TY - JOUR
T1 - Individualized PEEP to optimise respiratory mechanics during abdominal surgery
T2 - a pilot randomised controlled trial
AU - Fernandez-Bustamante, Ana
AU - Sprung, Juraj
AU - Parker, Robert A.
AU - Bartels, Karsten
AU - Weingarten, Toby N.
AU - Kosour, Carolina
AU - Thompson, B. Taylor
AU - Vidal Melo, Marcos F.
N1 - Funding Information:
Research reported in this article was supported by the National Heart, Lung and Blood Institute ( NHLBI ) of the National Institutes of Health of the United States under the awards R34HL123438 (MFVM, PI; AFB, BTT and JS, co-Investigators) and UG3HL140177 (MFVM and AFB, PIs). The funding source did not have any role in the development of the trial, or in the analysis or interpretation of the trial findings.
Publisher Copyright:
© 2020 British Journal of Anaesthesia
PY - 2020/9
Y1 - 2020/9
N2 - Background: Higher intraoperative driving pressures (ΔP) are associated with increased postoperative pulmonary complications (PPC). We hypothesised that dynamic adjustment of PEEP throughout abdominal surgery reduces ΔP, maintains positive end-expiratory transpulmonary pressures (Ptp_ee) and increases respiratory system static compliance (Crs) with PEEP levels that are variable between and within patients. Methods: In a prospective multicentre pilot study, adults at moderate/high risk for PPC undergoing elective abdominal surgery were randomised to one of three ventilation protocols: (1) PEEP≤2 cm H2O, compared with periodic recruitment manoeuvres followed by individualised PEEP to either optimise respiratory system compliance (PEEPmaxCrs) or maintain positive end-expiratory transpulmonary pressure (PEEPPtp_ee). The composite primary outcome included intraoperative ΔP, Ptp_ee, Crs, and PEEP values (median (interquartile range) and coefficients of variation [CVPEEP]). Results: Thirty-seven patients (48.6% female; age range: 47–73 yr) were assigned to control (PEEP≤2 cm H2O; n=13), PEEPmaxCrs (n=16), or PEEPPtp_ee (n=8) groups. The PEEPPtp_ee intervention could not be delivered in two patients. Subjects assigned to PEEPmaxCrs had lower ΔP (median8 cm H2O [7–10]), compared with the control group (12 cm H2O [10–15]; P=0.006). PEEPmaxCrs was also associated with higher Ptp_ee (2.0 cm H2O [-0.7 to 4.5] vs controls: -8.3 cm H2O [-13.0 to -4.0]; P≤0.001) and higher Crs (47.7 ml cm H2O [43.2–68.8] vs controls: 39.0 ml cm H2O [32.9–43.4]; P=0.009). Individualised PEEP (PEEPmaxCrs and PEEPPtp_ee combined) varied widely (median: 10 cm H2O [8-15]; CVPEEP=0.24 [0.14–0.35]), both between, and within, subjects throughout surgery. Conclusions: This pilot study suggests that individualised PEEP management strategies applied during abdominal surgery reduce driving pressure, maintain positive Ptp_ee and increase static compliance. The wide range of PEEP observed suggests that an individualised approach is required to optimise respiratory mechanics during abdominal surgery. Clinical trial registration: NCT02671721.
AB - Background: Higher intraoperative driving pressures (ΔP) are associated with increased postoperative pulmonary complications (PPC). We hypothesised that dynamic adjustment of PEEP throughout abdominal surgery reduces ΔP, maintains positive end-expiratory transpulmonary pressures (Ptp_ee) and increases respiratory system static compliance (Crs) with PEEP levels that are variable between and within patients. Methods: In a prospective multicentre pilot study, adults at moderate/high risk for PPC undergoing elective abdominal surgery were randomised to one of three ventilation protocols: (1) PEEP≤2 cm H2O, compared with periodic recruitment manoeuvres followed by individualised PEEP to either optimise respiratory system compliance (PEEPmaxCrs) or maintain positive end-expiratory transpulmonary pressure (PEEPPtp_ee). The composite primary outcome included intraoperative ΔP, Ptp_ee, Crs, and PEEP values (median (interquartile range) and coefficients of variation [CVPEEP]). Results: Thirty-seven patients (48.6% female; age range: 47–73 yr) were assigned to control (PEEP≤2 cm H2O; n=13), PEEPmaxCrs (n=16), or PEEPPtp_ee (n=8) groups. The PEEPPtp_ee intervention could not be delivered in two patients. Subjects assigned to PEEPmaxCrs had lower ΔP (median8 cm H2O [7–10]), compared with the control group (12 cm H2O [10–15]; P=0.006). PEEPmaxCrs was also associated with higher Ptp_ee (2.0 cm H2O [-0.7 to 4.5] vs controls: -8.3 cm H2O [-13.0 to -4.0]; P≤0.001) and higher Crs (47.7 ml cm H2O [43.2–68.8] vs controls: 39.0 ml cm H2O [32.9–43.4]; P=0.009). Individualised PEEP (PEEPmaxCrs and PEEPPtp_ee combined) varied widely (median: 10 cm H2O [8-15]; CVPEEP=0.24 [0.14–0.35]), both between, and within, subjects throughout surgery. Conclusions: This pilot study suggests that individualised PEEP management strategies applied during abdominal surgery reduce driving pressure, maintain positive Ptp_ee and increase static compliance. The wide range of PEEP observed suggests that an individualised approach is required to optimise respiratory mechanics during abdominal surgery. Clinical trial registration: NCT02671721.
KW - lung compliance
KW - mechanical ventilation
KW - positive end-expiratory pressure
KW - postoperative pulmonary complications
KW - respiratory mechanics
KW - ventilator-induced lung injury
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U2 - 10.1016/j.bja.2020.06.030
DO - 10.1016/j.bja.2020.06.030
M3 - Article
C2 - 32682559
AN - SCOPUS:85087944583
SN - 0007-0912
VL - 125
SP - 383
EP - 392
JO - British Journal of Anaesthesia
JF - British Journal of Anaesthesia
IS - 3
ER -