Individualized positive end-expiratory pressure following alveolar recruitment manoeuvres in lung-healthy anaesthetized dogs: a randomized clinical trial on early postoperative arterial oxygenation

  • Virginia García-Sanz
    Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Madrid, Spain
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  • Delia Aguado
    Correspondence: Delia Aguado, Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Avda. Puerta de Hierro s/n, 28040 Madrid, Spain.
    Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Madrid, Spain
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  • Ignacio A. Gómez de Segura
    Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Madrid, Spain
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  • Susana Canfrán
    Department of Animal Medicine and Surgery, Veterinary Teaching Hospital, Veterinary Faculty, Complutense University of Madrid, Madrid, Spain
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      To assess and compare the effect of intraoperative stepwise alveolar recruitment manoeuvres (ARMs), followed by individualized positive end-expiratory pressure (PEEP), defined as PEEP at maximal respiratory system compliance + 2 cmH2O (PEEPmaxCrs+2), with that of spontaneous ventilation (SV) and controlled mechanical ventilation (CMV) without ARM or PEEP on early postoperative arterial oxygenation in anaesthetized healthy dogs.

      Study design

      Prospective, randomized, nonblinded clinical study.


      A total of 32 healthy client-owned dogs undergoing surgery in dorsal recumbency.


      Dogs were ventilated intraoperatively (inspired oxygen fraction: 0.5) with one of the following strategies: SV, CMV alone, and CMV with PEEPmaxCrs+2 following a single ARM (ARM1) or two ARMs (ARM2, the second ARM at the end of surgery). Arterial blood gas analyses were performed before starting the ventilatory strategy, at the end of surgery, and at 5, 10, 15, 30 and 60 minutes after extubation while breathing room air. Data were analysed using Kruskal-Wallis and Friedman tests (p < 0.050).


      At any time point after extubation, PaO2 was not significantly different between groups. At 5 minutes after extubation, PaO2 was 95.1 (78.1–104.0), 93.8 (88.3–104.0), 96.9 (86.6–115.0) and 89.1 (87.6–102.0) mmHg in the SV, CMV, ARM1 and ARM2 groups, respectively. PaO2 decreased at 30 minutes after extubation in the CMV, ARM1 and ARM2 groups (p < 0.050), but it did not decrease after 30 minutes in the SV group. Moderate hypoxaemia (PaO2, 60–80 mmHg) was observed in one dog in the ARM1 group and two dogs each in the SV and ARM2 groups.

      Conclusions and clinical relevance

      Intraoperative ARMs, followed by PEEPmaxCrs+2, did not improve early postoperative arterial oxygenation compared with SV or CMV alone in healthy anaesthetized dogs. Therefore, this ventilatory strategy might not be clinically advantageous for improving postoperative arterial oxygenation in healthy dogs undergoing surgery when positioned in dorsal recumbency.


