Effect of Intraoperative Low Tidal Volume vs Conventional Tidal Volume on Postoperative Pulmonary Complications in Patients Undergoing Major Surgery

Karalapillai, Dharshi; Weinberg, Laurence; Peyton, Philip J; Ellard, Louise; Hu, Raymond; Pearce, Brett; Tan, Chong Oon; Story, David A; O’Donnell, Mark; Hamilton, Patrick; Oughton, Chad; Galtieri, Jonathan; Wilson, Anthony J.; Neto, Ary Serpa; Eastwood, Glenn M; Bellomo, Rinaldo; Jones, Daryl

doi:10.1001/jama.2020.12866

Cited by 124 publications

(154 citation statements)

References 19 publications

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“…In several trials, application of LPV in different types of surgery improved the rates of postoperative complications [ 14 , 15 , 18 ], postoperative arterial oxygenation and pulmonary function tests [ 15 ], and also decreased acute lung injury and atelectasis [ 19 ], as well as the need for reintubation [ 20 ], hemodynamic instability, and renal failure [ 21 ]. More recently, the enthusiasm for LPV has been mitigated by some studies reporting no outcome differences between low or high tidal volumes [ 22 ] and PEEP [ 23 , 24 ] during major surgeries. In addition, for fear of hypercapnia, the use of LPV strategies in cranial and spinal surgery is still debated because potentially contraindicated in neurosurgical patients [ 3 ].…”

Section: Discussionmentioning

confidence: 99%

Intraoperative protective ventilation in patients undergoing major neurosurgical interventions: a randomized clinical trial

Longhini

Pasin

Montagnini³

et al. 2021

BMC Anesthesiol

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Background Post-operative pulmonary complications (PPC) can develop in up to 13% of patients undergoing neurosurgical procedures and may adversely affect clinical outcome. The use of intraoperative lung protective ventilation (LPV) strategies, usually including the use of a low Vt, low PEEP and low plateau pressure, seem to reduce the risk of PPC and are strongly recommended in almost all surgical procedures. Nonetheless, feasibility of LPV strategies in neurosurgical patients are still debated because the use of low Vt during LPV might result in hypercapnia with detrimental effects on cerebrovascular physiology. Aim of our study was to determine whether LPV strategies would be feasible compared with a control group in adult patients undergoing cranial or spinal surgery. Methods This single-centre, pilot randomized clinical trial was conducted at the University Hospital “Maggiore della Carità” (Novara, Italy). Adult patients undergoing major cerebral or spinal neurosurgical interventions with risk index for pulmonary post-operative complications > 2 and not expected to need post-operative intensive care unit (ICU) admission were considered eligible. Patients were randomly assigned to either LPV (Vt = 6 ml/kg of ideal body weight (IBW), respiratory rate initially set at 16 breaths/min, PEEP at 5 cmH2O and application of a recruitment manoeuvre (RM) immediately after intubation and at every disconnection from the ventilator) or control treatment (Vt = 10 ml/kg of IBW, respiratory rate initially set at 6–8 breaths/min, no PEEP and no RM). Primary outcomes of the study were intraoperative adverse events, the level of cerebral tension at dura opening and the intraoperative control of PaCO2. Secondary outcomes were the rate of pulmonary and extrapulmonary complications, the number of unplanned ICU admissions, ICU and hospital lengths of stay and mortality. Results A total of 60 patients, 30 for each group, were randomized. During brain surgery, the number of episodes of intraoperative hypercapnia and grade of cerebral tension were similar between patients randomized to receive control or LPV strategies. No difference in the rate of intraoperative adverse events was found between groups. The rate of postoperative pulmonary and extrapulmonary complications and major clinical outcomes were similar between groups. Conclusions LPV strategies in patients undergoing major neurosurgical intervention are feasible. Larger clinical trials are needed to assess their role in postoperative clinical outcome improvements. Trial registration registered on the Australian New Zealand Clinical Trial Registry (www.anzctr.org.au), registration number ACTRN12615000707561.

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Section: Discussionmentioning

confidence: 99%

Intraoperative protective ventilation in patients undergoing major neurosurgical interventions: a randomized clinical trial

Longhini

Pasin

Montagnini³

et al. 2021

BMC Anesthesiol

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“…Similar results were received in a recent randomised clinical trial (RCT) of patients scheduled for one-lung ventilation during oesophagectomy; patients in the protective ventilation group (Vt 6 ml kg −1 PBW) had a greater need for vasopressors and also developed hypercapnia more frequently than patients in the conventional ventilation group (Vt 10 ml kg −1 PBW) [ 24 ]. Among adult patients undergoing major surgery, intraoperative ventilation with low tidal volume (6 ml kg −1 PBW) compared with conventional tidal volume (10 ml·kg −1 PBW), with PEEP applied equally between groups, did not significantly reduce pulmonary complications within the first 7 postoperative days [ 25 ].…”

