Influence of Low Tidal Volume Ventilation on Time to Extubation in Cardiac Surgical Patients

Sundar, Sugantha; Novack, Victor; Jervis, Karinne; Bender, S. Patrick; Lerner, Adam; Panzica, Peter; Mahmood, Feroze; Malhotra, Atul; Talmor, Daniel

doi:10.1097/aln.0b013e318215e254

Cited by 113 publications

(68 citation statements)

References 34 publications

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“…Early extubation, generally considered to be that which is performed during the first 6-8 hours once the preoperative homeostatic state has been reestablished (40), offers a substantial advantage in terms of accelerated recovery, shorter intensive care unit and hospital stay, suggesting that efforts to reduce extubation time are cost-effective (65). Cardiac surgical patients in whom low tidal volumes are administered are more likely to undergo early extubation (37.3% vs. 20.3%; P=0.02) and less likely to require re-intubation (1.3% vs. 9.5%; P=0.03) (66). Safety and efficacy of fast-track care in patients undergoing cardiac surgery was brilliantly assessed by Zhu and colleagues (67) who showed no statistically significant difference in mortality between early and conventional extubation in patients considered to be at low to moderate risk.…”

Section: Non-surgical Techniquesmentioning

confidence: 98%

Acute respiratory distress syndrome after cardiac surgery

2016

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Acute respiratory distress syndrome (ARDS) is a leading cause of postoperative respiratory failure, with a mortality rate approaching 40% in the general population and 80% in the subset of patients undergoing cardiac surgery. The increased risk of ARDS in these patients has traditionally been associated with the use of cardiopulmonary bypass (CPB), the need for blood product transfusions, large volume shifts, mechanical ventilation and direct surgical insult. Indeed, the impact of ARDS in the cardiac population is substantial, affecting not only survival but also in-hospital length of stay and long-term physical and psychological morbidity. No patient undergoing cardiac surgery can be considered ARDS risk-free. Early identification of those at higher risk is crucial to warrant the adoption of both surgical and non-surgical specific preventative strategies. The present review focuses on epidemiology, risk assessment, pathophysiology, prevention and management of ARDS in the specific setting of patients undergoing cardiac surgery.

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Section: Non-surgical Techniquesmentioning

confidence: 98%

Acute respiratory distress syndrome after cardiac surgery

2016

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“…Nevertheless, Cai et al showed that applying ventilation with V T of 6 ml/kg alone was associated with no diff erence in the amount of atelectasis compared to ventilation with V T of 10 ml/kg [27] and application of PEEP may additionally counteract this eff ect [24]. Several studies have shown that protective ventilation can improve lung mechanics, gas exchange and decrease the incidence of postoperative pulmonary complications [24], [25], [28] (Table 1). To better investigate the impact of protective ventilation itself involving low V T or PEEP and recruitment maneuvers, a large RCT including 900 patients and investigating the eff ect on postoperative pulmonary complications of an open lung strategy with high PEEP and recruitment maneuvers in short term mechanical ventilation has recently been completed (PROVHILO) [29].…”

Section: In Surgerymentioning

confidence: 99%

Protective Mechanical Ventilation in the Non-injured Lung: Review and Meta-analysis

Sutherasan

Vargas

Pelosi

2014

Annual Update in Intensive Care and Emergency Medicine 2014

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“…Sundar et al 50 examined the time to extubation for cardiac surgical subjects receiving either 6 mL/kg or 10 mL/kg PBW. They found that, although the time to extubation did not significantly decrease, significantly more subjects in the lower V T group were extubated and breathing without assistance 6 -8 h after surgery.…”

Section: Ventilation Of Surgical Patientsmentioning

confidence: 99%

Should A Tidal Volume of 6 mL/kg Be Used in All Patients?

2016

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It has been shown that mechanical ventilation by itself can cause lung injury and affect outcomes. Ventilator-induced lung injury is associated with high tidal volumes in lungs afflicted with ARDS. However, the question is: Do high tidal volumes have this same effect in normal lungs or lungs that have respiratory compromise stemming from something other than ARDS? Many clinicians believe that a tidal volume strategy of 6 mL/kg predicted body weight should be standard practice in all patients receiving mechanical ventilation. There is a growing body of evidence related to this issue, and this is the debate that will be tackled in this paper from both pro and con perspectives. Key words: tidal volume; predicted body weight; mechanical ventilation; lung-protective ventilation; time constant; ARDS; stress; strain; hypercapnia. [Respir Care 2016;61(6):774 -790 . © 2016 Daedalus Enterprises] IntroductionIt is well known that the use of mechanical ventilation has the potential to aggravate pulmonary injury, but emerging evidence indicates that it may also precipitate lung injury in patients with no previous injury. Lung-protective ventilation has evolved over the past couple of decades to the point that it has become standard of care for patients with ARDS. The use of lower tidal volume (V T ) 4 -8 mL/kg predicted body weight (PBW) is part of this lung-protective strategy for mechanical ventilation (mechanical ventilation) along with limiting the plateau pressure to a maximum of 30 cm H 2 O and prudent use of PEEP to prevent atelectasis. Since we now know that the use of lower V T strategies (more specifically 6 mL/kg PBW) helps to limit the pulmonary damage during ARDS, the question now is: Should we be using this strategy in all mechanically ventilated patients? Anatomically speaking, it makes sense to, since the normal physiologic V T for humans is approximately 6 mL/kg PBW. 1 There is a growing body of evidence that points toward the use of lower V T values leading to improved outcomes in patients suffering from other forms and degrees of respiratory failure. The aim of this paper is to examine the evidence relating to the use of lower V T values in conditions other than ARDS in which mechanical ventilation is required. This will be done with viewpoints from both the pro and con positions. Early StudiesThere is a plethora of preclinical evidence from animal studies supporting the fact that the use of high V T values can directly cause injury to normal lungs. Animal studies have shown that high V T ventilation increases levels of pro-inflammatory mediators, leads to pulmonary edema, and causes increased alveolar-capillary permeability and structural abnormalities. [2][3][4][5][6][7][8] With the emergence of these animal data, clinicians began to question the traditional use of V T values in the range of 10 -15 mL/kg PBW in humans. Several small human studies were reported in the mid-to late 1990s that produced conflicting results. 9-11 These studies were hampered by several factors, including higher than predicte...

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Influence of Low Tidal Volume Ventilation on Time to Extubation in Cardiac Surgical Patients

Cited by 113 publications

References 34 publications

Acute respiratory distress syndrome after cardiac surgery

Acute respiratory distress syndrome after cardiac surgery

Protective Mechanical Ventilation in the Non-injured Lung: Review and Meta-analysis

Should A Tidal Volume of 6 mL/kg Be Used in All Patients?

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