Intraoperative ventilation strategies to prevent postoperative pulmonary complications: a network meta-analysis of randomised controlled trials

Abstract

Background: The debate on lung-protective ventilation strategies for surgical patients is ongoing. Evidence suggests that the use of low tidal volume V T improves clinical outcomes. However, the optimal levels of PEEP and recruitment manoeuvre (RM) strategies incorporated into low V T ventilation remain unclear. Methods: Several electronic databases were searched to identify RCTs that focused on comparison between low V T strategy and conventional mechanical ventilation (CMV), or between two different low V T strategies in surgical patients. The primary outcome was postoperative pulmonary complications (PPCs). The secondary outcomes were atelectasis, pneumonia, acute respiratory distress syndrome, and short-term mortality. Bayesian network meta-analyses were performed using WinBUGS. The odds ratios (ORs) and corresponding 95% credible intervals (CrIs) were estimated. Results: Compared with CMV, low V T ventilation with moderate-to-high PEEP reduced the risk of PPCs (moderate PEEP [5e8 cm H 2 O]: OR 0.50 [95% CrI: 0.28, 0.89]; moderate PEEPþRMs: 0.39 [0.19, 0.78]; and high PEEP [!9 cm H 2 O]þRMs: 0.34 [0.14, 0.79]). Low V T ventilation with moderate-to-high PEEP and RMs also specifically reduced the risk of atelectasis compared with CMV (moderate PEEPþRMs: OR 0.36 [95% CrI: 0.16, 0.87]; and high PEEPþRMs: 0.41 [0.15, 0.97]), whilst low V T ventilation with moderate PEEP was superior to CMV in reducing the risk of pneumonia (OR 0.46 [95% CrI: 0.15, 0.94]). Conclusions: The combination of low V T ventilation and moderate-to-high PEEP (!5 cm H 2 O) seems to confer lung protection in surgical patients undergoing general anaesthesia. Clinical trial registration: PROSPERO (CRD42019144561) Editor's key pointsThe authors used a network meta-analytical method to allow comparison and ranking of intraoperative ventilation strategies.Of the ventilation strategies examined, tidal volume 8 ml kg À1 with PEEP !5 cm H 2 O was found to be associated with a reduced risk of postoperative pulmonary complications. High-quality clinical investigations are needed to clarify the optimal levels of PEEP and to identify the best recruitment strategies.

RETRACTED: Effect of Intraoperative Ventilation Strategies on Postoperative Pulmonary Complications: A Meta-Analysis

“…Two previous meta-analysis studies found a significant difference between protective ventilation and conventional ventilation in acute respiratory distress syndrome ( 52 , 53 ). However, similar to our results another meta-analysis study did not find any significance in acute respiratory distress syndrome ( 54 ). The difference may be because of different methodologies used in those studies.…”

Reversal of residual neuromuscular block with neostigmine or sugammadex and postoperative pulmonary complications: a prospective, randomised, double-blind trial in high-risk older patients

“…Lung-protective ventilation strategies are known to influence the rate of postoperative complications. 27 However, all participating trial centres used lung-protective ventilation strategies with low-to-modest tidal volumes, positive end-expiratory airway pressure of at least 5 cm H 2 O, and pressure-controlled ventilation.…”

The impact of ultrasound-guided recruitment maneuvers on the risk of postoperative pulmonary complications in patients undergoing general anesthesia

“…Recruitment maneuvers are one of the constituents of optimal intraoperative ventilation ( 17 ) . Their effectiveness has been extensively discussed in literature; however, even based on large meta-analyses the most optimal procedure for performing them has not been determined thus far ( 18 , 19 ) . Because of the risk of both respiratory and circulatory complications (mainly hypotension), it is justified to closely monitor their course, also with the application of imaging techniques.…”