atelectasis being a key contributor that increases postoperative mortality and prolongs hospitalization. Our research hypothesis is that ultrasound-guided individualized PEEP titration can reduce postoperative atelectasis. This single-center randomized controlled trial recruited elderly patients for laparoscopic surgery. Patients were randomly assigned to two group: the study group (individualized PEEP groups, PEEP Ind group) and the control group (Fixed PEEP group, PEEP 5 group). All patients in these two groups received volume-controlled ventilation during general anesthesia. Patients in the study group were given ultrasound-guided PEEP, while those in the control group were given a fixed 5 cmH 2 O PEEP. Bedside ultrasound assessed lung ventilation. The primary outcome was the severity of atelectasis within seven days post-surgery. Eighty-nine patients scheduled for elective laparoscopic radical surgery for colorectal cancer were enrolled in our study. Lung ultrasound scores (LUSs) in the study group during postoperative seven days was significantly decreased compared with that in the control group ( P  < 0.05). The severity of postoperative atelectasis in the study group was significantly improved. The incidence of PPCs during postoperative 7 days in the study group was significantly less than that in the control group (48.6% vs. 77.8%; RR  = 0.625; CI  = 0.430–0.909; P  = 0.01). In elderly patients undergoing laparoscopic radical resection, lung ultrasound-guided individualized PEEP can alleviate the severity of postoperative atelectasis. Clinical trial number and registry URL : No. ChiCTR2200062979 ( https://www.chictr.org.cn ).

Background Postoperative pulmonary complications (PPCs) often occur after cardiac operations and are a leading cause of morbidity, inhibit oxygenation, and increase hospital length of stay and mortality. Although clinical evidence for PPCs prevention is often unclear and crucial, measures occur to reduce PPCs. One device usually used for this reason is incentive spirometry (IS). The aim of the study is to evaluate the effect of preoperative incentive spirometry to prevent postoperative pulmonary complications, improve postoperative oxygenation, and decrease hospital stay following coronary artery bypass graft (CABG) surgery patients. Methods This was a clinical randomized prospective study. A total of 80 patients were selected as candidates for CABG at An-Najah National University Hospital, Nablus-Palestine. Patients had been randomly assigned into two groups: incentive spirometry group (IS), SI performed before surgery (study group) and control group, preoperative spirometry was not performed. The 40 patients in each group received the same protocol of anesthesia and ventilation in the operating room. Result The study findings showed a significant difference between the IS and control groups in the incidence of postoperative atelectasis. There were 8 patients (20.0%) in IS group and 17 patients (42.5%) in the control group ( p  = 0.03). Mechanical ventilation duration was significantly less in IS group. The median was four hours versus six hours in the control group ( p  < 0.001). Hospital length of stay was significantly less in IS group, and the median was six days versus seven days in the control group ( p  < 0.001). The median of the amount of arterial blood oxygen and oxygen saturation was significantly improved in the IS group ( p  < 0.005). Conclusion Preoperative incentive spirometry for two days along with the exercise of deep breathing, encouraged coughing, and early ambulation following CABG are in connection with prevention and decreased incidence of atelectasis, hospital stay, mechanical ventilation duration and improved postoperative oxygenation with better pain control. A difference that can be considered both significant and clinically relevant. Trial registration Thai Clinical Trials Registry: TCTR20201020005. Registered 17 October 2020—retrospectively registered.

Purpose Postoperative pulmonary complications (PPCs) are a common cause of morbidity. Postoperative atelectasis is thought to be a significant risk factor in their development. Recent imaging studies suggest that patients’ extubation may result in similar postoperative atelectasis regardless of the intraoperative mechanical ventilation strategy used. In this pilot trial, we hypothesized that a study investigating the effects of an open lung extubation strategy compared with a conventional one on PPCs would be feasible. Methods We conducted a pilot, single-centre, double-blinded randomized controlled trial. Adult patients at moderate to high risk of PPCs and scheduled for elective surgery were eligible. Patients were randomized to an open lung extubation strategy (semirecumbent position, fraction of inspired oxygen [F I O 2 ] 50%, pressure support ventilation, unchanged positive end-expiratory pressure) or to a conventional extubation strategy (dorsal decubitus position, F I O 2 100%, manual bag ventilation). The primary feasibility outcome was global protocol adherence while the primary exploratory efficacy outcome was PPCs. Results We randomized 35 patients to the conventional extubation group and 34 to the open lung extubation group. We observed a global protocol adherence of 96% (95% confidence interval, 88 to 99), which was not different between groups. Eight PPCs occurred (two in the conventional extubation group vs six in the open lung extubation group). Less postoperative supplemental oxygen and better lung aeration were observed in the open lung extubation group. Conclusions In this single-centre pilot trial, we observed excellent feasibility. A multicentre pilot trial comparing the effect of an open lung extubation strategy with that of a conventional extubation strategy on the occurrence of PPCs is feasible. Study registration date ClinicalTrials.gov (NCT04993001); registered 6 August 2021.

