Choice of Respiratory Support During Cardiac Bypass in Cardiac Surgical Patients (Pilot Study)

Currently, there is no uniform respiratory support strategy during cardiopulmonary bypass (CPB) in cardiac anesthesiology.

The aim of the study was to examine possible variants of respiratory support during CPB and determine the most effective technique capable to reduce the incidence of postoperative pulmonary complications.

Material and methods. Ninety cardiac surgery patients were enrolled in the pilot study and divided into groups (CPAP, VC, and apnea). In the CPAP group, positive airway pressure of + 5 cm H₂O was maintained during CPB. The VC group patients underwent mechanical ventilation during CPB with a reduced tidal volume of 3 mL/kg, respiratory rate of 6/min, and REER of + 5 cm H₂O. In the apnea group, patients received no respiratory support (non-rebreathing system).

Results. In both the apnea and CPAP (constant positive airway pressure) group, there was a decrease in oxygenation index (OI) at the end of the CPB compared with baseline values. In the apnea group, the OI dropped from 316.31±81.76 to 230.10±102.48, while in the CPAP group it decreased from 319.37±80.01 to 223.17±152.36 (P<0.001). No significant changes in this parameter were observed in the VC group. The frequency of recruitment maneuvers after CPB to correct the impaired respiratory oxygenation was maximal in patients from apnea group (22 cases (73%) versus 13 cases (43%) in the CPAP group and 5 cases (16%) in the VC group) (P<0.001). Frequency of pulmonary atelectasis on chest radiology in postoperative period was 47, 37, 10% in apnea, CPAP, and VC groups, respectively, and the difference was also significant (P=0.006).

Conclusion. Low-volume ventilation is the preferable method of respiratory support in cardiac surgery patients during CPB.

1. Fischer M.O., Courteille B., Guinot P.G., Dupont H., Gérard J.L., Hanouz J-L., Lorne E.; collaboration of ARCOTHOVA, CARGO Groups. Perioperative ventilatory management in cardiac surgery: a French Nationwide Survey. Medicine (Baltimore). 2016; 95 (9): e2655. DOI: 10.1097/MD.0000000000002655. PMID: 26945353.

2. Bignami E., Di Lullo A., Saglietti F., Guarnieri M., Pota V., Scolletta S., Volta C.A., Vetrugno L., Cavaliere F., Tritapepe L. Routine practice in mechanical ventilation in cardiac surgery in Italy. J Thorac Dis, 2019; 11 (4): 1571–1579. DOI: 10.21037/jtd.2019.03.04. PMID: 31179101.

3. Nguyen L. S., Estagnasie P., Merzoug M., Brusset A., Law Koune J-D., Aubert S, Waldmann T., Naudin C., Grinda J-M., Gibert H., Squara P. Low-tidal volume mechanical ventilation against no ventilation during cardiopulmonary bypass in heart surgery (MECANO): a randomized controlled trial. Chest. 2021; 159 (5): 1843–1853. DOI: 10.1016/j.chest.2020.10.082. PMID: 33217416.

4. Pasquina P., Merlani P., Granier J. M., Ricou B. Continuous positive airway pressure versus noninvasive pressure support ventilation to treat atelectasis after cardiac surgery. Anesth Analg. 2004; 99 (4): 1001–1008. DOI: 10.1213/01.ane.0000130621.11024.97. PMID: 15385340.

5. Кириллов А.Ю., Яворовский А.Г., Выжигина М.А., Комаров Р.Н., Ногтев П.В., Багдасаров П.С., Халикова Е.Ю., Яворовская Д.А., Но И.И. Респираторная тактика во время искусственного кровообращения при кардиохирургических операциях. Вестник анестезиологии и реаниматологии. 2021; 18 (2): 40–47. DOI: 10.21292/2078-5658-2021-18-2-40-47.

6. Szakmany T., Heigl P., Molnar Z. Correlation between extravascular lung water and oxygenation in ALI/ARDS patients in septic shock: possible role in the development of atelectasis? Anaesth Intensive Care. 2004; 32 (2): 196–201. DOI: 10.1177/0310057X0403200206. PMID: 15957716.

