The association of intraoperative positive end-expiratory pressure with pulmonary complications after thoracoscopic lung surgery: A propensity score-matching study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHANG Gongwei ^1,2 , LIU Hongmei ³ , ZHANG Hongwei ⁴ ,  YU Hai ¹

1. Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;
2. Department of Anesthesiology, The First People's Hospital of Shuangliu District, West China (Airport) Hospital, Sichuan University, Chengdu, 610200, P. R. China;
3. Department of Anesthesiology, West China Fourth Hospital, Sichuan University, Chengdu, 610044, P. R. China;
4. Department of Anesthesiology, Tumor Hospital of Sichuan Province, Chengdu, 610041, P. R. China;

Corresponding author：

YU Hai, Email: yuhai@scu.edu.cn

Keywords：

Positive end-expiratory pressure; one-lung ventilation; video-assisted thoracoscopic surgery; pneumonectomy; postoperative pulmonary complications; propensity score-matching analysis

DOI：

10.7507/1007-4848.202311050

Video：

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Objective To evaluate the correlation between positive end-expiratory pressure (PEEP) level and postoperative pulmonary complications (PPCs) in patients undergoing thoracoscopic lung surgery. Methods The clinical data of patients who underwent elective thoracoscopic lung surgery at West China Hospital of Sichuan University from January 2022 to June 2023 were retrospectively analyzed. Patients were divided into 2 groups according to intraoperative PEEP levels: a PEEP 5 cm H₂O group and a PEEP 10 cm H₂O group. The incidence of PPCs in the two groups after matching was compared using a nearest neighbor matching method with a ratio of 1∶1, setting the clamp value as 0.02. Results A total of 538 patients were screened, and after propensity score-matching, a total of 229 pairs (458 patients) were matched, with an average age of 53.9 years and 69.4% (318/458) females. A total of 118 (25.8%) patients had PPCs during hospitalization after surgery, including 60 (26.2%) patients in the PEEP 5 cm H₂O group and 58 (25.3%) patients in the PEEP 10 cm H₂O group, with no statistically significant difference between the two groups [OR=0.997, 95%CI (0.495, 1.926), P=0.915]. Multivariate logistic regression analysis showed that PEEP was not an independent risk factor for PPCs [OR=0.920, 95%CI (0.587, 1.441), P=0.715]. Conclusion For patients undergoing thoracoscopic lung surgery, intraoperative PEEP (5 cm H₂O or 10 cm H₂O) is not associated with the risk of PPCs during hospitalization after surgery, which needs to be further verified by prospective, large-sample randomized controlled studies.

Citation： ZHANG Gongwei, LIU Hongmei, ZHANG Hongwei, YU Hai. The association of intraoperative positive end-expiratory pressure with pulmonary complications after thoracoscopic lung surgery: A propensity score-matching study. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2024, 31(5): 702-709. doi: 10.7507/1007-4848.202311050 Copy

