Protective versus Conventional Ventilation for Surgery
Tóm tắt
Recent studies show that intraoperative mechanical ventilation using low tidal volumes (VT) can prevent postoperative pulmonary complications (PPCs). The aim of this individual patient data meta-analysis is to evaluate the individual associations between VT size and positive end–expiratory pressure (PEEP) level and occurrence of PPC.
Randomized controlled trials comparing protective ventilation (low VT with or without high levels of PEEP) and conventional ventilation (high VT with low PEEP) in patients undergoing general surgery. The primary outcome was development of PPC. Predefined prognostic factors were tested using multivariate logistic regression.
Fifteen randomized controlled trials were included (2,127 patients). There were 97 cases of PPC in 1,118 patients (8.7%) assigned to protective ventilation and 148 cases in 1,009 patients (14.7%) assigned to conventional ventilation (adjusted relative risk, 0.64; 95% CI, 0.46 to 0.88; P < 0.01). There were 85 cases of PPC in 957 patients (8.9%) assigned to ventilation with low VT and high PEEP levels and 63 cases in 525 patients (12%) assigned to ventilation with low VT and low PEEP levels (adjusted relative risk, 0.93; 95% CI, 0.64 to 1.37; P = 0.72). A dose–response relationship was found between the appearance of PPC and VT size (R2 = 0.39) but not between the appearance of PPC and PEEP level (R2 = 0.08).
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.
Từ khóa
Tài liệu tham khảo
2012, Mortality after surgery in Europe: A 7 day cohort study., Lancet, 380, 1059, 10.1016/S0140-6736(12)61148-9
2010, Prediction of postoperative pulmonary complications in a population-based surgical cohort., Anesthesiology, 113, 1338, 10.1097/ALN.0b013e3181fc6e0a
2012, Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: A meta-analysis., JAMA, 308, 1651, 10.1001/jama.2012.13730
2013, A trial of intraoperative low-tidal-volume ventilation in abdominal surgery., N Engl J Med, 369, 428, 10.1056/NEJMoa1301082
2013, Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function., Anesthesiology, 118, 1307, 10.1097/ALN.0b013e31829102de
The PROVE Network Investigators, 2014, Higher versus lower positive end-expiratory pressure during general anaesthesia for open abdominal surgery—The PROVHILO trial., Lancet, 384, 495, 10.1016/S0140-6736(14)60416-5
2014, Low intraoperative tidal volume ventilation with minimal PEEP is associated with increased mortality., Br J Anaesth, 113, 97, 10.1093/bja/aeu054
2014, Protocol for a systematic review and individual patient data meta-analysis of benefit of so-called lung-protective ventilation settings in patients under general anesthesia for surgery., Syst Rev, 3, 2, 10.1186/2046-4053-3-2
2000, Protective ventilation attenuates postoperative pulmonary dysfunction in patients undergoing cardiopulmonary bypass., J Cardiothorac Vasc Anesth, 14, 514, 10.1053/jcan.2000.9487
2004, Effects of protective and conventional mechanical ventilation on pulmonary function and systemic cytokine release after cardiopulmonary bypass., Intensive Care Med, 30, 620, 10.1007/s00134-003-2104-5
2006, Protective ventilation influences systemic inflammation after esophagectomy: A randomized controlled study., Anesthesiology, 105, 911, 10.1097/00000542-200611000-00011
2007, Effect of low tidal volume ventilation on atelectasis in patients during general anesthesia: A computed tomographic scan., J Clin Anesth, 19, 125, 10.1016/j.jclinane.2006.08.008
2011, Does a protective ventilation strategy reduce the risk of pulmonary complications after lung cancer surgery? A randomized controlled trial., Chest, 139, 530, 10.1378/chest.09-2293
2012, Comparison between conventional and protective one-lung ventilation for ventilator-assisted thoracic surgery., Anaesth Intensive Care, 40, 780, 10.1177/0310057X1204000505
2004, The effects of different ventilatory settings on pulmonary and systemic inflammatory responses during major surgery., Anesth Analg, 98, 775
