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. 2021 Jan 11:39:e2019275.
doi: 10.1590/1984-0462/2021/39/2019275. eCollection 2021.

ALVEOLAR RECRUITMENT MANEUVERS FOR CHILDREN WITH CANCER AND ACUTE RESPIRATORY DISTRESS SYNDROME: A FEASIBILITY STUDY

[Article in English, Portuguese]
Marcela Salvador Galassi  1 , Rodrigo Genaro Arduini  1 , Orlei Ribeiro de Araújo  1 , Rosa Masssa Kikuchi Sousa  1 , Antonio Sergio Petrilli  1 , Dafne Cardoso Bourguignon da Silva  1
Affiliations

ALVEOLAR RECRUITMENT MANEUVERS FOR CHILDREN WITH CANCER AND ACUTE RESPIRATORY DISTRESS SYNDROME: A FEASIBILITY STUDY

[Article in English, Portuguese]
Marcela Salvador Galassi et al. Rev Paul Pediatr. .

Abstract
in English, Portuguese

Objective: Acute respiratory distress syndrome (ARDS) can be a devastating condition in children with cancer and alveolar recruitment maneuvers (ARMs) can theoretically improve oxygenation and survival. The study aimed to assess the feasibility of ARMs in critically ill children with cancer and ARDS.

Methods: We retrospectively analyzed 31 maneuvers in a series of 12 patients (median age of 8.9 years) with solid tumors (n=4), lymphomas (n=2), acute lymphoblastic leukemia (n=2), and acute myeloid leukemia (n=4). Patients received positive end-expiratory pressure from 25 up to 40 cmH20, with a delta pressure of 15 cmH2O for 60 seconds. We assessed blood gases pre- and post-maneuvers, as well as ventilation parameters, vital signs, hemoglobin, clinical signs of pulmonary bleeding, and radiological signs of barotrauma. Pre- and post-values were compared by the Wilcoxon test.

Results: Median platelet count was 53,200/mm3. Post-maneuvers, mean arterial pressure decreased more than 20% in two patients, and four needed an increase in vasoactive drugs. Hemoglobin levels remained stable 24 hours after ARMs, and signs of pneumothorax, pneumomediastinum, or subcutaneous emphysema were absent. Fraction of inspired oxygen decreased significantly after ARMs (FiO2; p=0.003). Oxygen partial pressure (PaO2)/FiO2 ratio increased significantly (p=0.0002), and the oxygenation index was reduced (p=0.01), but all these improvements were transient. Recruited patients' 28-day mortality was 58%.

Conclusions: ARMs, although feasible in the context of thrombocytopenia, lead only to transient improvements, and can cause significant hemodynamic instability.

Objetivo:: A síndrome do desconforto respiratório agudo (SDRA) pode ser uma condição devastadora em crianças com câncer e as manobras de recrutamento alveolar (MRA) podem melhorar a oxigenação e a sobrevida. O objetivo foi avaliar a viabilidade das MRA em crianças gravemente doentes com câncer e SDRA.

Métodos:: Analisamos retrospectivamente 31 manobras em 12 pacientes (idade mediana de 8,9 anos), com tumores sólidos (n=4), linfomas (n=2) e leucemias linfoide (n=2) e mieloide agudas (n=4). Os pacientes receberam pressão expiratória final positiva de 25 a 40 cmH20, com delta de pressão de 15 cmH2O por 60 segundos. Gasometrias foram analisadas pré e pós-manobras, bem como os parâmetros de ventilação, sinais vitais, hemoglobina, sinais clínicos de sangramento pulmonar e sinais radiológicos de barotrauma. Valores foram comparados com o teste de Wilcoxon.

Resultados:: A contagem mediana de plaquetas era de 53.200/mm3. Após as manobras, em dois pacientes, a pressão arterial média declinou mais de 20%, e quatro necessitaram de aumento de drogas vasoativas. A hemoglobina permaneceu estável 24 horas após a MRA, sem sinais de pneumotórax, pneumomediastino ou enfisema subcutâneo. Houve diminuição significativa nas frações inspiradas de oxigênio (FiO2; p=0,003). A relação pressão arterial de oxigênio (PaO2)/FiO2 aumentou (p=0,002), e o índice de oxigenação caiu (p=0,01), mas essas melhoras foram transitórias. A mortalidade em 28 dias foi de 58%.

Conclusões:: As MRA, embora viáveis no contexto da trombocitopenia, levam apenas a melhorias transitórias e podem causar instabilidade hemodinâmica significativa.

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Conflict of interest statement

The authors declare there is no conflict of interests.

Figures

Figure 1
Figure 1. Positive end-expiratory pressure escalation and titration during the alveolar recruitment maneuver.
Figure 2
Figure 2. Boxplots of the values for the oxygen partial pressure/fraction of inspired oxygen ratio, oxygenation index, and positive end-expiratory pressure, pre- and post-recruitment maneuver.
See this image and copyright information in PMC

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