Positive End-Expiratory Pressure (PEEP) during Anaesthesia for Prevention of Postoperative Pulmonary Complications: A Meta-Analysis_Chinese Journal of Evidence-Based Medicine

Authors：

 ZHANGYong-qiang , WUJian-jiang , ZHENGHong ,  WANGJiang

Department of Anesthesiology, The First Affiliated Hospital, Xinjiang Medical University, Urumqi 830054, China;

Corresponding author：

WANGJiang, Email: 710985359@qq.com

Keywords：

Positive end-expiratory pressure (PEEP); Perioperative period; Systematic review; Meta-analysis; Randomized controlled trial

DOI：

10.7507/1672-2531.20140079

Video：

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Objective To systematically evaluate the benefits and harms of intraoperative positive end-expiratory pressure (PEEP) to all adult patients suffered surgery, especially on the postoperative mortality and pulmonary outcomes. Methods We electronically searched PubMed, EMbase, The Cochrane library (Issue 3, 2012), CBM, CNKI from inception to January 2013, for randomized controlled trials (RCTs) about PEEP for the prevention of pulmonary complications. Two reviewers independently screened literature according to the inclusion and exclusion criteria, extracted the data, and evaluated the quality of the included studies. Then meta-analysis was conducted using RevMan 5.1 software. Results A total of 8 RCTs involving 336 patients were finally included. The results of meta-analysis showed that there was no difference between two groups in mortality (OR=0.95, 95%CI 0.13 to 6.92, P=0.96). However, the PEEP group had a higher PaO₂/FiO₂ the first day after surgery (MD=22.98, 95%CI 4.40 to 41.55, P=0.02), while there was no difference 2-3 days after surgery (MD=12.59, 95%CI-6.78 to 31.96, P=0.31). Meanwhile, postoperative atelectasis was less in the PEEP group (OR=0.27, 95%CI 0.08 to 0.9, P=0.03). Conclusion Choosing PEEP mode during general anaesthesia may improve postoperative oxygenation index in the first day after surgery, and reduce pulmonary complications, which has a protective effect on patients pulmonary function. However, it has no marked influence on the prognosis. Because of the limited quality and sampling size of the induced studies, this conclusion still needs to be further proved by more large-scale, multicenter and perspective RCTs.

Citation： ZHANGYong-qiang, WUJian-jiang, ZHENGHong, WANGJiang. Positive End-Expiratory Pressure (PEEP) during Anaesthesia for Prevention of Postoperative Pulmonary Complications: A Meta-Analysis. Chinese Journal of Evidence-Based Medicine, 2014, 14(4): 456-461. doi: 10.7507/1672-2531.20140079 Copy

1.	Hedenstierna G, Strandberg A, Brismar B.Functional residual capacity, thoracoabdominal dimensions, and central blood volume during general anesthesia with muscle paralysis and mechanical ventilation.Anesthesiology, 1985, 62(3):247-254.
2.	Hewlett AM, Hulands GH, Nunn JF.Functional residual capacity during anesthesia Ⅲ:Artificial ventilation.Br J Anaesth, 1974, 46(7):495-503.
3.	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.
4.	Higgins JPT, Green S.Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0.The Cochrane Collaboration.2011:1.Available at:http://www.cochrane.org/training/cochrane-handbook.
5.	Almarakbi WA, Fawzi HM, Alhashemi JA.Effects of four intraoperative ventilator strategies on respiratory compliance and gas exchange during laparoscopic gastric banding in obese patients.Br J Anaesth, 2009, 102(6):862-868.
6.	Azab T, El-Masry A, Salah M, et al.Effects of intraoperative use of positive end expiratory pressure on lung atelectasis during laparoscopic cholecystectomy.Egyptian J Anaesthesia, 2005, 21(3):219-225.
7.	Berthelsen P, Husum B, Kortsen H.Postoperative arterial oxygen tension after peroperative PEEP-ventilation.Acta Anaesthesiol Scand, 1979, 23(3):253-258.
8.	Choi G, Wolthuis EK, Bresser P.Mechanical ventilation with lower tidal volumes and positive end-expiratory pressure prevents alveolar coagulation in patients without lung injury.Anesthesiology, 2006, 105(4):689-695.
9.	Pang CK, Yap J, Chen PP.The effect of an alveolar recruitment strategy on oxygenation during laparascopic cholecystectomy.Anaesth Intensive Care, 2003, 31(2):176-180.
10.	Talab HF, Zabani IA, Abdelrahman HS.Intraoperative ventilatory strategies for prevention of pulmonary atelectasis in obese patients undergoing laparoscopic bariatric surgery.Anesth Analg, 2009, 109(5):1511-1516.
11.	Tusman G, Böhm SH.Alveolar recruitment strategy improves arterial oxygenation during general anaesthesia.Br J Anaesth, 1999, 82(1):8-13.
12.	Wetterslev J, Hansen EG, Roikjaer O.Optimizing peroperative compliance with PEEP during upper abdominal surgery:effects on perioperativeoxygenation and complications in patients without preoperative cardiopulmonary dysfunction.Eur J Anaesthesiol, 2001, 18(6):358-365.
13.	Maracajá-Neto LF, Verçosa N, Roncally AC.Beneficial effects of high positive end-expiratory pressure in lung respiratory mechanics during laparoscopic surgery.Acta Anaesthesiol Scand, 2009, 53(2):210-217.
14.	王少丽, 史大卓, 王承龙.持续气道正压通气或上呼吸道手术治疗对合并阻塞性睡眠呼吸暂停冠心病患者预后影响的系统评价.中国循证医学杂志, 2012, 12(9):1105-1109.
15.	Maisch S, Reissmann H, Fuellekrug B.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.
16.	Carvalho AR, Jandre FC, Pino AV.Effects of descending positive end-expiratory pressure on lung mechanics and aeration in healthy anaesthetized piglets.Crit Care, 2006, 10(4):R122.
17.	Terragni PP, Rosboch G.Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome.Am J Respir Crit Care Med, 2007, 175(2):160-166.
18.	Namendys-Silva SA, Dominguez-Cherit G.Mechanical ventilation can cause changes in pulmonary circulation.Crit Care Med, 2010, 38(8):1759-1760.
19.	Oba Y, Thameem DM, Zaza T.High levels of PEEP may improve survival in acute respiratory distress syndrome:a meta-analysis.Respir Med, 2009, 103(8):1174-1181.
20.	Pearse DB, Searcy RM, Mitzner W, et al.Effects of tidal volume and respiratory frequency on lung lymph flow.J Appl Physiol, 2005, 99(2):556-563.
21.	Meininger D, Byhahn C.Positive end-expiratory pressure improves arterial oxygenation during prolonged pneumoperitoneum.Acta Anaesthesiol Scand, 2005, 49(6):778-783.
22.	单志桂, 杨新玲, 姚亚妮.如何运用系统评价结果进行临床实践.中国循证医学杂志, 2012, 12(3):357-359.

