January Journal Club

[katevaughn]

This month's journal club is presented by Belinda. She chose an excellent article reviewing atelectasis and how we play a major role in the prevention of postoperative pulmonary complications. It is a great review that will help us continue to provide interventions that can make our patients' recoveries even better. Looking forward to hearing the different techniques used by everyone! Enjoy!

Here is a link to the article.

Questions to encompass:

1. After reading this article regarding atelectasis occurrence during general anesthesia do you think you may change your induction/emergence practice after reviewing this article?

2. List ways the anesthetist can prevent or treat atelectasis before, during and after anesthesia.​

[faresha]

1. A person can be more deliberate in decreasing the fi02 sooner after induction and utilize Pressure Support when emerging for an extended period on a spontaneously breathing patient. 

2. Decrease fi02 to as tolerated intraop, adequate TV during bag-mask ventilation, pressure support during emergence with avoidance of spontaneous breathing with small TV, and PEEP. 

[Kristen Horsman]

1. After reading this article regarding atelectasis occurrence during general anesthesia do you think you may change your induction/emergence practice after reviewing this article?

I typically only use alveolar recruitment maneuvers/sighs if I am having trouble getting my patients sats up. It seems I should start to institute this more often even in the setting of acceptable SaO2. Maintaining pressure support with PEEP until the patient is awake to extubate is another technique to consider.

2. List ways the anesthetist can prevent or treat atelectasis before, during and after anesthesia.​
Anesthetist can use lower tidal volumes (6-8 cc/kg) PEEP, ARMs, lower FiO2, pressure support on emergency and postop CPAP, incentive spirometer and have patient cough.

[Jessica Hadley]

1.Yes I do believe that I could be more intentional about giving ARM's immediately following induction and possible be more aware of a patient's Peep requirements as I typically use 5 for everyone immediately following induction.

2. By using low TV's, titrating Peep, ARMs, decreasing the Fi02 to lowest tolerable Fi02, considering CPAP after extubation, and encouraging incentive spirometry postoperatively.

[BrittneyKeating]

1.) This article was a great review of many practices that we can utilize to optimize respiratory outcomes for our patients. I often utilize alveolar recruitment maneuvers (ARMs) at the end of the case to open any atelectatic lung segments. However, this article highlights that atelectasis begin with the induction of general anesthesia due to the period of apnea/hypoventilation and compression of lung parenchyma with supine positioning and use of neuromuscular blockade. For this reason, I will be more cognizant of initiating the use of ARMs immediately following endotracheal tube placement.

This article had the greatest impact for me in highlighting how practitioners should assess the effectiveness of ARMs through changes in pulmonary compliance. On the newer ventilators we have available to us we can assess the effectiveness of ARMs with the pressure volume loop and calculated pulmonary compliance value, and with the older ventilators we can assess changes in compliance with use of ARMs by either a decrease in PIP with VCV or an increase in TV with PCV. In the past, I have relied on a change in my patient's SpO2 to assess the effectiveness of recruitment maneuvers, but this article has definitely shed light on more a more reliable indictor for ARMs.

2.) This article provides great summary/quick reference points on ways the anesthetist can promote an open lung ventilation status and prevent atelectasis at pre-, intra-, and post- anesthesia phases. Of those discussed, the following strategies had the strongest impact on changing my practice: 1.) Ultilize ARMs following induction/placement of endotracheal tube; 2.) Use a stepwise increase in PEEP as a method of ARMs; 3.) Titrate FiO2 to the lowest effective FiO2 for the patient; 4.) Utilize PEEP, such as on a pressure support ventilator mode, during emergence and until the endotracheal tube is removed to prevent atelectasis.

[Wai-Ling Lo]

1. After reading this article regarding atelectasis occurrence during general anesthesia do you think you may change your induction/emergence practice after reviewing this article?


I remembered this article well from previous reading. It reinforced the use of ARMs, PEEP, lung protective strategies and the lowest effective FIO2 to prevent atelectasis and postop resp complications. I have incorporated these strategies to my daily practice for a while. I especially like to use the stepwise increase in PEEP as ARMs without taking pt off the ventilator to avoid coughing.


2. List ways the anesthetist can prevent or treat atelectasis before, during and after anesthesia.​


To prevent or treat atelectasis, we can perform ARMs after induction and intraop; use lower TV (6-8mL/kg); titrate PEEP; use lowest effective FIO2; utilize CPAP after extubation; avoid high FIO2 and avoid pt breathing unassisted without PEEP.

[amandaeggert]

1. After reading this article regarding atelectasis occurrence during general anesthesia do you think you may change your induction/emergence practice after reviewing this article?


I can perform ARMs right after intubation or any circuit disconnect and use pressure support ventilation with PEEP until extubation


2. List ways the anesthetist can prevent or treat atelectasis before, during and after anesthesia.​


We can prevent atelectasis by using low tidal volume (6-8 ml/kg of the patient’s ideal body weight), using PEEP , ARMs, and using the lowest effective FiO2.

[kty67]

I read this article before at AANA website and thought what a great article.
1. Since then I try to be aware of FiO2 during my cases and if I give breaks to other providers. I noticed many anesthesia providers still using 100% FiO2 during the cases on healthy patients.
2. I use PEEP as soon as patient gets on a vent, use low TV with, PEEP, ARMs as needed.

[nanci]

1)After reading this article on atelectasis occurrence during general anesthesia do you think you may change your induction/emergence practice after reviewing this article?
-Yes use of ARM's at the beginning of the procedure after induction can be useful and I may change my induction practices. Also I may also change my intraop/emergence practices to incorporate these to optimize respiratory outcomes to include cases that I assume care from other providers (relief mid/end of workday).


2)List ways the anesthetist can prevent or treat atelectasis before, during, and after anesthesia.
-Keep using lower tidal volumes, PEEP throughout, decreasing FiO2 and ARMs.

[chrisdiem]

1)After reading this article on atelectasis occurrence during general anesthesia do you think you may change your induction/emergence practice after reviewing this article?

-This is the not the first time that I have read articles or studies regarding optimal ventilatory setting for the preoperative period. I have incorporated the use of lower tidal volumes 6-8ml/kg of ideal body weight as well as optimal PEEP and less than 100% Fio2 for some time now. That being said, I as someone else had mentioned I typically only provide recruitment maneuvers when having issues with oxygenation so I could incorporate ARMS multiple times throughout the case for patients that can tolerate it. Additionally, I have a habit of just putting everyone on %50 Fio2 instead of titrating down to the lowest tolerable Fio2.Finally, maintain the patient on pressure support ventilation with PEEP until extubation is something I will explore.

2)List ways the anesthetist can prevent or treat atelectasis before, during, and after anesthesia.
-Incorporating the using of optimal TV (6-8ml/kg) ideal body weight, use the lowest Fio2 allowable to maintain adequate Spo2, the use of ARMS regularly throughout the procedure, maintain the patient on pressure support with PEEP until extubation, assessing the patient for optimal PEEP levels.

[Chuck Eder]

1. Like previous responses, I can use ARMS right after induction/intubation in order to help with recruitment. This seems to be very beneficial to most patients undergoing GA. It very interesting how these simple and quick maneuvers early on can really benefit the patient throughout the procedure and post op.

2. Use of ARMS, lower TV/higher RR, decreasing FiO2 as much as possible, PEEP and PS during emergence. I always find that our anesthesia machines that have a PS mode are so much easier with emerging patients from anesthesia than those without that mode.

[emedina1]

this article has gave me some thoughts on my practice for induction and emergence.Decrease fi02 after induction.
I should give my pt ARM during the case.
use low fio2