Intraoperative ventilator settings and acute lung injury after elective surgery: a nested case control study

Abstract

Background: While acute lung injury (ALI) is among the most serious postoperative pulmonary complications, its incidence, risk factors and outcome have not been prospectively studied. Objective: To determine the incidence and survival of ALI associated postoperative respiratory failure and its association with intraoperative ventilator settings, specifically tidal volume. Design: Prospective, nested, case control study. Setting: Single tertiary referral centre. Patients: 4420 consecutive patients without ALI undergoing high risk elective surgeries for postoperative pulmonary complications. Measurements: Incidence of ALI, survival and 2:1 matched case control comparison of intraoperative exposures. Results: 238 (5.4%) patients developed postoperative respiratory failure. Causes included ALI in 83 (35%), hydrostatic pulmonary oedema in 74 (31%), shock in 27 (11.3%), pneumonia in nine (4%), carbon dioxide retention in eight (3.4%) and miscellaneous in 37 (15%). Compared with match controls (n = 166), ALI cases had lower 60 day and 1 year survival (99% vs 73% and 92% vs 56%; p,0.001). Cases were more likely to have a history of smoking, chronic obstructive pulmonary disease and diabetes, and to be exposed to longer duration of surgery, intraoperative hypotension and larger amount of fluid and transfusions. After adjustment for non-ventilator parameters, mean first hour peak airway pressure (OR 1.07; 95% CI 1.02 to 1.15 cm H 2 O) but not tidal volume (OR 1.03; 95% CI 0.84 to 1.26 ml/kg), positive end expiratory pressure (OR 0.89; 95% CI 0.77 to 1.04 cm H 2 O) or fraction of inspired oxygen (OR 1.0; 95% CI 0.98 to 1.03) were associated with ALI. Conclusion: ALI is the most common cause of postoperative respiratory failure and is associated with markedly lower postoperative survival. Intraoperative tidal volume was not associated with an increased risk for early postoperative ALI.Postoperative pulmonary complications, and in particular postoperative respiratory failure, are important causes of perioperative morbidity and mortality.

Pressure-controlled versus volume-controlled ventilation during one-lung ventilation for video-assisted thoracoscopic lobectomy

“…Blum et al (6) showed that the incidence of postoperative ARDS was 0.2% in a general surgical population and the intraoperative risk factor included driver pressure instead of low tide volume. In thoracic surgery, the expected incidence of postoperative ALI was as high as 4.2% (7) and the independent risk factors included intraoperative ventilatory pressure index instead of VT. Fernández-Pérez et al (8) designed a study to prove their hypothesis that higher VT would be associated with higher risk of respiratory failure secondary to ALI, but the result showed that mean first hour peak airway pressure but not VT was associated with ALI. The clinical researches above made us reconsider to utilize the ventilation mode with lower airway pressure during high risk operations especially thoracic surgeries with obligated OLV.…”

Evre III–IV Over Kanseri Nedeniyle Sitoredüktif Cerrahi Geçiren Hastalarda Postoperatif Yoğun Bakım Gereksiniminin Ön Belirleyicileri

“…Bu olguların takiplerinde 2 yıllık mortalite %40 olarak bildirilmektedir (17). Preoperatif dönemde akciğer parenkimi ile ilgili ya da primer ya da sekonder restriktif nedenlere bağlı solunumsal sorunları bulunan hastalarda postoperatif solunumsal komplikasyonlar artar (18). Çalışmamızda KOAH'ı bulunan hastalarda preoperatif SpO 2 'nin düşüklüğü mevcuttu ve bu hastalarda preoperatif YB'a kabulün anlamlı olarak arttığı görüldü.…”

Rationale and Design of a Prospective Cohort Study to Assess Extravascular Lung Water as an Early Predictor and Marker of the Severity of Reperfusion Lung Injury in Pulmonary Endarterectomy

“…ARDS is a leading cause of postoperative hypoxemic respiratory failure with reported prevalence of 3 to 9% and associated mortality rates between 27 and 45% (19,20). As many as 20% of patients undergoing cardiac surgery will develop ARDS during the perioperative period, with a mortality as high as 80% (21).…”