7. Emperador F. 4th , Bennett S.R., Gonzalez J., Saati A., Alsaywid B.S., Fernandez J.A. Extravascular lung water and effect on oxygenation assessed by lung ultrasound in adult cardiac surgery. Cureus. 2020; 12 (8): e9953. DOI: 10.7759/cureus.9953. PMID: 32983659.

8. Bendixen, H. H., Hedley-Whyte J., Laver, M. B. Impaired oxygenation in surgical patients during general anesthesia with controlled ventilation. N Engl J Med; 1963: 269 (19); 991–996. DOI: 10.1056/nejm196311072691901. PMID: 14059732.

9. Hedenstierna G., Tokics L., Strandberg Å., Lundquist H., Brismar B. Correlation of gas exchange impairment to development of atelectasis during anaesthesia and muscle paralysis. Acta Anaesthesiolog Scand. 1986; 30 (2): 183–191. DOI: 10.1111/j.1399-6576.1986.tb02393.x. PMID: 3085429.

10. Berkowitz D.M., Danai P.A., Eaton S., Moss M., Martin G.S. Accurate characterization of extravascular lung water in acute respiratory distress syndrome. Crit Care Med. 2008; 36 (6): 1803–1809. DOI: 10.1097/CCM.0b013e3181743eeb.PMID: 18496374.

11. Спринджук М. В., Адзерихо И. Э., Лаптева И. М., Дергачев А. В. Бронхолегочные осложнения в кардиохирургии. Новости хирургии 2008; 16: 149–157. eLIBRARY ID: 17974153.

12. Sasseron A. B., de Figueiredo L. C., Trova K., Cardoso A.L, Lima N.M.F.V, Olmos S.C, Petrucci O. Does the pain disturb the respiratory function after open heart surgery? Rev Bras Cir Cardiovasc 2009; 24 (4): 490–496. DOI: 10.1590/s0102-76382009000500010. PMID: 20305922.

13. Baumgarten, M. C. dos S., Garcia G. K., Frantzeski, M. H., Giacomazzi, C. M., Lagni, V. B., Dias, A. S., Monteiro, M. B. Pain and pulmonary function in patients submitted to heart surgery via sternotomy/Comportamento da dor e da função pulmonar em pacientes submetidos à cirurgia cardíaca via esternotomia. Rev Bras Cir Cardiovasc. (in Eng /Port.) 2009; 24 (4): 497–505. DOI: 10.1590/s0102-76382009000500011. PMID: 20305923.

14. Шмырев В.А., Пономарев Д.Н., Перовский П.П., Богачев-Прокофьев А.В., Корнилов И.А., Ломиворотов В.В. Особенности раннего периода после миниинвазивных кардиохирургических операций. Общая реаниматология. 2014; 10 (4): 74–81. DOI: 10.15360/1813-9779-2014-4-74-81.

15. Овечкин А. М., Баялиева А.Ж., Ежевская А.А., Еременко А.А., Заболотский Д.В., Заболотских И.Б., Карелов А.Е., Корячкин В.А., Спасова А.П., Хороненко В.Э., Уваров Д.Н., Ульрих Г.Э., Шадрин Р.В. Послеоперационное обезболивание. Клинические рекомендации. Вестник интенсивной терапии имени А. И. Салтанова. 2019; 4: 9–33. DOI: 10.21320/1818-474X-2019-4-9-33.

16. Gagnon J., Laporta D., Béïque F., Langlois Y., Morin J-F. Clinical relevance of ventilation during cardiopulmonary bypass in the prevention of postoperative lung dysfunction. Perfusion. 2010; 25 (4): 205–210. DOI: 10.1177/0267659110373839. PMID: 20605871.

17. Iha K., Koja K., Kuniyoshi Y., Akasaki M., Miyagi K., Shinya E., Ohmine Y., Shiroma H., Kina M., Kusaba A. [Extravascular lung water in patients after cardiac surgery]. Nihon Kyobu Geka Gakkai Zasshi. (in Japanese) 1993; 41 (3): 389–395. PMID: 8478565.

18. Boldt J., Kling D., von Bormann B., Scheld H.H., Hempelmann G. Resuscitation and extravascular lung fluid in cardiac surgery. [Reanimation und extravaskuläres lungenwasser in der herzchirurgie (in Germ.)]. Anaesthesist. 1988; 37 (2): 91–96. PMID: 3259113.