Salahuddin Moiz, Sarkiss Mona, Sagar Ala-Eddin S, Vlahos Ioannis, Chang Christopher H, Shah Archan, Sabath Bruce F, Lin Julie, Song Juhee, Moon Teresa, Norman Peter H, Eapen George A, Grosu Horiana B, Ost David E, Jimenez Carlos A, Chintalapani Gouthami, Casal Roberto F
Department of Pulmonary Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX.
Department of Anesthesia and Peri-Operative MedicineThe University of Texas MD Anderson Cancer Center, Houston, TX.
Chest. 2022 Dec;162(6):1393-1401. doi: 10.1016/j.chest.2022.06.045. Epub 2022 Jul 6.
Atelectasis negatively influences peripheral bronchoscopy, increasing CT scan-body divergence, obscuring targets, and creating false-positive radial-probe endobronchial ultrasound (RP-EBUS) images.
Can a ventilatory strategy reduce the incidence of atelectasis during bronchoscopy under general anesthesia?
Randomized controlled study (1:1) in which patients undergoing bronchoscopy were randomized to receive standard ventilation (laryngeal mask airway, 100% Fio, zero positive end-expiratory pressure [PEEP]) vs a ventilatory strategy to prevent atelectasis (VESPA) with endotracheal intubation followed by a recruitment maneuver, Fio titration (< 100%), and PEEP of 8 to 10 cm HO. All patients underwent chest CT imaging and a survey for atelectasis with RP-EBUS bilaterally on bronchial segments 6, 9, and 10 after artificial airway insertion (time 1) and 20 to 30 min later (time 2). Chest CT scans were reviewed by a blinded chest radiologist. RP-EBUS images were assessed by three independent, blinded readers. The primary end point was the proportion of patients with any atelectasis (either unilateral or bilateral) at time 2 according to chest CT scan findings.
Seventy-six patients were analyzed, 38 in each group. The proportion of patients with any atelectasis according to chest CT scan at time 2 was 84.2% (95% CI, 72.6%-95.8%) in the control group and 28.9% (95% CI, 15.4%-45.9%) in the VESPA group (P < .0001). The proportion of patients with bilateral atelectasis at time 2 was 71.1% (95% CI, 56.6%-85.5%) in the control group and 7.9% (95% CI, 1.7%-21.4%) in the VESPA group (P < .0001). At time 2, 3.84 ± 1.67 (mean ± SD) bronchial segments in the control group vs 1.21 ± 1.63 in the VESPA group were deemed atelectatic (P < .0001). No differences were found in the rate of complications.
VESPA significantly reduced the incidence of atelectasis, was well tolerated, and showed a sustained effect over time despite bronchoscopic nodal staging maneuvers. VESPA should be considered for bronchoscopy when atelectasis is to be avoided.
ClinicalTrials.gov; No.: NCT04311723; URL: www.
gov.
肺不张会对周围支气管镜检查产生负面影响，增加CT扫描与身体的偏差，使目标模糊，并产生假阳性的径向探头支气管内超声（RP-EBUS）图像。
一种通气策略能否降低全身麻醉下支气管镜检查期间肺不张的发生率？
随机对照研究（1:1），将接受支气管镜检查的患者随机分为接受标准通气（喉罩气道，100% 吸入氧浓度，呼气末正压 [PEEP] 为零）组与采用预防肺不张的通气策略（VESPA）组，后者采用气管插管，随后进行肺复张手法、吸入氧浓度滴定（<100%）以及8至10 cmH₂O的PEEP。所有患者在人工气道插入后（时间1）以及20至30分钟后（时间2），均接受胸部CT成像以及使用RP-EBUS对双侧支气管6、9和10段进行肺不张检查。胸部CT扫描由一位不知情的胸部放射科医生进行阅片。RP-EBUS图像由三位独立的、不知情的阅片者进行评估。主要终点是根据胸部CT扫描结果，在时间2时出现任何肺不张（单侧或双侧）的患者比例。
共分析了76例患者，每组38例。根据胸部CT扫描，在时间2时，对照组出现任何肺不张的患者比例为84.2%（95%CI，72.6%-95.8%），VESPA组为28.9%（95%CI，15.4%-45.9%）（P <.0001）。在时间2时，对照组双侧肺不张的患者比例为71.1%（95%CI，56.6%-85.5%），VESPA组为7.9%（95%CI，1.7%-21.4%）（P <.0001）。在时间2时，对照组被判定为肺不张的支气管段数为3.84±1.67（平均值±标准差），VESPA组为1.21±1.63（P <.0001）。两组并发症发生率无差异。
VESPA显著降低了肺不张的发生率，耐受性良好，并且尽管进行了支气管镜淋巴结分期操作，但随着时间推移仍显示出持续效果。在需要避免肺不张的支气管镜检查中，应考虑采用VESPA。
ClinicalTrials.gov；编号：NCT04311723；网址：www. CLINICALTRIALS: gov。
