Effect of driving pressure-guided lung protective ventilation strategy on early postoperative pulmonary function in adults patients undergoing heart valve surgery: A randomized controlled study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

JIANG Rongjuan ^1,2 , MAO Wenjie ^1,3 , YU Hong ¹ , LI Xuefei ¹ , ZHANG Mengqiu ¹ ,  YU Hai ¹

1. Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, P.R.China;
2. Department of Anesthesiology, Chengdu Second People’s Hospital, Chengdu, 610017, P.R.China;
3. Department of Anesthesiology, Jianyang People’s Hospital, Chengdu, 641400, P.R.China;

Corresponding author：

YU Hai, Email: yuhaishan117@yahoo.com

Keywords：

Positive end-expiratory pressure; oxygen index; valve surgery; lung protective ventilation strategy; driving pressure; randomized controlled study

DOI：

10.7507/1007-4848.202011081

Video：

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Objective To evaluate the effect of driving pressure-guided lung protective ventilation strategy on lung function in adult patients under elective cardiac surgery with cardiopulmonary bypass.Methods In this randomized controlled trial, 106 patients scheduled for elective valve surgery via median sternal incision under cardiopulmonary bypass from July to October 2020 at West China Hospital of Sichuan University were included in final analysis. Patients were divided into two groups randomly. Both groups received volume-controlled ventilation. A protective ventilation group (a control group, n=53) underwent traditional lung protective ventilation strategy with positive end-expiratory pressure (PEEP) of 5 cm H₂O and received conventional protective ventilation with tidal volume of 7 mL/kg of predicted body weight and PEEP of 5 cm H₂O, and recruitment maneuver. An individualized PEEP group (a driving pressure group, n=53) received the same tidal volume and recruitment, but with individualized PEEP which produced the lowest driving pressure. The primary outcome was oxygen index (OI) after ICU admission in 30 minutes, and the secondary outcomes were the incidence of OI below 300 mm Hg, the severity of OI descending scale (the Berlin definition), the incidence of pulmonary complications at 7 days after surgery and surgeons’ satisfaction on ventilation.Results There was a statistical difference in OI after ICU admission in 30 minutes between the two groups (273.5±75.5 mm Hg vs. 358.0±65.3 mm Hg, P=0.00). The driving pressure group had lower incidence of postoperative OI<300 mm Hg (16.9% vs. 49.0%, OR=0.21, 95%CI 0.08-0.52, P=0.00) and less severity of OI classification than the control group (P=0.00). The incidence of pulmonary complications at 7 days after surgery was comparable between the driving pressure group and the control group (28.3% vs. 33.9%, OR=0.76, 95%CI 0.33-1.75, P=0.48). The atelectasis rate was lower in the driving pressure group (1.0% vs. 15.0%, OR=0.10, 95%CI 0.01-0.89, P=0.01).Conclusion Application of driving pressure-guided ventilation is associated with a higher OI and less lung injury after ICU admission compared with the conventional protective ventilation in patients having valve surgery.

Citation： JIANG Rongjuan, MAO Wenjie, YU Hong, LI Xuefei, ZHANG Mengqiu, YU Hai. Effect of driving pressure-guided lung protective ventilation strategy on early postoperative pulmonary function in adults patients undergoing heart valve surgery: A randomized controlled study. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2021, 28(6): 663-669. doi: 10.7507/1007-4848.202011081 Copy

