Mechanical Power: Correlate or Cause of Ventilator-induced Lung Injury?

Abreu, Marcelo Gama de; Sessler, Daniel I.

doi:10.1097/aln.0000000000004240

Cited by 9 publications

(7 citation statements)

References 14 publications

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“…It suggests that the relationship between these parameters and PRF is not simply an expression that patients with poor respiratory mechanics, and therefore high mechanical power and ΔP, are at higher risk of adverse pulmonary outcomes (36). These findings thereby support a potential causative effect in previous studies (2, 4, 6, 15, 37), which has been the subject of debate (38). Even while effect sizes, as measured by aORs, were slightly diminished after exact matching for patients’ respiratory system compliance, our findings suggest that patients’ risk for PRF when receiving mechanical power greater than or equal to 6.7 J/min, or a ΔP greater than or equal to 15.0 cm H 2 O, increases by about 30% as compared with patients with values below these cutoffs.…”

Section: Discussionsupporting

confidence: 89%

High Mechanical Power and Driving Pressures are Associated With Postoperative Respiratory Failure Independent From Patients’ Respiratory System Mechanics*

Tartler,

Ahrens,

Munoz-Acuna

et al. 2023

Critical Care Medicine

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Objectives: High mechanical power and driving pressure (ΔP) have been associated with postoperative respiratory failure (PRF) and may be important parameters guiding mechanical ventilation. However, it remains unclear whether high mechanical power and ΔP merely reflect patients with poor respiratory system mechanics at risk of PRF. We investigated the effect of mechanical power and ΔP on PRF in cohorts after exact matching by patients’ baseline respiratory system compliance. Design: Hospital registry study. Setting: Academic hospital in New England. Patients: Adult patients undergoing general anesthesia between 2008 and 2020. Intervention: None. Measurements and Main Results: The primary exposure was high (≥ 6.7 J/min, cohort median) versus low mechanical power and the key-secondary exposure was high (≥ 15.0 cm H2O) versus low ΔP. The primary endpoint was PRF (reintubation or unplanned noninvasive ventilation within seven days). Among 97,555 included patients, 4,030 (4.1%) developed PRF. In adjusted analyses, high intraoperative mechanical power and ΔP were associated with higher odds of PRF (adjusted odds ratio [aOR] 1.37 [95% CI, 1.25–1.50]; p < 0.001 and aOR 1.45 [95% CI, 1.31–1.60]; p < 0.001, respectively). There was large variability in applied ventilatory parameters, dependent on the anesthesia provider. This facilitated matching of 63,612 (mechanical power cohort) and 53,260 (ΔP cohort) patients, yielding identical baseline standardized respiratory system compliance (standardized difference [SDiff] = 0.00) with distinctly different mechanical power (9.4 [2.4] vs 4.9 [1.3] J/min; SDiff = –2.33) and ΔP (19.3 [4.1] vs 11.9 [2.1] cm H2O; SDiff = –2.27). After matching, high mechanical power and ΔP remained associated with higher risk of PRF (aOR 1.30 [95% CI, 1.17–1.45]; p < 0.001 and aOR 1.28 [95% CI, 1.12–1.46]; p < 0.001, respectively). Conclusions: High mechanical power and ΔP are associated with PRF independent of patient’s baseline respiratory system compliance. Our findings support utilization of these parameters for titrating mechanical ventilation in the operating room and ICU.

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Section: Discussionsupporting

confidence: 89%

High Mechanical Power and Driving Pressures are Associated With Postoperative Respiratory Failure Independent From Patients’ Respiratory System Mechanics*

Tartler,

Ahrens,

Munoz-Acuna

et al. 2023

Critical Care Medicine

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“…After the univariate analysis, higher intraoperative FiO 2 , driving pressure, and average inspiratory pressure during OLV were observed in patients with PPCs. Whether more invasive ventilatory settings and higher intraoperative oxygen demand reflect the effects of preexisting structural lung disease [ 21 ], or whether it may contribute to ventilator-induced injury, remains unclear in our study and would require further investigation considering the complexity of ventilator-induced injury in thoracic surgery [ 22 , 23 ]. If invasive ventilation remains, despite trials of optimization, it could identify patients at risk and trigger necessary perioperative measures, such as admission to intensive care, or intensified chest and general physiotherapy.…”

Section: Discussionmentioning

confidence: 99%

“…Pulmonary hyperperfusion and fluid overload have been shown to be causative of PPCs in thoracic surgery and pneumonectomy patients [ 22 , 27 , 28 ]. The concept of restrictive fluid management in lung resection surgery is well established, although the thresholds are not clear, and postresection lung injury is not limited to the intraoperative fluid volume alone [ 29 , 30 , 31 , 32 , 33 , 34 , 35 ].…”

