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Importance: An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain., Objective: To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP., Design, Setting, and Participants: Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018., Interventions: Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H2O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H2O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight., Main Outcomes and Measures: The primary outcome was a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with Spo2 ≤92% for >1 minute)., Results: Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, -2.3% [95% CI, -5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P = .23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, -8.6% [95% CI, -11.1% to 6.1%]; P < .001)., Conclusions and Relevance: Among obese patients undergoing surgery under general anesthesia, an intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers, compared with a strategy with a lower level of PEEP, did not reduce postoperative pulmonary complications., Trial Registration: ClinicalTrials.gov Identifier: NCT02148692.

Atelectasis and pneumonia are common postoperative complications occurred in patients undergoing general thoracic surgery. Strategies to reduce the risk of postoperative pulmonary complications including these 2 disorders consist of smoking cessation, optimization of underlying chronic obstructive pulmonary disease( COPD), adequate pain control, intensive oral care, and so on. Preoperative treatments for patients with COPD are the same as those for COPD patients being not about to have surgery, which mainly consist of long-acting bronchodilators and pulmonary rehabilitation. Postoperative atelectasis can be treated with airway clearance techniques including postural drainage and coughing, and bronchial suctioning using bronchoscopy or tracheal catheter inserted through cricothyroid ligament as needed. Treatment for postoperative pneumonia starts with microbiologic studies on respiratory samples followed by assessment of existence or non-existence of sepsis, severity of the disease using I-ROAD (immunodeficiency, respiration, orientation, age, dehydration) prognostic guidelines, and risk factors for multidrug-resistance pathogens. Then, adequate selection of antibiotics and escalation or de-escalation principle is required according to the new guidelines recently published by the Japanese Respiratory Society.

Objective: To verify the effectiveness of noninvasive ventilation compared to conventional physiotherapy or oxygen therapy in the mortality rate and prevention of pulmonary complications in patients during the immediate postoperative period of cardiac surgery., Methods: Systematic review and meta-analysis recorded in the International Prospective Register of Ongoing Systematic Reviews (number CRD42016036441). The research included the following databases: MEDLINE, Cochrane Central, PEDro, LILACS and manual search of the references of studies published until March 2016. The review included randomized controlled trials with patients during the immediate postoperative period of cardiac surgery, which compared the use of noninvasive ventilation, BiLevel modes, continuous positive airway pressure, intermittent positive pressure breathing and positive pressure ventilation with conventional physiotherapy or oxygen therapy, and assessed the mortality rate, occurrence of pulmonary complications (atelectasis, pneumonia, acute respiratory failure, hypoxemia), reintubation rate, ventilation time, time spent in the intensive care unit (ICU), length of hospital stay and partial pressure of oxygen., Results: Among the 479 selected articles, ten were included in the systematic review (n=1050 patients) and six in the meta-analysis. The use of noninvasive ventilation did not significantly reduce the risk for atelectasis (RR: 0.60; CI95% 0.28-1.28); pneumonia (RR: 0.20; CI95% 0.04-1.16), reintubation rate (RR: 0.51; CI95%: 0.15-1.66), and time spent in the ICU (-0.04 days; CI95%: -0.13; 0.05)., Conclusion: Prophylactic noninvasive ventilation did not significantly reduce the occurrence of pulmonary complications such as atelectasis, pneumonia, reintubation rate and time spent in the ICU. The use is still unproven and new randomized controlled trials should be carried out.

