Intra-operative Alveolar Recruitment Manoeuvres: An Approach with Substantial Potential Benefits and Major Risks
Jawad, Monir LU
and Hannesdottir, Katrin
(2021)
SFAI/ANIVA Congress 2021
- Abstract
- Introduction
The benefits of alveolar recruitment manoeuvres (ARMs) conducted during general
anaesthesia (GA) have been a topic of debate. An ARM is an intentional transient increase in
trans-pulmonary pressure aimed at reopening non-aerated or poorly aerated alveoli that are
subsequently kept open by applying positive end-expiratory pressure (PEEP). However, an
inappropriately high positive intra-thoracic pressure could be harmful. ARM improves
oxygenation and respiratory system compliance by competing atelectasis. The latter is
correlated with post-operative pulmonary complications (PPC) and may lead to higher patient
morbidity and mortality and healthcare costs.
Objectives:
This article... (More) - Introduction
The benefits of alveolar recruitment manoeuvres (ARMs) conducted during general
anaesthesia (GA) have been a topic of debate. An ARM is an intentional transient increase in
trans-pulmonary pressure aimed at reopening non-aerated or poorly aerated alveoli that are
subsequently kept open by applying positive end-expiratory pressure (PEEP). However, an
inappropriately high positive intra-thoracic pressure could be harmful. ARM improves
oxygenation and respiratory system compliance by competing atelectasis. The latter is
correlated with post-operative pulmonary complications (PPC) and may lead to higher patient
morbidity and mortality and healthcare costs.
Objectives:
This article curated recent research to determine the proven/disproven benefits of ARM,
and elaborated the details of ARMs described in contemporary literature.
Methods:
A narrative review was performed to determine the appropriate protocol for ARM
during GA and to develop practice recommendations. Relevant publications were identified by
a PubMed search for systematic reviews, meta-analyses, and reviews published after 2014.
Results:
Lung protective ventilation (LPV) is the default strategy in critical care and is attaining
the same status in perioperative care. ARMs were mentioned in LPV strategies to improve
oxygenation with minimal injurious insults to the lungs. After considering the relevant
prerequisites, precautions, and contraindications, the studies advocated performing ARMs
mechanically by manipulations of ventilator settings rather than manually by the traditional
“bag inflation”. The benefits gained by ARMs were sustained by applying PEEP until
emergence from GA. In certain patient groups, sustainment of acceptable oxygenation into the
post-operative period required the application of continuous positive airway pressure (CPAP),
respiratory physiotherapy, and proper patient positioning. The selected studies did not report
any long-lasting benefits of non-individualized ARMs per se. Although the literature unequivocally recommends adherence to LPV, including ARMs when indicated, to reduce the
occurrence of PPCs, it was difficult to conclude if ARMs themselves were a beneficial
component of LPV or if their effectiveness was superseded by the effects of the other
components, i.e. low tidal volume and PEEP. No experimental studies were designed to
elaborate the role of ARM as a separate entity.
Conclusions:
Intra-operative ARMs are beneficial in preserving acceptable oxygenation during GA.
They are usually undertaken either prophylactically after certain events, e.g. intubation or
circuit disconnection, or as a simple rescue measure in case of desaturation. In certain patient
groups, e.g. obese patients or those with pulmonary diseases, further measures are required to
improve oxygenation post-operatively. This is because the effect of intra-operative ARMs is
lost after extubation, and no ARM-related reduction in PPC or mortality has been noticed yet. (Less)
Please use this url to cite or link to this publication:
https://lup.lub.lu.se/record/5939c946-9db5-4aa7-ae43-378b687988d3
- author
- Jawad, Monir
LU
and Hannesdottir, Katrin
- organization
- publishing date
- 2021
- type
- Contribution to conference
- publication status
- unpublished
- subject
- conference name
- SFAI/ANIVA Congress 2021
- conference location
- Örebro, Sweden
- conference dates
- 2021-09-21 - 2021-09-24
- language
- English
- LU publication?
- yes
- id
- 5939c946-9db5-4aa7-ae43-378b687988d3
- date added to LUP
- 2023-06-06 00:02:03
- date last changed
- 2026-02-17 07:37:16
@misc{5939c946-9db5-4aa7-ae43-378b687988d3,
abstract = {{Introduction <br/>The benefits of alveolar recruitment manoeuvres (ARMs) conducted during general <br/>anaesthesia (GA) have been a topic of debate. An ARM is an intentional transient increase in <br/>trans-pulmonary pressure aimed at reopening non-aerated or poorly aerated alveoli that are <br/>subsequently kept open by applying positive end-expiratory pressure (PEEP). However, an <br/>inappropriately high positive intra-thoracic pressure could be harmful. ARM improves <br/>oxygenation and respiratory system compliance by competing atelectasis. The latter is <br/>correlated with post-operative pulmonary complications (PPC) and may lead to higher patient <br/>morbidity and mortality and healthcare costs. <br/>Objectives: <br/>This article curated recent research to determine the proven/disproven benefits of ARM, <br/>and elaborated the details of ARMs described in contemporary literature.<br/>Methods: <br/>A narrative review was performed to determine the appropriate protocol for ARM <br/>during GA and to develop practice recommendations. Relevant publications were identified by <br/>a PubMed search for systematic reviews, meta-analyses, and reviews published after 2014.<br/>Results: <br/>Lung protective ventilation (LPV) is the default strategy in critical care and is attaining <br/>the same status in perioperative care. ARMs were mentioned in LPV strategies to improve <br/>oxygenation with minimal injurious insults to the lungs. After considering the relevant <br/>prerequisites, precautions, and contraindications, the studies advocated performing ARMs <br/>mechanically by manipulations of ventilator settings rather than manually by the traditional <br/>“bag inflation”. The benefits gained by ARMs were sustained by applying PEEP until <br/>emergence from GA. In certain patient groups, sustainment of acceptable oxygenation into the <br/>post-operative period required the application of continuous positive airway pressure (CPAP), <br/>respiratory physiotherapy, and proper patient positioning. The selected studies did not report<br/>any long-lasting benefits of non-individualized ARMs per se. Although the literature unequivocally recommends adherence to LPV, including ARMs when indicated, to reduce the <br/>occurrence of PPCs, it was difficult to conclude if ARMs themselves were a beneficial <br/>component of LPV or if their effectiveness was superseded by the effects of the other <br/>components, i.e. low tidal volume and PEEP. No experimental studies were designed to <br/>elaborate the role of ARM as a separate entity.<br/>Conclusions: <br/>Intra-operative ARMs are beneficial in preserving acceptable oxygenation during GA. <br/>They are usually undertaken either prophylactically after certain events, e.g. intubation or <br/>circuit disconnection, or as a simple rescue measure in case of desaturation. In certain patient <br/>groups, e.g. obese patients or those with pulmonary diseases, further measures are required to <br/>improve oxygenation post-operatively. This is because the effect of intra-operative ARMs is <br/>lost after extubation, and no ARM-related reduction in PPC or mortality has been noticed yet.}},
author = {{Jawad, Monir and Hannesdottir, Katrin}},
language = {{eng}},
title = {{Intra-operative Alveolar Recruitment Manoeuvres: An Approach with Substantial Potential Benefits and Major Risks}},
year = {{2021}},
}