Section: Discussionmentioning

confidence: 99%

The Impact of Postoperative Pulmonary Complications on Perioperative Outcomes in Patients Undergoing Pneumonectomy: A Multicenter Retrospective Cohort Study of the German Thorax Registry

Semmelmann,

Baar,

Fellmann

et al. 2023

JCM

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Postoperative pulmonary complications have a deleterious impact in regards to thoracic surgery. Pneumonectomy is associated with the highest perioperative risk in elective thoracic surgery. The data from 152 patients undergoing pneumonectomy in this multicenter retrospective study were extracted from the German Thorax Registry database and presented after univariate and multivariate statistical processing. This retrospective study investigated the incidence of postoperative pulmonary complications (PPCs) and their impact on perioperative morbidity and mortality. Patient-specific, preoperative, procedural, and postoperative risk factors for PPCs and in-hospital mortality were analyzed. A total of 32 (21%) patients exhibited one or more PPCs, and 11 (7%) died during the hospital stay. Multivariate stepwise logistic regression identified a preoperative FEV1 < 50% (OR 9.1, 95% CI 1.9–67), the presence of medical complications (OR 7.4, 95% CI 2.7–16.2), and an ICU stay of more than 2 days (OR 14, 95% CI 3.9–59) as independent factors associated with PPCs. PPCs (OR 13, 95% CI 3.2–52), a preoperative FEV1 < 60% in patients with previous pulmonary infection (OR 21, 95% CI 3.2–52), and continued postoperative mechanical ventilation (OR 8.4, 95% CI 2–34) were independent factors for in-hospital mortality. Our data emphasizes that PPCs are a significant risk factor for morbidity and mortality after pneumonectomy. Intensified perioperative care targeting the underlying risk factors and effects of PPCs, postoperative ventilation, and preoperative respiratory infections, especially in patients with reduced pulmonary reserve, could improve patient outcomes.

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“…Accordingly, exploratory analyses revealed that males were less likely to require PMV despite higher MP, demonstrating significantly lower power density (owing to higher dynamic compliance) than female recipients. Given that MP is thought to significantly contribute to ventilator-induced lung injury [ 6 , 43 ], the question arises whether MP is a cause or correlate of impaired respiratory mechanics associated with inferior outcomes [ 44 ].…”

Section: Discussionmentioning

confidence: 99%

Mechanical Power Density Predicts Prolonged Ventilation Following Double Lung Transplantation

Ghiani,

Kneidinger,

Neurohr

et al. 2023

Transpl Int

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Prolonged mechanical ventilation (PMV) after lung transplantation poses several risks, including higher tracheostomy rates and increased in-hospital mortality. Mechanical power (MP) of artificial ventilation unifies the ventilatory variables that determine gas exchange and may be related to allograft function following transplant, affecting ventilator weaning. We retrospectively analyzed consecutive double lung transplant recipients at a national transplant center, ventilated through endotracheal tubes upon ICU admission, excluding those receiving extracorporeal support. MP and derived indexes assessed up to 36 h after transplant were correlated with invasive ventilation duration using Spearman’s coefficient, and we conducted receiver operating characteristic (ROC) curve analysis to evaluate the accuracy in predicting PMV (>72 h), expressed as area under the ROC curve (AUROC). PMV occurred in 82 (35%) out of 237 cases. MP was significantly correlated with invasive ventilation duration (Spearman’s ρ = 0.252 [95% CI 0.129–0.369], p < 0.01), with power density (MP normalized to lung-thorax compliance) demonstrating the strongest correlation (ρ = 0.452 [0.345–0.548], p < 0.01) and enhancing PMV prediction (AUROC 0.78 [95% CI 0.72–0.83], p < 0.01) compared to MP (AUROC 0.66 [0.60–0.72], p < 0.01). Mechanical power density may help identify patients at risk for PMV after double lung transplantation.

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Mechanical Power: Correlate or Cause of Ventilator-induced Lung Injury?

Abstract: This editorial accompanies the article on p. 41. This article has an audio podcast.

Cited by 9 publications

References 14 publications

High Mechanical Power and Driving Pressures are Associated With Postoperative Respiratory Failure Independent From Patients’ Respiratory System Mechanics*

High Mechanical Power and Driving Pressures are Associated With Postoperative Respiratory Failure Independent From Patients’ Respiratory System Mechanics*

The Impact of Postoperative Pulmonary Complications on Perioperative Outcomes in Patients Undergoing Pneumonectomy: A Multicenter Retrospective Cohort Study of the German Thorax Registry

Mechanical Power Density Predicts Prolonged Ventilation Following Double Lung Transplantation

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