1.	Jia Y, Leung SM, Turan A, et al. Low tidal volumes are associated with slightly improved oxygenation in patients having cardiac surgery: A cohort analysis. Anesth Analg, 2020, 130(5): 1396-1406.
2.	Lellouche F, Dionne S, Simard S, et al. High tidal volumes in mechanically ventilated patients increase organ dysfunction after cardiac surgery. Anesthesiology, 2012, 116(5): 1072-1082.
3.	Mathis MR, Duggal NM, Likosky DS, et al. Intraoperative mechanical ventilation and postoperative pulmonary complications after cardiac surgery. Anesthesiology, 2019, 131(5): 1046-1062.
4.	Fan E, Brodie D, Slutsky AS. Acute respiratory distress syndrome: Advances in diagnosis and treatment. JAMA, 2018, 319(7): 698-710.
5.	Lagier D, Velly LJ, Guinard B, et al. Perioperative open-lung approach, regional ventilation, and lung injury in cardiac surgery. Anesthesiology, 2020, 133(5): 1029-1045.
6.	Lagier D, Fischer F, Fornier W, et al. Effect of open-lung vs conventional perioperative ventilation strategies on postoperative pulmonary complications after on-pump cardiac surgery: The PROVECS randomized clinical trial. Intensive Care Med, 2019, 45(10): 1401-1412.
7.	Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for perioperative care in cardiac surgery: Enhanced recovery after surgery society recommendations. JAMA Surg, 2019, 154(8): 755-766.
8.	Ball L, Costantino F, Pelosi P. Postoperative complications of patients undergoing cardiac surgery. Curr Opin Crit Care, 2016, 22(4): 386-392.
9.	O'Gara B, Talmor D. Perioperative lung protective ventilation. BMJ, 2018, 362: k3030.
10.	Deng QW, Tan WC, Zhao BC, et al. Intraoperative ventilation strategies to prevent postoperative pulmonary complications: A network meta-analysis of randomised controlled trials. Br J Anaesth, 2020, 124(3): 324-335.
11.	Ferrando C, Soro M, Unzueta C, et al. Individualised perioperative open-lung approach versus standard protective ventilation in abdominal surgery (iPROVE): A randomised controlled trial. Lancet Respir Med, 2018, 6(3): 193-203.
12.	Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med, 2015, 372(8): 747-755.
13.	Neto AS, Hemmes SN, Barbas CS, et al. Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: A meta-analysis of individual patient data. Lancet Respir Med, 2016, 4(4): 272-280.
14.	Bellani G, Laffey JG, Pham T, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA, 2016, 315(8): 788-800.
15.	Sundar S, Novack V, Jervis K, et al. Influence of low tidal volume ventilation on time to extubation in cardiac surgical patients. Anesthesiology, 2011, 114(5): 1102-1110.
16.	Park M, Ahn HJ, Kim JA, et al. Driving pressure during thoracic surgery: A randomized clinical trial. Anesthesiology, 2019, 130(3): 385-393.
17.	Fernandez-Bustamante A, Sprung J, Parker RA, et al. Individualized PEEP to optimise respiratory mechanics during abdominal surgery: A pilot randomised controlled trial. Br J Anaesth, 2020, 125(3): 383-392.
18.	Parzy G, Tourret M, Meillat H, et al. Association of driving pressure with post-operative complications after rectal surgery in cancer patients included in an Enhanced Recovery After Surgery protocol. J Clin Anesth, 2020, 64: 109856.
19.	Abbott TEF, Fowler AJ, Pelosi P, et al. A systematic review and consensus definitions for standardised end-points in perioperative medicine: Pulmonary complications. Br J Anaesth, 2018, 120(5): 1066-1079.
20.	Pereira SM, Tucci MR, Morais CCA, et al. Individual positive end-expiratory pressure settings optimize intraoperative mechanical ventilation and reduce postoperative atelectasis. Anesthesiology, 2018, 129(6): 1070-1081.
21.	Nestler C, Simon P, Petroff D, et al. Individualized positive end-expiratory pressure in obese patients during general anaesthesia: A randomized controlled clinical trial using electrical impedance tomography. Br J Anaesth, 2017, 119(6): 1194-1205.
22.	Eichler L, Truskowska K, Dupree A, et al. Intraoperative ventilation of morbidly obese patients guided by transpulmonary pressure. Obes Surg, 2018, 28(1): 122-129.
23.	Hata JS, Togashi K, Kumar AB, et al. The effect of the pressure-volume curve for positive end-expiratory pressure titration on clinical outcomes in acute respiratory distress syndrome: A systematic review. J Intensive Care Med, 2014, 29(6): 348-356.
24.	Beitler JR, Sarge T, Banner-Goodspeed VM, et al. Effect of titrating positive end-expiratory pressure (PEEP) with an esophageal pressure-guided strategy vs an empirical high PEEP-FiO₂ strategy on death and days free from mechanical ventilation among patients with acute respiratory distress syndrome: A randomized clinical trial. JAMA, 2019, 321(9): 846-857.

