Effect of protective lung ventilation on pulmonary complications after laparoscopic surgery: a meta-analysis of randomized controlled trials

Associations of intraoperative end-tidal CO2 levels with postoperative outcome-secondary analysis of a worldwide observational study

BACKGROUND

Patients receiving intraoperative ventilation during general anesthesia often have low end-tidal CO2 (etCO2). We examined the association of intraoperative etCO2 levels with the occurrence of postoperative pulmonary complications (PPCs) in a conveniently-sized international, prospective study named 'Local ASsessment of Ventilatory management during General Anesthesia for Surgery' (LAS VEGAS).

METHODS

Patients at high risk of PPCs were categorized as 'low etCO2' or 'normal to high etCO2' patients, using a cut-off of 35 mmHg. The primary endpoint was a composite of previously defined PPCs; the individual PPCs served as secondary endpoints. The need for unplanned oxygen was defined as mild PPCs and severe PPCs included pneumonia, respiratory failure, acute respiratory distress syndrome, barotrauma, and new invasive ventilation. We performed propensity score matching and LOESS regression to evaluate the relationship between the lowest etCO2 and PPCs.

RESULTS

The analysis included 1843 (74 %) 'low etCO2' patients and 648 (26 %) 'normal to high etCO2' patients. There was no difference in the occurrence of PPCs between 'low etCO2' and 'normal to high etCO2' patients (20 % vs. 19 %; RR 1.00 [95 %-confidence interval 0.94 to 1.06]; P = 0.84). The proportion of severe PPCs among total occurring PPCs, were higher in 'low etCO2' patients compared to 'normal to high etCO2' patients (35 % vs. 18 %; RR 1.16 [1.08 to 1.25]; P < 0.001). Propensity score matching did not change these findings. LOESS plot showed an inverse relationship of intraoperative etCO2 levels with the occurrence of PPCs.

CONCLUSIONS

In this cohort of patients at high risk of PPCs, the overall occurrence of PPCs was not different between 'low etCO2' patients and 'normal to high etCO2' patients, but severe PPCs occurred more often in 'low etCO2', with an inverse dose-dependent relationship between intraoperative etCO2 levels and PPCs.

FUNDING

This analysis was performed without additional funding. LAS VEGAS was partially funded and endorsed by the European Society of Anesthesiology and Intensive Care (ESAIC) and the Amsterdam University Medical Centers, location 'AMC'.

REGISTRATION

LAS VEGAS was registered at Clinicaltrials.gov (NCT01601223), first posted on May 17, 2012.

Comparison of Ventilation Strategies Across the Perioperative Period in Patients Undergoing General Anesthesia: A Narrative Review

General anesthesia is a critical component of surgical procedures, requiring effective ventilation strategies to ensure adequate oxygenation and prevent complications. This narrative review aims to compare various ventilation techniques used during general anesthesia, focusing on their physiological foundations, clinical applications, and outcomes. Traditional methods, such as high tidal volume ventilation, have evolved into more sophisticated approaches, including protective lung ventilation, which are particularly beneficial for high-risk patients with respiratory comorbidities. The review highlights that protective lung ventilation, characterized by lower tidal volumes and optimal positive end-expiratory pressure, is associated with improved oxygenation, reduced incidence of post-operative pulmonary complications, and enhanced overall recovery. Despite the advantages of personalized ventilation approaches, current evidence remains limited by small sample sizes and variability in study designs. This underscores the need for larger, randomized controlled trials to establish definitive guidelines. Future research should also explore emerging technologies to optimize the real-time management of ventilation parameters. The findings emphasize the importance of individualized ventilation strategies in clinical practice to improve patient outcomes and inform policy development. By advancing our understanding of ventilation techniques, this review aims to contribute to safer anesthesia practices and enhance recovery in surgical patients.

Intraoperative lung protection: strategies and their impact on outcomes

PURPOSE OF REVIEW

The present review summarizes the current knowledge and the barriers encountered when implementing tailoring lung-protective ventilation strategies to individual patients based on advanced monitoring systems.

RECENT FINDINGS

Lung-protective ventilation has become a pivotal component of perioperative care, aiming to enhance patient outcomes and reduce the incidence of postoperative pulmonary complications (PPCs). High-quality research has established the benefits of strategies such as low tidal volume ventilation and low driving pressures. Debate is still ongoing on the most suitable levels of positive end-expiratory pressure (PEEP) and the role of recruitment maneuvers. Adapting PEEP according to patient-specific factors offers potential benefits in maintaining ventilation distribution uniformity, especially in challenging scenarios like pneumoperitoneum and steep Trendelenburg positions. Advanced monitoring systems, which continuously assess patient responses and enable the fine-tuning of ventilation parameters, offer real-time data analytics to predict and prevent impending lung complications. However, their impact on postoperative outcomes, particularly PPCs, is an ongoing area of research.

SUMMARY

Refining protective lung ventilation is crucial to provide patients with the best possible care during surgery, reduce the incidence of PPCs, and improve their overall surgical journey.