Individual Positive End-expiratory Pressure Settings Optimize Intraoperative Mechanical Ventilation and Reduce Postoperative Atelectasis
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW BACKGROUND:Intraoperative lung-protective ventilation has been recommended to reduce postoperative pulmonary complications after abdominal surgery. Although the protective role of a more physiologic tidal volume has been es...
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| Veröffentlicht in: | Anesthesiology (Philadelphia) 2018-12, Vol.129 (6), p.1070-1081 |
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| creator | Pereira, Sérgio M Tucci, Mauro R Morais, Caio C A Simões, Claudia M Tonelotto, Bruno F F Pompeo, Michel S Kay, Fernando U Pelosi, Paolo Vieira, Joaquim E Amato, Marcelo B P |
| description | WHAT WE ALREADY KNOW ABOUT THIS TOPIC
WHAT THIS ARTICLE TELLS US THAT IS NEW
BACKGROUND:Intraoperative lung-protective ventilation has been recommended to reduce postoperative pulmonary complications after abdominal surgery. Although the protective role of a more physiologic tidal volume has been established, the added protection afforded by positive end-expiratory pressure (PEEP) remains uncertain. The authors hypothesized that a low fixed PEEP might not fit all patients and that an individually titrated PEEP during anesthesia might improve lung function during and after surgery.
METHODS:Forty patients were studied in the operating room (20 laparoscopic and 20 open-abdominal). They underwent elective abdominal surgery and were randomized to institutional PEEP (4 cm H2O) or electrical impedance tomography–guided PEEP (applied after recruitment maneuvers and targeted at minimizing lung collapse and hyperdistension, simultaneously). Patients were extubated without changing selected PEEP or fractional inspired oxygen tension while under anesthesia and submitted to chest computed tomography after extubation. Our primary goal was to individually identify the electrical impedance tomography–guided PEEP value producing the best compromise of lung collapse and hyperdistention.
RESULTS:Electrical impedance tomography–guided PEEP varied markedly across individuals (median, 12 cm H2O; range, 6 to 16 cm H2O; 95% CI, 10–14). Compared with PEEP of 4 cm H2O, patients randomized to the electrical impedance tomography–guided strategy had less postoperative atelectasis (6.2 ± 4.1 vs. 10.8 ± 7.1% of lung tissue mass; P = 0.017) and lower intraoperative driving pressures (mean values during surgery of 8.0 ± 1.7 vs. 11.6 ± 3.8 cm H2O; P < 0.001). The electrical impedance tomography–guided PEEP arm had higher intraoperative oxygenation (435 ± 62 vs. 266 ± 76 mmHg for laparoscopic group; P < 0.001), while presenting equivalent hemodynamics (mean arterial pressure during surgery of 80 ± 14 vs. 78 ± 15 mmHg; P = 0.821).
CONCLUSIONS:PEEP requirements vary widely among patients receiving protective tidal volumes during anesthesia for abdominal surgery. Individualized PEEP settings could reduce postoperative atelectasis (measured by computed tomography) while improving intraoperative oxygenation and driving pressures, causing minimum side effects. |
| doi_str_mv | 10.1097/ALN.0000000000002435 |
| format | Article |
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WHAT THIS ARTICLE TELLS US THAT IS NEW
BACKGROUND:Intraoperative lung-protective ventilation has been recommended to reduce postoperative pulmonary complications after abdominal surgery. Although the protective role of a more physiologic tidal volume has been established, the added protection afforded by positive end-expiratory pressure (PEEP) remains uncertain. The authors hypothesized that a low fixed PEEP might not fit all patients and that an individually titrated PEEP during anesthesia might improve lung function during and after surgery.
