Induction of anesthesia by inhalation is the most common method of induction (70% in France) for young children admitted for non-emergency surgery. It has the advantage of not requiring an intravenous line.
Serious respiratory adverse events such as laryngospasm or bronchospasm remain common in young children during anesthesia induction (approximately 4%) and can reach up to 30% when mild respiratory adverse events (coughing, desaturation \< 95%, airway obstruction) are included.
Traditionally, inhalation induction is performed under spontaneous ventilation using the anesthesia ventilator circuit. However, modern ventilators offer the option of applying positive end-expiratory pressure (PEEP) and pressure support ventilation (PSV). Several physiological studies suggest that the use of PEEP + PSV during anesthesia may help maintain airway patency, minute ventilation, and functional residual capacity (FRC).
Our hypothesis is that administering PEEP + PSV at the time of induction may reduce the risk of respiratory complications.
The primary objective is to demonstrate that induction of anesthesia using PEP + PSV, compared with induction of anesthesia under spontaneous ventilation, reduces the risk of adverse respiratory events in children requiring general anesthesia with planned inhalational induction.
Child between 3 months and 6 years old
Without significant comorbidity (ASA 1 or 2)
Admitted for elective or emergency/urgent surgery under general anesthesia
With induction of anaesthesia by inhalation by sevoflurane on the machine circuit
Children with severe upper respiratory tract infection (severe moist cough, fever and lethargy, oxygen requirement) in the last 7 days requiring intravenous induction or postpone of the surgery
Thoracic surgery with selective control of intubation
Criteria for difficult intubation or known history of difficult intubation
Children with a contraindication to sevoflurane (ex: risk of malignant hyperthermia)
Parallel
Induction with PEEP (5 cmH2O) and PSV (2-12 cmH2O)
Procedure/SurgerySevoflurane will initially be at 6% (with a fresh gas flow between 2L/min and 10L/min) or increase progressively according to local habits, which can be reduced between 4 and 6% during the installation of the vascular access and increased again to 6% before the control of the airway. The FiO2 will be set at 80% and can be increased up to 100% in case of desaturation. In the experimental group, the level of PEEP will be set at 5 cmH2O and inspiratory support between 2 and 12 cmH2O and adjusted by the anaesthetist in charge to optimize respiratory mechanics and obtain a physiological tidal volume of 8ml/kg.
Induction in spontaneous breathing
Procedure/SurgerySevoflurane will initially be at 6% (with a fresh gas flow between 2L/min and 10L/min) or increase progressively according to local habits, which can be reduced between 4 and 6% during the installation of the vascular access and increased again to 6% before the control of the airway. The FiO2 will be set at 80% and can be increased up to 100% in case of desaturation. In the control group, there is no PEEP
Number of respiratory adverse events among laryngospasm, bronchospasm, oxygen desaturation, airway obstruction and severe cough
* Laryngospasm: complete or partial obstruction of the airway associated with rigidity of the abdominal and thoracic muscles measured by the physician in charge * Bronchospasm: increase in work of breathing, particularly in exhalation (signs of respiratory distress) with wheezing measured by the physician in charge * Oxygen desaturation: \<95% more than 10 sec or \< 90% measured by the physician in charge * Airway obstruction: airway obstruction with inspiratory noise and increased work of breathing or requiring manual ventilation measured by the physician in charge * Severe cough: coughing fit lasting more than 10 sec or requiring drug intervention (intravenous anaesthetic agents, lidocaine, neuromuscular blockade agents) measured by the physician in charge
Number of respiratory adverse events among laryngospasm, bronchospasm and oxygen desaturation < 90%.
Risk difference and risk ratio at T4
Number of respiratory adverse events among airway obstruction, desaturation < 95% for more than 10s and severe cough
Risk difference and risk ratio at T4
Use of oropharyngeal cannula or need for manual ventilation for difficult ventilation.
Risk difference and risk ratio at T4
Number of attempts to control the airways
Attempts at tracheal intubation or laryngeal mask insertion, as reported by the physician in charge. Risk difference and risk ratio at T4
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