1. Hedenstierna G, Strandberg A, Brismar B.Functional residual capacity, thoracoabdominal dimensions, and central blood volume during general anesthesia with muscle paralysis and mechanical ventilation.Anesthesiology, 1985, 62(3):247-254.
2. Hewlett AM, Hulands GH, Nunn JF.Functional residual capacity during anesthesia Ⅲ:Artificial ventilation.Br J Anaesth, 1974, 46(7):495-503.
3. 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.
4. Higgins JPT, Green S.Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0.The Cochrane Collaboration.2011:1.Available at:http://www.cochrane.org/training/cochrane-handbook.
5. Almarakbi WA, Fawzi HM, Alhashemi JA.Effects of four intraoperative ventilator strategies on respiratory compliance and gas exchange during laparoscopic gastric banding in obese patients.Br J Anaesth, 2009, 102(6):862-868.
6. Azab T, El-Masry A, Salah M, et al.Effects of intraoperative use of positive end expiratory pressure on lung atelectasis during laparoscopic cholecystectomy.Egyptian J Anaesthesia, 2005, 21(3):219-225.
7. Berthelsen P, Husum B, Kortsen H.Postoperative arterial oxygen tension after peroperative PEEP-ventilation.Acta Anaesthesiol Scand, 1979, 23(3):253-258.
8. Choi G, Wolthuis EK, Bresser P.Mechanical ventilation with lower tidal volumes and positive end-expiratory pressure prevents alveolar coagulation in patients without lung injury.Anesthesiology, 2006, 105(4):689-695.
9. Pang CK, Yap J, Chen PP.The effect of an alveolar recruitment strategy on oxygenation during laparascopic cholecystectomy.Anaesth Intensive Care, 2003, 31(2):176-180.
10. Talab HF, Zabani IA, Abdelrahman HS.Intraoperative ventilatory strategies for prevention of pulmonary atelectasis in obese patients undergoing laparoscopic bariatric surgery.Anesth Analg, 2009, 109(5):1511-1516.
11. Tusman G, Böhm SH.Alveolar recruitment strategy improves arterial oxygenation during general anaesthesia.Br J Anaesth, 1999, 82(1):8-13.
12. Wetterslev J, Hansen EG, Roikjaer O.Optimizing peroperative compliance with PEEP during upper abdominal surgery:effects on perioperativeoxygenation and complications in patients without preoperative cardiopulmonary dysfunction.Eur J Anaesthesiol, 2001, 18(6):358-365.
13. Maracajá-Neto LF, Verçosa N, Roncally AC.Beneficial effects of high positive end-expiratory pressure in lung respiratory mechanics during laparoscopic surgery.Acta Anaesthesiol Scand, 2009, 53(2):210-217.
14. 王少丽, 史大卓, 王承龙.持续气道正压通气或上呼吸道手术治疗对合并阻塞性睡眠呼吸暂停冠心病患者预后影响的系统评价.中国循证医学杂志, 2012, 12(9):1105-1109.
15. Maisch S, Reissmann H, Fuellekrug B.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.
16. Carvalho AR, Jandre FC, Pino AV.Effects of descending positive end-expiratory pressure on lung mechanics and aeration in healthy anaesthetized piglets.Crit Care, 2006, 10(4):R122.
17. Terragni PP, Rosboch G.Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome.Am J Respir Crit Care Med, 2007, 175(2):160-166.
18. Namendys-Silva SA, Dominguez-Cherit G.Mechanical ventilation can cause changes in pulmonary circulation.Crit Care Med, 2010, 38(8):1759-1760.
19. Oba Y, Thameem DM, Zaza T.High levels of PEEP may improve survival in acute respiratory distress syndrome:a meta-analysis.Respir Med, 2009, 103(8):1174-1181.
20. Pearse DB, Searcy RM, Mitzner W, et al.Effects of tidal volume and respiratory frequency on lung lymph flow.J Appl Physiol, 2005, 99(2):556-563.
21. Meininger D, Byhahn C.Positive end-expiratory pressure improves arterial oxygenation during prolonged pneumoperitoneum.Acta Anaesthesiol Scand, 2005, 49(6):778-783.
22. 单志桂, 杨新玲, 姚亚妮.如何运用系统评价结果进行临床实践.中国循证医学杂志, 2012, 12(3):357-359.

Chinese Journal of Evidence-Based Medicine

Positive End-Expiratory Pressure (PEEP) during Anaesthesia for Prevention of Postoperative Pulmonary Complications: A Meta-Analysis

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