1.	Lohser J, Slinger P. Lung injury after one-lung ventilation: A review of the pathophysiologic mechanisms affecting the ventilated and the collapsed lung. Anesth Analg, 2015, 121(2): 302-318.
2.	Li XF, Jin L, Yang JM, et al. Effect of ventilation mode on postoperative pulmonary complications following lung resection surgery: A randomised controlled trial. Anaesthesia, 2022, 77(11): 1219-1227.
3.	Serpa Neto A, Hemmes SN, Barbas CS, et al. Incidence of mortality and morbidity related to postoperative lung injury in patients who have undergone abdominal or thoracic surgery: A systematic review and meta-analysis. Lancet Respir Med, 2014, 2(12): 1007-1015.
4.	Bluth T, Serpa Neto A, Schultz MJ, et al. 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(23): 2292-2305.
5.	樊迪, 刘晓芬, 李云, 等. 不同水平脉压差变异率指导肺切除术中液体管理的随机对照研究. 安徽医学, 2019, 40(8): 852-857.
6.	Fernandez-Bustamante A, Frendl G, Sprung J, et al. Postoperative pulmonary complications, early mortality, and hospital stay following noncardiothoracic surgery: A multicenter study by the perioperative research network investigators. JAMA Surg, 2017, 152(2): 157-166.
7.	Miskovic A, Lumb AB. Postoperative pulmonary complications. Br J Anaesth, 2017, 118(3): 317-334.
8.	Kaufmann K, Heinrich S. Minimizing postoperative pulmonary complications in thoracic surgery patients. Curr Opin Anaesthesiol, 2021, 34(1): 13-19.
9.	支修益, 刘伦旭, 中国胸外科围手术期气道管理指南(2020版)编写委员会. 中国胸外科围手术期气道管理指南(2020版). 中国胸心血管外科临床杂志, 2021, 28(3): 251-262.
10.	Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: Recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg, 2019, 55(1): 91-115.
11.	Peel JK, Funk DJ, Slinger P, et al. Positive end-expiratory pressure and recruitment maneuvers during one-lung ventilation: A systematic review and meta-analysis. J Thorac Cardiovasc Surg, 2020, 160(4): 1112-1122.
12.	Campos NS, Bluth T, Hemmes SNT, et al. Intraoperative positive end-expiratory pressure and postoperative pulmonary complications: A patient-level meta-analysis of three randomised clinical trials. Br J Anaesth, 2022, 128(6): 1040-1051.
13.	Canet J, Gallart L, Gomar C, et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology, 2010, 113(6): 1338-1350.
14.	Jammer I, Wickboldt N, Sander M, et al. Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: A statement from the ESA-ESICM joint taskforce on perioperative outcome measures. Eur J Anaesthesiol, 2015, 32(2): 88-105.
15.	Nishida T, Mikami I, Fujii Y. New technique to prevent prolonged air leak: Use of 'Tachosuture' technique. Gen Thorac Cardiovasc Surg, 2017, 65(2): 133-136.
16.	von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. Int J Surg, 2014, 12(12): 1495-1499.
17.	Gómez-Hernández MT, Forcada C, Varela G, et al. Operating time: An independent and modifiable risk factor for short-term complications after video-thoracoscopic pulmonary lobectomy. Eur J Cardiothorac Surg, 2022, 62(6): ezac503.
18.	Ceppa DP, Kosinski AS, Berry MF, et al. Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: A Society of Thoracic Surgeons Database analysis. Ann Surg, 2012, 256(3): 487-493.
19.	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.
20.	Spadaro S, Grasso S, Karbing DS, et al. Physiologic evaluation of ventilation perfusion mismatch and respiratory mechanics at different positive end-expiratory pressure in patients undergoing protective one-lung ventilation. Anesthesiology, 2018, 128(3): 531-538.
21.	Buonanno P, Marra A, Iacovazzo C, et al. Impact of ventilation strategies on pulmonary and cardiovascular complications in patients undergoing general anaesthesia for elective surgery: A systematic review and meta-analysis. Br J Anaesth, 2023, 131(6): 1093-1101.
22.	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.
23.	De Meyer GRA, Morrison SG, Saldien V, et al. Minimizing lung injury during laparoscopy in head-down tilt: A physiological cohort study. Anesth Analg, 2023, 137(4): 841-849.
24.	Chun EH, Baik HJ, Moon HS, et al. Comparison of low and high positive end-expiratory pressure during low tidal volume ventilation in robotic gynaecological surgical patients using electrical impedance tomography: A randomised controlled trial. Eur J Anaesthesiol, 2019, 36(9): 641-648.
25.	Maisch S, Reissmann H, Fuellekrug B, et al. Compliance and dead space fraction indicate an optimal level of positive end-expiratory pressure after recruitment in anesthetized patients. Anesth Analg, 2008, 106(1): 175-181.
26.	Park M, Yoon S, Nam JS, et al. Driving pressure-guided ventilation and postoperative pulmonary complications in thoracic surgery: A multicentre randomised clinical trial. Br J Anaesth, 2023, 130(1): e106-e118.
27.	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.
28.	Gattinoni L, Collino F, Maiolo G, et al. Positive end-expiratory pressure: How to set it at the individual level. Ann Transl Med, 2017, 5(14): 288.
29.	Della RG, Coccia C. Ventilatory management of one-lung ventilation. Minerv Anestes, 2011, 77(5): 534-536.
30.	Choi JY, Al-Saedy MA, Carlson B. Positive end-expiratory pressure and postoperative complications in patients with obesity: A review and meta-analysis. Obesity (Silver Spring), 2023, 31(4): 955-964.
31.	Aldenkortt M, Lysakowski C, Elia N, et al. Ventilation strategies in obese patients undergoing surgery: A quantitative systematic review and meta-analysis. Br J Anaesth, 2012, 109(4): 493-502.
32.	Kiss T, Wittenstein J, Becker C, et al. Protective ventilation with high versus low positive end-expiratory pressure during one-lung ventilation for thoracic surgery (PROTHOR): Study protocol for a randomized controlled trial. Trials, 2019, 20(1): 213.
33.	Yu J, Wu Z, An R, et al. Association between driving pressure and postoperative pulmonary complications in patients undergoing lung resection surgery: A randomised clinical trial. Anaesth Crit Care Pain Med, 2023, 42(1): 101160.
34.	Park M, Ahn HJ, Kim JA, et al. Driving pressure during thoracic surgery: A randomized clinical trial. Anesthesiology, 2019, 130(3): 385-393.
35.	Ahn HJ, Park M, Kim JA, et al. Driving pressure guided ventilation. Korean J Anesthesiol, 2020, 73(3): 194-204.

