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Gu WJ, Cen Y, Zhao FZ, Wang HJ, Yin HY, Zheng XF. Association between driving pressure-guided ventilation and postoperative pulmonary complications in surgical patients: a meta-analysis with trial sequential analysis. Br J Anaesth 2024; 133:647-657. [PMID: 38937217 DOI: 10.1016/j.bja.2024.04.060] [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: 01/22/2024] [Revised: 03/22/2024] [Accepted: 04/15/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Prior studies have reported inconsistent results regarding the association between driving pressure-guided ventilation and postoperative pulmonary complications (PPCs). We aimed to investigate whether driving pressure-guided ventilation is associated with a lower risk of PPCs. METHODS We systematically searched electronic databases for RCTs comparing driving pressure-guided ventilation with conventional protective ventilation in adult surgical patients. The primary outcome was a composite of PPCs. Secondary outcomes were pneumonia, atelectasis, and acute respiratory distress syndrome (ARDS). Meta-analysis and subgroup analysis were conducted to calculate risk ratios (RRs) with 95% confidence intervals (CI). Trial sequential analysis (TSA) was used to assess the conclusiveness of evidence. RESULTS Thirteen RCTs with 3401 subjects were included. Driving pressure-guided ventilation was associated with a lower risk of PPCs (RR 0.70, 95% CI 0.56-0.87, P=0.001), as indicated by TSA. Subgroup analysis (P for interaction=0.04) found that the association was observed in non-cardiothoracic surgery (nine RCTs, 1038 subjects, RR 0.61, 95% CI 0.48-0.77, P< 0.0001), with TSA suggesting sufficient evidence and conclusive result; however, it did not reach significance in cardiothoracic surgery (four RCTs, 2363 subjects, RR 0.86, 95% CI 0.67-1.10, P=0.23), with TSA indicating insufficient evidence and inconclusive result. Similarly, a lower risk of pneumonia was found in non-cardiothoracic surgery but not in cardiothoracic surgery (P for interaction=0.046). No significant differences were found in atelectasis and ARDS between the two ventilation strategies. CONCLUSIONS Driving pressure-guided ventilation was associated with a lower risk of postoperative pulmonary complications in non-cardiothoracic surgery but not in cardiothoracic surgery. SYSTEMATIC REVIEW PROTOCOL INPLASY 202410068.
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Affiliation(s)
- Wan-Jie Gu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Yun Cen
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Feng-Zhi Zhao
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Hua-Jun Wang
- Department of Bone and Joint Surgery and Sports Medicine Center, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Hai-Yan Yin
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China.
| | - Xiao-Fei Zheng
- Department of Bone and Joint Surgery and Sports Medicine Center, The First Affiliated Hospital of Jinan University, Guangzhou, China.
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Snyder M, Njie BY, Grabenstein I, Viola S, Abbas H, Bhatti W, Lee R, Traficante R, Yeung SYA, Chow JH, Tabatabai A, Taylor BS, Dahi S, Scalea T, Rabin J, Grazioli A, Calfee CS, Britton N, Levine AR. Functional recovery in a cohort of ECMO and non-ECMO acute respiratory distress syndrome survivors. Crit Care 2023; 27:440. [PMID: 37964311 PMCID: PMC10644522 DOI: 10.1186/s13054-023-04724-y] [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: 08/12/2023] [Accepted: 11/06/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND The mortality benefit of VV-ECMO in ARDS has been extensively studied, but the impact on long-term functional outcomes of survivors is poorly defined. We aimed to assess the association between ECMO and functional outcomes in a contemporaneous cohort of survivors of ARDS. METHODS Multicenter retrospective cohort study of ARDS survivors who presented to follow-up clinic. The primary outcome was FVC% predicted. Univariate and multivariate regression models were used to evaluate the impact of ECMO on the primary outcome. RESULTS This study enrolled 110 survivors of ARDS, 34 of whom were managed using ECMO. The ECMO cohort was younger (35 [28, 50] vs. 51 [44, 61] years old, p < 0.01), less likely to have COVID-19 (58% vs. 96%, p < 0.01), more severely ill based on the Sequential Organ Failure Assessment (SOFA) score (7 [5, 9] vs. 4 [3, 6], p < 0.01), dynamic lung compliance (15 mL/cmH20 [11, 20] vs. 27 mL/cmH20 [23, 35], p < 0.01), oxygenation index (26 [22, 33] vs. 9 [6, 11], p < 0.01), and their need for rescue modes of ventilation. ECMO patients had significantly longer lengths of hospitalization (46 [27, 62] vs. 16 [12, 31] days, p < 0.01) ICU stay (29 [19, 43] vs. 10 [5, 17] days, p < 0.01), and duration of mechanical ventilation (24 [14, 42] vs. 10 [7, 17] days, p < 0.01). Functional outcomes were similar in ECMO and non-ECMO patients. ECMO did not predict changes in lung function when adjusting for age, SOFA, COVID-19 status, or length of hospitalization. CONCLUSIONS There were no significant differences in the FVC% predicted, or other markers of pulmonary, neurocognitive, or psychiatric functional recovery outcomes, when comparing a contemporaneous clinic-based cohort of survivors of ARDS managed with ECMO to those without ECMO.
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Affiliation(s)
| | - Binta Y Njie
- University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Sara Viola
- Department of Medicine, Division of Critical Care Medicine, University of Maryland Baltimore Washington Medical Center, Baltimore, MD, USA
| | - Hatoon Abbas
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, 110 S. Paca St, Baltimore, MD, 21231, USA
| | - Waqas Bhatti
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, 110 S. Paca St, Baltimore, MD, 21231, USA
| | - Ryan Lee
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, 110 S. Paca St, Baltimore, MD, 21231, USA
| | - Rosalie Traficante
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, 110 S. Paca St, Baltimore, MD, 21231, USA
| | - Siu Yan Amy Yeung
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, MD, USA
| | - Jonathan H Chow
- Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine, Washington, DC, USA
| | - Ali Tabatabai
- Department of Medicine, Division of Education, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bradley S Taylor
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Siamak Dahi
- Division of Cardiothoracic Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas Scalea
- Department of Surgery and Program in Trauma, R Adams Crowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joseph Rabin
- Department of Surgery and Program in Trauma, R Adams Crowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Alison Grazioli
- Department of Medicine, University of Maryland School of Medicine, Program in Trauma, Baltimore, MD, USA
| | - Carolyn S Calfee
- Division of Pulmonary and Critical Care, Department of Medicine, University of California, San Francisco, CA, USA
| | - Noel Britton
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andrea R Levine
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, 110 S. Paca St, Baltimore, MD, 21231, USA.
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3
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Sun M, Jia R, Wang L, Sun D, Wei M, Wang T, Jiang L, Wang Y, Yang B. Effect of protective lung ventilation on pulmonary complications after laparoscopic surgery: a meta-analysis of randomized controlled trials. Front Med (Lausanne) 2023; 10:1171760. [PMID: 37305134 PMCID: PMC10248173 DOI: 10.3389/fmed.2023.1171760] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 05/05/2023] [Indexed: 06/13/2023] Open
Abstract
Introduction Compared with traditional open surgery, laparoscopic surgery is widely used in surgery, with the advantages of being minimally invasive, having good cosmetic effects, and having short hospital stays, but in laparoscopic surgery, pneumoperitoneum and the Trendelenburg position can cause complications, such as atelectasis. Recently, several studies have shown that protective lung ventilation strategies are protective for abdominal surgery, reducing the incidence of postoperative pulmonary complications (PPCs). Ventilator-associated lung injury can be reduced by protective lung ventilation, which includes microtidal volume (4-8 mL/kg) ventilation and positive end-expiratory pressure (PEEP). Therefore, we used randomized, controlled trials (RCTs) to assess the results on this topic, and RCTs were used for meta-analysis to further evaluate the effect of protective lung ventilation on pulmonary complications in patients undergoing laparoscopic surgery. Methods In this meta-analysis, we searched the relevant literature contained in six major databases-CNKI, CBM, Wanfang Medical, Cochrane, PubMed, and Web of Science-from their inception to October 15, 2022. After screening the eligible literature, a randomized, controlled method was used to compare the occurrence of postoperative pulmonary complications when a protective lung ventilation strategy and conventional lung ventilation strategy were applied to laparoscopic surgery. After statistical analysis, the results were verified to be statistically significant. Results Twenty-three trials were included. Patients receiving protective lung ventilation were 1.17 times less likely to develop pulmonary complications after surgery than those receiving conventional lung ventilation (hazard ratio [RR] 0.18, 95% confidence interval [CI] 1.13-1.22; I2 = 0%). When tested for bias (P = 0.36), the result was statistically significant. Patients with protective lung ventilation were less likely to develop pulmonary complications after laparoscopic surgery. Conclusion Compared with conventional mechanical ventilation, protective lung ventilation reduces the incidence of postoperative pulmonary complications. For patients undergoing laparoscopic surgery, we suggest the use of protective lung ventilation, which is effective in reducing the incidence of lung injury and pulmonary infection. Implementation of a low tidal volume plus moderate positive end-expiratory pressure strategy reduces the risk of postoperative pulmonary complications.
