Perioperative lung-protective ventilation strategy reduces postoperative pulmonary complications in patients undergoing thoracic and major abdominal surgery.
01 Feb 2016-Korean Journal of Anesthesiology (Korean Society of Anesthesiologists)-Vol. 69, Iss: 1, pp 3-7
TL;DR: Facilitating perioperative bundle care by combining prophylactic and postoperative positive-pressure ventilation with intraoperative lung-protective ventilation may be helpful to reduce postoperative pulmonary complications.
Abstract: The occurrence of postoperative pulmonary complications is strongly associated with increased hospital mortality and prolonged postoperative hospital stays. Although protective lung ventilation is commonly used in the intensive care unit, low tidal volume ventilation in the operating room is not a routine strategy. Low tidal volume ventilation, moderate positive end-expiratory pressure, and repeated recruitment maneuvers, particularly for high-risk patients undergoing major abdominal surgery, can reduce postoperative pulmonary complications. Facilitating perioperative bundle care by combining prophylactic and postoperative positive-pressure ventilation with intraoperative lung-protective ventilation may be helpful to reduce postoperative pulmonary complications.
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TL;DR: Low tidal volumes during surgery decreased the need for postoperative invasive ventilatory support and the effect size increased proportionally to the peak pressure measured at the end of surgery in the high volume group.
Abstract: Background Since the 2000s, there has been a trend towards decreasing tidal volumes for positive pressure ventilation during surgery. This an update of a review first published in 2015, trying to determine if lower tidal volumes are beneficial or harmful for patients. Objectives To assess the benefit of intraoperative use of low tidal volume ventilation (less than 10 mL/kg of predicted body weight) compared with high tidal volumes (10 mL/kg or greater) to decrease postoperative complications in adults without acute lung injury. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2017, Issue 5), MEDLINE (OvidSP) (from 1946 to 19 May 2017), Embase (OvidSP) (from 1974 to 19 May 2017) and six trial registries. We screened the reference lists of all studies retained and of recent meta-analysis related to the topic during data extraction. We also screened conference proceedings of anaesthesiology societies, published in two major anaesthesiology journals. The search was rerun 3 January 2018. Selection criteria We included all parallel randomized controlled trials (RCTs) that evaluated the effect of low tidal volumes (defined as less than 10 mL/kg) on any of our selected outcomes in adults undergoing any type of surgery. We did not retain studies with participants requiring one-lung ventilation. Data collection and analysis Two authors independently assessed the quality of the retained studies with the Cochrane 'Risk of bias' tool. We analysed data with both fixed-effect (I2 statistic less than 25%) or random-effects (I2 statistic greater than 25%) models based on the degree of heterogeneity. When there was an effect, we calculated a number needed to treat for an additional beneficial outcome (NNTB) using the odds ratio. When there was no effect, we calculated the optimum information size. Main results We included seven new RCTs (536 participants) in the update.In total, we included 19 studies in the review (776 participants in the low tidal volume group and 772 in the high volume group). There are four studies awaiting classification and three are ongoing. All included studies were at some risk of bias. Participants were scheduled for abdominal surgery, heart surgery, pulmonary thromboendarterectomy, spinal surgery and knee surgery. Low tidal volumes used in the studies varied from 6 mL/kg to 8.1 mL/kg while high tidal volumes varied from 10 mL/kg to 12 mL/kg.Based on 12 studies including 1207 participants, the effects of low volume ventilation on 0- to 30-day mortality were uncertain (risk ratio (RR) 0.80, 95% confidence interval (CI) 0.42 to 1.53; I2 = 0%; low-quality evidence). Based on seven studies including 778 participants, lower tidal volumes probably reduced postoperative pneumonia (RR 0.45, 95% CI 0.25 to 0.82; I2 = 0%; moderate-quality evidence; NNTB 24, 95% CI 16 to 160), and it probably reduced the need for non-invasive postoperative ventilatory support based on three studies including 506 participants (RR 0.31, 95% CI 0.15 to 0.64; moderate-quality evidence; NNTB 13, 95% CI 11 to 24). Based on 11 studies including 957 participants, low tidal volumes during surgery probably decreased the need for postoperative invasive ventilatory support (RR 0.33, 95% CI 0.14 to 0.77; I2 = 0%; NNTB 39, 95% CI 30 to 166; moderate-quality evidence). Based on five studies including 898 participants, there may be little or no difference in the intensive care unit length of stay (standardized mean difference (SMD) -0.06, 95% CI -0.22 to 0.10; I2 = 33%; low-quality evidence). Based on 14 studies including 1297 participants, low tidal volumes may have reduced hospital length of stay by about 0.8 days (SMD -0.15, 95% CI -0.29 to 0.00; I2 = 27%; low-quality evidence). Based on five studies including 708 participants, the effects of low volume ventilation on barotrauma (pneumothorax) were uncertain (RR 1.77, 95% CI 0.52 to 5.99; I2 = 0%; very low-quality evidence). Authors' conclusions We found moderate-quality evidence that low tidal volumes (defined as less than 10 mL/kg) decreases pneumonia and the need for postoperative ventilatory support (invasive and non-invasive). We found no difference in the risk of barotrauma (pneumothorax), but the number of participants included does not allow us to make definitive statement on this. The four studies in 'Studies awaiting classification' may alter the conclusions of the review once assessed.