Background: Atelectasis after cardiopulmonary bypass (CPB) can affect right ventricular (RV) performance by increasing its outflow impedance., Objective: The aim of this study was to determine whether a lung recruitment manoeuvre improves RV function by re-aerating the lung after CPB., Design: Randomised controlled study., Setting: Single-institution study, community hospital, Córdoba, Argentina., Patients: Forty anaesthetised patients with New York Heart Association class I or II, preoperative left ventricular ejection fraction at least 50% and Euroscore 6 or less scheduled for cardiac surgery with CPB., Interventions: Patients were assigned to receive either standard ventilation with 6 cmH2O of positive end-expiratory pressure (PEEP; group C, n = 20) or standard ventilation with a recruitment manoeuvre and 10 cmH2O of PEEP after surgery (group RM, n = 20). RV function, left ventricular cardiac index (CI) and lung aeration were assessed by transoesophageal echocardiography (TOE) before, at the end of surgery and 30 min after surgery., Main Outcome Measures: RV function parameters and atelectasis assessed by TOE., Results: Haemodynamic data and atelectasis were similar between groups before surgery. At the end of surgery, CI had decreased from 2.9 ± 1.1 to 2.6 ± 0.9 l min m in group C (P = 0.24) and from 2.8 ± 1.0 to 2.6 ± 0.8 l min m in group RM (P = 0.32). TOE-derived RV function parameters confirmed a mild decrease in RV performance in 95% of patients, without significant differences between groups (multivariate Hotelling t-test P = 0.16). Atelectasis was present in 18 patients in group C and 19 patients in group RM (P = 0.88). After surgery, CI decreased further from 2.6 to 2.4 l min m in group C (P = 0.17) but increased from 2.6 to 3.7 l min m in group RM (P < 0.001). TOE-derived RV function parameters improved only in group RM (Hotelling t-test P < 0.001). Atelectasis was present in 100% of patients in group C but only in 10% of those in group RM (P < 0.001)., Conclusion: Atelectasis after CPB impairs RV function but this can be resolved by lung recruitment using 10 cmH2O of PEEP., Trial Registration: Protocol started on October 2014.

Background and Purpose: This case report describes the physiotherapy assessments and interventions provided to a 56-year-old male in an Australian intensive care unit. The non-intubated patient suffered from respiratory deterioration, secretion retention, complete opacification of the left hemithorax on chest X-ray (CXR) and widespread coarse crackles on lung auscultation. The addition of lung ultrasound (LUS) facilitated more accurate diagnosis than what was formed on the basis of CXR and lung auscultation resulting in more effective treatment., Methods: The method used is a case report. Written consent was obtained from the patient for these data to be published., Summary: Secretion retention was initially suspected (based on clinical examination and CXR) and treated with airway clearance techniques, patient positioning and nasopharyngeal suction. Even though this assisted with secretion removal, the patient continued to have a high perceived work of breathing and increasing oxygen requirements. Physiotherapist performed LUS, under supervision, and revealed a large pleural effusion (1500 mL), which was then drained by the medical team., Discussion: The addition of LUS to the critical care physiotherapist's assessment skills may provide clinical benefit. The increased diagnostic accuracy of LUS compared with other routine assessments warrants further investigation.

Objective: To assess the effect of early use of continuous positive airway pressure (CPAP) therapy to treat or prevent acute atelectasis in post-operative cardiac patients particularly smokers and elderly patients., Methods: A pilot study suggested enrolling at least 32 participants in each group to be significant. One hundred and eight patients from King Fahd Armed Forces Hospital, Jeddah, Kingdom of Saudi Arabia who met the inclusion criteria participated in this study conducted between March 2010 and March 2011. The participants were divided randomly into 3 groups, incentive spirometry (IS) therapy, and CPAP therapy every 2 (CPAP 2 hrs), or 4 hours (CPAP 4 hrs). Inspiratory capacity (IC) was used to compare the 3 therapy regimes. Simultaneously, respiratory rate (RR), heart rate (HR) and oxygen saturation (SpO2) were measured for all groups. Failure was defined as requiring intubation, bi-level positive airway pressure, or added chest physiotherapy., Results: Thirty-six patients participated in each group (98 male and 10 female, with a mean age of 62+/-9.3 years). The IC increased significantly in the CPAP 2 hrs group when compared with the control group or the CPAP 4hrs group. The SpO2 decreased significantly in the control group and the CPAP 4 hrs groups when compared with the CPAP 2 hrs group. Also, there were no significant differences in RR and HR between all groups., Conclusion: Early use of CPAP via mask therapy for half an hour every 2 hours had better outcomes to re-open collapsed alveoli after cardiac surgery.

