Positive end-expiratory pressure (PEEP) during anaesthesia for prevention of mortality and postoperative pulmonary complications

Barbosa, Fabiano Timbó; Castro, Aldemar Araújo; Sousa‐Rodrigues, Célio Fernando de

doi:10.1002/14651858.cd007922.pub3

Cited by 33 publications

(31 citation statements)

References 72 publications

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“…The current study evaluated patients in both groups post-operatively via chest CT and found that protective ventilation was superior to conventional ventilation in the prevention of atelectasis, as reflected by a higher atelectasis score in the standard ventilation group, in which 52% of the patients developed atelectasis (40% showed lamellar atelectasis and 12% showed plate atelectasis), compared to 36% of the patients in the protective ventilation group (all these cases revealed lamellar atelectasis). This finding in consistent with that of Coussa et al [33], who reported similar results and concluded that the application of PEEP (10 cm H 2 O) in morbidly obese patients was very effective in preventing atelectasis during the induction of general anesthesia, as well as with that of Talab et al [16], who reported that the application of the VCM followed by 10 cm H 2 O of PEEP resulted in better intraoperative and postoperative oxygenation in addition to a lower atelectasis score on chest CT scans approximately 2 h postoperatively than those for the application of the VCM alone. Barbosa et al [34] performed a meta-analysis and suggested that an open lung approach with PEEP in surgical patients improves postoperative oxygenation and decreases post-operative atelectasis without any adverse events.…”

Section: Discussionsupporting

confidence: 94%

A Comparative Study between Protective Lung Ventilation versus Conventional Ventilation in Obese Patients Undergoing Abdominal Laparoscopic Surgery

Eldemrdash¹,

Gamaleldeen²,

Ahmed³

et al. 2017

J Anesth Clin Res

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Background: Obesity is a serious problem worldwide. During general anesthesia and post-operative period, obese patients more likely to develop post-operative pulmonary complications as atelectasis and impaired pulmonary function compared to non-obese. Intraoperative protective ventilation consisting of low tidal volume, high PEEP and recruitment maneuvers resulted in alveolar recruitment and optimization of intraoperative respiratory mechanics.

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Section: Discussionsupporting

confidence: 94%

A Comparative Study between Protective Lung Ventilation versus Conventional Ventilation in Obese Patients Undergoing Abdominal Laparoscopic Surgery

Eldemrdash¹,

Gamaleldeen²,

Ahmed³

et al. 2017

J Anesth Clin Res

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“…The effect of PEEP and FiO 2 on PPCs was less clear and is controversial in the literature. 12,29,30 Our observed narrow range of PEEP and FiO 2 may have influenced the lack of a detectable effect. Future specific studies will be required to establish the effect of those variables on surgical outcomes.…”

Section: Discussionmentioning

confidence: 83%

Postoperative Pulmonary Complications, Early Mortality, and Hospital Stay Following Noncardiothoracic Surgery

