Driving Pressure during Thoracic Surgery

Abstract

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Recently, several retrospective studies have suggested that pulmonary complication is related with driving pressure more than any other ventilatory parameter. Thus, the authors compared driving pressure–guided ventilation with conventional protective ventilation in thoracic surgery, where lung protection is of the utmost importance. The authors hypothesized that driving pressure–guided ventilation decreases postoperative pulmonary complications more than conventional protective ventilation. Methods In this double-blind, randomized, controlled study, 292 patients scheduled for elective thoracic surgery were included in the analysis. The protective ventilation group (n = 147) received conventional protective ventilation during one-lung ventilation: tidal volume 6 ml/kg of ideal body weight, positive end-expiratory pressure (PEEP) 5 cm H2O, and recruitment maneuver. The driving pressure group (n = 145) received the same tidal volume and recruitment, but with individualized PEEP which produces the lowest driving pressure (plateau pressure–PEEP) during one-lung ventilation. The primary outcome was postoperative pulmonary complications based on the Melbourne Group Scale (at least 4) until postoperative day 3. Results Melbourne Group Scale of at least 4 occurred in 8 of 145 patients (5.5%) in the driving pressure group, as compared with 18 of 147 (12.2%) in the protective ventilation group (P = 0.047, odds ratio 0.42; 95% CI, 0.18 to 0.99). The number of patients who developed pneumonia or acute respiratory distress syndrome was less in the driving pressure group than in the protective ventilation group (10/145 [6.9%] vs. 22/147 [15.0%], P = 0.028, odds ratio 0.42; 95% CI, 0.19 to 0.92). Conclusions Application of driving pressure–guided ventilation during one-lung ventilation was associated with a lower incidence of postoperative pulmonary complications compared with conventional protective ventilation in thoracic surgery.

Driving Pressure During General Anesthesia for Open Abdominal Surgery (DESIGNATION): study protocol of a randomized clinical trial

“…In the DESIGNATION trial, the level of PEEP that results in the lowest ΔP will be identified by the decremental PEEP trial. While in one previous trial of individualized PEEP, an incremental PEEP trial was used to find the best level of PEEP [16], here a decremental PEEP trial is chosen to ascertain that the resulting PEEP sustains the beneficial effects of the RM before the PEEP trial. This cannot be guaranteed when using an incremental PEEP trial, because PEEP is most likely below the closing pressure at start of an incremental PEEP trial.…”

“…Patients in the "low PEEP" group receive ventilation with PEEP 5 cm H 2 O. The decision to use a PEEP of 5 cm H 2 O derives from previous trials of intraoperative ventilation [15,16]. PEEP 5 cm H 2 O is the most frequently chosen level in daily practice [1,36]; although there is no absolute consensus on the best level of PEEP, the overall recommendation is to ventilate patients with healthy lungs with this PEEP level.…”

“…However, the individualized PEEP strategy did reduce PPC, one of the secondary endpoints of that study [15]. Another RCT, in patients undergoing intraoperative one-lung ventilation for thoracic surgery, also showed an individualized high PEEP strategy to protect against PPC [16], albeit at a low fragility index [17]. Thus, the results of these two RCTs should be interpreted with caution.…”

Does a pulmonary rehabilitation based ERAS program (PREP) affect pulmonary complication incidence, pulmonary function and quality of life after lung cancer surgery? Study protocol for a multicenter randomized controlled trial

“…The primary outcome of the PREP trial is the incidence of PPCs within the first 14 post-operative days. PPCs is defined with the Melbourne Group Scale (MGS) diagnostic scoring tool, which is reliable and valid following thoracic surgery with high inter-rater reliability [35][36][37]. A PPC will be diagnosed when the following four or more factors are identified: 1) new abnormal breath sounds different to pre-operative; 2) chest X-ray findings of atelectasis or consolidation; 3) raised white cell count (WCC) (> 11 × 10 9 /L); 4) temperature > 38°C; 5) purulent sputum differing from preoperative status; 6) signs of infection on sputum culture; 7) pulse oximetry oxygen saturation (SpO 2 ) < 90% without oxygen therapy; and 8) pneumonia diagnosed based on physician's experience [38].…”

The effects of protective lung ventilation on regional cerebral oxygen saturation in intracranial tumor operation during dura opening: study protocol for a randomized controlled trial

“…In the P group, VT will be set at 6 ml/kg of predicted body weight combined with individualized PEEP during intraoperative dura mater opening [6,7], but in other periods of general anesthesia, VT will be set at 8 ml/kg of predicted body weight. For the titration method of individualized PEEP [19], VT and respiratory rate will be fixed at 6 ml/kg and 15 beats per minute during PEEP trial. Titration can only begin once the dura is opened.…”