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Affiliation(s)
- Menglin Sun
- Department of Anesthesiology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ruolin Jia
- Department of Obstetrics and Gynecology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lijuan Wang
- Department of Anesthesiology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Daqi Sun
- Department of Anesthesiology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Mingqian Wei
- Department of Anesthesiology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tao Wang
- Department of Anesthesiology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Lihua Jiang
- Department of Anesthesiology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuxia Wang
- Department of Anesthesiology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Bo Yang
- Department of Anesthesiology, Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Wang ZY, Ye SS, Fan Y, Shi CY, Wu HF, Miao CH, Zhou D. Individualized positive end-expiratory pressure with and without recruitment maneuvers in obese patients during bariatric surgery. Kaohsiung J Med Sci 2022; 38:858-868. [PMID: 35866347 DOI: 10.1002/kjm2.12576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 05/26/2022] [Accepted: 06/22/2022] [Indexed: 11/10/2022] Open
Abstract
This study aimed to determine whether regular recruitment maneuvers (RMs) are essential for obese patients (OPs) undergoing elective laparoscopic bariatric surgery (LBS) during intraoperative ventilation with individualized positive end-expiratory pressure (PEEP). Patients were randomly assigned to two arms: the RM + PEEP-EIT arm consisted of individualized PEEP titrated by electrical impedance tomography (EIT) with two regular RMs and the PEEP-EIT arm consisted of individualized PEEP titrated by EIT without additional RMs. For these two arms together, EIT-guided PEEP varied among individuals. The partial pressure of oxygen in arterial blood to fractional inspired oxygen (PaO2 /FiO2 ) ratio in the RM + PEEP-EIT arm was higher than that in the PEEP-EIT arm at 1 h after pneumoperitoneum (p = 0.024) and at the end of surgery (p = 0.035). There was no great difference in the PaO2 /FiO2 ratio between these two arms when measured 5 min prior to postanesthesia care unit (PACU) departure and on postoperative day 1. Compared with the PEEP-EIT arm, patients in the RM + PEEP-EIT arm had significantly higher intraoperative dynamic respiratory system compliance (p < 0.001) but consumed more vasopressors (p = 0.036). Postoperative pulmonary complications occurred in 1 of 29 patients in the RM + PEEP-EIT arm compared with 2 of 31 patients in the PEEP-EIT arm. Regular lung RMs can improve intraoperative oxygenation and respiratory system compliance among OPs undergoing LBS with EIT-guided individual PEEP. However, the improvement might disappear before leaving the PACU, and regular RMs resulted in more vasopressor consumption.
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Affiliation(s)
- Zhi-Yao Wang
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shan-Shan Ye
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yu Fan
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Cheng-Ye Shi
- Department of Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hai-Fu Wu
- Department of Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chang-Hong Miao
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Di Zhou
- Department of Anesthesiology, Zhongshan Hospital, Fudan University, Shanghai, China
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Niroomand A, Qvarnström S, Stenlo M, Malmsjö M, Ingemansson R, Hyllén S, Lindstedt S. The role of mechanical ventilation in primary graft dysfunction in the postoperative lung transplant recipient: A single center study and literature review. Acta Anaesthesiol Scand 2022; 66:483-496. [PMID: 35014027 PMCID: PMC9303877 DOI: 10.1111/aas.14025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 12/10/2021] [Accepted: 12/22/2021] [Indexed: 12/11/2022]
Abstract
Background Primary graft dysfunction (PGD) is still a major complication in patients undergoing lung transplantation (LTx). Much is unknown about the effect of postoperative mechanical ventilation on outcomes, with debate on the best approach to ventilation. Aim/Purpose The goal of this study was to generate hypotheses on the association between postoperative mechanical ventilation settings and allograft size matching in PGD development. Method This is a retrospective study of LTx patients between September 2011 and September 2018 (n = 116). PGD was assessed according to the International Society of Heart and Lung Transplantation (ISHLT) criteria. Data were collected from medical records, including chest x‐ray assessments, blood gas analysis, mechanical ventilator parameters and spirometry. Results Positive end‐expiratory pressures (PEEP) of 5 cm H2O were correlated with lower rates of grade 3 PGD. Graft size was important as tidal volumes calculated according to the recipient yielded greater rates of PGD when low volumes were used, a correlation that was lost when donor metrics were used. Conclusion Our results highlight a need for greater investigation of the role donor characteristics play in determining post‐operative ventilation of a lung transplant recipient. The mechanical ventilation settings on postoperative LTx recipients may have an implication for the development of acute graft dysfunction. Severe PGD was associated with the use of a PEEP higher than 5 and lower tidal volumes and oversized lungs were associated with lower long‐term mortality. Lack of association between ventilatory settings and survival may point to the importance of other variables than ventilation in the development of PGD.
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Affiliation(s)
- Anna Niroomand
- Department of Cardiothoracic Anesthesia and Intensive Care and Cardiothoracic Surgery and Transplantation Skåne University Hospital Lund University Lund Sweden
- Wallenberg Center for Molecular Medicine Lund University Lund Sweden
- Lund Stem Cell Center Lund University Lund Sweden
- Department of Clinical Sciences Lund University Lund Sweden
- Rutgers Robert University New Brunswick New Jersey USA
| | - Sara Qvarnström
- Department of Cardiothoracic Anesthesia and Intensive Care and Cardiothoracic Surgery and Transplantation Skåne University Hospital Lund University Lund Sweden
| | - Martin Stenlo
- Department of Cardiothoracic Anesthesia and Intensive Care and Cardiothoracic Surgery and Transplantation Skåne University Hospital Lund University Lund Sweden
- Lund Stem Cell Center Lund University Lund Sweden
- Department of Clinical Sciences Lund University Lund Sweden
| | - Malin Malmsjö
- Department of Clinical Sciences Lund University Lund Sweden
| | - Richard Ingemansson
- Department of Cardiothoracic Anesthesia and Intensive Care and Cardiothoracic Surgery and Transplantation Skåne University Hospital Lund University Lund Sweden
- Department of Clinical Sciences Lund University Lund Sweden
| | - Snejana Hyllén
- Department of Cardiothoracic Anesthesia and Intensive Care and Cardiothoracic Surgery and Transplantation Skåne University Hospital Lund University Lund Sweden
- Lund Stem Cell Center Lund University Lund Sweden
- Department of Clinical Sciences Lund University Lund Sweden
| | - Sandra Lindstedt
- Department of Cardiothoracic Anesthesia and Intensive Care and Cardiothoracic Surgery and Transplantation Skåne University Hospital Lund University Lund Sweden
- Wallenberg Center for Molecular Medicine Lund University Lund Sweden
- Lund Stem Cell Center Lund University Lund Sweden
- Department of Clinical Sciences Lund University Lund Sweden
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Smith JA, Secombe P, Aromataris E. Conservative management of occult pneumothorax in mechanically ventilated patients: A systematic review and meta-analysis. J Trauma Acute Care Surg 2021; 91:1025-1040. [PMID: 34225346 DOI: 10.1097/ta.0000000000003322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this systematic review was to investigate the safety and effectiveness of conservative management versus prophylactic intercostal catheter (ICC) insertion for the management of occult pneumothoraces in mechanically ventilated patients. METHODS PubMed, Embase, CINAHL, Web of Science, Cochrane Central, and other trial registries were searched. Eligible studies were critically appraised using standardized instruments. Meta-analysis was performed with mixed-methods logistic regression where appropriate and sensitivity analyses were performed with alternative statistical methods (Stata™ 15 or RevMan 5.3) or summarized in narrative. Randomized controlled trials (RCTs) and cohort studies were analyzed separately. RESULTS Twelve studies with a total of 354 participants were included; three RCTs (178 participants) and nine cohort studies (176 participants). The majority of the included studies, particularly the cohort studies, were well conducted. Two of the RCTs were rated as low quality. Statistically significant differences were observed in the RCT analysis: ICC insertion (any reason) (odds ratio, 2.86; 95% confidence interval, 1.26-6.43, 2 RCTs) in favor of prophylactic ICC; ICC complications (odds ratio, 0.12; 95% confidence interval, 0.02-0.62, 2 RCTs) in favor of conservative management. Nonstatistically significant differences were observed for progression of pneumothorax, ICC insertion (progression to simple pneumothorax), and ICC insertion (nonpneumothorax reasons). Results of analyses showed high imprecision (wide confidence limits). Conservative management showed a low rate of tension pneumothorax (2.8%). Complications were higher in the ICC group (19.5% vs. 5.8%). CONCLUSION Available evidence suggests that conservative management is safe for the management of occult pneumothoraces in mechanically ventilated patients, especially when undergoing short-term (<4 days) ventilation. We recommend that patients undergoing mechanical ventilation for a procedure alone and patients suspected to be ventilated less than 4 days can be conservatively managed. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.
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Affiliation(s)
- Jeremy Adam Smith
- From the JBI, Faculty of Health and Medical Sciences (J.A.S., E.A.), The University of Adelaide, SA; Intensive Care Unit (J.A.S.), The Alfred Hospital, Melbourne, VIC; Intensive Care Unit (P.S.), Alice Springs Hospital, Alice Springs, NT; School of Medicine (P.S.), Flinders University, Bedford Park, SA; and Australian and New Zealand Intensive Care Research Centre (P.S.), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Hatton GE, Mollett PJ, Du RE, Wei S, Korupolu R, Wade CE, Adams SD, Kao LS. High tidal volume ventilation is associated with ventilator-associated pneumonia in acute cervical spinal cord injury. J Spinal Cord Med 2021; 44:775-781. [PMID: 32043943 PMCID: PMC8477933 DOI: 10.1080/10790268.2020.1722936] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
CONTEXT/OBJECTIVE Pneumonia is the leading cause of death after acute spinal cord injury (SCI). High tidal volume ventilation (HVtV) is used in SCI rehabilitation centers to overcome hypoventilation while weaning patients from the ventilator. Our objective was to determine if HVtV in the acute post-injury period in SCI patients is associated with lower incidence of ventilator-associated pneumonia (VAP) when compared to patients receiving standard tidal volume ventilation. DESIGN Cohort study. SETTING Red Duke Trauma Institute, University of Texas Health Science Center at Houston, TX, USA. PARTICIPANTS Adult Acute Cervical SCI Patients, 2011-2018. INTERVENTIONS HVtV. OUTCOME MEASURES VAP, ventilator dependence at discharge, in-hospital mortality. RESULTS Of 181 patients, 85 (47%) developed VAP. HVtV was utilized in 22 (12%) patients. Demographics, apart from age, were similar between patients who received HVtV and standard ventilation; patients were younger in the HVtV group. VAP developed in 68% of patients receiving HVtV and in 44% receiving standard tidal volumes (P = 0.06). After adjustment, HVtV was associated with a 1.96 relative risk of VAP development (95% credible interval 1.55-2.17) on Bayesian analysis. These results correlate with a >99% posterior probability that HVtV is associated with increased VAP when compared to standard tidal volumes. HVtV was also associated with increased rates of ventilator dependence. CONCLUSIONS While limited by sample size and selection bias, our data revealed an association between HVtV and increased VAP. Further investigation into optimal early ventilation settings is needed for SCI patients, who are at a high risk of VAP.