Background: Postoperative hypoxemia is a common complication in the anesthesia recovery room (ARR), which is predominantly based on the development of atelectasis, excessive intraoperative fluid shift and insufficient ventilation. The goal of this prospective observational study was to compare the effect of standard oxygen administration via a face mask with oxygen administration using the EzPAP® system, a device which additionally provides a positive end-expiratory pressure (PEEP)., Methods: This study included 210 patients with postoperative hypoxemia (S(p)O(2) < 93%) subdivided into the control group (105 patients) and the EzPAP group (105 patients). Postoperative residual paralysis was excluded using relaxometry and a train of four (TOF) ratio of 0.9 was assumed to ensure sufficient recovery of respiratory function from neuromuscular blockade. Patients who received a reversal of neuromuscular blockade were excluded. In cases of hypoxemia (S(p)O(2) < 93%) control patients were treated with oxygen (6 l/min) using a face mask, whereas the EzPAP group received oxygen using the EzPAP® system. In order to adjust the PEEP in the EzPAP group, the O(2) flow was verified and measured by a manometer. After 1 h of oxygen therapy, the oxygen supply was stopped. In cases of reoccurring hypoxemia (S(p)O(2) < 93%, persistence > 5 min), the oxygen therapy was restarted in both groups via a facemask. Both groups were compared using repeat measurement analysis of variance (ANOVA), the unpaired t-test, the Mann-Whitney U-test, Fisher's exact test and the χ(2)-test. The correlation of O(2) flow and PEEP was evaluated by regression analysis and p < 0.05 was considered to be statistically significant. Apart from this a subgroup analysis was performed depending on body-mass index (BMI), American Society of Anesthesiologists (ASA) classification, intraoperative airway management, the use of neuromuscular blocking agents and co-existing disorders, e.g. chronic obstructive lung disease (COLD), obesity and chronic heart failure., Results: All patients were equally distributed between both groups with respect to demographic data, ASA classification, BMI, co-existing disorders and surgical procedures. The S(p)O(2) values did not differ between the EzPAP patients and the control group, except for 0.5 min after initiation of oxygen therapy: EzPAP group 96 ± 3.7% (mean ± standard deviation) versus the control group 93.8 ± 4.4% (p < 0.001). However, restarting oxygen therapy was less common in the EzPAP group (EzPAP group 25 versus control group 41, p = 0.03), as well as the occurrence of postoperative complications (EzPAP group 13 versus control group 25, p = 0.02), e.g. nosocomial pneumonia (0 versus 4) and wound infections (2 versus 3). Furthermore, patients with obesity and pulmonary disorders, such as COLD had a benefit from oxygen administration using the EzPAP device and showed higher postoperative than preoperative S(p)O(2) values. In contrast, the subgroup analysis of patients with heart failure did not reveal any differences between both groups and both groups did not differ in terms of time spent in the recovery room (EzPAP group 113 min versus control group 174.8 min, p = 0.2)., Conclusions: In this observational study oxygen supply using the EzPAP® system appeared to be at least equally as effective in the therapy of postoperative hypoxemia compared to standard oxygen supply using a face mask. In patients with a high risk of postoperative hypoxemia, such as patients with obesity and/or pulmonary disorders, oxygen administration using the EzPAP® system possibly improves pulmonary oxygenation more effectively and is longer lasting compared to standard oxygen supply via a face mask. Hence, the EzPAP® system represents a well-tolerated, effective, cost-effective and easily operated tool to improve postoperative oxygenation. In order to investigate the possibilities of this promising tool more intensively, randomized clinical trials are warranted.

Objective: This case report describes an unusual presentation of right upper lobe atelectasis associated with refractory hypoxemia to conventional alveolar recruitment maneuvers in a patient soon after coronary artery bypass grafting surgery., Method: Case-report., Results: The alveolar recruitment with PEEP = 40 cm H2O improved the patient's atelectasis and hypoxemia., Conclusion: In the present report, the unusual alveolar recruitment maneuver with PEEP 40 cm H2O showed to be safe and efficient to reverse refractory hypoxemia and uncommon atelectasis in a patient after cardiac surgery.

Reexpansion of a pulmonary atelectasis is often difficult, even after removing possible causes of bronchial obstruction. Chest ultrasounds, inexpensive and readily available at the patient bedside, may offer valuable support to guide recruitment maneuvers. We report the case of a 57-year-old woman that developed a complete collapse of the left lung seven days after undergoing an intestinal resection for perforation. A mucous plug occluding the main bronchus was removed with bronchoscopy, but persistent hypoxemia required mechanical ventilation; 24 hours later, an attempt to wean the patient from the ventilator failed. Chest X-rays revealed the persistence of a partial collapse of the left inferior lobe associated with a pleural effusion. A chest ultrasound confirmed the presence of a lung consolidation and of a modest pleural effusion. Manual reexpansion was then attempted, and ventilatory pressures as well as the duration of forced inspirations were based on real-time ultrasound images. Complete reexpansion was achieved within a few minutes and confirmed by chest X-ray. The patient was weaned from mechanical ventilation on the same day and discharged from ICU three days later.

