TY - JOUR
T1 - Ventilatory Strategy to Prevent Atelectasis During Bronchoscopy Under General Anesthesia
T2 - A Multicenter Randomized Controlled Trial (Ventilatory Strategy to Prevent Atelectasis -VESPA- Trial)
AU - Salahuddin, Moiz
AU - Sarkiss, Mona
AU - Sagar, Ala Eddin S.
AU - Vlahos, Ioannis
AU - Chang, Christopher H.
AU - Shah, Archan
AU - Sabath, Bruce F.
AU - Lin, Julie
AU - Song, Juhee
AU - Moon, Teresa
AU - Norman, Peter H.
AU - Eapen, George A.
AU - Grosu, Horiana B.
AU - Ost, David E.
AU - Jimenez, Carlos A.
AU - Chintalapani, Gouthami
AU - Casal, Roberto F.
N1 - Funding Information:
Author contributions: R. F. C. is the guarantor of the content of the manuscript, had full access to all the data in the study, and takes responsibility for the integrity of the data and the accuracy of the data analysis. M. Sarkiss, A.-E. S. S. B. F. S. T. M. P. H. N. G. A. E. and R. F. C. contributed to the study design, bronchoscopy, image analysis, data collection and interpretation, and manuscript composition and revision. I. V. contributed to image analysis, data collection and interpretation, and manuscript composition and revision. M. Salahuddin, C. H. C. A. S. and J. L. contributed to bronchoscopy, data collection and interpretation, and manuscript composition and revision. J. S. contributed to study design, statistical data analysis, and manuscript composition and revision. H. B. G. D. E. O. and C. A. J. contributed to study design, data interpretation, and manuscript composition and revision. G. C. contributed to image collection and manuscript composition and revision. Funding/support: This research was supported in part by the National Institutes of Health through MD Anderson's Cancer Center Support Grant [Grant CA016672]. Financial/nonfinancial disclosures: The authors have reported to CHEST the following: R. F. C. has received research grants from Siemens, Nanobiotix, and Olympus and is a paid consultant for Olympus, Intuitive Surgical, and Siemens. D. E. O. is a paid consultant for Intuitive Surgical, Beckton-Dickinson, and UpToDate. None declared (M. Sarkiss, M. Salahuddin, A. S. S. I. V. C. H. C. A. S. B. F. S. J. L. J. S. T. M. P. H. N. G. A. E. H. B. G. C. A. J. and G. C.). Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript. Other contributions: The authors thank Lee Taylor, Justin Hair, William Newton, Mehrnoosh Amirian, Rodney Green, David Banay, Charles Jones, and Mark Robbin for their assistance with bronchoscopy and image recording. Without their invaluable assistance, this study would have not been possible. Additional information: The e-Appendix, and e-Tables are available online under “Supplementary Data.”
Funding Information:
Funding/support: This research was supported in part by the National Institutes of Health through MD Anderson’s Cancer Center Support Grant [Grant CA016672].
Publisher Copyright:
© 2022 American College of Chest Physicians
PY - 2022/12
Y1 - 2022/12
N2 - 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;
AB - 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;
KW - atelectasis
KW - bronchoscopy
KW - general anesthesia
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U2 - 10.1016/j.chest.2022.06.045
DO - 10.1016/j.chest.2022.06.045
M3 - Article
C2 - 35803302
AN - SCOPUS:85140925806
SN - 0012-3692
VL - 162
SP - 1393
EP - 1401
JO - Chest
JF - Chest
IS - 6
ER -