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Affiliation(s)
- Gabrielle E. Hatton
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Center for Surgical Trials and Evidence-based Practice, HoustonTexas, USA,Corresponding to: Gabrielle E. Hatton, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, 6410 Fannin Street Suite 471, Houston, TX77030, USA; Ph: 713-500-4330, fax: 713-500-0714.
| | - Patrick J. Mollett
- Department of Physical Medicine and Rehabilitation, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Reginald E. Du
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,McGovern Medical School at the University of Texas Health Science Center, HoustonTexas, USA
| | - Shuyan Wei
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Center for Surgical Trials and Evidence-based Practice, HoustonTexas, USA
| | - Radha Korupolu
- Department of Physical Medicine and Rehabilitation, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Charles E. Wade
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Sasha D. Adams
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Lillian S. Kao
- Center for Translational Injury Research, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Department of Surgery, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA,Center for Surgical Trials and Evidence-based Practice, HoustonTexas, USA
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Tague LK, Bedair B, Witt C, Byers DE, Vazquez-Guillamet R, Kulkarni H, Alexander-Brett J, Nava R, Puri V, Kreisel D, Trulock EP, Gelman A, Hachem RR. Lung protective ventilation based on donor size is associated with a lower risk of severe primary graft dysfunction after lung transplantation. J Heart Lung Transplant 2021; 40:1212-1222. [PMID: 34353713 DOI: 10.1016/j.healun.2021.06.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/11/2021] [Accepted: 06/26/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Mechanical ventilation immediately after lung transplantation may impact the development of primary graft dysfunction (PGD), particularly in cases of donor-recipient size mismatch as ventilation is typically based on recipient rather than donor size. METHODS We conducted a retrospective cohort study of adult bilateral lung transplant recipients at our center between January 2010 and January 2017. We defined donor-based lung protective ventilation (dLPV) as 6 to 8 ml/kg of donor ideal body weight and plateau pressure <30 cm H2O. We calculated the donor-recipient predicted total lung capacity (pTLC) ratio and used logistic regression to examine relationships between pTLC ratio, dLPV and PGD grade 3 at 48 to 72 hours. We used Cox proportional hazards modelling to examine the relationship between pTLC ratio, dLPV and 1-year survival. RESULTS The cohort included 373 recipients; 24 (6.4%) developed PGD grade 3 at 48 to 72 hours, and 213 (57.3%) received dLPV. Mean pTLC ratio was 1.04 ± 0.18. dLPV was associated with significantly lower risks of PGD grade 3 (OR = 0.44; 95% CI: 0.29-0.68, p < 0.001) and 1-year mortality (HR = 0.49; 95% CI: 0.29-0.8, p = 0.018). There was a significant association between pTLC ratio and the risk of PGD grade 3, but this was attenuated by the use of dLPV. CONCLUSIONS dLPV is associated with decreased risk of PGD grade 3 at 48 to 72 hours and decreased 1-year mortality. Additionally, dLPV attenuates the association between pTLC and both PGD grade 3 and 1-year mortality. Donor-based ventilation strategies may help to mitigate the risk of PGD and other adverse outcomes associated with size mismatch after lung transplantation.
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Affiliation(s)
- Laneshia K Tague
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.
| | - Bahaa Bedair
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Chad Witt
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Derek E Byers
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Rodrigo Vazquez-Guillamet
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Hrishikesh Kulkarni
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Jennifer Alexander-Brett
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Ruben Nava
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Elbert P Trulock
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Andrew Gelman
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Ramsey R Hachem
- Division of Pulmonary & Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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Bameshki A, Khayat Kashani HR, Razavi M, Shobeiry M, Taghavi Gilani M. Comparison of the effects of 2 ventilatory strategies using tidal volumes of 6 and 8 ml/kg on pulmonary shunt and alveolar dead space volume in upper abdominal cancers surgery. Med J Islam Repub Iran 2021; 35:79. [PMID: 34291003 PMCID: PMC8285548 DOI: 10.47176/mjiri.35.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Indexed: 11/11/2022] Open
Abstract
Background: High tidal volume leads to inflammation, and low tidal volume leads to atelectasia and hypoxemia. This study was conducted to compare the effect of 6 mL/kg with positive end-expiratory pressure (PEEP) and 8 mL/kg without PEEP on pulmonary shunt and dead space volume.
Methods: This clinical trial was done on 36 patients aged 20 to 65 years old with ASA I-II. They were candidates for upper abdominal surgery and divided randomly into 2 groups. One group were ventilated with the tidal volume = 8 mL/kg without PEEP (TV8). The other group received the tidal volume = 6 mL/kg with low PEEP = 5 cm H2O (TV6). Arterial and central venous blood gases were taken after intubation and 2 hours later. Additionally, the vital signs of the patients were checked every 30 minutes. Data analysis was performed using t test, chi-square test, and repeated measures analysis of variance with SPSS software, version 16 (SPSS Inc). P value less than.05 were meaningful.
Results: There was no significant difference on the preanesthesia parameters. The pulmonary shunt was 13.5±0.1% and 18.6±0.2% in the groups TV6 and TV8, respectively (p=0.132), which slightly decreased after 2 hours in both groups without any significant difference (p=0.284). Prior to the ventilation, the ratios of dead space to tidal volume were 0.25±0.2 and 0.14±0.1 in the TV6 and TV8 groups, respectively (p=0.163), and after 2 hours, they were 0.23±0.11 and 0.16±0.1 in the TV6 and TV8 groups, respectively (p=0.271). There was no significant difference between the groups for blood pressure and peripheral and arterial oxygenation changes.
Conclusion: The tidal volume of 6 mL/kg with the PEEP of 5 mmHg was similar to the tidal volume of 8 mL/kg without PEEP for hemodynamic and pulmonary changes (oxygenation, shunt, and dead space).
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Affiliation(s)
- Alireza Bameshki
- Lung Disease Research Center, Department of Anesthesiology, Mashhad University of Medical Sciences, Mashhad, Iran
| | | | - Majid Razavi
- Lung Disease Research Center, Department of Anesthesiology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Maryam Shobeiry
- Lung Disease Research Center, Department of Anesthesiology, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mehryar Taghavi Gilani
- Lung Disease Research Center, Department of Anesthesiology, Mashhad University of Medical Sciences, Mashhad, Iran
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10
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Short B, Serra A, Tariq A, Moitra V, Brodie D, Patel S, Baldwin MR, Yip NH. Implementation of lung protective ventilation order to improve adherence to low tidal volume ventilation: A RE-AIM evaluation. J Crit Care 2021; 63:167-174. [PMID: 33004237 PMCID: PMC7979571 DOI: 10.1016/j.jcrc.2020.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/27/2020] [Accepted: 09/15/2020] [Indexed: 12/21/2022]
Abstract
PURPOSE Lung protective ventilation (LPV), defined as a tidal volume (Vt) ≤8 cc/kg of predicted body weight, reduces ventilator-induced lung injury but is applied inconsistently. MATERIALS AND METHODS We conducted a prospective, quasi-experimental, cohort study of adults mechanically ventilated admitted to intensive care units (ICU) in the year before, year after, and second year after implementation of an electronic medical record based LPV order, and a cross-sectional qualitative study of ICU providers regarding their perceptions of the order. We applied the Reach, Efficacy, Adoption, Implementation, and Maintenance (RE-AIM) framework to evaluate the implementation. RESULTS There were 1405, 1424, and 1342 in the control, adoption, and maintenance cohorts, representing 95% of mechanically ventilated adult ICU patients. The overall prevalence of LPV increased from 65% to 73% (p < 0.001, adjusted-OR for LPV adherence: 1.9, 95% CI 1.5-2.3), but LPV adherence in women was approximately 30% worse than in men (women: 44% to 56% [p < 0.001],men: 79% to 86% [p < 0.001]). ICU providers noted difficulty obtaining an accurate height measurement and mistrust of the Vt calculation as barriers to implementation. LPV adherence increased further in the second year post implementation. CONCLUSION We designed and implemented an LPV order that sustainably improved LPV adherence across diverse ICUs.
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Affiliation(s)
- Briana Short
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America.
| | - Alexis Serra
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Abdul Tariq
- The Value Institute at NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Vivek Moitra
- Department of Anesthesia, Columbia University Vagelos College of Physicians & Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Sapana Patel
- The New York State Psychiatric Institute, Research Foundation for Mental Hygiene, New York, NY, United States of America; Department of Psychiatry, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, United States of America
| | - Matthew R Baldwin
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America
| | - Natalie H Yip
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Columbia University Vagelos College of Physicians & Surgeons/NewYork-Presbyterian Hospital, New York, NY, United States of America
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11
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Nguyen TK, Mai DH, Le AN, Nguyen QH, Nguyen CT, Vu TA. A review of intraoperative lung-protective mechanical ventilation strategy. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2021. [DOI: 10.1016/j.tacc.2020.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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12
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Korupolu R, Stampas A, Jimenez I, Cruz D, Di Giusto M, Verduzco-Gutierrez M, Davis M. Mechanical ventilation and weaning practices for adults with spinal cord injury - An international survey. THE JOURNAL OF THE INTERNATIONAL SOCIETY OF PHYSICAL AND REHABILITATION MEDICINE 2021. [DOI: 10.4103/jisprm-000124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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13
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Wang Y, Huang W, He M, Peng L, Cai M, Yuan C, Hu Z, Li K. [Inverse ratio ventilation combined with PEEP in infants undergoing thoracoscopic surgery with one lung ventilation for lung cystadenomas: a randomized control trial of 63 cases]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2020; 40:1008-1012. [PMID: 32895160 DOI: 10.12122/j.issn.1673-4254.2020.07.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To investigate the effect of inverse ratio ventilation (IRV) combined with positive end-expiratory pressure (PEEP) in infants undergoing thoracoscopic surgery with single lung ventilation (OLV) for lung cystadenomas. METHODS A total of 66 infants undergoing thoracoscopic surgery with OLV for lung cystadenomas in our hospital from February, 2018 to February, 2019 were randomized into conventional ventilation groups (group N, n=33) and inverse ventilation group (group R, n=33). Hemodynamics and respiratory parameters of the infants were recorded and arterial blood gas analysis was performed at 15 min after two lung ventilation (TLV) (T1), OLV30 min (T2), OLV60 min (T3), and 15 min after recovery of TLV (T4). Bronchoalveolar lavage fluid was collected before and after surgery to detect the expression level of advanced glycation end product receptor (RAGE). RESULTS Sixty-three infants were finally included in this study. At T2 and T3, Cdyn, PaO2 and OI in group R were significantly higher (P < 0.05) and Ppeak, PaCO2 and PA-aO2 were significantly lower than those in group N (P < 0.05). There was no significant difference in HR or MAP between the two groups at T2 and T3 (P > 0.05). The level of RAGE significantly increased after the surgery in both groups (P < 0.05), and was significantly lower in R group than in N group (P < 0.05). CONCLUSIONS In infants undergoing thoracoscopic surgery with OLV for pulmonary cystadenoma, appropriate IRV combined with PEEP does not affect hemodynamic stability and can increases pulmonary compliance, reduce the peak pressure, and improve oxygenation to provide pulmonary protection.
