Protective <i>versus</i> Conventional Ventilation for Surgery

Neto, Ary Serpa; Hemmes, Sabrine N.T.; Barbas, Carmen Sílvia Valente; Beiderlinden, Martin; Biehl, Michelle; Binnekade, Jan M.; Canet, Jaume; Fernandez-Bustamante, Ana; Futier, Emmanuel; Gajic, Ognjen; Hedenstierna, Göran; Hollmann, Markus W.; Jaber, Samir; Kozian, Alf; Licker, Marc; Lin, Wen‐Shan; Maslow, Andrew; Memtsoudis, Stavros G.; Miranda, Dinis Reis; Moine, Pierre; Ng, Tony; Paparella, Domenico; Putensen, Christian; Ranieri, Marco; Scavonetto, Federica; Schilling, Thomas; Schmid, Werner; Selmo, Gabriele; Severgnini, Paolo; Šprung, Juraj; Sundar, Sugantha; Talmor, Daniel; Treschan, Tanja A.; Unzueta, Carmen; Weingarten, Toby N.; Wolthuis, Esther K.; Wrigge, Hermann; Abreu, Marcelo Gama de; Pelosi, Paolo; Schultz, Marcus J.

doi:10.1097/aln.0000000000000706

Cited by 286 publications

(109 citation statements)

References 38 publications

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“…One more recent randomized controlled trial, however, showed no difference in the incidence of pulmonary complication when two different levels of PEEP were compared during low tidal volume ventilation [50]. Interestingly in this context is that a recent individual patient meta-analysis of intraoperative ventilation settings suggests that benefit mainly comes from tidal volume reductions, and not increases in PEEP, in patients undergoing mechanical ventilation for general anesthesia for surgery [51]. …”

Section: Discussionmentioning

confidence: 99%

Associations between positive end-expiratory pressure and outcome of patients without ARDS at onset of ventilation: a systematic review and meta-analysis of randomized controlled trials

Neto

Filho

Cherpanath

et al. 2016

Ann. Intensive Care

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BackgroundThe aim of this investigation was to compare ventilation at different levels of positive end-expiratory pressure (PEEP) with regard to clinical important outcomes of intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) at onset of ventilation.MethodsMeta-analysis of randomized controlled trials (RCTs) comparing a lower level of PEEP with a higher level of PEEP was performed. The primary outcome was in-hospital mortality.ResultsTwenty-one RCTs (1393 patients) were eligible. PEEP ranged from 0 to 10 cmH2O and from 5 to 30 cmH2O in the lower PEEP and the higher PEEP arms of included RCTs, respectively. In-hospital mortality was not different between the two PEEP arms in seven RCTs (risk ratio [RR] 0.87; 95% confidence interval [CI] 0.62–1.21; I 2 = 26%, low quality of evidence [QoE]), as was duration of mechanical ventilation in three RCTs (standardized mean difference [SMD] 0.68; 95% CI −0.24 to 1.61; I 2 = 82%, very low QoE). PaO2/FiO2 was higher in the higher PEEP arms in five RCTs (SMD 0.72; 95% CI 0.10–1.35; I 2 = 86%, very low QoE). Development of ARDS and the occurrence of hypoxemia (2 RCTs) were lower in the higher PEEP arms in four RCTs and two RCTs, respectively (RR 0.43; 95% CI 0.21–0.91; I 2 = 56%, low QoE; RR 0.42; 95%–CI 0.19–0.92; I 2 = 19%, low QoE). There was no association between the level of PEEP and any hemodynamic parameter (four RCTs).ConclusionVentilation with higher levels of PEEP in ICU patients without ARDS at onset of ventilation was not associated with lower in-hospital mortality or shorter duration of ventilation, but with a lower incidence of ARDS and hypoxemia, as well as higher PaO2/FiO2. These findings should be interpreted with caution, as heterogeneity was moderate to high, the QoE was low to very low, and the available studies prevented us from addressing the effects of moderate levels of PEEP.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-016-0208-7) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Associations between positive end-expiratory pressure and outcome of patients without ARDS at onset of ventilation: a systematic review and meta-analysis of randomized controlled trials

Neto

Filho

Cherpanath

et al. 2016

Ann. Intensive Care

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“…Although use of higher tidal volumes may be influenced by inaccuracies in calculating PBW, it is also likely that a belief may continue among anesthesiologists that lower tidal volumes are harmful 1416. However, high quality data exist to suggest the opposite 9444546474849…”

Section: Evidence Based Strategies For Perioperative Lung Protective mentioning

confidence: 99%

“…Regardless, the results contribute to a body of evidence that is still inconclusive regarding the benefit of higher PEEP in the intraoperative population. For example, an updated patient level meta-analysis after PROVHILO showed no difference in incidence of PPC between patients ventilated with less than 5 cm H 2 O and those with 5 cm H 2 O or higher PEEP 49. Drawing from this conclusion and incorporating the knowledge from the ARDS literature that high PEEP may benefit only patients with more severe disease, it may be reasonable to infer that higher PEEP is not necessary for most of the intraoperative population but can be considered for patients at very high risk for atelectasis or with concomitant lung injury 65.…”

