Background

Atelectasis negatively influences peripheral bronchoscopy, increasing CT scan-body divergence, obscuring targets, and creating false-positive radial-probe endobronchial ultrasound (RP-EBUS) images.

Research Question

Can a ventilatory strategy reduce the incidence of atelectasis during bronchoscopy under general anesthesia?

Study Design and Methods

Randomized controlled study (1:1) in which patients undergoing bronchoscopy were randomized to receive standard ventilation (laryngeal mask airway, 100% Fio₂, zero positive end-expiratory pressure [PEEP]) vs a ventilatory strategy to prevent atelectasis (VESPA) with endotracheal intubation followed by a recruitment maneuver, Fio₂ titration (< 100%), and PEEP of 8 to 10 cm H₂O. 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.

Results

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.

Interpretation

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.

Trial Registry

ClinicalTrials.gov; No.: NCT04311723; URL: www.clinicaltrials.gov;

中文翻译：

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全身麻醉下支气管镜检查预防肺不张的通气策略

背景

肺不张会对周围支气管镜检查产生负面影响，增加 CT 扫描身体的发散，模糊目标，并产生假阳性的径向探头支气管内超声 (RP-EBUS) 图像。

研究问题

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？

研究设计和方法

随机对照研究 (1:1)，接受支气管镜检查的患者随机接受标准通气（喉罩气道、100% Fio2、零呼气末正压 [PEEP]）与预防肺不张的通气策略 (VESPA ₎气管插管后进行复张操作、F io ₂滴定 (< 100%) 和 8 至 10 cm H _{2的 PEEP}O. 所有患者在人工气道插入后（时间 1）和 20 至 30 分钟后（时间 2）均接受了胸部 CT 成像和双侧 RP-EBUS 检查支气管第 6、9 和 10 段肺不张情况。胸部 CT 扫描由不知情的胸部放射科医师进行审查。RP-EBUS 图像由三名独立的盲法读者评估。主要终点是根据胸部 CT 扫描结果在时间 2 出现任何肺不张（单侧或双侧）的患者比例。

结果

共分析了 76 名患者，每组 38 名。根据时间 2 的胸部 CT 扫描，任何肺不张患者的比例在对照组中为 84.2%（95% CI，72.6%-95.8%），在 VESPA 中为 28.9%（95% CI，15.4%-45.9%）组 ( P  < .0001)。时间 2 双侧肺不张患者的比例在对照组中为 71.1%（95% CI，56.6%-85.5%），在 VESPA 组中为 7.9%（95% CI，1.7%-21.4%）（P  < . 0001）。在时间 2，对照组有 3.84 ± 1.67（平均值 ± SD）个支气管节段，而 VESPA 组为 1.21 ± 1.63 个支气管节段被视为不张（P  < .0001）。并发症发生率未见差异。

解释

VESPA 显着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，但随着时间的推移显示出持续的效果。当要避免肺不张时，应考虑使用 VESPA 进行支气管镜检查。

试用注册表

临床试验.gov；编号：NCT04311723；网址：www.clinicaltrials.gov；