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Affiliation(s)
- Yun Wang
- Department of Anesthesiology, Guangdong Women and Children's Hospital, Guangzhou 511400, China
| | - Weijian Huang
- Department of Anesthesiology, Guangdong Women and Children's Hospital, Guangzhou 511400, China
| | - Mudan He
- Department of Anesthesiology, Guangdong Women and Children's Hospital, Guangzhou 511400, China
| | - Lingli Peng
- Department of Anesthesiology, Guangdong Women and Children's Hospital, Guangzhou 511400, China
| | - Mingyang Cai
- Department of Anesthesiology, Guangdong Women and Children's Hospital, Guangzhou 511400, China
| | - Chao Yuan
- Department of Anesthesiology, Guangdong Women and Children's Hospital, Guangzhou 511400, China
| | - Zurong Hu
- Department of Anesthesiology, Guangdong Women and Children's Hospital, Guangzhou 511400, China
| | - Kunwei Li
- Department of Anesthesiology, Guangdong Women and Children's Hospital, Guangzhou 511400, China
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14
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Korupolu R, Stampas A, Uhlig-Reche H, Ciammaichella E, Mollett PJ, Achilike EC, Pedroza C. Comparing outcomes of mechanical ventilation with high vs. moderate tidal volumes in tracheostomized patients with spinal cord injury in acute inpatient rehabilitation setting: a retrospective cohort study. Spinal Cord 2020; 59:618-625. [PMID: 32647326 DOI: 10.1038/s41393-020-0517-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 07/01/2020] [Accepted: 07/01/2020] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVES The primary objective of this study was to evaluate safety and efficacy of higher tidal volumes (HVt) compared to moderate Vt (MVt) in people with spinal cord injury (SCI) admitted to acute inpatient rehabilitation (AIR) facility on mechanical ventilation via tracheostomy. SETTING AIR facility in the United States. METHODS Eighty-four adults with SCI were divided into MVt group if maximum Vt received in AIR was <15 ml/kg predicted body weight (PBW) and HVt group if maximum Vt was >15 ml/kg PBW. Primary outcomes were incidence of pneumonia and composite pulmonary adverse events (pneumonia, weaning failure, or acute care transfers due to respiratory complications). Secondary outcomes were AIR preweaning days defined as time from AIR admission to beginning of weaning, weaning days defined as days from start to end of weaning, and AIR ventilator days calculated as days on ventilator from AIR admission to discharge. RESULTS MVt was utilized in 50 patients and HVt was utilized in 34 patients. The risk of pneumonia in HVt group was 4.3 times higher [95% confidence interval (CI): 1.5-12] compared to MVt group. Odds of pulmonary adverse events in HVt group was 5.4 times higher (CI: 1.8-17) compared to MVt group. There was no difference in preweaning days, weaning days, or AIR ventilator days between the two groups. CONCLUSIONS Our data suggest that HVt is associated with increased risk of pneumonia and higher odds of pulmonary adverse events in tracheostomized patients with SCI which warrants further investigation.
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Affiliation(s)
- Radha Korupolu
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA.
| | - Argyrios Stampas
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA
| | - Hannah Uhlig-Reche
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA
| | - Ellia Ciammaichella
- Division of Physical Medicine and Rehabilitation, University of Utah, Salt Lake, UT, USA
| | | | - Emmanuel Chigozie Achilike
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA
| | - Claudia Pedroza
- Center for Clinical Research and Evidence Based Medicine (Biostatistician), The University of Texas Health Science Center, Houston, TX, USA
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15
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Dafilou B, Schwester D, Ruhl N, Marques-Baptista A. It's In The Bag: Tidal Volumes in Adult and Pediatric Bag Valve Masks. West J Emerg Med 2020; 21:722-726. [PMID: 32421525 PMCID: PMC7234703 DOI: 10.5811/westjem.2020.3.45788] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 03/11/2020] [Indexed: 01/09/2023] Open
Abstract
Introduction A bag valve mask (BVM) is a life saving device used by all levels of health care professionals during resuscitative care. We focus most of our time optimizing the patient’s position, firmly securing the mask, and frequency of ventilations. However, despite our best efforts to control these factors, we may still be precipitating harm to the patient. Multiple studies have shown the tidal volumes typically delivered by the adult BVM are often higher than recommended for lung-protective ventilation protocols. In this study we measure and compare the ventilation parameters delivered by the adult and pediatric BVM ventilators. Methods A RespiTrainer Advance® adult mannequin was used to simulate a patient. Healthcare providers were directed to manually ventilate an intubated mannequin for two minutes using adult and pediatric sized BVMs. Tidal volume, minute ventilation, peak pressure, and respiration rate was recorded. Results The adult BVM provided a mean tidal volume of 807.7mL versus the pediatric BVM providing 630.7mL, both of which exceeded the upper threshold of 560mL of tidal volume necessary for lung protective ventilation of an adult male with an ideal body weight of 70kg. The adult BVM exceeded this threshold by 44.2% versus the pediatric BVM’s 12.6% with 93% of participants exceeding the maximum threshold with the adult BVM and 82.3% exceeding it with the pediatric BVM. Conclusion The pediatric BVM in our study provided far more consistent and appropriate ventilation parameters for adult patients compared to an adult BVM, but still exceeded the upper limits of lung protective ventilation parameters. The results of this study highlight the potential dangers in using an adult BVM due to increased risk of pulmonary barotrauma. These higher tidal volumes can contribute to lung injury. This study confirms that smaller BVMs may provide safer ventilatory parameters. Future studies should focus on patient-centered outcomes with BVM.
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Affiliation(s)
- Benjamin Dafilou
- Capital Health Hospital System, Department of Emergency Medical Services, Trenton, New Jersey
| | - Daniel Schwester
- Capital Health Hospital System, Department of Emergency Medical Services, Trenton, New Jersey
| | - Nathan Ruhl
- Rowan University, Department of Biological Sciences, Glassboro, New Jersey
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16
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Cheng CD, Lin WL, Chen YW, Cherng CH. Effects of lung protective ventilation on postoperative pulmonary outcomes for prolonged oral cancer combined with free flap surgery. Medicine (Baltimore) 2020; 99:e18999. [PMID: 32000439 PMCID: PMC7004797 DOI: 10.1097/md.0000000000018999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The intraoperative lung protective ventilation with low tidal volume, positive end expiratory pressure (PEEP) and intermittent lungs recruitment was found to decrease postoperative pulmonary complications. In this retrospective medical records study, we investigated the effects of lung protective ventilation on postoperative pulmonary outcomes among the patients received prolonged oral cancer combined with free flap surgery.We collected the medical records of the patients received oral cancer surgery with the operation time more than 12 hours from January 2011 to December 2015. We recordedFifty nine cases were included. Thirty cases received the lung protective ventilation and 29 cases received conventional ventilation. Compared to the patients received conventional ventilation, the patients received intraoperative lung protective ventilation showedIn conclusion, for the prolonged oral cancer combined with free flap surgery, the intraoperative lung protective ventilation improves postoperative pulmonary outcomes and decreases the duration of ICU stay.
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Affiliation(s)
| | - Wei-Lin Lin
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
| | | | - Chen-Hwan Cherng
- Department of Anesthesiology, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan
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17
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Mathis MR, Duggal NM, Likosky DS, Haft JW, Douville NJ, Vaughn MT, Maile MD, Blank RS, Colquhoun DA, Strobel RJ, Janda AM, Zhang M, Kheterpal S, Engoren MC. Intraoperative Mechanical Ventilation and Postoperative Pulmonary Complications after Cardiac Surgery. Anesthesiology 2019; 131:1046-1062. [PMID: 31403976 PMCID: PMC6800803 DOI: 10.1097/aln.0000000000002909] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Compared with historic ventilation strategies, modern lung-protective ventilation includes lower tidal volumes (VT), lower driving pressures, and application of positive end-expiratory pressure (PEEP). The contributions of each component to an overall intraoperative protective ventilation strategy aimed at reducing postoperative pulmonary complications have neither been adequately resolved, nor comprehensively evaluated within an adult cardiac surgical population. The authors hypothesized that a bundled intraoperative protective ventilation strategy was independently associated with decreased odds of pulmonary complications after cardiac surgery. METHODS In this observational cohort study, the authors reviewed nonemergent cardiac surgical procedures using cardiopulmonary bypass at a tertiary care academic medical center from 2006 to 2017. The authors tested associations between bundled or component intraoperative protective ventilation strategies (VT below 8 ml/kg ideal body weight, modified driving pressure [peak inspiratory pressure - PEEP] below 16 cm H2O, and PEEP greater than or equal to 5 cm H2O) and postoperative outcomes, adjusting for previously identified risk factors. The primary outcome was a composite pulmonary complication; secondary outcomes included individual pulmonary complications, postoperative mortality, as well as durations of mechanical ventilation, intensive care unit stay, and hospital stay. RESULTS Among 4,694 cases reviewed, 513 (10.9%) experienced pulmonary complications. After adjustment, an intraoperative lung-protective ventilation bundle was associated with decreased pulmonary complications (adjusted odds ratio, 0.56; 95% CI, 0.42-0.75). Via a sensitivity analysis, modified driving pressure below 16 cm H2O was independently associated with decreased pulmonary complications (adjusted odds ratio, 0.51; 95% CI, 0.39-0.66), but VT below 8 ml/kg and PEEP greater than or equal to 5 cm H2O were not. CONCLUSIONS The authors identified an intraoperative lung-protective ventilation bundle as independently associated with pulmonary complications after cardiac surgery. The findings offer insight into components of protective ventilation associated with adverse outcomes and may serve as targets for future prospective interventional studies investigating the impact of specific protective ventilation strategies on postoperative outcomes after cardiac surgery.