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        • Borges J.B.
        • Okamoto V.N.
        • Matos G.F.
        • et al.
        Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome.
        Am J Respir Crit Care Med. 2006; 174: 268-278
        • Campbell V.L.
        • Drobatz K.J.
        • Perkowski S.Z.
        Postoperative hypoxemia and hypercarbia in healthy dogs undergoing routine ovariohysterectomy or castration and receiving butorphanol or hydromorphone for analgesia.
        J Am Vet Med Assoc. 2003; 222: 330-336
        • Canfrán S.
        • Gómez de Segura I.A.
        • Cediel R.
        • García-Fernández J.
        Effects of a stepwise lung recruitment manoeuvre and positive end-expiratory pressure on lung compliance and arterial blood oxygenation in healthy dogs.
        Vet J. 2012; 194: 89-93
        • Canfrán S.
        • Gómez de Segura I.A.
        • Cediel R.
        • García-Fernández J.
        Effects of fluid load on cardiovascular function during stepwise lung recruitment manoeuvre in healthy dogs.
        Vet J. 2013; 197: 800-805
        • Carvalho A.R.
        • Jandre F.C.
        • Pino A.V.
        • et al.
        Effects of descending positive end-expiratory pressure on lung mechanics and aeration in healthy anaesthetized piglets.
        Crit Care. 2006; 10: R122
        • Cavalcanti A.B.
        • Suzumura É.A.
        • Laranjeira L.N.
        • et al.
        • Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators
        Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome: a randomized clinical trial.
        JAMA. 2017; 318: 1335-1345
        • D’Antini D.
        • Huhle R.
        • Herrmann J.
        • et al.
        Respiratory system mechanics during low versus high positive end-expiratory pressure in open abdominal surgery: a substudy of PROVHILO randomized controlled trial.
        Anesth Analg. 2018; 126: 143-149
        • De Monte V.
        • Grasso S.
        • De Marzo C.
        • et al.
        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: 25-33
        • Fernandez-Bustamante A.
        • Frendl G.
        • Sprung J.
        • et al.
        Postoperative pulmonary complications, early mortality, and hospital stay following noncardiothoracic surgery: a multicenter study by the perioperative research network investigators.
        JAMA surgery. 2017; 152: 157-166
        • Ferro Lopes P.C.
        • Nunes N.
        • Sousa M.G.
        • et al.
        The effects of different inspired oxygen fractions on gas exchange and Tei-index of myocardial performance in propofol-anesthetized dogs.
        Vet Anaesth Analg. 2013; 40: 573-583
        • Futier E.
        • Constantin J.-M.
        • Paugam-Burtz C.
        • et al.
        A trial of intraoperative low-tidal-volume ventilation in abdominal surgery.
        N Engl J Med. 2013; 369: 428-437
        • García-Sanz V.
        • Aguado D.
        • Gómez de Segura I.A.
        • Canfrán S.
        Comparative effects of open-lung positive end-expiratory pressure (PEEP) and fixed PEEP on respiratory system compliance in the isoflurane anaesthetised healthy dog.
        Res Vet Sci. 2019; 127: 91-98
        • Haskins S.
        • Pascoe P.J.
        • Ilkiw J.E.
        • et al.
        Reference cardiopulmonary values in normal dogs.
        Comp Med. 2005; 55: 156-161
        • Hemmes S.N.
        • Gama de Abreu M.
        • Pelosi P.
        • Schultz M.J.
        High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial.
        Lancet. 2014; 384: 495-503
        • Hickling K.G.
        Best compliance during a decremental, but not incremental, positive end-expiratory pressure trial is related to open-lung positive end-expiratory pressure: a mathematical model of acute respiratory distress syndrome lungs.
        Am J Respir Crit Care Med. 2001; 163: 69-78
        • Hopster K.
        • Rohn K.
        • Ohnesorge B.
        • Kästner S.B.
        Controlled mechanical ventilation with constant positive end-expiratory pressure and alveolar recruitment manoeuvres during anaesthesia in laterally or dorsally recumbent horses.
        Vet Anaesth Analg. 2017; 44: 121-126
        • Jeon K.
        • Jeon I.S.
        • Suh G.Y.
        • et al.
        Two methods of setting positive end-expiratory pressure in acute lung injury: an experimental computed tomography volumetric study.
        J Korean Med Sci. 2007; 22: 476-483
        • Laflamme D.
        Development and validation of a body condition score system for dogs.
        Canine Pract. 1997; 22: 10-15
        • Lindberg P.
        • Gunnarsson L.
        • Tokics L.
        • et al.
        Atelectasis and lung function in the postoperative period.
