Recruitment maneuver for prevention of alevolar derecruitment during percutaneous dilation tracheostomy

Introduction

Alveolar derecruitment is an early complication of percutaneous dilational tracheostomy (PDT). The aim of this prospective study was to evaluate the efficacy of performing a recruitment maneuver (RM) before tracheostomy, in order to prevent the alveolar derecruitment in critically ill patients.

Methods

We enrolled 16 patients admitted to the ICU between December 2008 and July 2009, with PaO₂/FiO₂ ratio ≤3 who underwent PDT. We used the Ciaglia/Blue Rhino technique with endoscopic guidance throughout the procedure. Patients were ventilated before and during PDT on volume-controlled mechanical ventilation (tidal volume of 6 ml/kg body weight) and FiO₂ set at 1. Patients were randomized into two groups: MRa group (seven patients who underwent RM 10 minutes before PDT) and no-MRa group (nine patients without application of RM before PDT). RM was performed by imposition of continuous positive airway pressure (CPAP) of 40 cmH₂O for 40 seconds. We collected gas exchange, respiratory and hemodynamic data at four times: 1 hour before RM (T1), 5 minutes after RM (T2), 5 and 30 minutes after PDT (T3 and T4, respectively).

Results

The average duration of the technique was similar in both groups: 20 ± 3.5 minutes (MRa) vs 17.5 ± 3.2 minutes (no-MRa). MR induced a statistically significant increase (P < 0.05) in PaO₂/FiO₂ ratio of MRa patients at T2, T3, T4 (Table 1). We did not find significant differences of respiratory and hemodynamic data between groups; MR did not induce cardiovascular instability: the mean cardiac output was 5.2 ± 2.2 vs 4.9 ± 1.5 l/min (MRa vs no-MRa, respectively).

Table 1 PaO₂/FiO₂ in MRa and in no-MRa groups

Conclusions

RM with CPAP performed before PDT could be performed safely to prevent alveolar derecruitment due to PDT.