Objective: To investigate the effect of bronchial intubation for constant-pressure expanding ipsilateral lung on postoperative intractable atelectasis., Methods: For this prospective study, we recruited 18 patients with pulmonary atelectasis who could not been relieved by bronchoscopic suctioning, closed thoracic drainage, backslap, blowing hall and other routine treatments for over a week. After bronchial intubation, ipsilateral lung was expanded with a constant pressure. And the therapeutic effect was evaluated by chest radiographic examination and auscultation at the following day., Results: Collapsed lung tissue were examined in 15 patients (83.3%) after the first treatment and in 2 patients (11.1%) after twice inflation. And another case failed even after three times treatment. During the procedure, the vital signs of all patients were stable and no complication occurred., Conclusion: Constant-pressure expanding of ipsilateral lung during bronchial intubation is a safe and effective treatment for postoperative intractable atelectasis.

We report the case of an unexpected respiratory complication after a surgical treatment of scoliosis during postoperative period in an adolescent patient. This complication results of a vascular compression of the left main bronchus between the aorta and the pulmonary artery, which induces severe atelectasis of left lower lobe. Prolonged non-invasive ventilation with high level of positive end-expiratory pressure prevents aorto-pulmonary compression, allows a pulmonary recruitment associated with a favorable prognostic for the adolescent., (Copyright © 2010. Published by Elsevier SAS.)

Respiratory complications are a significant cause of post-operative morbidity and mortality. Peri-operative atelectasis, in particular, affects 90% of surgical patients and its effects can be prolonged, due to changes in respiratory mechanics, pulmonary circulation and hypoxaemia. Alveolar collapse is caused by certain predisposing factors, mainly by compression and absorption mechanisms. To prevent or treat these atelectasis several therapeutic strategies have been proposed, such as alveolar recruitment manoeuvres, which has become popular in the last few years. Its application in patients with alveolar collapse, but without a previous significant acute lung lesion, has some special features, therefore its use is not free of uncertainties and complications. This review describes the frequency, pathophysiology, importance and treatment of peri-operative atelectasis. Special attention is paid to treatment with recruitment manoeuvres, with the purpose of providing a basis for the their rational and appropriate use., (2009 SEPAR. Published by Elsevier Espana. All rights reserved.)

Background: Even several days after surgery, obese patients exhibit a measureable amount of atelectasis and thus are predisposed to postoperative pulmonary complications. Particularly in ambulatory surgery, rapid recovery of pulmonary function is desired to ensure early discharge of the obese patient. In this study, we wanted to evaluate intensive short-term respiratory physical therapy treatment (incentive spirometry) in the postanesthesia care unit (PACU) and its impact on pulmonary function in the obese., Methods: After ethics committee approval and informed consent, we prospectively studied 60 obese patients (BMI 30-40) undergoing minor peripheral surgery, half of which were randomly assigned to receive respiratory physiotherapy during their PACU stay, while the others received routine treatment. Premedication, general anesthesia, and respiratory settings were standardized. We measured arterial oxygen saturation by pulse oximetry on air breathing. Inspiratory and expiratory lung functions were measured preoperatively (baseline) and at 10 min, 1, 2, 6, and 24 h after extubation, with the patient supine, in a 30 degrees head-up position. The two groups were compared using repeated-measure analysis of variance and t test analysis. Statistical significance was considered to be P < 0.05., Results: There were no differences at the first assessment, but, during the PACU stay, pulmonary function in the physiotherapy group was significantly better than the controls' (p < 0.0001), an effect which persisted for at least 24 h after surgery (p < 0.009)., Conclusion: Short-term respiratory physiotherapy during the PACU stay promotes more rapid recovery of postoperative lung function in the obese during the first 24 h.

Complications are quite common in thoracic surgery due to the comorbidities of the mostly elderly patients and to the fact that the surgical procedure itself compromises the respiratory apparatus. Consequently, pneumonia and respiratory failure represent the most common causes of death. Postoperatively, early diagnosis and treatment of these complications are paramount while most other events can be anticipated and thus be avoided with corresponding operative experience.

