Individualized positive end-expiratory pressure (PEEP) during one-lung ventilation for prevention of postoperative pulmonary complications in patients undergoing thoracic surgery

Li, Pule; Kang, Xin; Miao, Mengrong; Zhang, Jiaqiang

doi:10.1097/md.0000000000026638

Cited by 12 publications

(7 citation statements)

References 45 publications

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“…Clinical trials investigating the effect of nonindividualized PEEP have shown equivocal results (41, 42). Strategies aiming to individualize PEEP strategies based on patient’s respiratory system compliance have been linked to lower postoperative complications in high-risk scenarios (43, 44).…”

Section: Discussionmentioning

confidence: 99%

High Mechanical Power and Driving Pressures are Associated With Postoperative Respiratory Failure Independent From Patients’ Respiratory System Mechanics*

Tartler,

Ahrens,

Munoz-Acuna

et al. 2023

Critical Care Medicine

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Objectives: High mechanical power and driving pressure (ΔP) have been associated with postoperative respiratory failure (PRF) and may be important parameters guiding mechanical ventilation. However, it remains unclear whether high mechanical power and ΔP merely reflect patients with poor respiratory system mechanics at risk of PRF. We investigated the effect of mechanical power and ΔP on PRF in cohorts after exact matching by patients’ baseline respiratory system compliance. Design: Hospital registry study. Setting: Academic hospital in New England. Patients: Adult patients undergoing general anesthesia between 2008 and 2020. Intervention: None. Measurements and Main Results: The primary exposure was high (≥ 6.7 J/min, cohort median) versus low mechanical power and the key-secondary exposure was high (≥ 15.0 cm H2O) versus low ΔP. The primary endpoint was PRF (reintubation or unplanned noninvasive ventilation within seven days). Among 97,555 included patients, 4,030 (4.1%) developed PRF. In adjusted analyses, high intraoperative mechanical power and ΔP were associated with higher odds of PRF (adjusted odds ratio [aOR] 1.37 [95% CI, 1.25–1.50]; p < 0.001 and aOR 1.45 [95% CI, 1.31–1.60]; p < 0.001, respectively). There was large variability in applied ventilatory parameters, dependent on the anesthesia provider. This facilitated matching of 63,612 (mechanical power cohort) and 53,260 (ΔP cohort) patients, yielding identical baseline standardized respiratory system compliance (standardized difference [SDiff] = 0.00) with distinctly different mechanical power (9.4 [2.4] vs 4.9 [1.3] J/min; SDiff = –2.33) and ΔP (19.3 [4.1] vs 11.9 [2.1] cm H2O; SDiff = –2.27). After matching, high mechanical power and ΔP remained associated with higher risk of PRF (aOR 1.30 [95% CI, 1.17–1.45]; p < 0.001 and aOR 1.28 [95% CI, 1.12–1.46]; p < 0.001, respectively). Conclusions: High mechanical power and ΔP are associated with PRF independent of patient’s baseline respiratory system compliance. Our findings support utilization of these parameters for titrating mechanical ventilation in the operating room and ICU.

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Section: Discussionmentioning

confidence: 99%

High Mechanical Power and Driving Pressures are Associated With Postoperative Respiratory Failure Independent From Patients’ Respiratory System Mechanics*

Tartler,

Ahrens,

Munoz-Acuna

et al. 2023

Critical Care Medicine

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“…( 21 , 22 , 24 , 25 ) However, low V T does not appear to be associated with lower PPC S ( 26 – 29 ). Moreover, individual characteristics, such as chest wall size and shape, abdominal contents, lung weight, and pleural pressure, vary from person to person, so a fixed PEEP may not be appropriate for everyone ( 30 ). Therefore, the definition of protective ventilation in thoracic surgery is still unclear.…”

Section: Discussionmentioning

confidence: 99%

Effect of Driving Pressure-Oriented Ventilation on Patients Undergoing One-Lung Ventilation During Thoracic Surgery: A Systematic Review and Meta-Analysis

Li¹,

Xue²,

Zhang³

et al. 2022

Front. Surg.

