title: Neonatal Pneumothorax Pressures Surpass Higher Threshold in Lung Recruitment Maneuvers: An In Vivo Interventional Study.
abstract: BACKGROUND
  Causing pneumothorax is one of the main concerns of lung recruitment maneuvers in pediatric patients, especially newborns. Therefore, these maneuvers are not performed routinely during anesthesia. Our objective was to determine the pressures that cause pneumothorax in healthy newborns by a prospective experimental study of 10 newborn piglets (<48 h old) with healthy lungs under general anesthesia.
  
  
  METHODS
  The primary outcome was peak inspiratory pressure (PIP) causing pneumothorax. Animals under anesthesia and bilateral chest tube catheterization were randomly allocated to 2 groups: one with PEEP and fixed inspiratory driving pressure of 15 cm H2O (PEEP group) and the second one with PEEP = 0 cm H2O and non-fixed inspiratory driving pressure (zero PEEP group). In both groups, the ventilation mode was pressure-controlled, and PIP was raised at 2-min intervals, with steps of 5 cm H2O until air leak was observed through the chest tubes. The PEEP group raised PIP through 5-cm H2O PEEP increments, and the zero PEEP group raised PIP through 5-cm H2O inspiratory driving pressure increments.
  
  
  RESULTS
  Pneumothorax was observed with a PIP of 90.5 ± 15.7 cm H2O with no statistically significant differences between the PEEP group (92 ± 14.8 cm H2O) and the zero PEEP group (89 ± 18.2 cm H2O). The zero PEEP group had hypotension, with a PIP of 35 cm H2O; the PEEP group had hypotension, with a PIP of 60 cm H2O (P = .01). The zero PEEP group presented bradycardia, with PIP of 40 cm H2O; the PEEP group presented bradycardia, with PIP of 70 cm H2O (P = .002).
  
  
  CONCLUSIONS
  Performing recruitment maneuvers in newborns without lung disease is a safe procedure in terms of pneumothorax. Pneumothorax does not seem to occur in the clinically relevant PIPs of <50 cm H2O. Hemodynamic impairment may occur with high driving pressures. More studies are needed to determine the exact hemodynamic impact of these procedures and pneumothorax PIP in poorly compliant lungs.
authors.affiliation: Anaesthesia and Intensive Care Department, Akademiska Sjukhuset, Uppsala, Sweden. pgpizarro@gmail.com.
authors.forename: Patricio
authors.initials: P
authors.lastname: González-Pizarro
authors.affiliation: Anaesthesiology and Critical Care Department, Puerta de Hierro University Hospital, Madrid, Spain.
authors.forename: Javier
authors.initials: J
authors.lastname: García-Fernández
authors.affiliation: Veterinary Clinical Hospital, Complutense University, Madrid, Spain.
authors.forename: Susana
authors.initials: S
authors.lastname: Canfrán
authors.affiliation: Anaesthesiology Department, La Paz University Hospital, Madrid, Spain.
authors.forename: Fernando
authors.initials: F
authors.lastname: Gilsanz
mesh_terms: D000818:Animals; D000831:Animals, Newborn; D001794:Blood Pressure / Q000502:physiology; D001919:Bradycardia / Q000209:etiology; D006339:Heart Rate / Q000502:physiology; D007022:Hypotension / Q000209:etiology; D007320:Inspiratory Capacity / Q000502:physiology; D008168:Lung / Q000503:physiopathology; D011030:Pneumothorax / Q000209:etiology*; D011175:Positive-Pressure Respiration / Q000009:adverse effects* / Q000379:methods; D011312:Pressure; D011897:Random Allocation; D013552:Swine
keywords: anesthesia; barotrauma; mechanical ventilation; pediatrics; positive-pressure respiration; ventilator-induced lung injury