Radiological evidence of pulmonary complications and possible aetiological factors were investigated in 50 consecutive patients after heart operations with cardiopulmonary bypass. Atelectasis was the most frequent pulmonary complication except for small pleural effusions, with an incidence of 64 per cent. Several types of atelectasis frequently co-existed, with a predominance of the less extensive plate and subsegmental forms. The incidence of atelectasis was the same on each side and the site of atelectasis was basal in three quarters of the patients. Preoperative clinical and catheter data were unrelated to the incidence of atelectasis. There was a significant positive correlation between a short cardiopulmonary bypass time and plate atelectasis, between a large fluid load after bypass and segmental atelectasis, between re-operation for bleeding and subsegmental atelectasis and between post-operative gastric dilation and atelectasis. The type of operation, the use of the intra-aortic balloon and the length of postoperative respiratory ventilation were unrelated to the incidence of atelectasis. The mechanism of development of atelectasis is discussed.

Pulmonary Atelectasis and Other Respiratory Complications after Cardiopulmonary Bypass and Investigation of Aetiological Factors

In patients with uninjured lungs, increasing evidence indicates that tidal volume (VT) reduction improves outcomes in the intensive care unit (ICU) and in the operating room (OR). However, the degree to which this evidence has translated to clinical changes in ventilator settings for patients with uninjured lungs is unknown. To clarify whether ventilator settings have changed, we searched MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science for publications on invasive ventilation in ICUs or ORs, excluding those on patients 25% of patients with acute respiratory distress syndrome (ARDS). Our primary end point was temporal change in VT over time. Secondary end points were changes in maximum airway pressure, mean airway pressure, positive end-expiratory pressure, inspiratory oxygen fraction, development of ARDS (ICU studies only), and postoperative pulmonary complications (OR studies only) determined using correlation analysis and linear regression. We identified 96 ICU and 96 OR studies comprising 130,316 patients from 1975 to 2014 and observed that in the ICU, VT size decreased annually by 0.16 mL/kg (-0.19 to -0.12 mL/kg) (P < .001), while positive end-expiratory pressure increased by an average of 0.1 mbar/y (0.02-0.17 mbar/y) (P = .017). In the OR, VT size decreased by 0.09 mL/kg per year (-0.14 to -0.04 mL/kg per year) (P < .001). The change in VTs leveled off in 1995. Other intraoperative ventilator settings did not change in the study period. Incidences of ARDS (ICU studies) and postoperative pulmonary complications (OR studies) also did not change over time. We found that, during a 39-year period, from 1975 to 2014, VTs in clinical studies on mechanical ventilation have decreased significantly in the ICU and in the OR.

Temporal Changes in Ventilator Settings in Patients With Uninjured Lungs: A Systematic Review.

Introduction: Despite technological advances aimed at reducing complications and hospital stay, pulmonary complications in the postoperative period of CABG surgery remain one of the most important causes of morbidity. These may be related to the patient´s quality of life, the use of cardiopulmonary bypass, as well as a decline in postoperative respiratory muscle strength, contributing to the emergence of restrictive respiratory disorders. Objective: Assess pulmonary complications in patients undergoing coronary artery bypass graft surgery and identify their association with risk factors. Methods: A retrospective study with non-probability convenience sampling of 168 patients at the Hospital do Coracao of Alagoas, undergoing CABG between January 2009 and October 2013. Results: The 168 patients undergoing CABG had a mean age of 60.08 ± 10.03 years, 24.4% women and 75.6% men. Among the cardiovascular risk factors were: Hypertension (89.9%); Heredity for cardiovascular disease (54.8%); Diabetes Mellitus (45.2%); Dyslipidemia (41.1%); Smoking (32.1%); and Stroke (1.2%). Pulmonary complications after surgery include pleural effusion (17.9%); atelectasis (5.4%); pneumothorax, pulmonary embolism, and acute respiratory failure (1.2%); and bronchopneumonia (0.6%). Female patients and those aged 70 years or older experienced more pulmonary complications after surgery. Conclusion: Women and patients older than 70 years had the most severe postoperative pulmonary complications, the most common being pleural effusion and atelectasis.

https://periodicos.pucpr.br/fisio/article/download/21875/21011

Pulmonary complications in patients undergoing coronary artery bypass grafting at a hospital in Maceio, Brazil

Safety and effectiveness of alveolar recruitment maneuvers and positive end-expiratory pressure during general anesthesia for cesarean section: a prospective, randomized trial.