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Affiliation(s)
- Michael R. Mathis
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Neal M. Duggal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Donald S. Likosky
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Jonathan W. Haft
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Nicholas J. Douville
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Michelle T. Vaughn
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Michael D. Maile
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Randal S. Blank
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Douglas A. Colquhoun
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Raymond J. Strobel
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Allison M. Janda
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Min Zhang
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Sachin Kheterpal
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
| | - Milo C. Engoren
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
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18
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Grant MC, Gibbons MM, Ko CY, Wick EC, Cannesson M, Scott MJ, McEvoy MD, King AB, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Anesth Analg 2019; 129:51-60. [DOI: 10.1213/ane.0000000000003696] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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19
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Soffin EM, Gibbons MM, Wick EC, Kates SL, Cannesson M, Scott MJ, Grant MC, Ko SS, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery: Focus on Anesthesiology for Hip Fracture Surgery. Anesth Analg 2019; 128:1107-1117. [PMID: 31094775 DOI: 10.1213/ane.0000000000003925] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Enhanced recovery after surgery (ERAS) protocols represent patient-centered, evidence-based, multidisciplinary care of the surgical patient. Although these patterns have been validated in numerous surgical specialities, ERAS has not been widely described for patients undergoing hip fracture (HFx) repair. As part of the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery, we have conducted a full evidence review of interventions that form the basis of the anesthesia components of the ERAS HFx pathway. A literature search was performed for each protocol component, and the highest levels of evidence available were selected for review. Anesthesiology components of care were identified and evaluated across the perioperative continuum. For the preoperative phase, the use of regional analgesia and nonopioid multimodal analgesic agents is suggested. For the intraoperative phase, a standardized anesthetic with postoperative nausea and vomiting prophylaxis is suggested. For the postoperative phase, a multimodal (primarily nonopioid) analgesic regimen is suggested. A summary of the best available evidence and recommendations for inclusion in ERAS protocols for HFx repair are provided.
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Affiliation(s)
- Ellen M Soffin
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
| | - Melinda M Gibbons
- Department of Surgery, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, Maryland
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Maxime Cannesson
- Department of Anesthesiology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Samantha S Ko
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Christopher L Wu
- From the Department of Anesthesiology, The Hospital for Special Surgery, New York, New York
- Department of Anesthesiology, Weill Cornell Medicine, New York, New York
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20
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Cui Y, Cao R, Li G, Gong T, Ou Y, Huang J. The effect of lung recruitment maneuvers on post-operative pulmonary complications for patients undergoing general anesthesia: A meta-analysis. PLoS One 2019; 14:e0217405. [PMID: 31141541 PMCID: PMC6541371 DOI: 10.1371/journal.pone.0217405] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Accepted: 05/11/2019] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Respiratory function would be impaired during general anesthesia period. Researchers devoted their energies to finding effective strategies for protecting respiratory function. Low tidal volume, positive end-expiratory pressure (PEEP), and lung recruitment maneuvers (LRMs) were recommended for patients under mechanical ventilation. However, based on the current evidence, there was no consensus on whether LRMs should be routinely used for anesthetized patients with healthy lungs, and the benefits of them remained to be determined. MATERIALS AND METHODS To evaluate the benefits of LRMs on patients undergoing surgery with general anesthesia, we searched relevant studies in PubMed, EMBASE, Ovid Medline and the Cochrane Library up to June 30, 2018. The primary outcome was postoperative pulmonary complications (PPCs). RESULTS Twelve trials involving 2756 anesthetized patients were included. The results of our study showed a significant benefit of LRMs for reducing the incidence of PPCs (RR = 0.67; 95%CI, 0.49 to 0.90; P<0.05; Chi2 = 32.94, p for heterogeneity = 0.0005, I2 = 67%). After subgroup analyses, we found LRMs combining with lung protective ventilation strategy and sustained recruitment maneuvers were associated with reducing the occurrence of PPCs. The results also revealed that the use of LRMs improved PaO2/FiO2 in non-obese patients, but with extremely high heterogeneity (I2 = 95%). CONCLUSION According to the findings from contemporary meta-analysis, LRMs combining with lung protective ventilation strategy may have an association with decreasing in the incidence of PPCs and improvement of oxygenation on non-obese patients. However, the conclusions must be interpreted cautiously as the outcome may be influenced dramatically due to varied LRMs and ventilation patterns.
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Affiliation(s)
- Yu Cui
- Department of Anesthesiology, Chengdu Women’s and Children’s Central Hospital, Chengdu, Sichuan, China
| | - Rong Cao
- Department of Anesthesiology, Chengdu Women’s and Children’s Central Hospital, Chengdu, Sichuan, China
| | - Gen Li
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Tianqing Gong
- Department of Anesthesiology, Chengdu Women’s and Children’s Central Hospital, Chengdu, Sichuan, China
| | - Yingyu Ou
- Department of Anesthesiology, Chengdu Women’s and Children’s Central Hospital, Chengdu, Sichuan, China
| | - Jing Huang
- Department of Anesthesiology, Chengdu Women’s and Children’s Central Hospital, Chengdu, Sichuan, China
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21
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Soffin EM, Gibbons MM, Ko CY, Kates SL, Wick EC, Cannesson M, Scott MJ, Wu CL. Evidence Review Conducted for the Agency for Healthcare Research and Quality Safety Program for Improving Surgical Care and Recovery. Anesth Analg 2019; 128:454-465. [DOI: 10.1213/ane.0000000000003663] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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22
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Grant MC, Gibbons MM, Ko CY, Wick EC, Cannesson M, Scott MJ, Wu CL. Evidence review conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery: focus on anesthesiology for gynecologic surgery. Reg Anesth Pain Med 2019; 44:rapm-2018-100071. [PMID: 30737316 DOI: 10.1136/rapm-2018-100071] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/11/2018] [Accepted: 12/27/2018] [Indexed: 12/27/2022]
Abstract
Enhanced recovery after surgery (ERAS) protocols for gynecologic (GYN) surgery are increasingly being reported and may be associated with superior outcomes, reduced length of hospital stay, and cost savings. The Agency for Healthcare Research and Quality, in partnership with the American College of Surgeons and the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, has developed the Safety Program for Improving Surgical Care and Recovery, which is a nationwide initiative to disseminate best practices in perioperative care to more than 750 hospitals across five major surgical service lines in a 5-year period. The program is designed to identify evidence-based process measures shown to prevent healthcare-associated conditions and hasten recovery after surgery, integrate those into a comprehensive service line-based pathway, and assist hospitals in program implementation. In conjunction with this effort, we have conducted an evidence review of the various anesthesia components which may influence outcomes and facilitate recovery after GYN surgery. A literature search was performed for each intervention, and the highest levels of available evidence were considered. Anesthesiology-related interventions for preoperative (carbohydrate loading/fasting, multimodal preanesthetic medications), intraoperative (standardized intraoperative pathway, regional anesthesia, protective ventilation strategies, fluid minimization) and postoperative (multimodal analgesia) phases of care are included. We have summarized the best available evidence to recommend the anesthetic components of care for ERAS for GYN surgery.
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Affiliation(s)
- Michael Conrad Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Melinda M Gibbons
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Clifford Y Ko
- Department of Surgery, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins Hospital and Health System, Baltimore, Maryland, USA
| | - Maxime Cannesson
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Michael J Scott
- Department of Anesthesiology, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
- Department of Anesthesiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Christopher L Wu
- Anesthesiology, Hospital for Special Surgery, New York City, New York, USA
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Guay J, Ochroch EA, Kopp S. Intraoperative use of low volume ventilation to decrease postoperative mortality, mechanical ventilation, lengths of stay and lung injury in adults without acute lung injury. Cochrane Database Syst Rev 2018; 7:CD011151. [PMID: 29985541 PMCID: PMC6513630 DOI: 10.1002/14651858.cd011151.pub3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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.
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Affiliation(s)
- Joanne Guay
- University of SherbrookeDepartment of Anesthesiology, Faculty of MedicineSherbrookeQuebecCanada
- University of Quebec in Abitibi‐TemiscamingueTeaching and Research Unit, Health SciencesRouyn‐NorandaQCCanada
- Faculty of Medicine, Laval UniversityDepartment of Anesthesiology and Critical CareQuebec CityQCCanada
| | - Edward A Ochroch
- University of PennsylvaniaDepartment of Anesthesiology3400 Spruce StreetPhiladelphiaPAUSA19104
| | - Sandra Kopp
- Mayo Clinic College of MedicineDepartment of Anesthesiology and Perioperative Medicine200 1st St SWRochesterMNUSA55901
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Kim SH, Na S, Lee WK, Choi H, Kim J. Application of intraoperative lung-protective ventilation varies in accordance with the knowledge of anaesthesiologists: a single-Centre questionnaire study and a retrospective observational study. BMC Anesthesiol 2018; 18:33. [PMID: 29606090 PMCID: PMC5879938 DOI: 10.1186/s12871-018-0495-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 03/08/2018] [Indexed: 11/12/2022] Open
Abstract
Background The benefits of lung-protective ventilation (LPV) with a low tidal volume (6 mL/kg of ideal body weight [IBW]), limited plateau pressure (< 28–30 cm H2O), and appropriate positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome have become apparent and it is now widely adopted in intensive care units. Recently evidence for LPV in general anaesthesia has been accumulated, but it is not yet generally applied by anaesthesiologists in the operating room. Methods This study investigated the perception about intraoperative LPV among 82 anaesthesiologists through a questionnaire survey and identified the differences in ventilator settings according to recognition of lung-protective ventilation. Furthermore, we investigated the changes in the trend for using this form of ventilation during general anaesthesia in the past 10 years. Results Anaesthesiologists who had received training in LPV were more knowledgeable about this approach. Anaesthesiologists with knowledge of the concept behind LPV strategies applied a lower tidal volume (median (IQR [range]), 8.2 (8.0–9.2 [7.1–10.3]) vs. 9.2 (9.1–10.1 [7.6–10.1]) mL/kg; p = 0.033) and used PEEP more frequently (69/72 [95.8%] vs. 5/8 [62.5%]; p = 0.012; odds ratio, 13.8 [2.19–86.9]) for laparoscopic surgery than did those without such knowledge. Anaesthesiologists who were able to answer a question related to LPV correctly (respondents who chose ‘height’ to a multiple choice question asking what variables should be considered most important in the initial setting of tidal volume) applied a lower tidal volume in cases of laparoscopic surgery and obese patients. There was an increase in the number of patients receiving LPV (VT < 10 mL/kgIBW and PEEP ≥5 cm H2O) between 2004 and 2014 (0/818 [0.0%] vs. 280/818 [34.2%]; p < 0.001). Conclusions Our study suggests that the knowledge of LPV is directly related to its implementation, and can explain the increase in LPV use in general anaesthesia. Further studies should assess the impact of using intraoperative LPV on clinical outcomes and should determine the efficacy of education on intraoperative LPV implementation. Electronic supplementary material The online version of this article (10.1186/s12871-018-0495-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Seung Hyun Kim
- Department of anesthesiology and Pain Medicine, anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Sungwon Na
- Department of anesthesiology and Pain Medicine, anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Woo Kyung Lee
- Department of anesthesiology and Pain Medicine, anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Hyunwoo Choi
- Department of anesthesiology and Pain Medicine, anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea
| | - Jeongmin Kim
- Department of anesthesiology and Pain Medicine, anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-gu, Seoul, 03722, South Korea.