74 citations
TL;DR: Despite an improvement of surgical and anaesthesia techniques that resulted in a significant decrease in mortality, postoperative complications play a major role in affecting morbidity, mortality, length of hospital stay and patients’ quality of life.
Abstract: Purpose of reviewCardiac surgery is at high risk for the development of postoperative complications involving cardiovascular and respiratory system, as well as kidneys and central nervous system. The aim of this review is to provide an overview on the most recent findings concerning the type and inc
65 citations
TL;DR: In patients at potential risk of developing PPCs undergoing major spinal surgery, there was no evidence indicating any difference between the lung protective and conventional ventilation in postoperative pulmonary function and oxygenation.
Abstract: Background:Spinal surgery in the prone position is accompanied by increased intrathoracic pressure and decreased respiratory compliance. This study investigated whether intraoperative lung protective mechanical ventilation improved lung function evaluated with pulmonary function tests in patients at
16 citations
TL;DR: Postoperative pulmonary functions were less impaired in patients ventilated with a VT of 6 mL/kg and 8 cm H
Abstract: OBJECTIVE The aim was to compare the effects of low tidal volume (VT) and moderate positive end-expiratory pressure (PEEP) with high VT and zero end-expiratory pressure (ZEEP) on postoperative pulmonary functions and oxygenation in patients undergoing robot-assisted laparoscopic radical prostatectomy. SUBJECTS AND METHODS Forty-four patients were randomized into low VT-PEEP and high VT-ZEEP groups. The patients were ventilated with a VT of 6 mL/kg and 8 cm H2O PEEP in the low VT-PEEP group and a VT of 10 mL/kg and 0 cm H2O PEEP in the high VT-ZEEP group. Preoperative and postoperative spirometric measurements were done and chest X-rays were evaluated using the radiological atelectasis score (RAS). p < 0.05 was considered statistically significant. RESULTS The intraoperative and postoperative arterial partial pressure of oxygen and arterial oxygen saturation values were significantly higher in the low VT-PEEP group than in the high VT-ZEEP group. At all times, the arterial-to-alveolar oxygenation gradients were significantly lower in the low VT-PEEP group than in the high VT-ZEEP group. Preoperative RAS were similar in both groups, but the postoperative RAS was significantly lower in the low VT-PEEP group (p < 0.001). Forced vital capacity, forced expiratory volume in 1 s, and peak expiratory flow rate recorded postoperatively were significantly lower in the high VT-ZEEP group (p < 0.001). CONCLUSIONS Postoperative pulmonary functions were less impaired in patients ventilated with a VT of 6 mL/kg and 8 cm H2O PEEP than in patients ventilated with a VT of 10 mL/kg and ZEEP.
14 citations
TL;DR: Lung-protective ventilation principles using more physiological tidal volumes, avoiding high inspiratory plateau pressures, along with appropriate levels of positive end-expiratory pressure have been shown to decrease pulmonary complications and improve outcomes in patients with acute respiratory distress syndrome requiring ongoing ventilatory support in the ICU.