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BackgroundHypoxemia and fluctuations in respiratory mechanics parameters are common during one-lung ventilation (OLV) in thoracic surgery. Additionally, the incidence of postoperative pulmonary complications (PPCS) in thoracic surgery is higher than that in other surgeries. Previous studies have demonstrated that driving pressure-oriented ventilation can reduce both mortality in patients with acute respiratory distress syndrome (ARDS) and the incidence of PPCS in patients undergoing general anesthesia. Our aim was to determine whether driving pressure-oriented ventilation improves intraoperative physiology and outcomes in patients undergoing thoracic surgery.MethodsWe searched MEDLINE via PubMed, Embase, Cochrane, Web of Science, and ClinicalTrials.gov and performed a meta-analysis to compare the effects of driving pressure-oriented ventilation with other ventilation strategies on patients undergoing OLV. The primary outcome was the PaO2/FiO2 ratio (P/F ratio) during OLV. The secondary outcomes were the incidence of PPCS during follow-up, compliance of the respiratory system during OLV, and mean arterial pressure during OLV.ResultsThis review included seven studies, with a total of 640 patients. The PaO2/FiO2 ratio was higher during OLV in the driving pressure-oriented ventilation group (mean difference [MD]: 44.96; 95% confidence interval [CI], 24.22–65.70.32; I2: 58%; P < 0.0001). The incidence of PPCS was lower (OR: 0.58; 95% CI, 0.34–0.99; I2: 0%; P = 0.04) and the compliance of the respiratory system was higher (MD: 6.15; 95% CI, 3.97–8.32; I2: 57%; P < 0.00001) in the driving pressure-oriented group during OLV. We did not find a significant difference in the mean arterial pressure between the two groups.ConclusionDriving pressure-oriented ventilation during OLV in patients undergoing thoracic surgery was associated with better perioperative oxygenation, fewer PPCS, and improved compliance of the respiratory system.Systematic Review RegistrationPROSPERO, identifier: CRD42021297063.

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“…Several targets have been proposed for individualized titration, including improving intraoperative oxygenation and hemodynamics, providing optimal pulmonary compliance, 28,95,103-108 and reducing the incidence of postoperative pulmonary complications. [24][25][26][27]109,110 An animal experiment also confirmed the importance of individualized PEEP, in which Reiniush et al obtained the appropriate range of PEEP according to oxygenation, driving pressure and cardiac output. PEEP exceeded this range would cause ventilation/perfusion mismatch of the ventilated lung.…”

Section: Explore the Optimal Individualized Peep Valuementioning

confidence: 91%

A structured narrative review of clinical and experimental studies of the use of different positive end‐expiratory pressure levels during thoracic surgery

Yueyi

Tan

2022

Clinical Respiratory J

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Objectives This study aimed to present a review on the general effects of different positive end‐expiratory pressure (PEEP) levels during thoracic surgery by qualitatively categorizing the effects into detrimental, beneficial, and inconclusive. Data source Literature search of Pubmed, CNKI, and Wanfang was made to find relative articles about PEEP levels during thoracic surgery. We used the following keywords as one‐lung ventilation, PEEP, and thoracic surgery. Results We divide the non‐individualized PEEP value into five grades, that is, less than 5, 5, 5–10, 10, and more than 10 cmH2O, among which 5 cmH2O is the most commonly used in clinic at present to maintain alveolar dilatation and reduce the shunt fraction and the occurrence of atelectasis, whereas individualized PEEP, adjusted by test titration or imaging method to adapt to patients' personal characteristics, can effectively ameliorate intraoperative oxygenation and obtain optimal pulmonary compliance and better indexes relating to respiratory mechanics. Conclusions Available data suggest that PEEP might play an important role in one‐lung ventilation, the understanding of which will help in exploring a simple and economical method to set the appropriate PEEP level.

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Individualized positive end-expiratory pressure (PEEP) during one-lung ventilation for prevention of postoperative pulmonary complications in patients undergoing thoracic surgery

Cited by 12 publications

References 45 publications

High Mechanical Power and Driving Pressures are Associated With Postoperative Respiratory Failure Independent From Patients’ Respiratory System Mechanics*

High Mechanical Power and Driving Pressures are Associated With Postoperative Respiratory Failure Independent From Patients’ Respiratory System Mechanics*

Effect of Driving Pressure-Oriented Ventilation on Patients Undergoing One-Lung Ventilation During Thoracic Surgery: A Systematic Review and Meta-Analysis

A structured narrative review of clinical and experimental studies of the use of different positive end‐expiratory pressure levels during thoracic surgery

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