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Josephs SA, Lemmink GA, Strong JA, Barry CL, Hurford WE. Improving Adherence to Intraoperative Lung-Protective Ventilation Strategies at a University Medical Center. Anesth Analg 2018; 126:150-160. [PMID: 28742774 DOI: 10.1213/ane.0000000000002299] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Intraoperative lung-protective ventilation (ILPV) is defined as tidal volumes <8 mL/kg ideal bodyweight and is increasingly a standard of care for major abdominal surgical procedures performed under general anesthesia. In this study, we report the result of a quality improvement initiative targeted at improving adherence to ILPV guidelines in a large academic teaching hospital. METHODS We performed a time-series study to determine whether anesthesia provider adherence to ILPV was affected by certain improvement interventions and patient ideal body weight (IBW). Tidal volume data were collected at 3 different time points for 191 abdominal surgical cases from June 2014 through April 2015. Improvement interventions during that period included education at departmental grand rounds, creation of a departmental ILPV policy, feedback of tidal volume and failure rate data at grand rounds sessions, and reducing default ventilator settings for tidal volume. Mean tidal volume per kilogram of ideal body weight (VT/kg IBW) and rates of noncompliance with ILPV were analyzed before and after the interventions. A survey was administered to assess provider attitudes after implementation of improvement interventions. Responses before and after interventions and between physician and nonphysician providers were analyzed. RESULTS Reductions in mean VT/kg IBW and rates of failure for providers to use ILPV occurred after improvement interventions. Patients with IBW <65 kg received higher VT/kg IBW and had higher rates of failure to use ILPV than patients with IBW >65 kg. Surveyed providers demonstrated stronger agreement to having knowledge and practice consistent with ILPV after interventions. CONCLUSIONS Our interventions improved anesthesia provider adherence to low tidal volume ILPV. IBW was found to be an important factor related to provider adherence to ILPV. Provider attitudes about their knowledge and practice consistent with ILPV also changed with our interventions.
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Affiliation(s)
- Sean A Josephs
- From the Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Brescia AA, Rankin JS, Cyr DD, Jacobs JP, Prager RL, Zhang M, Matsouaka RA, Harrington SD, Dokholyan RS, Bolling SF, Fishstrom A, Pasquali SK, Shahian DM, Likosky DS. Determinants of Variation in Pneumonia Rates After Coronary Artery Bypass Grafting. Ann Thorac Surg 2017; 105:513-520. [PMID: 29174785 DOI: 10.1016/j.athoracsur.2017.08.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 06/29/2017] [Accepted: 08/07/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although conventional wisdom suggests that differences in patient risk profiles drive variability in postoperative pneumonia rates after coronary artery bypass grafting (CABG), this teaching has yet to be empirically tested. We determined to what extent patient risk factors account for hospital variation in pneumonia rates. METHODS We studied 324,085 patients undergoing CABG between July 1, 2011, and December 31, 2013, across 998 hospitals using The Society of Thoracic Surgeons Adult Cardiac Database. We developed 5 models to estimate our incremental ability to explain hospital variation in pneumonia rates. Model 1 contained patient demographic characteristics and admission status, while Model 2 added patient risk factors. Model 3 added measures of pulmonary function, Model 4 added measures of cardiac anatomy and function and medications, and Model 5 further added measures of intraoperative and postoperative care. RESULTS Although 9,175 patients (2.83%) experienced pneumonia, the median estimated distribution of pneumonia rates across hospitals was 2.5% (25th to 75th percentile: 1.5% to 4.0%). Wide variability in pneumonia rates was evident, with some hospitals having rates more than 6 times higher than others (10th to 90th percentile: 1.0% to 6.1%). Among all five models, Model 2 accounted for the most variability at 4.24%. In total, 2.05% of hospital variation in pneumonia rates was explained collectively by traditional patient factors, leaving 97.95% of variation unexplained. CONCLUSIONS Our findings suggest that patient risk profiles only account for a fraction of hospital variation in pneumonia rates; enhanced understanding of other contributory factors (eg, processes of care) is required to lessen the likelihood of such nosocomial infections.
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Affiliation(s)
| | - J Scott Rankin
- West Virginia Heart and Vascular Institute, West Virginia University, Morgantown, West Virginia
| | - Derek D Cyr
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Jeffrey P Jacobs
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard L Prager
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative
| | - Min Zhang
- Department of Biostatistics, University of Michigan, Ann Arbor, Michigan
| | - Roland A Matsouaka
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Steven D Harrington
- Heart and Vascular Institute, Henry Ford Macomb Hospitals, Clinton Township, Michigan
| | - Rachel S Dokholyan
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Astrid Fishstrom
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - David M Shahian
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan; Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative.
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Bagchi A, Rudolph MI, Ng PY, Timm FP, Long DR, Shaefi S, Ladha K, Vidal Melo MF, Eikermann M. The association of postoperative pulmonary complications in 109,360 patients with pressure-controlled or volume-controlled ventilation. Anaesthesia 2017; 72:1334-1343. [PMID: 28891046 DOI: 10.1111/anae.14039] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/03/2017] [Indexed: 12/20/2022]
Abstract
We thought that the rate of postoperative pulmonary complications might be higher after pressure-controlled ventilation than after volume-controlled ventilation. We analysed peri-operative data recorded for 109,360 adults, whose lungs were mechanically ventilated during surgery at three hospitals in Massachusetts, USA. We used multivariable regression and propensity score matching. Postoperative pulmonary complications were more common after pressure-controlled ventilation, odds ratio (95%CI) 1.29 (1.21-1.37), p < 0.001. Tidal volumes and driving pressures were more varied with pressure-controlled ventilation compared with volume-controlled ventilation: mean (SD) variance from the median 1.61 (1.36) ml.kg-1 vs. 1.23 (1.11) ml.kg-1 , p < 0.001; and 3.91 (3.47) cmH2 O vs. 3.40 (2.69) cmH2 O, p < 0.001. The odds ratio (95%CI) of pulmonary complications after pressure-controlled ventilation compared with volume-controlled ventilation at positive end-expiratory pressures < 5 cmH2 O was 1.40 (1.26-1.55) and 1.20 (1.11-1.31) when ≥ 5 cmH2 O, both p < 0.001, a relative risk ratio of 1.17 (1.03-1.33), p = 0.023. The odds ratio (95%CI) of pulmonary complications after pressure-controlled ventilation compared with volume-controlled ventilation at driving pressures of < 19 cmH2 O was 1.37 (1.27-1.48), p < 0.001, and 1.16 (1.04-1.30) when ≥ 19 cmH2 O, p = 0.011, a relative risk ratio of 1.18 (1.07-1.30), p = 0.016. Our data support volume-controlled ventilation during surgery, particularly for patients more likely to suffer postoperative pulmonary complications.
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Affiliation(s)
- A Bagchi
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M I Rudolph
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - P Y Ng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - F P Timm
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - D R Long
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - S Shaefi
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - K Ladha
- Department of Anesthesia and Pain Medicine, University of Toronto and Toronto General Hospital, Toronto, ON, Canada
| | - M F Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M Eikermann
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany
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Lung-Protective Ventilation Strategies for Relief from Ventilator-Associated Lung Injury in Patients Undergoing Craniotomy: A Bicenter Randomized, Parallel, and Controlled Trial. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2017; 2017:6501248. [PMID: 28757912 PMCID: PMC5516714 DOI: 10.1155/2017/6501248] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 04/26/2017] [Accepted: 05/17/2017] [Indexed: 12/16/2022]
Abstract
Current evidence indicates that conventional mechanical ventilation often leads to lung inflammatory response and oxidative stress, while lung-protective ventilation (LPV) minimizes the risk of ventilator-associated lung injury (VALI). This study evaluated the effects of LPV on relief of pulmonary injury, inflammatory response, and oxidative stress among patients undergoing craniotomy. Sixty patients undergoing craniotomy received either conventional mechanical (12 mL/kg tidal volume [VT] and 0 cm H2O positive end-expiratory pressure [PEEP]; CV group) or protective lung (6 mL/kg VT and 10 cm H2O PEEP; PV group) ventilation. Hemodynamic variables, lung function indexes, and inflammatory and oxidative stress markers were assessed. The PV group exhibited greater dynamic lung compliance and lower respiratory index than the CV group during surgery (P < 0.05). The PV group exhibited higher plasma interleukin- (IL-) 10 levels and lower plasma malondialdehyde and nitric oxide and bronchoalveolar lavage fluid, IL-6, IL-8, tumor necrosis factor-α, IL-10, malondialdehyde, nitric oxide, and superoxide dismutase levels (P < 0.05) than the CV group. There were no significant differences in hemodynamic variables, blood loss, liquid input, urine output, or duration of mechanical ventilation between the two groups (P > 0.05). Patients receiving LPV during craniotomy exhibited low perioperative inflammatory response, oxidative stress, and VALI.