Perioperative hypoxaemia is a common but serious problem with well recognised causes. However, an anomalous bronchus causing lobar collapse as a cause is seldom mentioned. A healthy young male patient was anaesthetised for a knee operation. He required re-intubation immediately postoperatively for hypoxia. He was found to have right upper lobe collapse. Fibreoptic examination of the trachea demonstrated an anomalous bronchus as the cause. Intra-operatively, the endotracheal tube had been inserted too deeply and the bronchial orifice had been obstructed by the tip. It took several hours for the lung to re-expand. Greater awareness of this potential complication is needed.

Pulmonary complications are an important cause of the mortality associated with liver transplantation. The efficacy of noninvasive ventilation (NIV) in pediatric patients following transplantation is unknown. The purpose of this retrospective study is to investigate the effects of NIV for pediatric patients undergoing liver transplantation. Of 102 pediatric patients who underwent liver transplantation, 15 patients (aged 73 months; range 2.5-179) were supported by NIV because of atelectasis, hypercapnia, hypoxemia, pneumonia, massive effusion, or postextubation ventilatory support. Of 15 patients, 5 were under the age of 1 year (range 2.5-12 months). Of the 15 patients, 7 had required multiple intubations before NIV treatment because of pulmonary complications. NIV treatment was administered to 6 patients because of hypercapnia. Partial pressure of arterial carbon dioxide (PaCO(2)) levels improved from 56.9 (95% confidence interval [CI]: 48.4-65.4) to 41.5 (95% CI: 36.8-46.2) mmHg (P = .028) within 2 days. NIV treatment was very effective for patients with atelectasis with and without other pulmonary complications. Mean inspiratory positive pressure (IPAP) was 7.2 (95% CI: 6.0-8.3) cm H(2)O and expiratory positive pressure (EPAP) was 3.5 (95% CI: 3.2-3.9) cm of H(2)O. Mean duration of NIV was 18.5 (95% CI: 8.6-28.4) days. IPAP and EPAP levels were closely and significantly correlated with height (IPAP: r = .65, P = .016; EPAP: r = .77, P = .004). A total of 13 patients recovered and 2 patients died. However, no patient died of respiratory complications. In conclusion, NIV is effective in pediatric patients undergoing liver transplantation with subsequent pulmonary complications. The IPAP and EPAP levels may be predicted by the height of the patient.

Atelectasis is common after cardiac surgery and may result in impaired gas exchange. Continuous positive airway pressure (CPAP) is often used to prevent or treat postoperative atelectasis. We hypothesized that noninvasive pressure support ventilation (NIPSV) by increasing tidal volume could improve the evolution of atelectasis more than CPAP. One-hundred-fifty patients admitted to our surgical intensive care unit (SICU) with a Radiological Atelectasis Score >or=2 after cardiac surgery were randomly assigned to receive either CPAP or NIPSV four times a day for 30 min. Positive end-expiratory pressure was set at 5 cm H(2)O in both groups. In the NIPSV group, pressure support was set to provide a tidal volume of 8-10 mL/kg. At SICU discharge, we observed an improvement of the Radiological Atelectasis Score in 60% of the patients with NIPSV versus 40% of those receiving CPAP (P = 0.02). There was no difference in oxygenation (Pao(2)/fraction of inspired oxygen at SICU discharge: 280 +/- 38 in the CPAP group versus 301 +/- 40 in the NIPSV group), pulmonary function tests, or length of stay. Minor complications, such as gastric distensions, were similar in the two groups. NIPSV was superior to CPAP regarding the improvement of atelectasis based on radiological score but did not confer any additional clinical benefit, raising the question of its usefulness for altering outcome.

Two patients developed postoperative pulmonary atelectasis after receving laparoscopic nephrectomy in the lateral kidney position. In both patients, the trachea was intubated with a single lumen tube and the lateral kidney position was kept over 9 hours. Because the pulmonary atelectasis had developed on the lower side of the lungs, we considered it as the gravity dependent atelectasis (GDA). We have also described treatments and prophylaxis for GDA in this case report.

