Ventilatory Strategy to Prevent Atelectasis During Bronchoscopy Under General Anesthesia

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; Atelectasis negatively influences peripheral bronchoscopy, increasing CT scan-body divergence, obscuring targets, and creating false-positive radial-probe endobronchial ultrasound (RP-EBUS) images. Can a ventilatory strategy reduce the incidence of atelectasis during bronchoscopy under general anesthesia? 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. 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. 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. ClinicalTrials.gov; No.: NCT04311723; URL: www.clinicaltrials.gov; ResponseCHESTVol. 162Issue 5PreviewWe appreciate the letter to the editor by Aretha et al regarding our article entitled “Ventilatory Strategy to Prevent Atelectasis During Bronchoscopy Under General Anesthesia: A Multicenter Randomized Controlled Trial (Ventilatory Strategy to Prevent Atelectasis Trial)”.1 They bring up important points of discussion from our article. Full-Text PDF Ventilatory Strategy to Prevent Atelectasis During Bronchoscopy With General Anesthesia: The Role of Laryngeal Mask AirwayCHESTVol. 162Issue 5PreviewWe read with great interest the recently published article by Salahuddin et al1 in CHEST, where it was shown that, during bronchoscopy with general anesthesia, a ventilatory strategy to prevent atelectasis (VESPA) with endotracheal intubation followed by a recruitment maneuver, significantly reduces the incidence of atelectasis; it is well-tolerated and has a sustained effect over time, despite the bronchoscopic nodal staging. We appreciate the important information presented in this article, and we wish to comment on some associated issues. Full-Text PDF The Intersection of Ventilatory Strategy to Prevent Atelectasis and Teslas in Navigational BronchoscopyCHESTVol. 162Issue 6PreviewAdvanced peripheral diagnostic bronchoscopy is a technologically driven field with an accelerating pace of new innovation coming to market. The first electromagnetic navigational bronchoscopy (NB) platform, cleared by the US Food and Drug Administration in 2004, turns 18 this year.1 As NB has come of age, a wave of additional features, platforms, and adjuncts have made their debut: radial probe endobronchial ultrasound scanning (R-EBUS), integrated digital tomosynthesis, and intraprocedural cone beam CT scanning for improved target visualization; virtual bronchoscopy, transparenchymal nodule access catheters, and ever thinner flexible bronchoscopes as alternative targeting modalities; and electromagnetically tip-tracked instruments and novel miniature cryoprobes as examples of biopsy tool innovations. Full-Text PDF