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Jin Z, Suen KC, Ma D. Perioperative "remote" acute lung injury: recent update. J Biomed Res 2017; 31:197-212. [PMID: 28808222 PMCID: PMC5460608 DOI: 10.7555/jbr.31.20160053] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/16/2016] [Indexed: 01/21/2023] Open
Abstract
Perioperative acute lung injury (ALI) is a syndrome characterised by hypoxia and chest radiograph changes. It is a serious post-operative complication, associated with considerable mortality and morbidity. In addition to mechanical ventilation, remote organ insult could also trigger systemic responses which induce ALI. Currently, there are limited treatment options available beyond conservative respiratory support. However, increasing understanding of the pathophysiology of ALI and the biochemical pathways involved will aid the development of novel treatments and help to improve patient outcome as well as to reduce cost to the health service. In this review we will discuss the epidemiology of peri-operative ALI; the cellular and molecular mechanisms involved on the pathological process; the clinical considerations in preventing and managing perioperative ALI and the potential future treatment options.
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Affiliation(s)
- Zhaosheng Jin
- Anaesthetics, Pain Medicine and intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London SW10 9NH, UK
| | - Ka Chun Suen
- Anaesthetics, Pain Medicine and intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London SW10 9NH, UK
| | - Daqing Ma
- Anaesthetics, Pain Medicine and intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, Chelsea & Westminster Hospital, London SW10 9NH, UK
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Haliloglu M, Bilgili B, Ozdemir M, Umuroglu T, Bakan N. Low Tidal Volume Positive End-Expiratory Pressure versus High Tidal Volume Zero-Positive End-Expiratory Pressure and Postoperative Pulmonary Functions in Robot-Assisted Laparoscopic Radical Prostatectomy. Med Princ Pract 2017; 26:573-578. [PMID: 29131002 PMCID: PMC5848477 DOI: 10.1159/000484693] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 10/31/2017] [Indexed: 11/19/2022] Open
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.
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Affiliation(s)
- Murat Haliloglu
- Department of Anesthesiology and Intensive Care Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Beliz Bilgili
- Department of Anesthesiology and Intensive Care Medicine, Marmara University School of Medicine, Istanbul, Turkey
- *Beliz Bilgili, Fevzi Cakmak Mah., Mimar Sinan Cad., No. 41 34000 Ust Kaynarca, TR-34899 Istanbul (Turkey), E-Mail
| | - Mehtap Ozdemir
- Umraniye Education and Research Hospital, Istanbul, Turkey
| | - Tumay Umuroglu
- Department of Anesthesiology and Intensive Care Medicine, Marmara University School of Medicine, Istanbul, Turkey
| | - Nurten Bakan
- Umraniye Education and Research Hospital, Istanbul, Turkey
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Zhang Z, Gu WJ, Chen K, Ni H. Mechanical Ventilation during Extracorporeal Membrane Oxygenation in Patients with Acute Severe Respiratory Failure. Can Respir J 2017; 2017:1783857. [PMID: 28127231 PMCID: PMC5239989 DOI: 10.1155/2017/1783857] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 11/28/2016] [Accepted: 12/18/2016] [Indexed: 02/07/2023] Open
Abstract
Conventionally, a substantial number of patients with acute respiratory failure require mechanical ventilation (MV) to avert catastrophe of hypoxemia and hypercapnia. However, mechanical ventilation per se can cause lung injury, accelerating the disease progression. Extracorporeal membrane oxygenation (ECMO) provides an alternative to rescue patients with severe respiratory failure that conventional mechanical ventilation fails to maintain adequate gas exchange. The physiology behind ECMO and its interaction with MV were reviewed. Next, we discussed the timing of ECMO initiation based on the risks and benefits of ECMO. During the running of ECMO, the protective ventilation strategy can be employed without worrying about catastrophic hypoxemia and carbon dioxide retention. There is a large body of evidence showing that protective ventilation with low tidal volume, high positive end-expiratory pressure, and prone positioning can provide benefits on mortality outcome. More recently, there is an increasing popularity on the use of awake and spontaneous breathing for patients undergoing ECMO, which is thought to be beneficial in terms of rehabilitation.
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Affiliation(s)
- Zhongheng Zhang
- 1Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
- *Zhongheng Zhang:
| | - Wan-Jie Gu
- 2Department of Anesthesiology, Nanjing Drum Tower Hospital, Medical College of Nanjing University, Nanjing 210008, China
| | - Kun Chen
- 3Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Zhejiang, China
| | - Hongying Ni
- 3Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Zhejiang, China
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Acute respiratory distress syndrome following cardiovascular surgery: current concepts and novel therapeutic approaches. Curr Opin Anaesthesiol 2016; 29:94-100. [PMID: 26598954 DOI: 10.1097/aco.0000000000000283] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW This review gives an update on current treatment options and novel concepts on the prevention and treatment of the acute respiratory distress syndrome (ARDS) in cardiovascular surgery patients. RECENT FINDINGS The only proven beneficial therapeutic options in ARDS are those that help to prevent further ventilator-induced lung injury, such as prone position, use of lung-protective ventilation strategies, and extracorporeal membrane oxygenation. In the future also new approaches like mesenchymal cell therapy, activation of hypoxia-elicited transcription factors or targeting of purinergic signaling may be successful outside the experimental setting. Owing to the so far limited treatment options, it is of great importance to determine patients at risk for developing ARDS already perioperatively. In this context, serum biomarkers and lung injury prediction scores could be useful. SUMMARY Preventing ARDS as a severe complication in the cardiovascular surgery setting may help to reduce morbidity and mortality. As cardiovascular surgery patients are of greater risk to develop ARDS, preventive interventions should be implemented early on. Especially, use of low tidal volumes, avoiding of fluid overload and restrictive blood transfusion regimes may help to prevent ARDS.
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Preoxygenation and intraoperative ventilation strategies in obese patients: a comprehensive review. Curr Opin Anaesthesiol 2016; 29:109-18. [PMID: 26545146 DOI: 10.1097/aco.0000000000000267] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Obesity along with its pathophysiological changes increases risk of intraoperative and perioperative respiratory complications. The aim of this review is to highlight recent updates in preoxygenation techniques and intraoperative ventilation strategies in obese patients to optimize gas exchange and pulmonary mechanics and reduce pulmonary complications. RECENT FINDINGS There is no gold standard in preoxygenation or intraoperative ventilatory management protocol for obese patients. Preoxygenation in head up or sitting position has been shown to be superior to supine position. Apneic oxygenation and use of continuous positive airway pressure increases safe apnea duration. Recent evidence encourages the intraoperative use of low tidal volume to improve oxygenation and lung compliance without adverse effects. Contrary to nonobese patients, some studies have reported the beneficial effect of recruitment maneuvers and positive end-expiratory pressure in obese patients. No difference has been observed between volume controlled and pressure controlled ventilation. SUMMARY The ideal ventilatory plan for obese patients is indeterminate. A multimodal preoxygenation and intraoperative ventilation plan is helpful in obese patients to reduce perioperative respiratory complications. More studies are needed to identify the role of low tidal volume, positive end-expiratory pressure, and recruitment maneuvers in obese patients undergoing general anesthesia.
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Kimura S, Stoicea N, Rosero Britton BR, Shabsigh M, Branstiter A, Stahl DL. Preventing Ventilator-Associated Lung Injury: A Perioperative Perspective. Front Med (Lausanne) 2016; 3:25. [PMID: 27303668 PMCID: PMC4885020 DOI: 10.3389/fmed.2016.00025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 05/17/2016] [Indexed: 01/22/2023] Open
Abstract
Introduction Research into the prevention of ventilator-associated lung injury (VALI) in patients with acute respiratory distress syndrome (ARDS) in the intensive care unit (ICU) has resulted in the development of a number of lung protective strategies, which have become commonplace in the treatment of critically ill patients. An increasing number of studies have applied lung protective ventilation in the operating room to otherwise healthy individuals. We review the history of lung protective strategies in patients with acute respiratory failure and explore their use in patients undergoing mechanical ventilation during general anesthesia. We aim to provide context for a discussion of the benefits and drawbacks of lung protective ventilation, as well as to inform future areas of research. Methods We completed a database search and reviewed articles investigating lung protective ventilation in both the ICU and in patients receiving general anesthesia through May 2015. Results Lung protective ventilation was associated with improved outcomes in patients with acute respiratory failure in the ICU. Clinical evidence is less clear regarding lung protective ventilation for patients undergoing surgery. Conclusion Lung protective ventilation strategies, including low tidal volume ventilation and moderate positive end-expiratory pressure, are well established therapies to minimize lung injury in critically ill patients with and without lung disease, and may provide benefit to patients undergoing general anesthesia.
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Affiliation(s)
- Satoshi Kimura
- Department of Anesthesiology, The Ohio State University Wexner Medical Center , Columbus, OH , USA
| | - Nicoleta Stoicea
- Department of Anesthesiology, The Ohio State University Wexner Medical Center , Columbus, OH , USA
| | | | - Muhammad Shabsigh
- Department of Anesthesiology, The Ohio State University Wexner Medical Center , Columbus, OH , USA
| | - Aly Branstiter
- Department of Anesthesiology, The Ohio State University Wexner Medical Center , Columbus, OH , USA
| | - David L Stahl
- Department of Anesthesiology, The Ohio State University Wexner Medical Center , Columbus, OH , USA
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Nieman GF, Gatto LA, Bates JHT, Habashi NM. Mechanical Ventilation as a Therapeutic Tool to Reduce ARDS Incidence. Chest 2016; 148:1396-1404. [PMID: 26135199 DOI: 10.1378/chest.15-0990] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Trauma, hemorrhagic shock, or sepsis can incite systemic inflammatory response syndrome, which can result in early acute lung injury (EALI). As EALI advances, improperly set mechanical ventilation (MV) can amplify early injury into a secondary ventilator-induced lung injury that invariably develops into overt ARDS. Once established, ARDS is refractory to most therapeutic strategies, which have not been able to lower ARDS mortality below the current unacceptably high 40%. Low tidal volume ventilation is one of the few treatments shown to have a moderate positive impact on ARDS survival, presumably by reducing ventilator-induced lung injury. Thus, there is a compelling case to be made that the focus of ARDS management should switch from treatment once this syndrome has become established to the application of preventative measures while patients are still in the EALI stage. Indeed, studies have shown that ARDS incidence is markedly reduced when conventional MV is applied preemptively using a combination of low tidal volume and positive end-expiratory pressure in both patients in the ICU and in surgical patients at high risk for developing ARDS. Furthermore, there is evidence from animal models and high-risk trauma patients that superior prevention of ARDS can be achieved using preemptive airway pressure release ventilation with a very brief duration of pressure release. Preventing rather than treating ARDS may be the way forward in dealing with this recalcitrant condition and would represent a paradigm shift in the way that MV is currently practiced.