Objective: To identify the causes of respiratory complications following liver transplantation (LT) and to discuss the management of these complications., Methods: One hundred and twenty four cases with pulmonary complications in the first two weeks after LT were identified among 163 patients admitted to the First Affiliated Hospital, College of Medicine, Zhejiang University from February, 1999 to March, 2003., Results: The incidence rate of complications was 76%(124/163) with the total cure rate of 92%(114/124). The cure rates of the various complications were as follows: pleural effusion 100%(113/113), pneumonia 92%(76/83), respiratory insufficiency 91%(59/65), pulmonary hypertension 98%(101/103), pulmonary edema 98(58/59), atelectasis 100%(4/4) and pneumothorax 100%(2/2)., Conclusion: To drainage the pleural effusion with an unicameral venous catheter is safety and effective. To cure or prevent pneumonia and atelectasis, aseptic manipulating, aspiration of sputum and keeping respiratory channel open were the key measurements of treatment. Restrictive ventilatory functional disturbance (RVFD) and dysfunction of ventilation are two major types of respiratory insufficiency in early stage of post-transplantation. The causes of pulmonary hypertension and edema are associated with pulmonary angiotasis and blood flow volume, and the vasodilator and diuretic often introduced in the therapy.

Purpose of this paper is to evaluate the risk of ateletasis in patients that underwent surgery of the abdomen (cesarean section), since the reflex of cough in these patients is notably altered for the limitation of the diaphragmatic excursions, due to analgesic contracture. The inhibition of cough's reflex causes retention of secretions with consequent bronchial obstruction and atelectasis. Personal experience in 6 cases of atelectasis following cesarean section is reported.

A 7-year-old girl presented to the pediatric intensive care unit following a craniotomy that left her with dysphagia, poor cough, and problems with retained secretions. Pulmonary function and blood oxygen saturation worsened for 3 days after surgery. Noninvasive positive-pressure ventilation and increased fraction of inspired oxygen improved oxygenation. Glycopyrrolate was administered to decrease secretions but had little effect. The first chest radiograph showed left lung hyperinflation. The right lung showed loss of volume and elevation of the right hemidiaphragm. There was no mediastinal shift. Another chest radiograph 3 hours later showed substantial improvement. We discuss the causes of acute lung volume asymmetry and possible interpretations of the radiographs.

Severe pulmonary oxygenation impairment resulting from peripheral lung atelectasis occurred in some patients with pleurotomy during the harvest of the internal mammary artery graft followed by coronary artery bypass grafting (CABG). We studied the efficacy of intraoperative positive end-expiratory airway pressure (PEEP) therapy for the prevention of postoperative pulmonary oxygenation impairment. A total of 66 patients with solitary CABG procedure were included in this study. The pleural cavity was intraoperatively opened in 44 patients and not opened in 22. PEEP therapy was not used in any patient before May 1996 (referred to herein as the former period) and was used more recently in eight patients with pleurotopmy (referred to herein as the latter period). PEEP was initiated immediately after pleurotomy during the harvest of the internal mammary artery graft. Without PEEP therapy, values of PaO2, A-aDO2, and respiratory index (RI) were worse in patients with pleurotomy than in those without pleurotomy. Meanwhile, there were no major differences in these values between patients with or without pleurotomy after the induction of PEEP therapy. Respiratory insufficiency (A-aDO2 > 400 mmHg and RI > 1.5) was detected in six patients with pleurotomy in the former period. Three of these six patients required over 1 week of long-term mechanical respiratory support. No respiratory insufficiency occurred in patients of the latter period. In conclusion, PEEP therapy, which is initiated just after pleurotomy, may prevent oxygen impairment and pulmonary atelectasis after extracorporeal circulation (ECC) and is recommended for patients with pleurotomy, especially for patients with preoperative low respiratory function.

Postoperative atelectasis is a common problem following any surgery. Limited atelectasis is usually well-tolerated and easily reversible. However, complete atelectasis of the remaining lung following partial lung resection may be poorly tolerated. Thoracic surgical procedures increase the risk because pain, thoracic muscle injury, chest wall instability, and diaphragmatic dysfunction impair clearance of secretions by cough. In addition, patients with lung diseases are prone to increased bronchial secretions. Prophylaxis includes preoperative and postoperative physiotherapy and medications, which should be graded in accordance to the individual patient's risk factors. Large atelectasis requires bronchoscopy to remove mucous plugs. Tracheostomy should be considered in patients with relapsing atelectasis or swallow disorders.

Ipsilateral bronchial intubation was used for reexpansion of unilateral pulmonary atelectasis in a newborn, who developed postoperative right atelectasis following extrapleural repair of tracheoesophageal fistula.

