A Meta-analysis of Intraoperative Ventilation Strategies to Prevent Pulmonary Complications

Yang, Dongjie; Grant, Michael C.; Stone, Alexander B.; Wu, Christopher L.; Wick, Elizabeth C.

doi:10.1097/sla.0000000000001443

Cited by 114 publications

(70 citation statements)

References 35 publications

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“…8 mL/kg predicted bodyweight). This is in line with current recommendations [25][26][27] and is used in previous clinical trials of intraoperative ventilation before [12,13,15], allowing for good comparison of the DESIGNATION results with those from preceding trials.…”

Section: Discussionsupporting

confidence: 77%

Driving Pressure During General Anesthesia for Open Abdominal Surgery (DESIGNATION): study protocol of a randomized clinical trial

Hol¹,

Nijbroek²,

Neto³

et al. 2020

Trials

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Background: Intraoperative driving pressure (ΔP) is associated with development of postoperative pulmonary complications (PPC). When tidal volume (V T ) is kept constant, ΔP may change according to positive end-expiratory pressure (PEEP)-induced changes in lung aeration. ΔP may decrease if PEEP leads to a recruitment of collapsed lung tissue but will increase if PEEP mainly causes pulmonary overdistension. This study tests the hypothesis that individualized high PEEP, when compared to fixed low PEEP, protects against PPC in patients undergoing open abdominal surgery. Methods:The "Driving prESsure durIng GeNeral AnesThesIa for Open abdomiNal surgery trial" (DESIGNATION) is an international, multicenter, two-group, double-blind randomized clinical superiority trial. A total of 1468 patients will be randomly assigned to one of the two intraoperative ventilation strategies. Investigators screen patients aged ≥ 18 years and with a body mass index ≤ 40 kg/m 2 , scheduled for open abdominal surgery and at risk for PPC. Patients either receive an intraoperative ventilation strategy with individualized high PEEP with recruitment maneuvers (RM) ("individualized high PEEP") or one in which PEEP of 5 cm H 2 O without RM is used ("low PEEP"). In the "individualized high PEEP" group, PEEP is set at the level at which ΔP is lowest. In both groups of the trial, V T is kept at 8 mL/kg predicted body weight. The primary endpoint is the occurrence of PPC, recorded as a collapsed composite of adverse pulmonary events.Discussion: DESIGNATION will be the first randomized clinical trial that is adequately powered to compare the effects of individualized high PEEP with RM versus fixed low PEEP without RM on the occurrence of PPC after open abdominal surgery. The results of DESIGNATION will support anesthesiologists in their decisions regarding PEEP settings during open abdominal surgery. Trial registration: Clinicaltrials.gov, NCT03884543. Registered on 21 March 2019.

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Section: Discussionsupporting

confidence: 77%

Driving Pressure During General Anesthesia for Open Abdominal Surgery (DESIGNATION): study protocol of a randomized clinical trial

Hol¹,

Nijbroek²,

Neto³

et al. 2020

Trials

View full text Add to dashboard Cite

show abstract

“…Pulmonary ventilation, controlled by volume rather than pressure, might modify the rate of postoperative pulmonary complications, even though studies in patients with acute lung injury have not shown significant differences . Postoperative pulmonary complications are associated with intra‐operative PEEP, ventilatory driving pressure and oxygen partial pressure . Studies have reported effects of pressure‐controlled vs. volume‐controlled intra‐operative ventilation on physiological variables but not clinical pulmonary outcomes .…”

Section: Introductionmentioning

confidence: 99%

The association of postoperative pulmonary complications in 109,360 patients with pressure‐controlled or volume‐controlled ventilation