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Affiliation(s)
- Gary F Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY.
| | | | | | - Nader M Habashi
- R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD
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Singh PM, Borle A, Shah D, Sinha A, Makkar JK, Trikha A, Goudra BG. Optimizing Prophylactic CPAP in Patients Without Obstructive Sleep Apnoea for High-Risk Abdominal Surgeries: A Meta-regression Analysis. Lung 2016; 194:201-17. [DOI: 10.1007/s00408-016-9855-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2015] [Accepted: 02/05/2016] [Indexed: 01/29/2023]
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Sadowitz B, Jain S, Kollisch-Singule M, Satalin J, Andrews P, Habashi N, Gatto LA, Nieman G. Preemptive mechanical ventilation can block progressive acute lung injury. World J Crit Care Med 2016; 5:74-82. [PMID: 26855896 PMCID: PMC4733459 DOI: 10.5492/wjccm.v5.i1.74] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 10/15/2015] [Accepted: 01/04/2016] [Indexed: 02/06/2023] Open
Abstract
Mortality from acute respiratory distress syndrome (ARDS) remains unacceptable, approaching 45% in certain high-risk patient populations. Treating fulminant ARDS is currently relegated to supportive care measures only. Thus, the best treatment for ARDS may lie with preventing this syndrome from ever occurring. Clinical studies were examined to determine why ARDS has remained resistant to treatment over the past several decades. In addition, both basic science and clinical studies were examined to determine the impact that early, protective mechanical ventilation may have on preventing the development of ARDS in at-risk patients. Fulminant ARDS is highly resistant to both pharmacologic treatment and methods of mechanical ventilation. However, ARDS is a progressive disease with an early treatment window that can be exploited. In particular, protective mechanical ventilation initiated before the onset of lung injury can prevent the progression to ARDS. Airway pressure release ventilation (APRV) is a novel mechanical ventilation strategy for delivering a protective breath that has been shown to block progressive acute lung injury (ALI) and prevent ALI from progressing to ARDS. ARDS mortality currently remains as high as 45% in some studies. As ARDS is a progressive disease, the key to treatment lies with preventing the disease from ever occurring while it remains subclinical. Early protective mechanical ventilation with APRV appears to offer substantial benefit in this regard and may be the prophylactic treatment of choice for preventing ARDS.
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Gale RM, Goddard C, Snell J. Lung Protective Ventilation- Compliance With Best Practice Guidance: Critical Care Network Audit. Intensive Care Med Exp 2015. [PMCID: PMC4797879 DOI: 10.1186/2197-425x-3-s1-a508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Nieman GF, Gatto LA, Habashi NM. Impact of mechanical ventilation on the pathophysiology of progressive acute lung injury. J Appl Physiol (1985) 2015; 119:1245-61. [PMID: 26472873 DOI: 10.1152/japplphysiol.00659.2015] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 10/01/2015] [Indexed: 02/08/2023] Open
Abstract
The earliest description of what is now known as the acute respiratory distress syndrome (ARDS) was a highly lethal double pneumonia. Ashbaugh and colleagues (Ashbaugh DG, Bigelow DB, Petty TL, Levine BE Lancet 2: 319-323, 1967) correctly identified the disease as ARDS in 1967. Their initial study showing the positive effect of mechanical ventilation with positive end-expiratory pressure (PEEP) on ARDS mortality was dampened when it was discovered that improperly used mechanical ventilation can cause a secondary ventilator-induced lung injury (VILI), thereby greatly exacerbating ARDS mortality. This Synthesis Report will review the pathophysiology of ARDS and VILI from a mechanical stress-strain perspective. Although inflammation is also an important component of VILI pathology, it is secondary to the mechanical damage caused by excessive strain. The mechanical breath will be deconstructed to show that multiple parameters that comprise the breath-airway pressure, flows, volumes, and the duration during which they are applied to each breath-are critical to lung injury and protection. Specifically, the mechanisms by which a properly set mechanical breath can reduce the development of excessive fluid flux and pulmonary edema, which are a hallmark of ARDS pathology, are reviewed. Using our knowledge of how multiple parameters in the mechanical breath affect lung physiology, the optimal combination of pressures, volumes, flows, and durations that should offer maximum lung protection are postulated.
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Affiliation(s)
- Gary F Nieman
- Department of Surgery, Upstate Medical University, Syracuse, New York;
| | - Louis A Gatto
- Biological Sciences Department, State University of New York, Cortland, New York; and
| | - Nader M Habashi
- R Adams Cowley Shock/Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
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Intraoperative mechanical ventilation for the pediatric patient. Best Pract Res Clin Anaesthesiol 2015; 29:371-9. [PMID: 26643101 DOI: 10.1016/j.bpa.2015.10.001] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 10/01/2015] [Accepted: 10/02/2015] [Indexed: 11/23/2022]
Abstract
Invasive mechanical ventilation is required when children undergo general anesthesia for any procedure. It is remarkable that one of the most practiced interventions such as pediatric mechanical ventilation is hardly supported by any scientific evidence but rather based on personal experience and data from adults, especially as ventilation itself is increasingly recognized as a harmful intervention that causes ventilator-induced lung injury. The use of low tidal volume and higher levels of positive end-expiratory pressure became an integral part of lung-protective ventilation following the outcomes of clinical trials in critically ill adults. This approach has been readily adopted in pediatric ventilation. However, a clear association between tidal volume and mortality has not been ascertained in pediatrics. In fact, experimental studies have suggested that young children might be less susceptible to ventilator-induced lung injury. As such, no recommendations on optimal lung-protective ventilation strategy in children with or without lung injury can be made.
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Janssens ACJW, Gwinn M. Novel citation-based search method for scientific literature: application to meta-analyses. BMC Med Res Methodol 2015; 15:84. [PMID: 26462491 PMCID: PMC4604708 DOI: 10.1186/s12874-015-0077-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 10/02/2015] [Indexed: 12/17/2022] Open
Abstract
Background Finding eligible studies for meta-analysis and systematic reviews relies on keyword-based searching as the gold standard, despite its inefficiency. Searching based on direct citations is not sufficiently comprehensive. We propose a novel strategy that ranks articles on their degree of co-citation with one or more “known” articles before reviewing their eligibility. Method In two independent studies, we aimed to reproduce the results of literature searches for sets of published meta-analyses (n = 10 and n = 42). For each meta-analysis, we extracted co-citations for the randomly selected ‘known’ articles from the Web of Science database, counted their frequencies and screened all articles with a score above a selection threshold. In the second study, we extended the method by retrieving direct citations for all selected articles. Results In the first study, we retrieved 82 % of the studies included in the meta-analyses while screening only 11 % as many articles as were screened for the original publications. Articles that we missed were published in non-English languages, published before 1975, published very recently, or available only as conference abstracts. In the second study, we retrieved 79 % of included studies while screening half the original number of articles. Conclusions Citation searching appears to be an efficient and reasonably accurate method for finding articles similar to one or more articles of interest for meta-analysis and reviews. Electronic supplementary material The online version of this article (doi:10.1186/s12874-015-0077-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- A Cecile J W Janssens
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, Georgia, 30322, USA. .,Department of Clinical Genetics/EMGO Institute for Health and Care Research, Section Community Genetics, VU University Medical Center, Amsterdam, The Netherlands.
| | - M Gwinn
- Department of Epidemiology, Rollins School of Public Health, Emory University, 1518 Clifton Road NE, Atlanta, Georgia, 30322, USA.
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Barnes L, Reed RM, Parekh KR, Bhama JK, Pena T, Rajagopal S, Schmidt GA, Klesney-Tait JA, Eberlein M. MECHANICAL VENTILATION FOR THE LUNG TRANSPLANT RECIPIENT. CURRENT PULMONOLOGY REPORTS 2015; 4:88-96. [PMID: 26495241 DOI: 10.1007/s13665-015-0114-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Mechanical ventilation (MV) is an important aspect in the intraoperative and early postoperative management of lung transplant (LTx)-recipients. There are no randomized-controlled trials of LTx-recipient MV strategies; however there are LTx center experiences and international survey studies reported. The main early complication of LTx is primary graft dysfunction (PGD), which is similar to the adult respiratory distress syndrome (ARDS). We aim to summarize information pertinent to LTx-MV, as well as PGD, ARDS, and intraoperative MV and to synthesize these available data into recommendations. Based on the available evidence, we recommend lung-protective MV with low-tidal-volumes (≤6 mL/kg predicted body weight [PBW]) and positive end-expiratory pressure for the LTx-recipient. In our opinion, the MV strategy should be based on donor characteristics (donor PBW as a parameter of actual allograft size), rather than based on recipient characteristics; however this donor-characteristics-based protective MV is based on indirect evidence and requires validation in prospective clinical studies.
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Affiliation(s)
- Lindsey Barnes
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics
| | - Robert M Reed
- Division of Pulmonary and Critical Care Medicine, University of Maryland
| | - Kalpaj R Parekh
- Department of Thoracic and Cardiovascular Surgery, University of Iowa Hospitals and Clinics
| | - Jay K Bhama
- Department of Thoracic and Cardiovascular Surgery, University of Iowa Hospitals and Clinics
| | - Tahuanty Pena
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Pennsylvania
| | | | - Gregory A Schmidt
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics
| | - Julia A Klesney-Tait
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics
| | - Michael Eberlein
- Division of Pulmonary, Critical Care and Occupational Medicine, University of Iowa Hospitals and Clinics
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