Background and Purpose: The purpose of this study was to determine whether the addition of incentive spirometry (IS) to postoperative pulmonary physical therapy is more effective than physical therapy alone in reducing postoperative pulmonary complications in high-risk patients after coronary artery bypass grafting (CABG). Patients were given the spirometer and instructed in its use, as often occurs in clinical settings., Subjects: Patients with chronic airflow limitation following CABG (N = 185) participated., Methods: Subjects were randomly assigned to receive either postoperative pulmonary physical therapy (breathing exercises, secretion removal, mobility) or physical therapy combined with IS., Results: No difference was found between the two groups in atelectasis, spirometry, oxygen saturation, pulmonary infection, or hospital stay., Conclusion and Discussion: Incentive spirometry combined with physical therapy is no more effective than postoperative physical therapy alone in reducing atelectasis for this population. Use of the spirometer, however, was not monitored, and although the study mimicked practice as it often occurs, the effectiveness of the spirometer cannot be fully evaluated.

Complications have occurred in 30 (9.4%) of 318 patients, operated on for benign pulmonary tumor. In 5 patients rethoracotomy was conducted for haemothorax within 1-2 days, not influencing the duration of treatment. All the patients are alive.

Postoperative pulmonary complications, specifically atelectasis and pneumonia, are the leading cause of postoperative morbidity and death. It is crucial that the clinician have a thorough understanding of the pathophysiology, risk factors, and scientific basis for currently used respiratory interventions to tailor the patient's care in the preoperative, intraoperative, and postoperative settings. Given the changing healthcare environment and increasing economic constraints, all respiratory interventions must be reevaluated for use in patient care, keeping in mind the factors of scientific basis, patient needs, appropriate utilization, and quality patient outcomes.

The perioperative respiratory care of the cardiac surgical patient can present many challenges to the caring physician that he or she may not see among the usual patient population. Knowledge of the effects of the heart-lung machine on pulmonary performance, awareness of the anatomic changes brought on by the surgeon, and consideration of the patient's baseline cardiac and pulmonary function need to be addressed so that the pulmonary problems that they present can be managed optimally.

This report gives the results of a cost-efficiency analysis of a prospective longitudinal study evaluating two forms of prophylaxis against postoperative pulmonary complications in 876 patients undergoing abdominal surgery. It cost $12.19 per patient for conventional chest physiotherapy, and equivalent costs accrue when incentive spirometers are recycled and used on average 2.3 times (in the Royal Perth Hospital, incentive spirometers are recycled an average of 4.7 times). Maximum cost-containment can be achieved by carefully selecting patients for physical chest care and then instigating a programme of perioperative chest care utilizing recycled incentive spirometers. This approach does not compromise the clinical benefits of prophylactic chest care and allows physiotherapy resources to be directed toward patients with established pulmonary problems.

Although treatment of refractory atelectasis has been improved by pulmonary insufflation through FOB with balloon cuff, low pulmonary compliance and high critical opening pressure of alveoli in the atelectatic areas require a more selective approach to prevent pressure dispersion to highly compliant zones. To achieve the highest insufflation selectivity and reduce patient discomfort, we have devised a small caliber balloon-tipped catheter to easily reach even the minor branches of the bronchial tree. This result was obtained by utilizing the performed curve of the catheter distal end after withdrawing the internal stylet. The catheter was introduced through the nostrils (16 patients) or through an endotracheal tube (two patients) and advanced under fluoroscopic guidance. Reexpansion of atelectatic areas was accomplished by repeated air injections through a 60-ml syringe. No complications were observed. Complete disappearance of x-ray film evidence of atelectasis was obtained in 15 patients and partial reexpansion in 3 patients.

Study of 219 tuberculosis patients who underwent segmental resections showed that the rate of atelectasis development constituted 16.4%. In the right-sided operations atelectases developed 3 times more frequently than those in the left-sided ones (27.5 and 7.5%, respectively) and were mainly segmental (atelectasis of the anterior segment after excision of the ++apico-posterior segment), while in the left-sided intervention they were total in the majority of patients. The character of atelectasis in the right- and left-sided operations was determined by specific features of bronchial structure of the right and left lungs. As a result of therapeutic measures all total atelectases were relieved within 3-5 days, while segmental atelectases persisted for a long time; in 6 patients they still remained by the time of discharge.

