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Optimal inspiratory pressure for face mask ventilation in paralyzed and unparalyzed children to prevent gastric insufflation: a prospective, randomized, non-blinded study

  • Ji-Hyun Lee
  • Haesun Jung
  • Eun-Hee Kim
  • In-Kyung Song
  • Hee-Soo Kim
  • Jin-Tae Kim
Reports of Original Investigations

Abstract

Background

Gastric insufflation is common during face mask ventilation and results in unfavourable respiratory events in children. The purpose of this study was to evaluate the effect of a muscle relaxant on gastric insufflation and determine the optimal inspiratory pressure during face mask ventilation in children.

Methods

Children aged one month to five years were randomly assigned to neuromuscular blocker (NM) or non-neuromuscular blocker (non-NM) groups. After administering intravenous anesthetics, face mask ventilation commenced via pressure-controlled mechanical ventilator. Initial inspiratory pressure was 10 cmH2O and was increased by 2 cmH2O until gastric insufflation was detected via gastric ultrasonography or epigastric auscultation. The primary outcome was the difference in the inspiratory pressure that causes gastric insufflation between the two groups. Diagnostic methods that detect gastric insufflation first were also evaluated.

Results

There was no significant difference in the median [interquartile range] inspiratory pressure inducing gastric insufflation between the non-NM (n = 52) and NM groups (n = 60) (18 [16-18] cmH2O vs 18.0 [16-20] cmH2O; median difference, 0 cmH2O; 95% confidence interval [CI], 0 to 2; P = 0.57). The incidence of gastric insufflation increased with increasing inspiratory pressure. Gastric insufflation was detected first by ultrasonography in 44% and by epigastric auscultation in 19% of the non-NM group (difference in percentage, 25%; 95% CI, 6 to 42; P = 0.006) and by ultrasonography in 73% and by epigastric auscultation in 7% of the NM group (difference in percentage, 66%; 95% CI, 50 to 78; P < 0.001).

Conclusions

A neuromuscular blocking agent has minimal effect on the inspiratory pressure that causes gastric insufflation during face mask ventilation in children.

Trial Registration

www.clinicaltrials.gov (NCT02471521); registered 15 June 2015.

Pression inspiratoire optimale pour ventilation au masque facial évitant l’insufflation gastrique chez des enfants paralysés et non paralysés: une étude randomisée sans insu

Résumé

Contexte

L’insufflation gastrique est fréquente au cours de la ventilation au masque et entraîne des événements respiratoires délétères chez les enfants. L’objectif de cette étude était d’évaluer l’effet d’un relaxant musculaire sur l’insufflation gastrique et de déterminer la pression inspiratoire optimale pendant la ventilation au masque des enfants.

Méthodes

Des enfants âgées d’un mois à cinq ans ont été affectés de manière aléatoire dans un groupe recevant un bloqueur neuromusculaire (groupe NM) ou dans un groupe n’en recevant pas (groupe non-NM). La ventilation au masque avec un ventilateur mécanique à contrôle de pression a commencé après l’administration intraveineuse des anesthésiques. La pression inspiratoire initiale était de 10 cmH2O et a été augmentée par incréments de 2 cmH2O jusqu’à ce qu’une insufflation gastrique soit détectée par échographie gastrique ou auscultation épigastrique. Le critère d’évaluation principal était la différence de pression inspiratoire entraînant une insufflation entre les deux groupes. Les méthodes diagnostiques de détection précoce de l’insufflation gastrique ont été également évaluées.

Résultats

Il n’y a pas eu de différence significative concernant la valeur médiane [écart interquartile] de la pression inspiratoire induisant une insufflation gastrique entre le groupe non-NM (n = 52) et le groupe NM (n = 60) (18 [16-18] cmH2O contre 18,0 [16-20] cmH2O; différence des médianes, 0 cmH2O; intervalle de confiance [IC] à 95 %: 0 à 2; P = 0,57). L’incidence de l’insufflation gastrique a augmenté avec l’augmentation de la pression inspiratoire. L’insufflation gastrique a d’abord été détectée par l’échographie dans 44 % des cas, et par auscultation épigastrique dans 19 % des cas dans le groupe non-NM (différence en pourcentage, 25 %; IC à 95 %, 6 à 42; P = 0,006) et par échographie dans 73 % et par auscultation épigastrique dans 7 % des cas dans le groupe NM (différence en pourcentage, 66 %; IC à 95 %, 50 à 78; P = 0,001).

Conclusions

Un agent bloqueur neuromusculaire n’a qu’un effet minime sur la pression inspiratoire entraînant une insufflation gastrique au cours de la ventilation au masque chez des enfants.

Enregistrement de l’essai clinique

www.clinicaltrials.gov (NCT02471521); enregistré le 15 juin 2015.

Notes

Conflict of interest

None declared.

Editorial responsibility

This submission was handled by Dr. Gregory L. Bryson, Deputy Editor-in-Chief, Canadian Journal of Anesthesia.

Author Contributions

Jin-Tae Kim and Ji-Hyun Lee contributed substantially to all aspects of this manuscript, including conception and design; acquisition, analysis, and interpretation of data; and drafting the article. Eun-Hee Kim contributed substantially to the conception and design of the manuscript. In-Kyung Song contributed substantially to the acquisition of data. Hee-Soo Kim contributed to the analysis of data. Haesun Jung contributed substantially to the interpretation of data.

Funding

Support was provided solely from institutional and/or department sources.

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Copyright information

© Canadian Anesthesiologists' Society 2018

Authors and Affiliations

  1. 1.Department of Anesthesiology and Pain MedicineSeoul National University Hospital, Seoul National University College of MedicineSeoulRepublic of Korea
  2. 2.Department of Anesthesiology and Pain Medicine, Asan Medical CenterUniversity of Ulsan College of MedicineSeoulRepublic of Korea

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