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Esposito T, Fregonese M, Morettini G, Carboni P, Tardioli C, Messina A, Vaschetto R, Della Corte F, Vetrugno L, Navalesi P, De Robertis E, Azzolina D, Piriyapatsom A, Tucci MR, Wrigge H, Simon P, Bignami E, Maggiore SM, Simonte R, Cammarota G. Intraoperative individualization of positive-end-expiratory pressure through electrical impedance tomography or esophageal pressure assessment: a systematic review and meta-analysis of randomized controlled trials. J Clin Monit Comput 2024; 38:89-100. [PMID: 37863862 DOI: 10.1007/s10877-023-01094-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 10/09/2023] [Indexed: 10/22/2023]
Abstract
PURPOSE This systematic review of randomized-controlled trials (RCTs) with meta-analyses aimed to compare the effects on intraoperative arterial oxygen tension to inspired oxygen fraction ratio (PaO2/FiO2), exerted by positive end-expiratory pressure (PEEP) individualized trough electrical impedance tomography (EIT) or esophageal pressure (Pes) assessment (intervention) vs. PEEP not tailored on EIT or Pes (control), in patients undergoing abdominal or pelvic surgery with an open or laparoscopic/robotic approach. METHODS PUBMED®, EMBASE®, and Cochrane Controlled Clinical trials register were searched for observational studies and RCTs from inception to the end of August 2022. Inclusion criteria were: RCTs comparing PEEP titrated on EIT/Pes assessment vs. PEEP not individualized on EIT/Pes and reporting intraoperative PaO2/FiO2. Two authors independently extracted data from the enrolled investigations. Data are reported as mean difference and 95% confidence interval (CI). RESULTS Six RCTs were included for a total of 240 patients undergoing general anesthesia for surgery, of whom 117 subjects in the intervention group and 123 subjects in the control group. The intraoperative mean PaO2/FiO2 was 69.6 (95%CI 32.-106.4 ) mmHg higher in the intervention group as compared with the control group with 81.4% between-study heterogeneity (p < 0.01). However, at meta-regression, the between-study heterogeneity diminished to 44.96% when data were moderated for body mass index (estimate 3.45, 95%CI 0.78-6.11, p = 0.011). CONCLUSIONS In patients undergoing abdominal or pelvic surgery with an open or laparoscopic/robotic approach, PEEP personalized by EIT or Pes allowed the achievement of a better intraoperative oxygenation compared to PEEP not individualized through EIT or Pes. PROSPERO REGISTRATION NUMBER CRD 42021218306, 30/01/2023.
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Affiliation(s)
- Teresa Esposito
- Department of Anesthesiology and Intensive Care, 'Maggiore della Carità' Hospital, Novara, Italy
| | - Martina Fregonese
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy
| | - Giulio Morettini
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy
| | - Paloma Carboni
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy
| | - Cecilia Tardioli
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy
| | - Antonio Messina
- Humanitas Clinical and Research Center-IRCCS, Rozzano, Italy
| | - Rosanna Vaschetto
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Francesco Della Corte
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, Università Gabriele D'Annunzio di Chieti-Pescara, Chieti, Italy
| | - Paolo Navalesi
- Department of Medicine, Università degli Studi Di Padova, Padova, Italy
| | - Edoardo De Robertis
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy
| | - Danila Azzolina
- Department of Ambiental Science and Prevention, Università degli Studi di Ferrara, Ferrara, Italy
| | - Annop Piriyapatsom
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Mauro R Tucci
- Service of Pneumology, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Hermann Wrigge
- Integrated Research and Treatment Centre Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital, Halle, Germany
- Medical Faculty, Martin-Luther University Halle-Wittenberg, Halle, Germany
| | - Philipp Simon
- Integrated Research and Treatment Centre Adiposity Diseases, University of Leipzig, Leipzig, Germany
- Anesthesiology and Operative Intensive Care, Faculty of Medicine, University of Augsburg, Augsburg, Germany
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Salvatore M Maggiore
- Department of Anesthesiology and Intensive Care, Ospedale SS Annunziata & Department of Innovative Technologies in Medicine and Odonto-stomatology, Università Gabriele D'Annunzio di Chieti-Pescara, Chieti, Italy
| | - Rachele Simonte
- Department of Anesthesiology and Intensive Care, 'Maggiore della Carità' Hospital, Novara, Italy
| | - Gianmaria Cammarota
- Department of Medicine and Surgery, Università degli Studi di Perugia, Perugia, Italy.
- Dipartimento di Medicina Traslazionale, Università degli Studi del Piemonte Orientale, Novara, Italy.
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Fernandez-Bustamante A, Sprung J, Parker RA, Bartels K, Weingarten TN, Kosour C, Thompson BT, Vidal Melo MF. Individualized PEEP to optimise respiratory mechanics during abdominal surgery: a pilot randomised controlled trial. Br J Anaesth 2020; 125:383-392. [PMID: 32682559 DOI: 10.1016/j.bja.2020.06.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/24/2020] [Accepted: 06/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Higher intraoperative driving pressures (ΔP) are associated with increased postoperative pulmonary complications (PPC). We hypothesised that dynamic adjustment of PEEP throughout abdominal surgery reduces ΔP, maintains positive end-expiratory transpulmonary pressures (Ptp_ee) and increases respiratory system static compliance (Crs) with PEEP levels that are variable between and within patients. METHODS In a prospective multicentre pilot study, adults at moderate/high risk for PPC undergoing elective abdominal surgery were randomised to one of three ventilation protocols: (1) PEEP≤2 cm H2O, compared with periodic recruitment manoeuvres followed by individualised PEEP to either optimise respiratory system compliance (PEEPmaxCrs) or maintain positive end-expiratory transpulmonary pressure (PEEPPtp_ee). The composite primary outcome included intraoperative ΔP, Ptp_ee, Crs, and PEEP values (median (interquartile range) and coefficients of variation [CVPEEP]). RESULTS Thirty-seven patients (48.6% female; age range: 47-73 yr) were assigned to control (PEEP≤2 cm H2O; n=13), PEEPmaxCrs (n=16), or PEEPPtp_ee (n=8) groups. The PEEPPtp_ee intervention could not be delivered in two patients. Subjects assigned to PEEPmaxCrs had lower ΔP (median8 cm H2O [7-10]), compared with the control group (12 cm H2O [10-15]; P=0.006). PEEPmaxCrs was also associated with higher Ptp_ee (2.0 cm H2O [-0.7 to 4.5] vs controls: -8.3 cm H2O [-13.0 to -4.0]; P≤0.001) and higher Crs (47.7 ml cm H2O [43.2-68.8] vs controls: 39.0 ml cm H2O [32.9-43.4]; P=0.009). Individualised PEEP (PEEPmaxCrs and PEEPPtp_ee combined) varied widely (median: 10 cm H2O [8-15]; CVPEEP=0.24 [0.14-0.35]), both between, and within, subjects throughout surgery. CONCLUSIONS This pilot study suggests that individualised PEEP management strategies applied during abdominal surgery reduce driving pressure, maintain positive Ptp_ee and increase static compliance. The wide range of PEEP observed suggests that an individualised approach is required to optimise respiratory mechanics during abdominal surgery. CLINICAL TRIAL REGISTRATION NCT02671721.
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Affiliation(s)
- Ana Fernandez-Bustamante
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Webb-Waring Center, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert A Parker
- Department of Medicine, Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Karsten Bartels
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Carolina Kosour
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcos F Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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