Abstract: Historically, mechanical ventilation of the lungs utilizing relatively large tidal volumes was common practice in the operating room and intensive care unit (ICU). The rationale behind this treatment strategy was to yield better patient outcomes, that is, fewer pulmonary complications, and a reduction in morbidity and mortality. As evidence-based practice has evolved, potential harmful effects of traditional, nonphysiological mechanical ventilation (ventilation with larger tidal volumes and the tolerance of high airway pressures) even in shortterm treatment have been shown to correlate with systemic inflammation and the development of ventilator-associated lung injury. Lung-protective ventilation principles using more physiological tidal volumes, avoiding high inspiratory plateau pressures, along with appropriate levels of positive end-expiratory pressure have been shown to decrease pulmonary complications and improve outcomes in patients with acute respiratory distress syndrome requiring ongoing ventilatory support in the ICU. In addition, current research is beginning to validate the benefit of providing more physiologic ventilator support in the operating room, particularly for high-risk patients undergoing major abdominal surgery, in minimizing acute lung injury. A review of lung-protective ventilation measures including benefits and potential side effects is presented. Additional treatment modalities and therapeutic considerations are offered for inclusion in optimal patient management.
10 citations
Cites background from "Perioperative lung-protective venti..."
...Lung-protective ventilation should be considered routine care in the presence of pulmonary disease, prolonged anesthesia, in high-risk patients, or for high-risk surgery, such as in patients undergoing major abdominal procedures (Coppola, Froio, & Chiumello, 2014; Park, 2016)....
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References
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TL;DR: The occurrence of a 30-day postoperative complication is more important than preoperative patient risk and intraoperative factors in determining the survival after major surgery in the VA.
Abstract: Objective: The objective of this study was to identify the determinants of 30-day postoperative mortality and long-term survival after major surgery as exemplified by 8 common operations. Background Data: The National Surgical Quality Improvement Program (NSQIP) database contains pre-, intra-, and 30-day postoperative data, prospectively collected in a standardized fashion by a dedicated nurse reviewer, on major surgery in the Veterans Administration (VA). The Beneficiary Identification and Records Locator Subsystem (BIRLS) is a VA file that depicts the vital status of U.S. veterans with 87% to 95% accuracy. Methods: NSQIP data were merged with BIRLS to determine the vital status of 105,951 patients who underwent 8 types of operations performed between 1991 and 1999, providing an average follow up of 8 years. Logistic and Cox regression analyses were performed to identify the predictors of 30-day mortality and long-term survival, respectively. Results: The most important determinant of decreased postoperative survival was the occurrence, within 30 days postoperatively, of any one of 22 types of complications collected in the NSQIP. Independent of preoperative patient risk, the occurrence of a 30-day complication in the total patient group reduced median patient survival by 69%. The adverse effect of a complication on patient survival was also influenced by the operation type and was sustained even when patients who did not survive for 30 days were excluded from the analyses. Conclusions: The occurrence of a 30-day postoperative complication is more important than preoperative patient risk and intraoperative factors in determining the survival after major surgery in the VA. Quality and process improvement in surgery should be directed toward the prevention of postoperative complications.
1,235 citations
"Perioperative lung-protective venti..." refers background in this paper
...associated with PPCs is 10% to 20% after major surgery [1]....
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TL;DR: The use of a lung-protective ventilation strategy in intermediate-risk and high-risk patients undergoing major abdominal surgery was associated with improved clinical outcomes and reduced health care utilization.
Abstract: The two intervention groups had similar characteristics at baseline. In the intention-to-treat analysis, the primary outcome occurred in 21 of 200 patients (10.5%) assigned to lung-protective ventilation, as compared with 55 of 200 (27.5%) assigned to nonprotective ventilation (relative risk, 0.40; 95% confidence interval [CI], 0.24 to 0.68; P = 0.001). Over the 7-day postoperative period, 10 patients (5.0%) assigned to lung-protective ventilation required noninvasive ventilation or intubation for acute respiratory failure, as compared with 34 (17.0%) assigned to nonprotective ventilation (relative risk, 0.29; 95% CI, 0.14 to 0.61; P = 0.001). The length of the hospital stay was shorter among patients receiving lung-protective ventilation than among those receiving nonprotective ventilation (mean difference, −2.45 days; 95% CI, −4.17 to −0.72; P = 0.006). CONCLUSIONS As compared with a practice of nonprotective mechanical ventilation, the use of a lung-protective ventilation strategy in intermediate-risk and high-risk patients undergoing major abdominal surgery was associated with improved clinical out comes and reduced health care utilization. (IMPROVE ClinicalTrials.gov number, NCT01282996.)
