Comparison of the effect of two recruitment manoeuvres to conventional ventilation on lung atelectasis in paediatric laparoscopic surgery- a prospective randomised controlled trial

Background

There is a high incidence of pulmonary atelectasis during paediatric laparoscopic surgeries. The authors hypothesised that utilising a recruitment manoeuvre or using continuous positive airway pressure may prevent atelectasis compared to conventional ventilation.

Objective

The primary objective was to compare the degree of lung atelectasis diagnosed by lung ultrasound (LUS) using three different ventilation techniques in children undergoing laparoscopic surgeries.

Design

Randomised, prospective three-arm trial.

Setting

Single institute, tertiary care, teaching hospital.

Patients

Children of ASA PS 1 and 2 up to the age of 10 years undergoing laparoscopic surgery with pneumoperitoneum lasting for more than 30 min.

Intervention

Random allocation to one of the three study groups:

CG group: Inspiratory pressure adjusted to achieve a TV of 5–8 ml/kg, PEEP of 5 cm H₂O, respiratory rate adjusted to maintain end-tidal carbon dioxide (ETCO₂) between 30-40 mm Hg with manual ventilation and no PEEP at induction.

RM group: A recruitment manoeuvre of providing a constant pressure of 30 cm H₂O for ten seconds following intubation was applied. A PEEP of 10 cm H₂O was maintained intraoperatively.

CPAP group: Intraoperative maintenance with PEEP 10 cm H₂O with CPAP of 10 cm H₂O at induction using mechanical ventilation was done.

Outcome measures

Lung atelectasis score at closure assessed by LUS.

Results

Post induction, LUS was comparable in all three groups. At the time of closure, the LUS for the RM group (8.6 ± 4.9) and the CPAP group (8.8 ± 6.8) were significantly lower (p < 0.05) than the CG group (13.3 ± 3.8). In CG and CPAP groups, the score at closure was significantly higher than post-induction. The PaO₂/FiO₂ ratio was significantly higher (p < 0.05) for the RM group (437.1 ± 44.9) and CPAP group (421.6 ± 57.5) than the CG group (361.3 ± 59.4) at the time of pneumoperitoneum.

Conclusion

Application of a recruitment manoeuvre post-intubation or CPAP during induction and maintenance with a high PEEP leads to less atelectasis than conventional ventilation during laparoscopic surgery in paediatric patients.

Trial registry.

CTRI/2019/08/02058.