1. Lohser J, Slinger P. Lung injury after one-lung ventilation: A review of the pathophysiologic mechanisms affecting the ventilated and the collapsed lung. Anesth Analg, 2015, 121(2): 302-318.
2. Li XF, Jin L, Yang JM, et al. Effect of ventilation mode on postoperative pulmonary complications following lung resection surgery: A randomised controlled trial. Anaesthesia, 2022, 77(11): 1219-1227.
3. Serpa Neto A, Hemmes SN, Barbas CS, et al. Incidence of mortality and morbidity related to postoperative lung injury in patients who have undergone abdominal or thoracic surgery: A systematic review and meta-analysis. Lancet Respir Med, 2014, 2(12): 1007-1015.
4. Bluth T, Serpa Neto A, Schultz MJ, et al. 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(23): 2292-2305.
5. 樊迪, 刘晓芬, 李云, 等. 不同水平脉压差变异率指导肺切除术中液体管理的随机对照研究. 安徽医学, 2019, 40(8): 852-857.
6. Fernandez-Bustamante A, Frendl G, Sprung J, et al. Postoperative pulmonary complications, early mortality, and hospital stay following noncardiothoracic surgery: A multicenter study by the perioperative research network investigators. JAMA Surg, 2017, 152(2): 157-166.
7. Miskovic A, Lumb AB. Postoperative pulmonary complications. Br J Anaesth, 2017, 118(3): 317-334.
8. Kaufmann K, Heinrich S. Minimizing postoperative pulmonary complications in thoracic surgery patients. Curr Opin Anaesthesiol, 2021, 34(1): 13-19.
9. 支修益, 刘伦旭, 中国胸外科围手术期气道管理指南(2020版)编写委员会. 中国胸外科围手术期气道管理指南(2020版). 中国胸心血管外科临床杂志, 2021, 28(3): 251-262.
10. Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: Recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg, 2019, 55(1): 91-115.
11. Peel JK, Funk DJ, Slinger P, et al. Positive end-expiratory pressure and recruitment maneuvers during one-lung ventilation: A systematic review and meta-analysis. J Thorac Cardiovasc Surg, 2020, 160(4): 1112-1122.
12. Campos NS, Bluth T, Hemmes SNT, et al. Intraoperative positive end-expiratory pressure and postoperative pulmonary complications: A patient-level meta-analysis of three randomised clinical trials. Br J Anaesth, 2022, 128(6): 1040-1051.
13. Canet J, Gallart L, Gomar C, et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology, 2010, 113(6): 1338-1350.
14. Jammer I, Wickboldt N, Sander M, et al. Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: A statement from the ESA-ESICM joint taskforce on perioperative outcome measures. Eur J Anaesthesiol, 2015, 32(2): 88-105.
15. Nishida T, Mikami I, Fujii Y. New technique to prevent prolonged air leak: Use of 'Tachosuture' technique. Gen Thorac Cardiovasc Surg, 2017, 65(2): 133-136.
16. von Elm E, Altman DG, Egger M, et al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies. Int J Surg, 2014, 12(12): 1495-1499.
17. Gómez-Hernández MT, Forcada C, Varela G, et al. Operating time: An independent and modifiable risk factor for short-term complications after video-thoracoscopic pulmonary lobectomy. Eur J Cardiothorac Surg, 2022, 62(6): ezac503.
18. Ceppa DP, Kosinski AS, Berry MF, et al. Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: A Society of Thoracic Surgeons Database analysis. Ann Surg, 2012, 256(3): 487-493.
19. 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.