1,086 citations
"Perioperative lung-protective venti..." refers methods in this paper
...The Intraoperative PROtective VEntilation (IMPROVE) trial was performed with low-VT ventilation, moderate PEEP, and repeated RMs, particularly for high-risk patients undergoing major abdominal surgery [37]....
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TL;DR: Meta-analyses of randomized, control trials confirm that postoperative epidural pain control can significantly decrease the incidence of pulmonary morbidity and support the utility of epidural analgesia for reducing postoperativemonary morbidity but do not support the use of surrogate measures of pulmonary outcome as predictors or determinants of pulmonary mortality in postoperative patients.
Abstract: We performed meta-analyses of randomized, control trials to assess the effects of seven analgesic therapies on postoperative pulmonary function after a variety of procedures: epidural opioid, epidural local anesthetic, epidural opioid with local anesthetic, thoracic versus lumbar epidural opioid, intercostal nerve block, wound infiltration with local anesthetic, and intrapleural local anesthetic. Measures of forced expiratory volume in 1 s (FEV,), forced vital capacity (FVC), vital capacity (VC), peak expiratory flow rate (PEFR), Pao,, and incidence of atelectasis, pulmonary infection, and pulmonary complications overall were analyzed. Compared with systemic opioids, epidural opioids decreased the incidence of atelectasis (risk ratio [RR] 0.53, 95% confidence interval [CI] 0.33-0.85) and had a weak tendency to reduce the incidence of pulmonaryinfections (RRO.53,95% CIO.18-1.53) and pulmonary complications overall (RR 0.51, 95% CI 0.20-1.33). Epidural local anesthetics increased Pao, (difference 4.56 mm Hg, 95% CI 0.058-9.075) and decreased the incidence of pulmonary infections (RR 0.36,95% CI 0.21-0.65) and pulmonary complications overall (RR 0.58,95% CI 0.42-0.80) compared with systemic opioids. Intercostal nerve blockade tends to improve pulmonary outcome measures (incidence of atelectasis: RR 0.65,95% CI 0.271.57, incidence of pulmonary complications overall: RR 0.47, 95% CI 0X3-1.22), but these differences did not achieve statistical significance. There were no clinically or statistically significant differences in the surrogate measures of pulmonary function (FEV,, FVC, and PEFR). These analyses support the utility of epidural analgesia for reducing postoperative pulmonary morbidity but do not support the use of surrogate measures of pulmonary outcome as predictors or determinants of pulmonary morbidity in postoperative patients. Implications: When individual trials are unable to produce significant results, it is often because of insufficient patient numbers. It may be impossible for a single institution to study enough patients. Meta-analysis is a useful tool for combining the data from multiple trials to increase the patient numbers. These meta-analyses confirm that postoperative epidural pain control can significantly decrease the incidence of pulmonary morbidity.
1,019 citations
"Perioperative lung-protective venti..." refers background in this paper
...Suitable epidural pain control significantly reduces the incidence of pulmonary complications (atelectasis, pneumonia, and respiratory failure) after major thoracic and abdominal surgery [23-25]....
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TL;DR: Most adverse morbid outcomes in high-risk patients undergoing major abdominal surgery are not reduced by use of combined epidural and general anaesthesia and postoperative epidural analgesia, however, the improvement in analgesIA, reduction in respiratory failure, and the low risk of serious adverse consequences suggest that many high- risk patients undergo major intra-abdominal surgery will receive substantial benefit from combined general and epidural anaesthesia intraoperatively with continuing postoperative analgesia.
948 citations
"Perioperative lung-protective venti..." refers background in this paper
...Suitable epidural pain control significantly reduces the incidence of pulmonary complications (atelectasis, pneumonia, and respiratory failure) after major thoracic and abdominal surgery [23-25]....
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TL;DR: In this article, the authors performed meta-analyses of randomized, control trials to assess the effects of seven analgesic therapies on postoperative pulmonary function after a variety of procedures: epidural opioid, epidural local anesthetic (ELAN), epidural opioids with LAN, thoracic versus lumbar LAN.
Abstract: We performed meta-analyses of randomized, control trials to assess the effects of seven analgesic therapies on postoperative pulmonary function after a variety of procedures: epidural opioid, epidural local anesthetic, epidural opioid with local anesthetic, thoracic versus lumbar epidural opioid, in
734 citations