Ary Serpa Neto1, Sabrine N T Hemmes2, Carmen S V Barbas3, Martin Beiderlinden4, Ana Fernandez-Bustamante5, Emmanuel Futier6, Ognjen Gajic7, Mohamed R El-Tahan8, Abdulmohsin A Al Ghamdi9, Ersin Günay10, Samir Jaber11, Serdar Kokulu12, Alf Kozian13, Marc Licker14, Wen-Qian Lin15, Andrew D Maslow16, Stavros G Memtsoudis17, Dinis Reis Miranda18, Pierre Moine5, Thomas Ng19, Domenico Paparella20, V Marco Ranieri21, Federica Scavonetto22, Thomas Schilling13, Gabriele Selmo23, Paolo Severgnini23, Juraj Sprung22, Sugantha Sundar24, Daniel Talmor24, Tanja Treschan25, Carmen Unzueta26, Toby N Weingarten22, Esther K Wolthuis2, Hermann Wrigge27, Marcelo B P Amato28, Eduardo L V Costa29, Marcelo Gama de Abreu30, Paolo Pelosi31, Marcus J Schultz32. 1. Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands; Program of Post-Graduation, Research and Innovation, Faculdade de Medicina do ABC, Santo André, Brazil; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil. Electronic address: aryserpa@terra.com.br. 2. Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands. 3. Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil. 4. Department of Anaesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany; Department of Anaesthesiology, Marienhospital Osnabrück, Osnabrück, Germany. 5. Department of Anesthesiology, University of Colorado, Aurora, CO, USA. 6. Department of Anesthesiology and Critical Care Medicine, Estaing University Hospital, Clermont-Ferrand, France. 7. Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA. 8. Department of Cardiothoracic Anaesthesia & Surgical Intensive Care, King Fahd Hospital, University of Dammam, Dammam, Saudi Arabia. 9. Department of Anesthesiology, King Fahd Hospital, University of Dammam, Dammam, Saudi Arabia. 10. Department of Chest Diseases, Research Unit INSERM U1046, Montpellier, France. 11. Department of Critical Care Medicine and Anesthesiology, Saint Eloi University Hospital, Research Unit INSERM U1046, Montpellier, France. 12. Department of Anaesthesiology and Reanimation, Research Unit INSERM U1046, Montpellier, France. 13. Department of Anesthesiology and Intensive Care Medicine, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany. 14. Department of Anaesthesiology, Pharmacology and Intensive Care, Faculty of Medicine, University Hospital of Geneva, Geneva, Switzerland. 15. State Key Laboratory of Oncology of South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China. 16. Department of Anesthesiology, The Warren Alpert School of Brown University, Providence, RI, USA. 17. Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA. 18. Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands. 19. Department of Surgery, The Warren Alpert School of Brown University, Providence, RI, USA. 20. Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy. 21. Department of Anesthesia and Intensive Care Medicine, Rome, Italy; Sapienza University of Rome, Rome, Italy; Policlinico Umberto I Hospital, Rome, Italy. 22. Department of Anesthesiology and Anesthesia Clinical Research Unit, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA. 23. Department Biotechnology and Sciences of Life, Azienda Ospedaliera Fondazione Macchi, University of Insubria, Varese, Italy. 24. Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA. 25. Department of Anaesthesiology, Düsseldorf University Hospital, Heinrich-Heine University, Düsseldorf, Germany. 26. Department of Anaesthesiology, Hospital de Sant Pau, Barcelona, Spain. 27. Department of Anaesthesiology and Intensive Care Medicine, University of Hospital Leipzig, Leipzig, Germany. 28. Cardio-Pulmonary Department, Pulmonary Division, Heart Institute, University of São Paulo, São Paulo, Brazil. 29. Cardio-Pulmonary Department, Pulmonary Division, Heart Institute, University of São Paulo, São Paulo, Brazil; Research and Education Institute, Hospital Sirio-Libanês, São Paulo, Brazil. 30. Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany. 31. Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST, University of Genoa, Genoa, Italy. 32. Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.
Abstract
BACKGROUND: Protective mechanical ventilation strategies using low tidal volume or high levels of positive end-expiratory pressure (PEEP) improve outcomes for patients who have had surgery. The role of the driving pressure, which is the difference between the plateau pressure and the level of positive end-expiratory pressure is not known. We investigated the association of tidal volume, the level of PEEP, and driving pressure during intraoperative ventilation with the development of postoperative pulmonary complications. METHODS: We did a meta-analysis of individual patient data from randomised controlled trials of protective ventilation during general anesthaesia for surgery published up to July 30, 2015. The main outcome was development of postoperative pulmonary complications (postoperative lung injury, pulmonary infection, or barotrauma). FINDINGS: We included data from 17 randomised controlled trials, including 2250 patients. Multivariate analysis suggested that driving pressure was associated with the development of postoperative pulmonary complications (odds ratio [OR] for one unit increase of driving pressure 1·16, 95% CI 1·13-1·19; p<0·0001), whereas we detected no association for tidal volume (1·05, 0·98-1·13; p=0·179). PEEP did not have a large enough effect in univariate analysis to warrant inclusion in the multivariate analysis. In a mediator analysis, driving pressure was the only significant mediator of the effects of protective ventilation on development of pulmonary complications (p=0·027). In two studies that compared low with high PEEP during low tidal volume ventilation, an increase in the level of PEEP that resulted in an increase in driving pressure was associated with more postoperative pulmonary complications (OR 3·11, 95% CI 1·39-6·96; p=0·006). INTERPRETATION: In patients having surgery, intraoperative high driving pressure and changes in the level of PEEP that result in an increase of driving pressure are associated with more postoperative pulmonary complications. However, a randomised controlled trial comparing ventilation based on driving pressure with usual care is needed to confirm these findings. FUNDING: None.
BACKGROUND: Protective mechanical ventilation strategies using low tidal volume or high levels of positive end-expiratory pressure (PEEP) improve outcomes for patients who have had surgery. The role of the driving pressure, which is the difference between the plateau pressure and the level of positive end-expiratory pressure is not known. We investigated the association of tidal volume, the level of PEEP, and driving pressure during intraoperative ventilation with the development of postoperative pulmonary complications. METHODS: We did a meta-analysis of individual patient data from randomised controlled trials of protective ventilation during general anesthaesia for surgery published up to July 30, 2015. The main outcome was development of postoperative pulmonary complications (postoperative lung injury, pulmonary infection, or barotrauma). FINDINGS: We included data from 17 randomised controlled trials, including 2250 patients. Multivariate analysis suggested that driving pressure was associated with the development of postoperative pulmonary complications (odds ratio [OR] for one unit increase of driving pressure 1·16, 95% CI 1·13-1·19; p<0·0001), whereas we detected no association for tidal volume (1·05, 0·98-1·13; p=0·179). PEEP did not have a large enough effect in univariate analysis to warrant inclusion in the multivariate analysis. In a mediator analysis, driving pressure was the only significant mediator of the effects of protective ventilation on development of pulmonary complications (p=0·027). In two studies that compared low with high PEEP during low tidal volume ventilation, an increase in the level of PEEP that resulted in an increase in driving pressure was associated with more postoperative pulmonary complications (OR 3·11, 95% CI 1·39-6·96; p=0·006). INTERPRETATION: In patients having surgery, intraoperative high driving pressure and changes in the level of PEEP that result in an increase of driving pressure are associated with more postoperative pulmonary complications. However, a randomised controlled trial comparing ventilation based on driving pressure with usual care is needed to confirm these findings. FUNDING: None.
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