ObjectiveTo examine if mechanical ventilation with positive end-expiratory pressure (PEEP) combined with intra-aortic balloon pump (IABP) provided a better outcome than IABP alone for the treatment...

https://journals.sagepub.com/doi/pdf/10.1177/0300060515621443

Intra-aortic balloon pump combined with mechanical ventilation for treating patients aged > 60 years in cardiogenic shock: Retrospective analysis:

BACKGROUND AND OBJECTIVES: Alveolar recruitment maneuver (ARM) with pressures of 40 cmH2 O in the airways is effective in the reversal of atelectasis after myocardial revascularization (MR); however, there is a lack of studies evaluating the hemodynamic impact of this maneuver in patients who evolve with cardiogenic shock after MR. The objective of this study was to test the hemodynamic tolerance to ARM in patients who develop cardiogenic shock after MR. METHODS: Ten hypoxemic patients in cardiogenic shock after MR were evaluated after admission to the ICU and hemodynamic stabilization. Ventilatory adjustments included tidal volume of 8 mL.kg-1, PEEP 5 cmH2O, RR 12, and FiO2 0.6. Continuous pressure of 40 cmH2O was applied to the airways for 40 seconds in three cycles. Between cycles, patients were ventilated for 30 seconds, and after the last cycle, PEEP was set at 10 cmH2O. Hemodynamic measurements were obtained 1, 10, 30, and 60 minutes after ARM, and arterial and venous blood samples were drawn 10 and 60 minutes after the maneuver to determine lactate levels and blood gases. ANOVA and the Friedman test were used to analyze the data. A p of 0.05 was considered significant. RESULTS: Alveolar recruitment maneuver increased the ratio PaO2/FiO2 from 87 to 129.5 after 10 minutes and to 120 after 60 minutes (p < 0.05) and reduced pulmonary shunting from 30% to 20% (p < 0.05). Hemodynamic changes or changes in oxygen transport immediately after or up to 60 minutes after the maneuver were not detected. CONCLUSIONS: In patients who evolved to cardiogenic shock and hypoxemia after MR, ARM improved oxygenation and was well tolerated hemodynamically.

/pdf/impacto-hemodinamico-de-manobra-de-recrutamento-alveolar-em-3gcqcm5429.pdf

Impacto hemodinâmico de manobra de recrutamento alveolar em pacientes evoluindo com choque cardiogênico no pós-operatório imediato de revascularização do miocárdio

JUSTIFICATIVA Y OBJETIVOS: Maniobras de reclutamiento alveolar (MRA) utilizando presiones de 40 cmH2O en las vias aereas son efectivas en revertir las atelectasias despues de la revascularizacion quirurgica del miocardio (RM), sin embargo, no existen estudios que evaluen el impacto hemodinamico de esta maniobra en pacientes que evolucionaron con choque cardiogenico. El objetivo fue probar la tolerancia hemodinamica a la MRA en pacientes que evolucionan con choque cardiogenico despues de la RM. METODO: Despues de la entrada en la UCI y de la estabilizacion hemodinamica, se estudiaron 10 pacientes hipoxemicos y en choque cardiogenico despues de RM. Los ajustes de ventilacion fueron volumen corriente de 8 mL.kg-1, PEEP 5 cmH2O, FR de 12 ipm y FiO2 de 0,6. Presion continua de 40 cmH2O se aplico en las vias aereas por 40 segundos en tres ciclos. Entre los ciclos, los pacientes fueron ventilados por 30 segundos y despues del ultimo ciclo, la PEEP fue ajustada en 10 cmH2O. Fueron obtenidas medidas hemodinamicas despues de 1, 10, 30 y 60 minutos de la MRA y recogidas muestras de sangre arteriales y venosas para la medida de lactato y de los gases sanguineos 10 y 60 minutos despues. Datos analizados a traves de ANOVA y test de Friedman. Valor de p fijado en 0,05. RESULTADOS: La MRA aumento la relacion PaO2/FiO2 de 87 para 129,5 despues de 10 minutos y 120 despues de 60 minutos (p < 0,05) y redujo el shunt pulmonar de 30% para 20% (p < 0,05). No se detectaron alteraciones hemodinamicas o en el transporte de oxigeno inmediatamente o en hasta 60 minutos despues de la MRA. CONCLUSIONES: En pacientes que evolucionaron con choque cardiogenico despues de RM e hipoxemia, la MRA mejoro la oxigenacion y fue bien tolerada hemodinamicamente.