        Acta Anaesthesiol Scand. 1992; 36: 546-553
        • Martin-Flores M.
        • Cannarozzo C.J.
        • Tseng C.T.
        • et al.
        Postoperative oxygenation in healthy dogs following mechanical ventilation with fractions of inspired oxygen of 0.4 or >0.9.
        Vet Anaesth Analg. 2020; 47: 295-300
        • Martin-Flores M.
        • Tseng C.T.
        • Robillard S.D.
        • et al.
        Effects of two fractions of inspired oxygen during anesthesia on early postanesthesia oxygenation in healthy dogs.
        Am J Vet Res. 2018; 79: 147-153
        • Mosing M.
        • German A.J.
        • Holden S.L.
        • et al.
        Oxygenation and ventilation characteristics in obese sedated dogs before and after weight loss: a clinical trial.
        Vet J. 2013; 198: 367-371
        • Neumann P.
        • Rothen H.U.
        • Berglund J.E.
        • et al.
        Positive end-expiratory pressure prevents atelectasis during general anaesthesia even in the presence of a high inspired oxygen concentration.
        Acta Anaesthesiol Scand. 1999; 43: 295-301
        • Pi X.
        • Cui Y.
        • Wang C.
        • et al.
        Low tidal volume with PEEP and recruitment expedite the recovery of pulmonary function.
        Int J Clin Exp Pathol. 2015; 8: 14305-14314
        • Sasse S.A.
        • Jaffe M.B.
        • Chen P.A.
        • et al.
        Arterial oxygenation time after an FIO2 increase in mechanically ventilated patients.
        Am J Respir Crit Care Med. 1995; 152: 148-152
        • Severgnini P.
        • Selmo G.
        • Lanza C.
        • et al.
        Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function.
        Anesthesiology. 2013; 118: 1307-1321
        • Siggaard-Andersen O.
        The acid-base status of the blood.
        4th edn. 1976 (Munksgaard, Denmark)
        • Siggaard-Andersen O.
        • Siggaard-Andersen M.
        The oxygen status algorithm: a computer program for calculating and displaying pH and blood gas data.
        Scand J Clin Lab Invest Suppl. 1990; 203: 29-45
        • Siggaard-Andersen O.
        • Wimberley P.D.
        • Fogh-Andersen N.
        • Gøthgen I.H.
        Measured and derived quantities with modern pH and blood gas equipment: Calculation algorithms with 54 equations.
        Scand J Clin Lab Invest. 1988; 48: 7-15
        • Soares J.H.N.
        • Carvalho A.R.
        • Bergamini B.C.
        • et al.
        Alveolar tidal recruitment/derecruitment and overdistension during four levels of end-expiratory pressure with protective tidal volume during anesthesia in a murine lung-healthy model.
        Lung. 2018; 196: 335-342
        • Staffieri F.
        • De Monte V.
        • De Marzo C.
        • et al.
        Alveolar recruiting maneuver in dogs under general anesthesia: effects on alveolar ventilation, gas exchange, and respiratory mechanics.
        Vet Res Commun. 2010; 34: S131-S134
        • Staffieri F.
        • Franchini D.
        • Carella G.L.
        • 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: 925-931
        • Strandberg A.
        • Tokics L.
        • Brismar B.
        • et al.
        Atelectasis during anaesthesia and in the postoperative period.
        Acta Anaesthesiol Scand. 1986; 30: 154-158
        • Suarez-Sipmann F.
        • Bohm S.H.
        • Tusman G.
        • et al.
        Use of dynamic compliance for open lung positive end-expiratory pressure titration in an experimental study.
        Crit Care Med. 2007; 35: 214-221
        • Valverde A.
        • Cantwell S.
        • Hernandez J.
        • Brotherson C.
        Effects of acepromazine on the incidence of vomiting associated with opioid administration in dogs.
        Vet Anaesth Analg. 2004; 31: 40-45
        • Vanova-Uhrikova I.
        • Rauserova-Lexmaulova L.
        • Rehakova K.
        • et al.
        Determination of reference intervals of acid-base parameters in clinically healthy dogs.
        J Vet Emerg Crit Care (San Antonio). 2017; 27: 325-332
        • Weingarten T.N.
        • Whalen F.X.
        • Warner D.O.
        • et al.
        Comparison of two ventilatory strategies in elderly patients undergoing major abdominal surgery.
        Br J Anaesth. 2010; 104: 16-22
        • Weinreich U.M.
        • Thomsen L.P.
        • Hansen A.
        • et al.
        Time to steady state after changes in FIO2 in patients with COPD.
        COPD. 2013; 10: 405-410
        • Zin W.A.
        • Martins M.A.
        • Silva P.R.
        • et al.
        Effects of abdominal opening on respiratory system mechanics in ventilated rats.
        J Appl Physiol (1985). 1989; 66: 2496-2501