1. Jia Y, Leung SM, Turan A, et al. Low tidal volumes are associated with slightly improved oxygenation in patients having cardiac surgery: A cohort analysis. Anesth Analg, 2020, 130(5): 1396-1406.
2. Lellouche F, Dionne S, Simard S, et al. High tidal volumes in mechanically ventilated patients increase organ dysfunction after cardiac surgery. Anesthesiology, 2012, 116(5): 1072-1082.
3. Mathis MR, Duggal NM, Likosky DS, et al. Intraoperative mechanical ventilation and postoperative pulmonary complications after cardiac surgery. Anesthesiology, 2019, 131(5): 1046-1062.
4. Fan E, Brodie D, Slutsky AS. Acute respiratory distress syndrome: Advances in diagnosis and treatment. JAMA, 2018, 319(7): 698-710.
5. Lagier D, Velly LJ, Guinard B, et al. Perioperative open-lung approach, regional ventilation, and lung injury in cardiac surgery. Anesthesiology, 2020, 133(5): 1029-1045.
6. Lagier D, Fischer F, Fornier W, et al. Effect of open-lung vs conventional perioperative ventilation strategies on postoperative pulmonary complications after on-pump cardiac surgery: The PROVECS randomized clinical trial. Intensive Care Med, 2019, 45(10): 1401-1412.
7. Engelman DT, Ben Ali W, Williams JB, et al. Guidelines for perioperative care in cardiac surgery: Enhanced recovery after surgery society recommendations. JAMA Surg, 2019, 154(8): 755-766.
8. Ball L, Costantino F, Pelosi P. Postoperative complications of patients undergoing cardiac surgery. Curr Opin Crit Care, 2016, 22(4): 386-392.
9. O'Gara B, Talmor D. Perioperative lung protective ventilation. BMJ, 2018, 362: k3030.
10. Deng QW, Tan WC, Zhao BC, et al. Intraoperative ventilation strategies to prevent postoperative pulmonary complications: A network meta-analysis of randomised controlled trials. Br J Anaesth, 2020, 124(3): 324-335.
11. Ferrando C, Soro M, Unzueta C, et al. Individualised perioperative open-lung approach versus standard protective ventilation in abdominal surgery (iPROVE): A randomised controlled trial. Lancet Respir Med, 2018, 6(3): 193-203.
12. Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med, 2015, 372(8): 747-755.
13. Neto AS, Hemmes SN, Barbas CS, et al. Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: A meta-analysis of individual patient data. Lancet Respir Med, 2016, 4(4): 272-280.
14. Bellani G, Laffey JG, Pham T, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA, 2016, 315(8): 788-800.
15. Sundar S, Novack V, Jervis K, et al. Influence of low tidal volume ventilation on time to extubation in cardiac surgical patients. Anesthesiology, 2011, 114(5): 1102-1110.
16. Park M, Ahn HJ, Kim JA, et al. Driving pressure during thoracic surgery: A randomized clinical trial. Anesthesiology, 2019, 130(3): 385-393.
17. Fernandez-Bustamante A, Sprung J, Parker RA, et al. Individualized PEEP to optimise respiratory mechanics during abdominal surgery: A pilot randomised controlled trial. Br J Anaesth, 2020, 125(3): 383-392.
18. Parzy G, Tourret M, Meillat H, et al. Association of driving pressure with post-operative complications after rectal surgery in cancer patients included in an Enhanced Recovery After Surgery protocol. J Clin Anesth, 2020, 64: 109856.
19. Abbott TEF, Fowler AJ, Pelosi P, et al. A systematic review and consensus definitions for standardised end-points in perioperative medicine: Pulmonary complications. Br J Anaesth, 2018, 120(5): 1066-1079.
20. Pereira SM, Tucci MR, Morais CCA, et al. Individual positive end-expiratory pressure settings optimize intraoperative mechanical ventilation and reduce postoperative atelectasis. Anesthesiology, 2018, 129(6): 1070-1081.
21. Nestler C, Simon P, Petroff D, et al. Individualized positive end-expiratory pressure in obese patients during general anaesthesia: A randomized controlled clinical trial using electrical impedance tomography. Br J Anaesth, 2017, 119(6): 1194-1205.
22. Eichler L, Truskowska K, Dupree A, et al. Intraoperative ventilation of morbidly obese patients guided by transpulmonary pressure. Obes Surg, 2018, 28(1): 122-129.
23. Hata JS, Togashi K, Kumar AB, et al. The effect of the pressure-volume curve for positive end-expiratory pressure titration on clinical outcomes in acute respiratory distress syndrome: A systematic review. J Intensive Care Med, 2014, 29(6): 348-356.
24. Beitler JR, Sarge T, Banner-Goodspeed VM, et al. Effect of titrating positive end-expiratory pressure (PEEP) with an esophageal pressure-guided strategy vs an empirical high PEEP-FiO₂ strategy on death and days free from mechanical ventilation among patients with acute respiratory distress syndrome: A randomized clinical trial. JAMA, 2019, 321(9): 846-857.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Effect of driving pressure-guided lung protective ventilation strategy on early postoperative pulmonary function in adults patients undergoing heart valve surgery: A randomized controlled study

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