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Campos NS, Bluth T, Hemmes SNT, Librero J, Pozo N, Ferrando C, Ball L, Mazzinari G, Pelosi P, Gama de Abreu M, Schultz MJ, Neto AS. Re-evaluation of the effects of high PEEP with recruitment manoeuvres versus low PEEP without recruitment manoeuvres during general anaesthesia for surgery -Protocol and statistical analysis plan for an individual patient data meta-analysis of PROVHILO, iPROVE and PROBESE. ACTA ACUST UNITED AC 2020; 67:76-89. [PMID: 31955891 DOI: 10.1016/j.redar.2019.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 07/25/2019] [Accepted: 08/02/2019] [Indexed: 10/25/2022]
Affiliation(s)
- N S Campos
- Deptartment of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brasil; Cardio-Pulmonary Department, Pulmonary Division, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Pãulo, Brasil
| | - T Bluth
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - S N T Hemmes
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, University of Amsterdam, Ámsterdam, Holanda; Department of Anaesthesiology, AnaesthesiologyDepartment Amsterdam UMC location 'AMC', University of Amsterdam, Ámsterdam, Países Bajos
| | - J Librero
- Navarrabiomed-Fundación Miguel Servet, Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Pamplona, Navarra, España
| | - N Pozo
- Department of Anesthesiology and Critical Care, Hospital Clínic de Barcelona, Barcelona, España
| | - C Ferrando
- Department of Anesthesiology and Critical Care, Hospital Clínic de Barcelona, Barcelona, España; CIBER of Respiratory Disease, Instituto de Salud Carlos III, Madrid, España
| | - L Ball
- IRCCS San Martino Policlinico Hospital, Genoa, Italia; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italia
| | - G Mazzinari
- Department of Anesthesiology and Pain Medicine, Hospital de Manises, Valencia, España
| | - P Pelosi
- IRCCS San Martino Policlinico Hospital, Genoa, Italia; Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italia
| | - M Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - M J Schultz
- Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, University of Amsterdam, Ámsterdam, Holanda; Research Group in Perioperative Medicine, Instituto de Investigación Sanitaria La Fe, Valencia, España; Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Tailandia
| | - A S Neto
- Deptartment of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brasil; Cardio-Pulmonary Department, Pulmonary Division, Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Sao Pãulo, Brasil; Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam UMC, University of Amsterdam, Ámsterdam, Holanda.
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Bluth T, Serpa Neto A, Schultz MJ, Pelosi P, Gama de Abreu M, Bluth T, Bobek I, Canet JC, Cinnella G, de Baerdemaeker L, Gama de Abreu M, Gregoretti C, Hedenstierna G, Hemmes SNT, Hiesmayr M, Hollmann MW, Jaber S, Laffey J, Licker MJ, Markstaller K, Matot I, Mills GH, Mulier JP, Pelosi P, Putensen C, Rossaint R, Schmitt J, Schultz MJ, Senturk M, Serpa Neto A, Severgnini P, Sprung J, Vidal Melo MF, Wrigge H. Effect of Intraoperative High Positive End-Expiratory Pressure (PEEP) With Recruitment Maneuvers vs Low PEEP on Postoperative Pulmonary Complications in Obese Patients: A Randomized Clinical Trial. JAMA 2019; 321:2292-2305. [PMID: 31157366 PMCID: PMC6582260 DOI: 10.1001/jama.2019.7505] [Citation(s) in RCA: 178] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain. OBJECTIVE To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018. INTERVENTIONS Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H2O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H2O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight. MAIN OUTCOMES AND MEASURES The primary outcome was a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with Spo2 ≤92% for >1 minute). RESULTS Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, -2.3% [95% CI, -5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P = .23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, -8.6% [95% CI, -11.1% to 6.1%]; P < .001). CONCLUSIONS AND RELEVANCE Among obese patients undergoing surgery under general anesthesia, an intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers, compared with a strategy with a lower level of PEEP, did not reduce postoperative pulmonary complications. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02148692.
