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Protective versus Conventional Ventilation for Surgery: A Systematic Review and Individual Patient Data

Ary Serpa Neto1, Sabrine N T Hemmes, Carmen S V Barbas

  • 1From the Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands (A.S.N., S.N.T.H., J.M.B., M.W.H., E.K.W., M.J.S.); Department of Pneumology, Heart Institute (INCOR), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil (A.S.N., C.S.V.B.); Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil (A.S.N., C.S.V.B.); Department of Anaesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany (M. Beiderlinden, T.T.); Department of Anaesthesiology, Marienhospital Osnabrück, Osnabrück, Germany (M. Beiderlinden); Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota (M. Biehl, O.G., J.S.); Department of Anesthesiology, Hospital Universitar I Germans Trias I Pujol, Barcelona, Spain (J.C.); Department of Anesthesiology, University of Colorado, Aurora, Colorado (A.F.-B., P.M.); Department of Anesthesiology and Critical Care Medicine, Estaing University Hospital, Clermont-Ferrand, France (E.F.); Department of Medical Sciences, Section of Clinical Physiology, University Hospital, Uppsala, Sweden (G.H.); Department of Critical Care Medicine and Anesthesiology (SAR B), Saint Eloi University Hospital, Montpellier, France (S.J.); Department of Anesthesiology and Intensive Care Medicine, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany (A.K., T.S.); Department of Anaesthesiology, Pharmacology and Intensive Care, Faculty of Medicine, University Hospital of Geneva, Geneva, Switzerland (M.L.); State Key Laboratory of Oncology of South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, People's Republic of China (W.-Q.L.); Department of Anesthesiology, The Warren Alpert School of Brown University, Providence, Rhode Island (A.D.M.); Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York (S.G.M.); Department of Intensive Ca

Anesthesiology
|May 16, 2015
PubMed

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Summary

Using low tidal volumes (VT) during mechanical ventilation significantly reduces postoperative pulmonary complications (PPCs). Higher positive end-expiratory pressure (PEEP) levels did not show a similar benefit in this meta-analysis.

Area of Science:

  • Anesthesiology
  • Critical Care Medicine
  • Thoracic Surgery

Background:

  • Intraoperative mechanical ventilation with low tidal volumes (VT) is increasingly recognized for its potential to prevent postoperative pulmonary complications (PPCs).
  • The precise impact of VT size and positive end-expiratory pressure (PEEP) on PPC occurrence requires further elucidation.
  • This meta-analysis aims to clarify the individual associations between ventilation parameters and PPCs.

Purpose of the Study:

  • To evaluate the association between intraoperative tidal volume (VT) size and the occurrence of postoperative pulmonary complications (PPCs).
  • To assess the association between positive end-expiratory pressure (PEEP) levels during mechanical ventilation and PPCs.
  • To compare the efficacy of protective ventilation strategies (low VT with or without high PEEP) versus conventional ventilation (high VT) in preventing PPCs.

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Main Methods:

  • An individual patient data meta-analysis of randomized controlled trials (RCTs) was conducted.
  • Included RCTs compared protective ventilation (low VT ± high PEEP) with conventional ventilation (high VT, low PEEP) in general surgery patients.
  • Multivariate logistic regression was used to analyze predefined prognostic factors, with PPC as the primary outcome.

Main Results:

  • Fifteen RCTs comprising 2,127 patients were analyzed.
  • Protective ventilation (low VT) significantly reduced PPCs compared to conventional ventilation (adjusted RR, 0.64; P < 0.01).
  • A dose-response relationship was observed between decreasing VT size and reduced PPCs (R² = 0.39), but not between PEEP levels and PPCs (R² = 0.08).

Conclusions:

  • The findings strongly support the use of low tidal volumes during intraoperative mechanical ventilation to reduce PPCs.
  • Further research is needed to determine the optimal role of higher PEEP levels in preventing PPCs, particularly in non-open abdominal surgeries.
  • Low VT ventilation is a key component of lung-protective strategies in surgical patients.