METHODS:Forty patients were studied in the operating room (20 laparoscopic and 20 open-abdominal). They underwent elective abdominal surgery and were randomized to institutional PEEP (4 cm H2O) or electrical impedance tomography–guided PEEP (applied after recruitment maneuvers and targeted at minimizing lung collapse and hyperdistension, simultaneously). Patients were extubated without changing selected PEEP or fractional inspired oxygen tension while under anesthesia and submitted to chest computed tomography after extubation. Our primary goal was to individually identify the electrical impedance tomography–guided PEEP value producing the best compromise of lung collapse and hyperdistention.
RESULTS:Electrical impedance tomography–guided PEEP varied markedly across individuals (median, 12 cm H2O; range, 6 to 16 cm H2O; 95% CI, 10–14). Compared with PEEP of 4 cm H2O, patients randomized to the electrical impedance tomography–guided strategy had less postoperative atelectasis (6.2 ± 4.1 vs. 10.8 ± 7.1% of lung tissue mass; P = 0.017) and lower intraoperative driving pressures (mean values during surgery of 8.0 ± 1.7 vs. 11.6 ± 3.8 cm H2O; P < 0.001). The electrical impedance tomography–guided PEEP arm had higher intraoperative oxygenation (435 ± 62 vs. 266 ± 76 mmHg for laparoscopic group; P < 0.001), while presenting equivalent hemodynamics (mean arterial pressure during surgery of 80 ± 14 vs. 78 ± 15 mmHg; P = 0.821).
CONCLUSIONS:PEEP requirements vary widely among patients receiving protective tidal volumes during anesthesia for abdominal surgery. Individualized PEEP settings could reduce postoperative atelectasis (measured by computed tomography) while improving intraoperative oxygenation and driving pressures, causing minimum side effects.</description><identifier>ISSN: 0003-3022</identifier><identifier>EISSN: 1528-1175</identifier><identifier>DOI: 10.1097/ALN.0000000000002435</identifier><identifier>PMID: 30260897</identifier><language>eng</language><publisher>United States: Copyright by , the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc</publisher><subject>Abdomen - surgery ; Adult ; Aged ; Anesthesia, Intravenous ; Elective Surgical Procedures ; Female ; Humans ; Intraoperative Care - methods ; Laparoscopy ; Length of Stay ; Male ; Middle Aged ; Oxygen Consumption ; Positive-Pressure Respiration - adverse effects ; Positive-Pressure Respiration - methods ; Postoperative Complications - prevention & control ; Precision Medicine - methods ; Pulmonary Atelectasis - epidemiology ; Pulmonary Atelectasis - etiology ; Pulmonary Atelectasis - prevention & control ; Respiration, Artificial - adverse effects ; Respiration, Artificial - methods ; Tidal Volume ; Tomography</subject><ispartof>Anesthesiology (Philadelphia), 2018-12, Vol.129 (6), p.1070-1081</ispartof><rights>Copyright © by 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved.</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-c4685-44d5d53c5b65ff96c0d28cf6c3e35cc4b7a1258f40b0f882401ca2dada4b06113</citedby><cites>FETCH-LOGICAL-c4685-44d5d53c5b65ff96c0d28cf6c3e35cc4b7a1258f40b0f882401ca2dada4b06113</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>314,776,780,27903,27904</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/30260897$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Pereira, Sérgio M</creatorcontrib><creatorcontrib>Tucci, Mauro R</creatorcontrib><creatorcontrib>Morais, Caio C A</creatorcontrib><creatorcontrib>Simões, Claudia M</creatorcontrib><creatorcontrib>Tonelotto, Bruno F F</creatorcontrib><creatorcontrib>Pompeo, Michel S</creatorcontrib><creatorcontrib>Kay, Fernando U</creatorcontrib><creatorcontrib>Pelosi, Paolo</creatorcontrib><creatorcontrib>Vieira, Joaquim E</creatorcontrib><creatorcontrib>Amato, Marcelo B P</creatorcontrib><title>Individual Positive End-expiratory Pressure Settings Optimize Intraoperative Mechanical Ventilation and Reduce Postoperative Atelectasis</title><title>Anesthesiology (Philadelphia)</title><addtitle>Anesthesiology</addtitle><description>WHAT WE ALREADY KNOW ABOUT THIS TOPIC
WHAT THIS ARTICLE TELLS US THAT IS NEW
BACKGROUND:Intraoperative lung-protective ventilation has been recommended to reduce postoperative pulmonary complications after abdominal surgery. Although the protective role of a more physiologic tidal volume has been established, the added protection afforded by positive end-expiratory pressure (PEEP) remains uncertain. The authors hypothesized that a low fixed PEEP might not fit all patients and that an individually titrated PEEP during anesthesia might improve lung function during and after surgery.