20. Spadaro S, Grasso S, Karbing DS, et al. Physiologic evaluation of ventilation perfusion mismatch and respiratory mechanics at different positive end-expiratory pressure in patients undergoing protective one-lung ventilation. Anesthesiology, 2018, 128(3): 531-538.
21. Buonanno P, Marra A, Iacovazzo C, et al. Impact of ventilation strategies on pulmonary and cardiovascular complications in patients undergoing general anaesthesia for elective surgery: A systematic review and meta-analysis. Br J Anaesth, 2023, 131(6): 1093-1101.
22. 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.
23. De Meyer GRA, Morrison SG, Saldien V, et al. Minimizing lung injury during laparoscopy in head-down tilt: A physiological cohort study. Anesth Analg, 2023, 137(4): 841-849.
24. Chun EH, Baik HJ, Moon HS, et al. Comparison of low and high positive end-expiratory pressure during low tidal volume ventilation in robotic gynaecological surgical patients using electrical impedance tomography: A randomised controlled trial. Eur J Anaesthesiol, 2019, 36(9): 641-648.
25. Maisch S, Reissmann H, Fuellekrug B, et al. Compliance and dead space fraction indicate an optimal level of positive end-expiratory pressure after recruitment in anesthetized patients. Anesth Analg, 2008, 106(1): 175-181.
26. Park M, Yoon S, Nam JS, et al. Driving pressure-guided ventilation and postoperative pulmonary complications in thoracic surgery: A multicentre randomised clinical trial. Br J Anaesth, 2023, 130(1): e106-e118.
27. 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.
28. Gattinoni L, Collino F, Maiolo G, et al. Positive end-expiratory pressure: How to set it at the individual level. Ann Transl Med, 2017, 5(14): 288.
29. Della RG, Coccia C. Ventilatory management of one-lung ventilation. Minerv Anestes, 2011, 77(5): 534-536.
30. Choi JY, Al-Saedy MA, Carlson B. Positive end-expiratory pressure and postoperative complications in patients with obesity: A review and meta-analysis. Obesity (Silver Spring), 2023, 31(4): 955-964.
31. Aldenkortt M, Lysakowski C, Elia N, et al. Ventilation strategies in obese patients undergoing surgery: A quantitative systematic review and meta-analysis. Br J Anaesth, 2012, 109(4): 493-502.
32. Kiss T, Wittenstein J, Becker C, et al. Protective ventilation with high versus low positive end-expiratory pressure during one-lung ventilation for thoracic surgery (PROTHOR): Study protocol for a randomized controlled trial. Trials, 2019, 20(1): 213.
33. Yu J, Wu Z, An R, et al. Association between driving pressure and postoperative pulmonary complications in patients undergoing lung resection surgery: A randomised clinical trial. Anaesth Crit Care Pain Med, 2023, 42(1): 101160.
34. Park M, Ahn HJ, Kim JA, et al. Driving pressure during thoracic surgery: A randomized clinical trial. Anesthesiology, 2019, 130(3): 385-393.
35. Ahn HJ, Park M, Kim JA, et al. Driving pressure guided ventilation. Korean J Anesthesiol, 2020, 73(3): 194-204.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

The association of intraoperative positive end-expiratory pressure with pulmonary complications after thoracoscopic lung surgery: A propensity score-matching study

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