Pneumoperitoneum is a risk factor for perioperative atelectasis in infants. This research aimed to investigate whether lung recruitment manoeuvres guided by ultrasound are more effective for young infants (<3 months) during laparoscopy under general anaesthesia. Young infants (<3 months) undergoing general anaesthesia during laparoscopic surgery (>2 h) were randomised to either conventional lung recruitment (control group) or ultrasound-guided lung recruitment (ultrasound group) once per hour. Mechanical ventilation was started with a tidal volume of 8 mL·kg−1, positive end-expiratory pressure of 6 cm H2O and 40% inspired oxygen fraction. Lung ultrasound (LUS) was performed four times (T1 was performed 5 min after intubation and before pneumoperitoneum set, T2 was performed after pneumoperitoneum, T3 was performed 1 min after surgery, and T4 was performed before being discharged from post-anaesthesia care unit [PACU]) in each infant. The primary outcome was the incidence of significant atelectasis at T3 and T4 (defined by LUS consolidation score ≥ 2 in any region). 62 babies were enrolled in the experiment and 60 infants were included in the analysis. Before the recruitment, atelectasis was similar between infants randomised to the control or ultrasound group at T1 (83.3% vs 80.0%; P = 0.500) and T2 (83,3% vs 76.7%; P = 0.519). The incidence of atelectasis at T3 and T4 were lower in the ultrasound group (26.7% and 33.3%), compared with infants randomised to conventional lung recruitment (66.7% and 70%) (P = 0.002; P = 0.004; respectively). Ultrasound-guided alveolar recruitment reduced the perioperative incidence of atelectasis in infants <3 months during laparoscopy under general anaesthesia. [Display omitted] •Pneumoperitoneum is a risk factor for perioperative atelectasis in infants.•Premature infants were vulnerable to atelectasis under general anaesthesia.•Lung recruitment manoeuvres guided by ultrasound are more effective for young infants.

Dexmedetomidine improves intrapulmonary shunt in thoracic surgery and minimizes inflammatory response during one-lung ventilation (OLV). However, it is unclear whether such benefits translate into less postoperative pulmonary complications (PPCs). Our objective was to determine the impact of dexmedetomidine on the incidence of PPCs after thoracic surgery. Major databases were used to identify randomized trials that compared dexmedetomidine versus placebo during thoracic surgery in terms of PPCs. Our primary outcome was atelectasis within 7 days after surgery. Other specific PPCs included hypoxemia, pneumonia, and acute respiratory distress syndrome (ARDS). Secondary outcome included intraoperative respiratory mechanics (respiratory compliance [Cdyn]) and postoperative lung function (forced expiratory volume [FEV1]). Random effects models were used to estimate odds ratios (OR). Twelve randomized trials, including 365 patients in the dexmedetomidine group and 359 in the placebo group, were analyzed in this meta-analysis. Patients in the dexmedetomidine group were less likely to develop postoperative atelectasis (2.3% vs 6.8%, OR 0.42, 95%CI 0.18–0.95, P = 0.04; low certainty) and hypoxemia (3.4% vs 11.7%, OR 0.26, 95%CI 0.10–0.68, P = 0.01; moderate certainty) compared to the placebo group. The incidence of postoperative pneumonia (3.2% vs 5.8%, OR 0.57, 95%CI 0.25–1.26, P = 0.17; moderate certainty) or ARDS (0.9% vs 3.5%, OR 0.39, 95%CI 0.07–2.08, P = 0.27; moderate certainty) was comparable between groups. Both intraoperative Cdyn and postoperative FEV1 were higher among patients that received dexmedetomidine with a mean difference of 4.42 mL/cmH2O (95%CI 3.13–5.72) and 0.27 L (95%CI 0.12–0.41), respectively. Dexmedetomidine administration during thoracic surgery may potentially reduce the risk of postoperative atelectasis and hypoxemia. However, current evidence is insufficient to demonstrate an effect on pneumonia or ARDS. •Translational research has demonstrated that dexmedetomidine minimizes inflammatory response during one-lung ventilation.•Our meta-analysis aimed to determine whether dexmedetomidine reduces pulmonary complications after thoracic surgery.•Dexmedetomidine administration reduces atelectasis and improves oxygenation in the postoperative period.•The current evidence is not sufficient to demonstrate any effect of dexmedetomidine on postoperative pneumonia.•A large, randomized trial is warranted to further clarify the potential benefit of dexmedetomidine on pulmonary outcomes