Bagchi

Rudolph

et al. 2017

Anaesthesia

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We thought that the rate of postoperative pulmonary complications might be higher after pressure-controlled ventilation than after volume-controlled ventilation. We analysed peri-operative data recorded for 109,360 adults, whose lungs were mechanically ventilated during surgery at three hospitals in Massachusetts, USA. We used multivariable regression and propensity score matching. Postoperative pulmonary complications were more common after pressure-controlled ventilation, odds ratio (95%CI) 1.29 (1.21-1.37), p < 0.001. Tidal volumes and driving pressures were more varied with pressure-controlled ventilation compared with volume-controlled ventilation: mean (SD) variance from the median 1.61 (1.36) ml.kg vs. 1.23 (1.11) ml.kg , p < 0.001; and 3.91 (3.47) cmH O vs. 3.40 (2.69) cmH O, p < 0.001. The odds ratio (95%CI) of pulmonary complications after pressure-controlled ventilation compared with volume-controlled ventilation at positive end-expiratory pressures < 5 cmH O was 1.40 (1.26-1.55) and 1.20 (1.11-1.31) when ≥ 5 cmH O, both p < 0.001, a relative risk ratio of 1.17 (1.03-1.33), p = 0.023. The odds ratio (95%CI) of pulmonary complications after pressure-controlled ventilation compared with volume-controlled ventilation at driving pressures of < 19 cmH O was 1.37 (1.27-1.48), p < 0.001, and 1.16 (1.04-1.30) when ≥ 19 cmH O, p = 0.011, a relative risk ratio of 1.18 (1.07-1.30), p = 0.016. Our data support volume-controlled ventilation during surgery, particularly for patients more likely to suffer postoperative pulmonary complications.

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“…Apart from pressure control ventilation, volume‐control ventilation and PEEP, the final component to the methodology involved alveolar recruitment. There are many methods described in the literature relating to alveolar recruitment . Amato et al.…”

Section: Discussionmentioning

confidence: 99%

Intra‐operative protective mechanical ventilation in lung transplantation: a randomised, controlled trial

et al. 2017

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Primary graft dysfunction occurs in up to 25% of patients after lung transplantation. Contributing factors include ventilator-induced lung injury, cardiopulmonary bypass, ischaemia-reperfusion injury and excessive fluid administration. We evaluated the feasibility, safety and efficacy of an open-lung protective ventilation strategy aimed at reducing ventilator-induced lung injury. We enrolled adult patients scheduled to undergo bilateral sequential lung transplantation, and randomly assigned them to either a control group (volume-controlled ventilation with 5 cmH O, positive end-expiratory pressure, low tidal volumes (two-lung ventilation 6 ml.kg , one-lung ventilation 4 ml.kg )) or an alveolar recruitment group (regular step-wise positive end-expiratory pressure-based alveolar recruitment manoeuvres, pressure-controlled ventilation set at 16 cmH O with 10 cmH O positive end-expiratory pressure). Ventilation strategies were commenced from reperfusion of the first lung allograft and continued for the duration of surgery. Regular PaO /F O ratios were calculated and venous blood samples collected for inflammatory marker evaluation during the procedure and for the first 24 h of intensive care stay. The primary end-point was the PaO /F O ratio at 24 h after first lung reperfusion. Thirty adult patients were studied. The primary outcome was not different between groups (mean (SD) PaO /F O ratio control group 340 (111) vs. alveolar recruitment group 404 (153); adjusted p = 0.26). Patients in the control group had poorer mean (SD) PaO /F O ratios at the end of the surgical procedure and a longer median (IQR [range]) time to tracheal extubation compared with the alveolar recruitment group (308 (144) vs. 402 (154) (p = 0.03) and 18 (10-27 [5-468]) h vs. 15 (11-36 [5-115]) h (p = 0.01), respectively). An open-lung protective ventilation strategy during surgery for lung transplantation is feasible, safe and achieves favourable ventilation parameters.

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A Meta-analysis of Intraoperative Ventilation Strategies to Prevent Pulmonary Complications

Cited by 114 publications

References 35 publications

Driving Pressure During General Anesthesia for Open Abdominal Surgery (DESIGNATION): study protocol of a randomized clinical trial

Driving Pressure During General Anesthesia for Open Abdominal Surgery (DESIGNATION): study protocol of a randomized clinical trial

The association of postoperative pulmonary complications in 109,360 patients with pressure‐controlled or volume‐controlled ventilation

Intra‐operative protective mechanical ventilation in lung transplantation: a randomised, controlled trial

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