Effect of Ultrasound-assisted Lung Recruitment Maneuver on Preventing Perioperative Atelectasis

Condition(s) studied

Investigational drug(s) / intervention(s)

recruitment maneuver: in the group 2, in addition to the fixed PEEP of 5 cm H₂O, a recruitment maneuver is planned at the end of the surgery. This will involve administering 6 breaths with VC × 2, I/E ratio of 1:1, and a plateau pressure of less than 35 cm H₂O, before extubation.

positional recruitment maneuver: In the third group, in addition to the fixed PEEP, a recruitment maneuver will be performed at the end of the surgery before extubation. This will involve administering 6 breaths with VC × 2, I/E ratio of 1:1, and a plateau pressure of less than 35 cm H₂O, with 3 breaths in the right lateral decubitus position and 3 breaths in the left lateral decubitus position

Study summary

This study is based on the hypothesis that recruitment maneuver reduces perioperative atelectasis and associated complications, and lung ultrasonography can be used to detect this.

Patients aged 1 to 14 years with an ASA physical status classification of 1 to 3 and undergoing surgical procedures with a minimum duration of 2 hours will be included in the study.

Patients with an ASA physical status classification of 4, including those with defined pulmonary diseases (e.g., asthma requiring medication and having had two emergency visits in the past year), prematurity ( \<36 weeks gestation / bronchopulmonary dysplasia), cystic fibrosis, diagnosed syndromic conditions, congenital cardiac diseases, abnormal chest X-rays, chest wall deformities, or a history of previous thoracic surgery, as well as those undergoing laparoscopic surgery, will be excluded from the study.

All patients will be premedicated with midazolam (0.05-1 mg/kg) if intravenous access is established, prior to transfer to the operating room. Upon arrival, standard monitoring will be initiated, including SpO2, ECG, and non-invasive blood pressure measurements. Following preoxygenation with 100% oxygen, induction will be performed using thiopental 5 mg/kg or propofol 2 mg/kg, fentanyl 2 mcg/kg, and rocuronium 0.6 mg/kg. After tracheal intubation, mechanical ventilation will be configured in pressure-controlled mode with a tidal volume of 8 ml/kg, PEEP of 5 cmH2O, FIO2 of 40%, and a respiratory rate adjusted to maintain ETCO2 within the range of 35-45 mmHg. Anesthesia maintenance will be achieved with sevoflurane and oxygen. During emergence, sugammadex 2 mg/kg will be administered as a neuromuscular reversal agent. The Aldrete scoring system will be employed for assessing patient readiness for transfer to the recovery unit.

GROUP 1: PEEP will be set at 5 cmH2O, and no recruitment maneuver will be performed.

GROUP 2: PEEP will be set at 5 cmH2O. Prior to extubation, a recruitment maneuver will be conducted with a Plato P max : 35 cmH2O, delivering 6 breaths at a vital capacity of 2 times, with an I/E ratio of 1:1.

GROUP 3: PEEP will be set at 5 cmH2O. Prior to extubation, a recruitment maneuver will be performed with a Plato P max : 35 cmH2O, delivering 3 breaths in the left lateral decubitus position and 3 breaths in the right lateral decubitus position, at a vital capacity of 2 times, with an I/E ratio of 1:1.

Lung ultrasonography will be performed at the following time points: 1) before induction, 2) at the 5-minute mark after induction, 3) before the recruitment maneuver, and 4) at the 5-minute mark after extubation.

The lungs will be assessed by dividing each hemithorax into 6 regions. Evaluation will include pleural sliding, A-lines, air bronchograms, B-score, and consolidation score. Both PLAPS points will be evaluated for B-score and consolidation score.

From the beginning of the operation, the following parameters will be recorded hourly: heart rate (HR), arterial blood pressure (ABP), oxygen saturation (SpO2), fraction of inspired oxygen (FIO2), end-tidal CO2 (ETCO2), peak pressure (Ppeak), PLATO pressure, delta pressure, and compliance.

During the postoperative 24-hour period, the following will be documented: temperature, desaturation, oxygen requirement, and the need for additional radiological investigations.

Eligibility

Primary outcome measure(s)

• B scores — Perioperative (Lung ultrasound will be performed four times on each patient: T1: Pre-induction T2: 5 minutes after induction T3: Pre-recruitment maneuver T4: 5 minutes after extubation.)
  Each hemithorax will be divided into six regions using three longitudinal (parasternal, anterior axillary, and posterior axillary) and two transverse (1 cm above the nipple line and diaphragm) lines. Each region will be scanned sequentially from right to left, top to bottom, and front to back, with the probe perpendicular to the ribs. Pleural sliding, A-lines, air bronchograms, juxtapleural consolidation, and B-lines will be assessed. Additionally, B scores will be evaluated at two specific PLAPS points.
• Consolidation Scores — Perioperative ( Lung ultrasound will be performed four times on each patient: T1: Pre-induction T2: 5 minutes after induction T3: Pre-recruitment maneuver T4: 5 minutes after extubation.)
  Each hemithorax will be divided into six regions using three longitudinal (parasternal, anterior axillary, and posterior axillary) and two transverse (1 cm above the nipple line and diaphragm) lines. Each region will be scanned sequentially from right to left, top to bottom, and front to back, with the probe perpendicular to the ribs. Consolidation scores will be evaluated at two specific PLAPS points

Trial sites (1)

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