METHODS:Forty patients were studied in the operating room (20 laparoscopic and 20 open-abdominal). They underwent elective abdominal surgery and were randomized to institutional PEEP (4 cm H2O) or electrical impedance tomography–guided PEEP (applied after recruitment maneuvers and targeted at minimizing lung collapse and hyperdistension, simultaneously). Patients were extubated without changing selected PEEP or fractional inspired oxygen tension while under anesthesia and submitted to chest computed tomography after extubation. Our primary goal was to individually identify the electrical impedance tomography–guided PEEP value producing the best compromise of lung collapse and hyperdistention.
RESULTS:Electrical impedance tomography–guided PEEP varied markedly across individuals (median, 12 cm H2O; range, 6 to 16 cm H2O; 95% CI, 10–14). Compared with PEEP of 4 cm H2O, patients randomized to the electrical impedance tomography–guided strategy had less postoperative atelectasis (6.2 ± 4.1 vs. 10.8 ± 7.1% of lung tissue mass; P = 0.017) and lower intraoperative driving pressures (mean values during surgery of 8.0 ± 1.7 vs. 11.6 ± 3.8 cm H2O; P < 0.001). The electrical impedance tomography–guided PEEP arm had higher intraoperative oxygenation (435 ± 62 vs. 266 ± 76 mmHg for laparoscopic group; P < 0.001), while presenting equivalent hemodynamics (mean arterial pressure during surgery of 80 ± 14 vs. 78 ± 15 mmHg; P = 0.821).
CONCLUSIONS:PEEP requirements vary widely among patients receiving protective tidal volumes during anesthesia for abdominal surgery. Individualized PEEP settings could reduce postoperative atelectasis (measured by computed tomography) while improving intraoperative oxygenation and driving pressures, causing minimum side effects.</description><subject>Abdomen - surgery</subject><subject>Adult</subject><subject>Aged</subject><subject>Anesthesia, Intravenous</subject><subject>Elective Surgical Procedures</subject><subject>Female</subject><subject>Humans</subject><subject>Intraoperative Care - methods</subject><subject>Laparoscopy</subject><subject>Length of Stay</subject><subject>Male</subject><subject>Middle Aged</subject><subject>Oxygen Consumption</subject><subject>Positive-Pressure Respiration - adverse effects</subject><subject>Positive-Pressure Respiration - methods</subject><subject>Postoperative Complications - prevention & control</subject><subject>Precision Medicine - methods</subject><subject>Pulmonary Atelectasis - epidemiology</subject><subject>Pulmonary Atelectasis - etiology</subject><subject>Pulmonary Atelectasis - prevention & control</subject><subject>Respiration, Artificial - adverse effects</subject><subject>Respiration, Artificial - methods</subject><subject>Tidal Volume</subject><subject>Tomography</subject><issn>0003-3022</issn><issn>1528-1175</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2018</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kUtP3DAUha0KBMPjH1Qoy24CtmMnznKEoB1peKgFtpFj33RMPU5qO7x-AT8bjwZKxYK7se7Rd86VfBD6SvAhwXV1NJ2fH-L_hrKCf0ETwqnICan4BpoktcgLTOk22gnhNq0VL8QW2k5aiUVdTdDzzGlzZ_QobXbZBxPNHWQnTufwMBgvY-8fs0sPIYwesl8Qo3G_Q3YxRLM0T5DNXPSyHyCRK-MZqIV0RqWwG3DR2CT3LpNOZz9BjwpWN-I7P41gQUUZTNhDm520AfZf3110fXpydfwjn198nx1P57lipeA5Y5prXijelrzr6lJhTYXqSlVAwZVibSUJ5aJjuMWdEJRhoiTVUkvW4pKQYhd9W-cOvv87QojN0gQF1koH_RgaSggra1xjkVC2RpXvQ_DQNYM3S-kfG4KbVQdN6qD52EGyHbxeGNsl6H-mt09PgFgD972N4MMfO96DbxYgbVx8nv0CCDaWZQ</recordid><startdate>201812</startdate><enddate>201812</enddate><creator>Pereira, Sérgio M</creator><creator>Tucci, Mauro R</creator><creator>Morais, Caio C A</creator><creator>Simões, Claudia M</creator><creator>Tonelotto, Bruno F F</creator><creator>Pompeo, Michel