/pdf/impacto-hemodinamico-de-maniobra-de-reclutamiento-alveolar-1y59xz2vut.pdf

Impacto hemodinámico de maniobra de reclutamiento alveolar en pacientes evolucionando con choque cardiogénico en el postoperatorio inmediato de revascularización del miocardio

/pdf/impacto-hemodinamico-de-manobra-de-recrutamento-alveolar-em-1yd87n7tnm.pdf

Impacto Hemodinâmico de Manobra de Recrutamento Alveolar em Pacientes Evoluindo com Choque Cardiogênico no Pós-Operatório Imediato de Revascularização do Miocárdio* Hemodynamic Impact of Alveolar Recruitment Maneuver in Patients Evolving with Cardiogenic Shock in the Immediate Postoperative Period of Myocardial Revascularization

BACKGROUND AND OBJECTIVES Alveolar recruitment maneuver (ARM) with pressures of 40 cmH2O in the airways is effective in the reversal of atelectasis after myocardial revascularization (MR); however, there is a lack of studies evaluating the hemodynamic impact of this maneuver in patients who evolve with cardiogenic shock after MR. The objective of this study was to test the hemodynamic tolerance to ARM in patients who develop cardiogenic shock after MR. METHODS Ten hypoxemic patients in cardiogenic shock after MR were evaluated after admission to the ICU and hemodynamic stabilization. Ventilatory adjustments included tidal volume of 8 mL x kg(-1), PEEP 5 cmH2O, RR 12, and FiO2 0.6. Continuous pressure of 40 cmH2O was applied to the airways for 40 seconds in three cycles. Between cycles, patients were ventilated for 30 seconds, and after the last cycle, PEEP was set at 10 cmH2O. Hemodynamic measurements were obtained 1, 10, 30, and 60 minutes after ARM, and arterial and venous blood samples were drawn 10 and 60 minutes after the maneuver to determine lactate levels and blood gases. ANOVA and the Friedman test were used to analyze the data. A p of 0.05 was considered significant. RESULTS Alveolar recruitment maneuver increased the ratio PaO2/ FiO2 from 87 to 129.5 after 10 minutes and to 120 after 60 minutes (p < 0.05) and reduced pulmonary shunting from 30% to 20% (p < 0.05). Hemodynamic changes or changes in oxygen transport immediately after or up to 60 minutes after the maneuver were not detected. CONCLUSIONS In patients who evolved to cardiogenic shock and hypoxemia after MR, ARM improved oxygenation and was well tolerated hemodynamically.

/pdf/hemodynamic-impact-of-alveolar-recruitment-maneuver-in-1ki8cu9cq5.pdf

Hemodynamic impact of alveolar recruitment maneuver in patients evolving with cardiogenic shock in the immediate postoperative period of myocardial revascularization.

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Impacto hemodinâmico de manobra de recrutamento alveolar em pacientes evoluindo com choque cardiogênico no pós-operatório imediato de revascularização do miocárdio

Impacto hemodinámico de maniobra de reclutamiento alveolar en pacientes evolucionando con choque cardiogénico en el postoperatorio inmediato de revascularización del miocardio

Hemodynamic impact of alveolar recruitment maneuver in patients evolving with cardiogenic shock in the immediate postoperative period of myocardial revascularization.