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Affiliation(s)
| | - Thomas Bluth
- Department of Anesthesiology and Critical Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Policlinico San Martino, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Critical Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
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Bluth T, Kiss T, Kircher M, Braune A, Bozsak C, Huhle R, Scharffenberg M, Herzog M, Roegner J, Herzog P, Vivona L, Millone M, Dössel O, Andreeff M, Koch T, Kotzerke J, Stender B, Gama de Abreu M. Measurement of relative lung perfusion with electrical impedance and positron emission tomography: an experimental comparative study in pigs. Br J Anaesth 2019; 123:246-254. [PMID: 31160064 DOI: 10.1016/j.bja.2019.04.056] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 04/08/2019] [Accepted: 04/09/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Electrical impedance tomography (EIT) with indicator dilution may be clinically useful to measure relative lung perfusion, but there is limited information on the performance of this technique. METHODS Thirteen pigs (50-66 kg) were anaesthetised and mechanically ventilated. Sequential changes in ventilation were made: (i) right-lung ventilation with left-lung collapse, (ii) two-lung ventilation with optimised PEEP, (iii) two-lung ventilation with zero PEEP after saline lung lavage, (iv) two-lung ventilation with maximum PEEP (20/25 cm H2O to achieve peak airway pressure 45 cm H2O), and (v) two-lung ventilation under unilateral pulmonary artery occlusion. Relative lung perfusion was assessed with EIT and central venous injection of saline 3%, 5%, and 10% (10 ml) during breath holds. Relative perfusion was determined by positron emission tomography (PET) using 68Gallium-labelled microspheres. EIT and PET were compared in eight regions of equal ventro-dorsal height (right, left, ventral, mid-ventral, mid-dorsal, and dorsal), and directional changes in regional perfusion were determined. RESULTS Differences between methods were relatively small (95% of values differed by less than 8.7%, 8.9%, and 9.5% for saline 10%, 5%, and 3%, respectively). Compared with PET, EIT underestimated relative perfusion in dependent, and overestimated it in non-dependent, regions. EIT and PET detected the same direction of change in relative lung perfusion in 68.9-95.9% of measurements. CONCLUSIONS The agreement between EIT and PET for measuring and tracking changes of relative lung perfusion was satisfactory for clinical purposes. Indicator-based EIT may prove useful for measuring pulmonary perfusion at bedside.
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Affiliation(s)
- T Bluth
- Pulmonary Engineering Group Dresden, Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - T Kiss
- Pulmonary Engineering Group Dresden, Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - M Kircher
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology, Karlsruhe, Germany
| | - A Braune
- Pulmonary Engineering Group Dresden, Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - C Bozsak
- Drägerwerk AG & Co. KGaA, Lübeck, Germany
| | - R Huhle
- Pulmonary Engineering Group Dresden, Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - M Scharffenberg
- Pulmonary Engineering Group Dresden, Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - M Herzog
- Pulmonary Engineering Group Dresden, Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - J Roegner
- Pulmonary Engineering Group Dresden, Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - P Herzog
- Pulmonary Engineering Group Dresden, Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - L Vivona
- Pulmonary Engineering Group Dresden, Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples Federico II, Naples, Italy
| | - M Millone
- Pulmonary Engineering Group Dresden, Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany; IRCCS AOU San Martino IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - O Dössel
- Institute of Biomedical Engineering, Karlsruhe Institute of Technology, Karlsruhe, Germany
| | - M Andreeff
- Department of Nuclear Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - T Koch
- Pulmonary Engineering Group Dresden, Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - J Kotzerke
- Department of Nuclear Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - B Stender
- Drägerwerk AG & Co. KGaA, Lübeck, Germany
| | - M Gama de Abreu
- Pulmonary Engineering Group Dresden, Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
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Spieth P, Güldner A, Uhlig C, Bluth T, Kiss T, Conrad C, Bischlager K, Braune A, Huhle R, Insorsi A, Tarantino F, Ball L, Schultz M, Abolmaali N, Koch T, Pelosi P, Gama de Abreu M. Variable versus conventional lung protective mechanical ventilation during open abdominal surgery (PROVAR): a randomised controlled trial. Br J Anaesth 2018; 120:581-591. [DOI: 10.1016/j.bja.2017.11.078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 07/31/2017] [Accepted: 09/18/2017] [Indexed: 10/18/2022] Open
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Spieth PM, Bluth T, Gama De Abreu M, Bacelis A, Goetz AE, Kiefmann R. Mechanotransduction in the lungs. Minerva Anestesiol 2014; 80:933-941. [PMID: 24299920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Mechanical ventilation may induce or aggravate lung injury, a phenomenon known as ventilator induced lung injury (VILI). On a macroscopic level, the effects of mechanical stress and strain on lung tissue are well described. Increased tidal volumes may lead to volutrauma, raised airway pressures may cause barotrauma and cyclic collapse and reopening of alveolar units contributes to atelectrauma. These three harmful mechanisms may lead to local and systemic pulmonary inflammatory response known as biotrauma. The purpose of this review was to elucidate fundamental mechanisms involved in the mechanotransduction of mechanical stimuli on a cellular level. Bronchial epithelial cells in the distal airways as well as alveolar epithelial cells are exposed to a variety of mechanical forces. These cells are involved in sensing and translation of mechanical stimuli into an inflammatory response. This review provides insight into current knowledge of cellular and molecular pathways during the process of pulmonary epithelial mechanosensation and mechanotransduction under different mechanical conditions. Since evidence for specific pathways is generally lacking in some fields of alveolar epithelial mechanotransduction, this article aims at providing reasonable hypothesis for further investigation.
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Affiliation(s)
- P M Spieth
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Therapy, University Hospital Carl Gustav Carus, Dresden, Germany -
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