S</creator><creator>Kay, Fernando U</creator><creator>Pelosi, Paolo</creator><creator>Vieira, Joaquim E</creator><creator>Amato, Marcelo B P</creator><general>Copyright by , the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope></search><sort><creationdate>201812</creationdate><title>Individual Positive End-expiratory Pressure Settings Optimize Intraoperative Mechanical Ventilation and Reduce Postoperative Atelectasis</title><author>Pereira, Sérgio M ; Tucci, Mauro R ; Morais, Caio C A ; Simões, Claudia M ; Tonelotto, Bruno F F ; Pompeo, Michel S ; Kay, Fernando U ; Pelosi, Paolo ; Vieira, Joaquim E ; Amato, Marcelo B P</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c4685-44d5d53c5b65ff96c0d28cf6c3e35cc4b7a1258f40b0f882401ca2dada4b06113</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2018</creationdate><topic>Abdomen - surgery</topic><topic>Adult</topic><topic>Aged</topic><topic>Anesthesia, Intravenous</topic><topic>Elective Surgical Procedures</topic><topic>Female</topic><topic>Humans</topic><topic>Intraoperative Care - methods</topic><topic>Laparoscopy</topic><topic>Length of Stay</topic><topic>Male</topic><topic>Middle Aged</topic><topic>Oxygen Consumption</topic><topic>Positive-Pressure Respiration - adverse effects</topic><topic>Positive-Pressure Respiration - methods</topic><topic>Postoperative Complications - prevention & control</topic><topic>Precision Medicine - methods</topic><topic>Pulmonary Atelectasis - epidemiology</topic><topic>Pulmonary Atelectasis - etiology</topic><topic>Pulmonary Atelectasis - prevention & control</topic><topic>Respiration, Artificial - adverse effects</topic><topic>Respiration, Artificial - methods</topic><topic>Tidal Volume</topic><topic>Tomography</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Pereira, Sérgio M</creatorcontrib><creatorcontrib>Tucci, Mauro R</creatorcontrib><creatorcontrib>Morais, Caio C A</creatorcontrib><creatorcontrib>Simões, Claudia M</creatorcontrib><creatorcontrib>Tonelotto, Bruno F F</creatorcontrib><creatorcontrib>Pompeo, Michel S</creatorcontrib><creatorcontrib>Kay, Fernando U</creatorcontrib><creatorcontrib>Pelosi, Paolo</creatorcontrib><creatorcontrib>Vieira, Joaquim E</creatorcontrib><creatorcontrib>Amato, Marcelo B P</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>Anesthesiology (Philadelphia)</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Pereira, Sérgio M</au><au>Tucci, Mauro R</au><au>Morais, Caio C A</au><au>Simões, Claudia M</au><au>Tonelotto, Bruno F F</au><au>Pompeo, Michel S</au><au>Kay, Fernando U</au><au>Pelosi, Paolo</au><au>Vieira, Joaquim E</au><au>Amato, Marcelo B P</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Individual Positive End-expiratory Pressure Settings Optimize Intraoperative Mechanical Ventilation and Reduce Postoperative Atelectasis</atitle><jtitle>Anesthesiology (Philadelphia)</jtitle><addtitle>Anesthesiology</addtitle><date>2018-12</date><risdate>2018</risdate><volume>129</volume><issue>6</issue><spage>1070</spage><epage>1081</epage><pages>1070-1081</pages><issn>0003-3022</issn><eissn>1528-1175</eissn><abstract>WHAT WE ALREADY KNOW ABOUT THIS TOPIC
WHAT THIS ARTICLE TELLS US THAT IS NEW
BACKGROUND:Intraoperative lung-protective ventilation has been recommended to reduce postoperative pulmonary complications after abdominal surgery. Although the protective role of a more physiologic tidal volume has been established, the added protection afforded by positive end-expiratory pressure (PEEP) remains uncertain. The authors hypothesized that a low fixed PEEP might not fit all patients and that an individually titrated PEEP during anesthesia might improve lung function during and after surgery.