2005, Mechanical ventilation affects inflammatory mediators in patients undergoing cardiopulmonary bypass for cardiac surgery: A randomized clinical trial., J Thorac Cardiovasc Surg, 130, 378, 10.1016/j.jtcvs.2004.11.061
2005, Ventilation according to the open lung concept attenuates pulmonary inflammatory response in cardiac surgery., Eur J Cardiothorac Surg, 28, 889, 10.1016/j.ejcts.2005.10.007
2005, The pulmonary immune effects of mechanical ventilation in patients undergoing thoracic surgery., Anesth Analg, 101, 957, 10.1213/01.ane.0000172112.02902.77
2008, Mechanical ventilation with lower tidal volumes and positive end-expiratory pressure prevents pulmonary inflammation in patients without preexisting lung injury., Anesthesiology, 108, 46, 10.1097/01.anes.0000296068.80921.10
2008, [Effects of the lung protective ventilatory strategy on proinflammatory cytokine release during one-lung ventilation]., Ai Zheng, 27, 870
2010, Comparison of two ventilatory strategies in elderly patients undergoing major abdominal surgery., Br J Anaesth, 104, 16, 10.1093/bja/aep319
2011, Influence of low tidal volume ventilation on time to extubation in cardiac surgical patients., Anesthesiology, 114, 1102, 10.1097/ALN.0b013e318215e254
2012, Ventilation with low tidal volumes during upper abdominal surgery does not improve postoperative lung function., Br J Anaesth, 109, 263, 10.1093/bja/aes140
2012, The effect of low versus high tidal volume ventilation on inflammatory markers in healthy individuals undergoing posterior spine fusion in the prone position: A randomized controlled trial., J Clin Anesth, 24, 263, 10.1016/j.jclinane.2011.08.003
2012, Alveolar recruitment improves ventilation during thoracic surgery: A randomized controlled trial., Br J Anaesth, 108, 517, 10.1093/bja/aer415
2013, A randomized comparison of different ventilator strategies during thoracotomy for pulmonary resection., J Thorac Cardiovasc Surg, 146, 38, 10.1016/j.jtcvs.2013.01.021
Acute Respiratory Distress Syndrome Network, 2000, Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome., N Engl J Med, 342, 1301, 10.1056/NEJM200005043421801
2013, Clinical outcomes of patients requiring ventilatory support in Brazilian intensive care units: A multicenter, prospective, cohort study., Crit Care, 17, R63, 10.1186/cc12594
2013, Evolution of mortality over time in patients receiving mechanical ventilation., Am J Respir Crit Care Med, 188, 220, 10.1164/rccm.201212-2169OC
2009, Mechanical ventilation using non-injurious ventilation settings causes lung injury in the absence of pre-existing lung injury in healthy mice., Crit Care, 13, R1, 10.1186/cc7688
2013, The extent of ventilator-induced lung injury in mice partly depends on duration of mechanical ventilation., Crit Care Res Pract, 2013, 435236
2013, Pulmonary vascular dysfunction induced by high tidal volume mechanical ventilation., Crit Care Med, 41, e149, 10.1097/CCM.0b013e318287ef4a
2004, Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation., Crit Care Med, 32, 1817, 10.1097/01.CCM.0000133019.52531.30
2012, A multicentre observational study of intra-operative ventilatory management during general anaesthesia: Tidal volumes and relation to body weight., Anaesthesia, 67, 999, 10.1111/j.1365-2044.2012.07218.x
2009, Intraoperative ventilator settings and acute lung injury after elective surgery: A nested case control study., Thorax, 64, 121, 10.1136/thx.2008.102228
2006, Lung recruitment in patients with the acute respiratory distress syndrome., N Engl J Med, 354, 1775, 10.1056/NEJMoa052052
1994, Tidal ventilation at low airway pressures can augment lung injury., Am J Respir Crit Care Med, 149, 1327, 10.1164/ajrccm.149.5.8173774
2010, Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: Systematic review and meta-analysis., JAMA, 303, 865, 10.1001/jama.2010.218
1997, The hemodynamic consequences of mechanical ventilation: An evolving story., Intensive Care Med, 23, 493, 10.1007/s001340050364
2014, Volutrauma, but not atelectrauma, induces systemic cytokine production by lung-marginated monocytes., Crit Care Med, 42, e49, 10.1097/CCM.0b013e31829a822a