et al. 2017

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IMPORTANCE Postoperative pulmonary complications (PPCs), a leading cause of poor surgical outcomes, are heterogeneous in their pathophysiology, severity, and reporting accuracy. OBJECTIVE To prospectively study clinical and radiological PPCs and respiratory insufficiency therapies in a high-risk surgical population. DESIGN, SETTING, AND PARTICIPANTS We performed a multicenter prospective observational study in 7 US academic institutions. American Society of Anesthesiologists physical status 3 patients who presented for noncardiothoracic surgery requiring 2 hours or more of general anesthesia with mechanical ventilation from May to November 2014 were included in the study. We hypothesized that PPCs, even mild, would be associated with early postoperative mortality and use of hospital resources. We analyzed their association with modifiable perioperative variables. EXPOSURE Noncardiothoracic surgery. MAIN OUTCOMES AND MEASURES Predefined PPCs occurring within the first 7 postoperative days were prospectively identified. We used bivariable and logistic regression analyses to study the association of PPCs with ventilatory and other perioperative variables. RESULTS This study included 1202 patients who underwent predominantly abdominal, orthopedic, and neurological procedures. The mean (SD) age of patients was 62.1 (13.8) years, and 636 (52.9%) were men. At least 1 PPC occurred in 401 patients (33.4%), mainly the need for prolonged oxygen therapy by nasal cannula (n = 235; 19.6%) and atelectasis (n = 206; 17.1%). Patients with 1 or more PPCs, even mild, had significantly increased early postoperative mortality, intensive care unit (ICU) admission, and ICU/hospital length of stay. Significant PPC risk factors included nonmodifiable (emergency [yes vs no]: odds ratio [OR], 4.47, 95% CI, 1.59–12.56; surgical site [abdominal/pelvic vs nonabdominal/pelvic]: OR, 2.54, 95% CI, 1.67–3.89; and age [in years]: OR, 1.03, 95% CI, 1.02–1.05) and potentially modifiable (colloid administration [yes vs no]: OR, 1.75, 95% CI, 1.03–2.97; preoperative oxygenation: OR, 0.86, 95% CI, 0.80–0.93; blood loss [in milliliters]: OR, 1.17, 95% CI, 1.05–1.30; anesthesia duration [in minutes]: OR, 1.14, 95% CI, 1.05–1.24; and tidal volume [in milliliters per kilogram of predicted body weight]: OR, 1.12, 95% CI, 1.01–1.24) factors. CONCLUSIONS AND RELEVANCE Postoperative pulmonary complications are common in patients with American Society of Anesthesiologists physical status 3, despite current protective ventilation practices. Even mild PPCs are associated with increased early postoperative mortality, ICU admission, and length of stay (ICU and hospital). Mild frequent PPCs (eg, atelectasis and prolonged oxygen therapy need) deserve increased attention and intervention for improving perioperative outcomes.

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“…14 A review including 10 randomized controlled trials with a limited number of patients concluded that evidence for the effect of intra-operative PEEP on postoperative mortality and respiratory complications is insufficient, and suggested differential effects of PEEP depending on the type of surgery. 28 …”

Section: Discussionmentioning

confidence: 99%

Differential Effects of Intraoperative Positive End-expiratory Pressure (PEEP) on Respiratory Outcome in Major Abdominal Surgery Versus Craniotomy

et al. 2016

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Objectives In this study, we examined whether (1) positive end-expiratory pressure (PEEP) has a protective effect on the risk of major postoperative respiratory complications in a cohort of patients undergoing major abdominal surgeries and craniotomies, and (2) the effect of PEEP is differed by surgery type. Background Protective mechanical ventilation with lower tidal volumes and PEEP reduces compounded postoperative complications after abdominal surgery. However, data regarding the use of intraoperative PEEP is conflicting. Methods In this observational study, we included 5915 major abdominal surgery patients and 5063 craniotomy patients. Analysis was performed using multivariable logistic regression. The primary outcome was a composite of major postoperative respiratory complications (respiratory failure, reintubation, pulmonary edema, and pneumonia) within 3 days of surgery. Results Within the entire study population (major abdominal surgeries and craniotomies), we found an association between application of PEEP ≥5cmH2O and a decreased risk of postoperative respiratory complications compared with PEEP <5cmH2O. Application of PEEP >5cmH2O was associated with a significant lower odds of respiratory complications in patients undergoing major abdominal surgery (odds ratio 0.53, 95% confidence interval 0.39 – 0.72), effects that translated to deceased hospital length of stay [median hospital length of stay : 6 days (4–9 days), incidence rate ratios for each additional day: 0.91 (0.84 - 0.98)], whereas PEEP >5cmH2O was not significantly associated with reduced odds of respiratory complications or hospital length of stay in patients undergoing craniotomy. Conclusions The protective effects of PEEP are procedure specific with meaningful effects observed in patients undergoing major abdominal surgery. Our data suggest that default mechanical ventilator settings should include PEEP of 5–10cmH2O during major abdominal surgery.

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Positive end-expiratory pressure (PEEP) during anaesthesia for prevention of mortality and postoperative pulmonary complications

Cited by 33 publications

References 72 publications

A Comparative Study between Protective Lung Ventilation versus Conventional Ventilation in Obese Patients Undergoing Abdominal Laparoscopic Surgery

A Comparative Study between Protective Lung Ventilation versus Conventional Ventilation in Obese Patients Undergoing Abdominal Laparoscopic Surgery

Postoperative Pulmonary Complications, Early Mortality, and Hospital Stay Following Noncardiothoracic Surgery

Differential Effects of Intraoperative Positive End-expiratory Pressure (PEEP) on Respiratory Outcome in Major Abdominal Surgery Versus Craniotomy

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