METHODS:Forty patients were studied in the operating room (20 laparoscopic and 20 open-abdominal). They underwent elective abdominal surgery and were randomized to institutional PEEP (4 cm H2O) or electrical impedance tomography–guided PEEP (applied after recruitment maneuvers and targeted at minimizing lung collapse and hyperdistension, simultaneously). Patients were extubated without changing selected PEEP or fractional inspired oxygen tension while under anesthesia and submitted to chest computed tomography after extubation. Our primary goal was to individually identify the electrical impedance tomography–guided PEEP value producing the best compromise of lung collapse and hyperdistention.
RESULTS:Electrical impedance tomography–guided PEEP varied markedly across individuals (median, 12 cm H2O; range, 6 to 16 cm H2O; 95% CI, 10–14). Compared with PEEP of 4 cm H2O, patients randomized to the electrical impedance tomography–guided strategy had less postoperative atelectasis (6.2 ± 4.1 vs. 10.8 ± 7.1% of lung tissue mass; P = 0.017) and lower intraoperative driving pressures (mean values during surgery of 8.0 ± 1.7 vs. 11.6 ± 3.8 cm H2O; P < 0.001). The electrical impedance tomography–guided PEEP arm had higher intraoperative oxygenation (435 ± 62 vs. 266 ± 76 mmHg for laparoscopic group; P < 0.001), while presenting equivalent hemodynamics (mean arterial pressure during surgery of 80 ± 14 vs. 78 ± 15 mmHg; P = 0.821).
CONCLUSIONS:PEEP requirements vary widely among patients receiving protective tidal volumes during anesthesia for abdominal surgery. Individualized PEEP settings could reduce postoperative atelectasis (measured by computed tomography) while improving intraoperative oxygenation and driving pressures, causing minimum side effects.</abstract><cop>United States</cop><pub>Copyright by , the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc</pub><pmid>30260897</pmid><doi>10.1097/ALN.0000000000002435</doi><tpages>12</tpages><oa>free_for_read</oa></addata></record> |
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| source | MEDLINE; Journals@Ovid Complete; EZB-FREE-00999 freely available EZB journals |
| subjects | Abdomen - surgery Adult Aged Anesthesia, Intravenous Elective Surgical Procedures Female Humans Intraoperative Care - methods Laparoscopy Length of Stay Male Middle Aged Oxygen Consumption Positive-Pressure Respiration - adverse effects Positive-Pressure Respiration - methods Postoperative Complications - prevention & control Precision Medicine - methods Pulmonary Atelectasis - epidemiology Pulmonary Atelectasis - etiology Pulmonary Atelectasis - prevention & control Respiration, Artificial - adverse effects Respiration, Artificial - methods Tidal Volume Tomography |
| title | Individual Positive End-expiratory Pressure Settings Optimize Intraoperative Mechanical Ventilation and Reduce Postoperative Atelectasis |
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