Section: Evidence Based Strategies For Perioperative Lung Protective mentioning

confidence: 99%

“…Although many descriptions have been used, some consensus has recently been reached as to how IOLPV should be defined 49. For the purposes of this review, we will accordingly define IOLPV as the combination of tidal volume 8 mL/kg PBW or lower and PEEP 5 cm H 2 O or higher, with or without a recruitment maneuver.…”

Section: Evidence Based Strategies For Perioperative Lung Protective mentioning

confidence: 99%

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Perioperative lung protective ventilation

O’Gara

Talmor

2018

BMJ

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Perioperative lung injury is a major source of postoperative morbidity, excess healthcare use, and avoidable mortality. Many potential inciting factors can lead to this condition, including intraoperative ventilator induced lung injury. Questions exist as to whether protective ventilation strategies used in the intensive care unit for patients with acute respiratory distress syndrome are equally beneficial for surgical patients, most of whom do not present with any pre-existing lung pathology. Studied both individually and in combination as a package of intraoperative lung protective ventilation, the use of low tidal volumes, moderate positive end expiratory pressure, and recruitment maneuvers have been shown to improve oxygenation and pulmonary physiology and to reduce postoperative pulmonary complications in at risk patient groups. Further work is needed to define the potential contributions of alternative ventilator strategies, limiting excessive intraoperative oxygen supplementation, use of non-invasive techniques in the postoperative period, and personalized mechanical ventilation. Although the weight of evidence strongly suggests a role for lung protective ventilation in moderate risk patient groups, definitive evidence of its benefit for the general surgical population does not exist. However, given the shift in understanding of what is needed for adequate oxygenation and ventilation under anesthesia, the largely historical arguments against the use of intraoperative lung protective ventilation may soon be outdated, on the basis of its expanding track record of safety and efficacy in multiple settings.

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“…results Logistic regression analysis showed active smoking was associated with an increase in ARDS (OR 3.91; 95% CI 1.33 to 11.5) and dihydropyridine use (OR 5.34;95% CI 1.56 to 18.3). Hospital length of stay was longer for those who took dihydropyridines (median 29 days (IQR 17-42) vs 13 days (IQR 10-18), P=0.0007) or were diabetic (median 25 days (IQR 14-39) vs 13 (IQR [10][11][12][13][14][15][16][17][18][19], P=0.023) but not for current smokers (median in never/ex-smokers 13 (IQR 10-23) vs current smokers [15][16][17][18][19][20], P=0.73). conclusions Smoking cessation trials should be promoted.…”

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confidence: 99%

ARDS following oesophagectomy: a comparison of two trials

et al. 2017

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IntroductionThe Beta Agonist Lung Injury Trial-Prevention (BALTI-P) translational substudy and Vitamin D to Prevent Acute Lung Injury Following Oesophagectomy (VINDALOO) trials recruited patients undergoing oesophagectomy, 4 years apart. The acute respiratory distress syndrome (ARDS) rates were lower in the VINDALOO trial. We sought to identify changes between these two trials and identify risk factors for ARDS in oesophagectomy.MethodsThere were data available from 61 patients in the BALTI-P substudy and 68 from VINDALOO. Databases were available for both trials; additional data were collected. Multivariate logistic regression was used to analyse risk factors for ARDS and postoperative complications in the cohorts combined.ResultsLogistic regression analysis showed active smoking was associated with an increase in ARDS (OR 3.91; 95% CI 1.33 to 11.5) and dihydropyridine use (OR 5.34;95% CI 1.56 to 18.3). Hospital length of stay was longer for those who took dihydropyridines (median 29 days (IQR 17–42) vs 13 days (IQR 10–18), P=0.0007) or were diabetic (median 25 days (IQR 14–39) vs 13 (IQR 10–19), P=0.023) but not for current smokers (median in never/ex-smokers 13 (IQR 10–23) vs current smokers 15 (IQR 11–20), P=0.73).ConclusionsSmoking cessation trials should be promoted. Dihydropyridine effects perioperatively require further clinical and mechanistic evaluation. Patients undergoing oesophagectomy are a useful model for studying perioperative ARDS.

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Protective versus Conventional Ventilation for Surgery

Abstract: These data support the beneficial effects of ventilation with use of low VT in patients undergoing surgery. Further trials are necessary to define the role of intraoperative higher PEEP to prevent PPC during nonopen abdominal surgery.

Cited by 286 publications

References 38 publications

Associations between positive end-expiratory pressure and outcome of patients without ARDS at onset of ventilation: a systematic review and meta-analysis of randomized controlled trials

Associations between positive end-expiratory pressure and outcome of patients without ARDS at onset of ventilation: a systematic review and meta-analysis of randomized controlled trials

Perioperative lung protective ventilation

ARDS following oesophagectomy: a comparison of two trials

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