Table 1.
Best available evidence on effect of select perioperative lung protective strategies on clinical outcomes
| Variable studied | Author, year | Study type | Population; No of patients | Intervention | Control | Results |
|---|---|---|---|---|---|---|
| Tidal volume | Sundar, 2011 | RCT | Cardiac surgery; 149 | TV 6 mL/kg; PEEP, FiO2: by table | TV 10 mL/kg; PEEP, FiO2: by table | No difference in time to extubation: median 643 (IQR 417-1032) v 450 (264-1044) min, P=0.10; higher % free from ventilation at 6 h: 37.3% v 20.3%, P=0.02; lower incidence of reintubation: 1.3% v 9.5%, P=0.03 |
| PEEP | Hemmes, 2013 | Meta-analysis | All surgery; 1669 | PEEP 3-12 cm H2O | PEEP ≤3 cm H2O | Lower incidence of postoperative lung injury (4.9% v 1.4%; RR 0.29, 95% CI 0.14 to 0.60), pulmonary infection (0.62, 0.40 to 0.96), and atelectasis (0.61, 0.41 to 0.91) |
| Hemmes, 2014 | RCT | Open abdominal surgery; 900 | TV 8 mL/kg; PEEP 12 cm H2O; RM | TV 8 mL/kg; PEEP ≤2 cm H2O; no RM | No difference in PPC incidence by POD 5 (RR 1.01, 0.86 to 1.20; P=0.86); higher incidence of intraoperative hypotension (46% v 36%; RR 1.29, 1.10 to 1.51; P=0.0016); more frequent intraoperative vasopressor use (62% v 51%; RR 1.20, 1.07 to 1.35; P=0.0016) | |
| Recruitment maneuvers | Choi, 2017 | RCT | Robotic prostatectomy; 60 | TV 6-8 mL/kg; PEEP 5 cm H2O; RM | TV 6-8 mL/kg; PEEP 5 cm H2O; no RM | Lower combined incidence of intraoperative oxygen desaturation and postoperative atelectasis: 17.8% v 43.3%, P=0.034 |
| Park, 2016 | RCT | Elective laparoscopy; 62 | TV 10 mL/kg; PEEP 0 cm H2O; RM | TV 6 mL/kg; PEEP 5 cm H2O; no RM | Higher incidence of PPCs: 47% v 14%, P=0.023 | |
| Lung protective ventilation | Futier, 2013 | RCT | Abdominal surgery; 400 | TV 6-8 mL/kg; PEEP 6-8 cm H2O; RM | TV 10-12 mL/kg; PEEP 0 cm H2O; no RM | Lower incidence of major pulmonary and non-pulmonary complications by POD 7 (10.5% v 27.5%; RR 0.40, 0.24 to 0.68; P=0.001); lower risk of needing postoperative ventilation (5.0% v 17.0%; RR 0.29, 0.14 to 0.61; P=0.001) |
| Serpa Neto, 2015 | Meta-analysis | General surgery; 2127 | TV ≤8 mL/kg; PEEP ≥5cm H2O; +/− RM | TV >8 mL/kg; PEEP <5 cm H2O; no RM | Lower incidence of PPC: 8.7% v 14.7%; RR 0.64, 0.46 to 0.88; P<0.01 | |
| Supplemental oxygen | Meyhoff, 2009 | RCT | Open abdominal surgery; 1400s | 80% FiO2 | 30% FiO2 | No difference in postoperative atelectasis (7.9% v 7.1%; OR 1.13, 0.73 to 1.72; P=0.56), postoperative pneumonia (6.0% v 6.3%; OR 0.95, 0.60 to 1.49; P=0.81), or postoperative respiratory failure (5.5% v 4.4%; OR 1.22, 0.74 to 2.03; P=0.44) |
| Postoperative NIPPV | Jaber, 2016 | RCT | Postoperative respiratory failure, abdominal surgery; 293 | IP 5-15 cm H2O; PEEP 5-10 cm H2O | Standard oxygen therapy | Lower incidence of reintubation: 33.1% v 45.5%, P=0.03; more ventilator-free days: 25.4 v 23.2 days, P=0.04; lower incidence of infection: 31.4% v 49.2%, P=0.003 |
FiO2=fraction of inspired oxygen; IP=inspiratory pressure; IQR=interquartile range; OR=odds ratio; NIPPV=non-invasive positive pressure ventilation; PEEP=positive end expiratory pressure; POD=postoperative day; PPC=postoperative pulmonary complications; RCT=randomized controlled trial; RM=recruitment maneuver; RR=relative risk; TV=tidal volume.