Section: Discussionmentioning

confidence: 99%

Heart-Protective Mechanical Ventilation in Postoperative Cardiosurgical Patients

Мазурок

Kasherininov

Баутин

et al. 2021

Critical Care Research and Practice

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Background. This study compared the hemodynamic effects and gas exchange under several different ventilator settings—with regard to tidal volume, respiratory rate, and end-expiratory pressure—in patients after coronary artery bypass grafting (CABG). Methods. Prospective interventional cohort study with a controlled group in a single cardiosurgical ICU involving 119 patients following on-pump CABG surgery. During the 1st postoperative hour, the intervention group patients were ventilated with Vt 10 ml × kg−1, RR 14/min, PEEP 5 cmH2O (“conventional ventilation”). During the 2nd hour, RR was reduced to 8/min (“reduced RR ventilation”). At 3 hrs, Vt was decreased to 6 ml × kg−1, RR returned to 14/min, and PEEP increased to 10 cmH2O (“low Vt-high PEEP ventilation”). Results. Patients in the “low Vt-high PEEP” ventilation period showed significantly lower alveolar ventilation and thoraco-pulmonary compliance than during “reduced RR” ventilation. Mean airway pressure and Vds/Vt peaked during low Vt-high PEEP ventilation; however, driving pressure was lower. Vt decrease and PEEP increase did not lead to oxygenation improvement and worsened CO2 elimination. Hemodynamically, the study revealed significant cardiac output decrease during low Vt-high PEEP ventilation. In 23.2% of patients, catecholamine therapy was initiated. Conclusions. In postoperative cardiosurgical patients, MV with Vt 6 ml × kg−1 and PEEP 10 cm H2O is characterized by worsened oxygenation and elimination of CO2 and a less favorable hemodynamic profile than ventilation with Vt 10 ml × kg−1 and PEEP 5 cmH2O. New and Noteworthy. (i) Patients after CABG may be especially sensitive to low tidal volume and increased PEEP as it negatively affects hemodynamic profile by means of the right heart preload decrease and afterload increase. (ii) Mechanical ventilation settings aiming to minimize mean airway pressure reduce the negative effects of positive inspiratory pressure and are favorable for hemodynamics.

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“…This view is further supported by recent trials that demonstrated no outcome improvements in patients randomized to receive lower V T . 30,31 In our analysis, the primary outcome is a composite of 11 distinct postoperative pulmonary complications, rather than a single outcome more directly related to lung injury (e.g., ARDS). It should be noted that the individual outcome events contributing to a composite outcome vary greatly on the basis of severity (i.e., ARDS vs. atelectasis) and frequency (range, 0.3 to 3.1%).…”

Section: One-lung Ventilation and Complicationsmentioning

confidence: 99%

A Lower Tidal Volume Regimen during One-lung Ventilation for Lung Resection Surgery Is Not Associated with Reduced Postoperative Pulmonary Complications

Colquhoun¹,

Leis²,

Shanks³

et al. 2021

Anesthesiology

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Background Protective ventilation may improve outcomes after major surgery. However, in the context of one-lung ventilation, such a strategy is incompletely defined. The authors hypothesized that a putative one-lung protective ventilation regimen would be independently associated with decreased odds of pulmonary complications after thoracic surgery. Methods The authors merged Society of Thoracic Surgeons Database and Multicenter Perioperative Outcomes Group intraoperative data for lung resection procedures using one-lung ventilation across five institutions from 2012 to 2016. They defined one-lung protective ventilation as the combination of both median tidal volume 5 ml/kg or lower predicted body weight and positive end-expiratory pressure 5 cm H2O or greater. The primary outcome was a composite of 30-day major postoperative pulmonary complications. Results A total of 3,232 cases were available for analysis. Tidal volumes decreased modestly during the study period (6.7 to 6.0 ml/kg; P < 0.001), and positive end-expiratory pressure increased from 4 to 5 cm H2O (P < 0.001). Despite increasing adoption of a “protective ventilation” strategy (5.7% in 2012 vs. 17.9% in 2016), the prevalence of pulmonary complications did not change significantly (11.4 to 15.7%; P = 0.147). In a propensity score matched cohort (381 matched pairs), protective ventilation (mean tidal volume 6.4 vs. 4.4 ml/kg) was not associated with a reduction in pulmonary complications (adjusted odds ratio, 0.86; 95% CI, 0.56 to 1.32). In an unmatched cohort, the authors were unable to define a specific alternative combination of positive end-expiratory pressure and tidal volume that was associated with decreased risk of pulmonary complications. Conclusions In this multicenter retrospective observational analysis of patients undergoing one-lung ventilation during thoracic surgery, the authors did not detect an independent association between a low tidal volume lung-protective ventilation regimen and a composite of postoperative pulmonary complications. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Effect of Intraoperative Low Tidal Volume vs Conventional Tidal Volume on Postoperative Pulmonary Complications in Patients Undergoing Major Surgery

Cited by 124 publications

References 19 publications

Intraoperative protective ventilation in patients undergoing major neurosurgical interventions: a randomized clinical trial

Intraoperative protective ventilation in patients undergoing major neurosurgical interventions: a randomized clinical trial

Heart-Protective Mechanical Ventilation in Postoperative Cardiosurgical Patients

A Lower Tidal Volume Regimen during One-lung Ventilation for Lung Resection Surgery Is Not Associated with Reduced Postoperative Pulmonary Complications

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