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Effects of an open lung extubation strategy compared with a conventional extubation strategy on postoperative pulmonary complications after general anesthesia: a single-centre pilot randomized controlled trial

Effets d’une stratégie d’extubation à poumon ouvert par rapport à une stratégie d’extubation conventionnelle sur les complications pulmonaires postopératoires après une anesthésie générale : une étude randomisée contrôlée pilote monocentrique

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Canadian Journal of Anesthesia/Journal canadien d'anesthésie Aims and scope Submit manuscript

Abstract

Purpose

Postoperative pulmonary complications (PPCs) are a common cause of morbidity. Postoperative atelectasis is thought to be a significant risk factor in their development. Recent imaging studies suggest that patients’ extubation may result in similar postoperative atelectasis regardless of the intraoperative mechanical ventilation strategy used. In this pilot trial, we hypothesized that a study investigating the effects of an open lung extubation strategy compared with a conventional one on PPCs would be feasible.

Methods

We conducted a pilot, single-centre, double-blinded randomized controlled trial. Adult patients at moderate to high risk of PPCs and scheduled for elective surgery were eligible. Patients were randomized to an open lung extubation strategy (semirecumbent position, fraction of inspired oxygen [FIO2] 50%, pressure support ventilation, unchanged positive end-expiratory pressure) or to a conventional extubation strategy (dorsal decubitus position, FIO2 100%, manual bag ventilation). The primary feasibility outcome was global protocol adherence while the primary exploratory efficacy outcome was PPCs.

Results

We randomized 35 patients to the conventional extubation group and 34 to the open lung extubation group. We observed a global protocol adherence of 96% (95% confidence interval, 88 to 99), which was not different between groups. Eight PPCs occurred (two in the conventional extubation group vs six in the open lung extubation group). Less postoperative supplemental oxygen and better lung aeration were observed in the open lung extubation group.

Conclusions

In this single-centre pilot trial, we observed excellent feasibility. A multicentre pilot trial comparing the effect of an open lung extubation strategy with that of a conventional extubation strategy on the occurrence of PPCs is feasible.

Study registration date

ClinicalTrials.gov (NCT04993001); registered 6 August 2021.

Résumé

Objectif

Les complications pulmonaires postopératoires (CPP) sont une cause fréquente de morbidité. L’atélectasie postopératoire est considérée comme un facteur de risque important de CPP. Des études d’imagerie récentes suggèrent que l’extubation des patient·es peut entraîner une atélectasie postopératoire semblable, quelle que soit la stratégie de ventilation mécanique peropératoire utilisée. Dans cet essai pilote, nous avons émis l’hypothèse qu’une étude examinant les effets sur les CPP d’une stratégie d’extubation à poumon ouvert par rapport à une stratégie d’extubation conventionnelle serait réalisable.

Méthode

Nous avons mené une étude randomisée contrôlée pilote, monocentrique et à double insu. Les patient·es adultes présentant un risque modéré à élevé de CPP et devant bénéficier d’une chirurgie non urgente étaient éligibles. Les patient·es ont été randomisé·es à une prise en charge par une stratégie d’extubation à poumon ouvert (position semi-couchée, fraction d’oxygène inspiré [FIO2] 50 %, ventilation par aide inspiratoire, pression positive télé-expiratoire inchangée) ou à une stratégie d’extubation conventionnelle (décubitus dorsal, FIO2 100 %, ventilation manuelle par masque). Le principal critère de faisabilité était l’adhésion au protocole global, tandis que les CPP constituaient le principal critère d’efficacité exploratoire.

Résultats

Nous avons randomisé 35 patient·es dans le groupe d’extubation conventionnelle et 34 dans le groupe d’extubation à poumon ouvert. Nous avons observé une adhésion globale au protocole de 96 % (intervalle de confiance à 95 %, 88 à 99), qui n’était pas différente entre les groupes. Huit CPP sont survenues (deux dans le groupe d’extubation conventionnelle vs six dans le groupe d’extubation à poumon ouvert). Nous avons observé des besoins moins importants en oxygène supplémentaire postopératoire et une meilleure aération pulmonaire dans le groupe extubé à poumon ouvert.

Conclusion

Dans cet essai pilote monocentrique, nous avons observé une excellente faisabilité. Une étude pilote multicentrique comparant l’effet d’une stratégie d’extubation à poumon ouvert à celui d’une stratégie d’extubation conventionnelle sur la survenue de CPP est réalisable.

Date d’enregistrement de l’étude

ClinicalTrials.gov (NCT04993001); enregistrée le 6 août 2021.

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Author contributions

Julie Girard contributed to data collection and revising the final draft of the paper. Cédrick Zaouter and Alex Moore contributed to study design, data collection, and revising the final draft of the paper. François M. Carrier contributed to study design, data analysis, and revising the final draft of the paper. Martin Girard contributed to study design, data collection, data analysis, writing the first draft of the paper, and revising the final draft of the paper.

Acknowledgements

The authors thank Monique Ruel, RN, Julie Desroches, PhD, and Vicky Thiffault, RN, for their valuable assistance and dedication.

Disclosures

Martin Girard is a paid consultant for the point-of-care ultrasonography group of GE Healthcare. The other authors declare no competing interests.

Funding statement

This study was supported by a 2021 research operating grant from the Fonds de développement du Département d’anesthésiologie et de médecine de la douleur de l’Université de Montréal. Dr. Carrier is a recipient of a Career Award from the Fonds de la Recherche du Québec – Santé.

Prior conference presentations

Preliminary results of this study were presented at the Société Française d’Anesthésie et de Réanimation’s annual congress in September 2022 (Paris, France).

Editorial responsibility

This submission was handled by Dr. Philip M. Jones, Deputy Editor-in-Chief, Canadian Journal of Anesthesia/Journal canadien d’anesthésie.

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Authors and Affiliations

  1. Department of Anesthesiology, Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada

    Julie Girard MD, Cédrick Zaouter MD, MSc, Alex Moore MD, François M. Carrier MD, MSc & Martin Girard MD, MSc

  2. Department of Anesthesiology and Pain Medicine, Université de Montréal, Montreal, QC, Canada

    Julie Girard MD, Cédrick Zaouter MD, MSc, Alex Moore MD, François M. Carrier MD, MSc & Martin Girard MD, MSc

  3. Centre de Recherche du Centre hospitalier de l’Université de Montréal, Montreal, QC, Canada

    François M. Carrier MD, MSc & Martin Girard MD, MSc

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Correspondence to Martin Girard MD, MSc.

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Girard, J., Zaouter, C., Moore, A. et al. Effects of an open lung extubation strategy compared with a conventional extubation strategy on postoperative pulmonary complications after general anesthesia: a single-centre pilot randomized controlled trial. Can J Anesth/J Can Anesth 70, 1648–1659 (2023). https://doi.org/10.1007/s12630-023-02533-z

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