Six cases of atelectasis developing in the unopened contralateral lung immediately after thoracotomy in the lateral position were presented, and its cause and treatment were discussed. Atelectasis due to retention of secretion showed various atelectatic X-ray shadows which differed in size by the segment or lobe unit. On the other hand, cases of atelectasis whose occurrence was surmised to be related to the lateral position and anesthesia showed mainly infiltrative shadows which extended from the outer region of the middle-lower lung field to the basal segments of the lung, although some cases were accompanied by atelectatic shadows of various size in terms of the segment or lobe unit. Therefore in order to prevent atelectasis, it is desirable to move sputum by aspiration and appropriately apply ventilation, intermittent pressurization and PEEP, while paying careful attention to the unopened lung. In the treatment of atelectasis, selective endobronchial pressurization using a bronchofiberscope equipped with a cuff was effective. It was also very effective to place an endotracheal tube for ordinary anesthesia near the target bronchus with the aid of a bronchofiberscope and perform selective endobronchial pressurization via that tube.

The results of a retrospective study on the management of respiratory infection after open heart surgery in 370 consecutive cases are presented in this paper. The incidence of postoperative respiratory infection was 3.8% (14 cases). There was atelectasis of the lung in 3, pneumonia in 6 and acute suppurative bronchitis in 5 cases. Among the 6 patients with postoperative pneumonia, one died of sepsis and another died of consolidation of the lung. The remaining 12 attained uneventful recovery after reasonable treatment with antibiotics, expectorant, oxygen therapy, inhalation therapy, bronchial lavage and aspiration. The prevention measures of postoperative respiratory infection are also discussed.

Pulmonary oxygen transfer, defined by PaO2/FIO2, and radiologic presence of atelectasis were measured pre-, intra-, and postoperatively to postoperative day 9 in elective cardiac aortocoronary bypass surgical patients, who were randomly allocated either to receive 18 h PEEP while on the ventilator followed by 12 h of nasal continuous positive airway pressure (nasal CPAP) or to be control subjects. The two groups were comparable in age, sex, forced expiratory volume in 1 sec (FEV1), the ratio of FEV1 over forced vital capacity (FVC), time on pump, units of blood transfused, New York Heart Association grading, and cardiac performance indices. The PaO2/FIO2 was significantly (p less than .05) better from half an hour after extubation until 24 h postextubation in the nasal CPAP group, but was decreased for the remainder of the study in both groups. Incidence of atelectasis/consolidation was not different in both groups during the study period. We conclude that nasal CPAP is well tolerated as a treatment of hypoxemia in the immediate postoperative period of aortocoronary bypass patients. CPAP does not change the course of postoperative atelectasis.

We report on a fourteen year old patient with pulmonary atelectasis following scoliosis treatment using Harrington's instrumentation. Changes in dynamic pulmonary function tests (FVK, FEV1, MF, MBC) and arterial blood gases are documented, therapy and etiology are discussed.

The Authors consider the high number of patients who are affected with chronic obstructive bronchitis due to various factors (cigarettes smoking, infections, pollution, reduced immune response). These patients, when submitted to middle-high abdominal surgery in total anaesthesia of middle-long duration, are at increased risk due to pulmonary complications. Therefore, an adequate respiratory protection is necessary; actually it is possible with high dose of Ambroxol (1 g). Two groups, both of 35 patients, were compared; the first group was treated with Ambroxol 1 g the second one with aminophilline, bromexine, B2 adrenergic agonists, corticosteroids. The results show the efficacy of respiratory protection by using Ambroxol 1g.

A national survey of hospitals was conducted to evaluate the usage of lung expansion maneuvers in the prevention and management of postoperative atelectasis associated with abdominal and thoracic surgery. Equal numbers of hospitals were randomly selected from the nine American Hospital Association regions and from bed-size groups of 50 to 200 beds, 201 to 400 beds, and greater than 400 beds. Preoperative and postoperative prophylactic therapy was found to be similar in all groups except for a lower usage of intermittent positive-pressure breathing (IPPB) in the western third of the United States compared with the central third. In the treatment of postoperative atelectasis there are significant differences in the use of chest physical therapy, IPPB, and intermittent continuous positive airway pressure based on hospital size. Objective measurements of tidal volume or inspiratory capacity as a guide to therapeutic decisions are performed more frequently in the western regions. Surgical statistics relative to the number of abdominal and surgical procedures done and the incidence of postoperative atelectasis are also presented.