2980-Anesthesia-Staffieri-Breathe Principles of - Eng

BREATHE: principles of ventilation in small animal practice
Francesco Staffieri
University of Bari, Italy
Department of Precision and Regenerative Medicine and Jonic Area
SP 62 per Casamassima km 3, 70010, Valenzano, Bari
Italy
General anesthesia (GA) has several side effects on respiratory function. Anesthetic-induced muscle
relaxation reduces functional residual capacity (FRC) for cranial diaphragmatic displacement and chest
wall volume reduction. This event promotes small airway closure in the most dependent area of the lung,
leading to alveolar collapse (atelectasis). The main mechanisms of pulmonary atelectasis induced by
anesthesia are the compression of the lung parenchyma and the use of high inspired oxygen fractions.
Pulmonary atelectasis, together with upper airway reduction, are the events that cause a reduction in lung
compliance and oxygenation during general anesthesia. In addition to these mechanisms, GA causes
respiratory drive depression and a reduction in minute ventilation, conditions that lead to hypercapnia.(1)
Positive pressure ventilation is the most common method used to support respiratory function during
anesthesia. Ventilators are now very popular in veterinary anesthesia, and appropriate use and settings
are important to provide effective support and avoid complications.
The goals of mechanical ventilation (MV) are to provide adequate minute ventilation, increase FRC,
reduce atelectasis (lung recruitment), and improve gas exchange (oxygenation). The use of MV also
optimizes anesthetic delivery in the case of inhalational anesthesia, favoring a stable plane of anesthesia.
Positive pressure ventilation may also have some negative effects on cardiovascular function by
increasing intrathoracic pressure and potentially reducing venous return. This effect is more important in
patients with cardiovascular instability. In addition, MV may cause pulmonary damage if not properly
adjusted.
Hypercapnia, decreased oxygenation, respiratory depression or apnea, and specific cases or surgical
procedures (e.g., thoracic surgery) are the main indicators for initiating MV. However, considering the
important side effects of anesthesia on respiratory function, MV can be performed in all cases under
general anesthesia.
The most common mode of ventilation during GA is volume- or pressure-controlled ventilation. This
means that the ventilator fully controls the respiratory function in terms of respiratory rate (RR), tidal
volume (TV), inspiratory to expiratory ratio (I:E) and inspired oxygen fraction (FiO2). Tidal volume should
be set between 12 and 15 ml/kg based on recent literature in dogs. Similarly, in cats, TV should be set at
15-20 mL/kg (2). Regarding RR, we should start with a baseline rate of 10-12 breaths per minute (bpm)
and then adjust based on end-tidal CO2 monitoring. The I:E determines the duration of inspiration and
expiration and should usually be set at 1:2 to 1:3. In fact, it is important to have a longer expiratory time to
promote complete emptying of the lungs during expiration, which is a passive process. The inspiratory
pause is a control present in most ventilators, it creates a short inspiratory pause at the end of inspiration.
The physiological significance of this function is to allow a more homogeneous distribution of the
delivered tidal volume throughout the lung parenchyma. The inspiratory pause should be set to
approximately 15-30% of the inspiratory time, as it is part of the inspiratory phase. Another important
setting is the FiO2 delivered to the patient. The optimal FiO2 level should be between 40 and 60%. The
use of high FiO2 promotes lung atelectasis due to absorption atelectasis as demonstrated by several
studies in dogs and cats. Oxygen should be mixed with medical air (3, 4).
Another important setting on the ventilator is positive end-expiratory pressure (PEEP), which acts on the
expiratory phase of the respiratory cycle to counteract alveolar collapse. Thus, PEEP promotes lung
recruitment and several studies in dogs have demonstrated its beneficial effects in increasing FRC and
improving oxygenation, even in healthy lungs. The optimal level of PEEP for dogs under anesthesia is
approximately 4-7 cmH2O. Studies in cats are not yet available, but it is the author's opinion that in this
species the range of PEEP should be between 3 and 5 cmH2O (5). More specific details on PEEP and
lung recruitment will be discussed in the pathologic lung lecture.
Other important considerations when providing MV include initiation of the procedure, patient adaptation
to the ventilator, and weaning. Complete adaptation of the patient to the ventilator is very important. In
fact, if the patient resists it, it can cause important pulmonary and cardiovascular side effects. In
bradipneic or apneic patients, it is usually necessary to set the ventilator to control CO2 in a physiological
range. In other situations, overcoming the patient's drive to breathe by temporarily imposing a higher
respiratory rate may be a practical way to adapt the patient. In some cases, it may be necessary to
promote a temporary respiratory depression by giving a small bolus of propofol or fentanyl if it does not
interfere with the patient's condition. The use of short-acting neuromuscular blocking agents may be
another option to ensure complete adaptation of the patient.
In terms of weaning from MV, it is usually sufficient to induce a transient hypercapnia that lowers the RR
and/or TV until the patient begins to breathe on their own. Hypercapnia and/or the administration of high
doses of opioids can cause complicated weaning and should be treated by treating the primary cause.
Mechanical ventilation is important to support respiratory function during general anesthesia. Appropriate
settings allow control of ventilation and oxygenation to counteract alveolar atelectasis and airway closure.
MV can also cause side effects that should be promptly recognized and treated appropriately.
REFERENCES
1) Hillman DR, Platt PR, Eastwood PR. The upper airway during anaesthesia. Br J Anaesth.
2003;91(1):31-39. doi:10.1093/bja/aeg126
2) De Monte V, Bufalari A, Grasso S, et al. Respiratory effects of low versus high tidal volume with or
without positive end-expiratory pressure in anesthetized dogs with healthy lungs. Am J Vet Res.
2018;79(5):496-504. doi:10.2460/ajvr.79.5.496
3) Staffieri F, Franchini D, Carella GL, et al. Computed tomographic analysis of the effects of two
inspired oxygen concentrations on pulmonary aeration in anesthetized and mechanically
ventilated dogs. Am J Vet Res. 2007;68(9):925-931. doi:10.2460/ajvr.68.9.925
4) Staffieri F, De Monte V, De Marzo C, Grasso S, Crovace A. Effects of two fractions of inspired
oxygen on lung aeration and gas exchange in cats under inhalant anaesthesia. Vet Anaesth Analg.
2010;37(6):483-490. doi:10.1111/j.1467-2995.2010.00567.x
5) De Monte V, Grasso S, De Marzo C, Crovace A, Staffieri F. Effects of reduction of inspired oxygen
fraction or application of positive end-expiratory pressure after an alveolar recruitment maneuver
on respiratory mechanics, gas exchange, and lung aeration in dogs during anesthesia and
neuromuscular blockade. Am J Vet Res. 2013;74(1):25-33. doi:10.2460/ajvr.74.1.25

2980-Anesthesia-Staffieri-Breathe Principles of - Eng

Uploaded by

Copyright:

Available Formats

2980-Anesthesia-Staffieri-Breathe Principles of - Eng

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

2980-Anesthesia-Staffieri-Breathe Principles of - Eng

Uploaded by

Copyright:

Available Formats

BREATHE: principles of ventilation in small animal practice

You might also like