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

6533b821fe1ef96bd127c28a

RESEARCH PRODUCT

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

T Bluth As Neto Mj Schultz P Pelosi De Abreu Mg I Bobek Jc Canet L De Baerdemaeker C Gregoretti G Hedenstierna Snt Hemmes M Hiesmayr M Hollmann S Jaber J Laffey Mj Licker K Markstaller I Matot G Mills Jp Mulier C Putensen R Rossaint J Schmitt M Senturk P Severgnini J Sprung Mfv Melo H Wrigge F Abelha S Abitagaoglu M Achilles A Adebesin I Adriaensens C Ahene F Akbar M Al Harbi Al Kallab Ra X Albanel F Aldenkortt Ras Alfouzan R Alruqaie F Altermatt Bld Araujo G Arbesu H Artsi C Aurilio Oh Ayanoglu A Bacuzzi H Baig Y Baird K Balonov J Balust S Banks Xd Bao M Baumgartner Ib Tortosa A Bergamaschi L Bergmann L Bigatello Eb Perez K Birr T Bluth E Bojaxhi C Bonenti I Bonney Ee Bos S Bowman Lg Braz E Brugnoni I Brunetti A Bruni Sl Buenvenida Cj Camerini J Canet B Capatti J Carmona J Carungcong M Carvalho A Cattan C Cavaleiro D Chiumello S Ciardo M Coburn U Colella V Contreras Pc Dincer E Cotter M Crovetto W Crovetto W Darrah S Davies L De Baerdemaeker S De Hert Ed Peces E Delphin J Diaper P Do Nascimento V Donatiello J Dong Md Dourado A Dullenkopf F Ebner H Elgendy C Ellenberger De Ari T Ermert F Farah A Fernandez-bustamante C Ferreira M Fiore A Fonte Cf Palahi A Galimberti N Garofano Lg Giaccari F Gilsanz F Girrbach L Gobbi Mb Godfried N Goettel Pa Goldstein O Goren A Gorlin Mg Gil A Gratarola J Graterol P Guyon K Haire P Harou A Helf Snt Hemmes G Hempel Mjh Cadiz B Heyse Mw Hollmann I Huercio J Ilievska L Jakus V Jeganath Y Jelting M Jung B Kabon A Kacha Mk Ilic A Karuppiah Ad Kavas Gk Barcelos Ta Kellogg J Kemper R Kerbrat S Khodr P Kienbaum B Kir T Kiss S Kivrak V Klaric T Koch C Koksal A Kowark P Kranke B Kuvaki B Kuzmanovska J Laffey M Lange De Lemos Mf Mj Licker M Lopez-baamonde A Lopez-hernandez M Lopez-martinez S Luise M Macgregor D Magalhaes J Maillard P Malerbi N Manimekalai M Margarson K Markstaller Dp Martin Yn Martin J Martinez-ocon I Martin-loeches E Maseda I Matot N Mcauliffe Tj Mckenzie P Medina M Meersch A Menzen E Mertens B Meurer T Meyer-treschan Ch Miao C Micalizzi M Milic Nsp Modolo P Moine P Molders A Montero-feijoo E Moret Mk Muller Z Murphy P Nalwaya F Naumovski P Navalesi Lhne Lima Vn Adam C Neumann C Newell Z Nisnevitch J Nizamuddin C Novazzi M O'connor G Oprea Mo Sungur S Ozbilgin Mc Pace M Pacheco B Packianathaswamy Ep Gonzalez F Papaspyros S Paredes Mb Passavanti Jc Pedemonte P Pelosi S Peremin C Philipsenburg D Pinho S Pinho Lm Posthuma V Pota B Preckel P Priani C Putensen Ma Rached A Radoeshki R Ragazzi T Rajamanickam A Rajamohan H Ramakrishna D Rangarajan C Reiterer Jr Renew T Reynaud R Rhys E Rivas L Robitzky R Rossaint F Rubulotta Hs Machado Cs Nunes G Sabbatini Jm Sanahuja P Sansone A Santos M Sayedalahl Ms Schaefer E Scharffenberg M Scharffenberg E Schiffer N Schliewe R Schorer Mj Schultz R Schumann G Selmo M Sendra M Senturk P Severgnini K Shaw M Shosholcheva A Sibai P Simon F Simonassi C Sinno N Sivrikoz V Skandalou N Smith M Soares Ts Artiles Ds Castro M Sousa S Spadaro J Sprung E Stamatakis La Steiner A Stevenazzi A Suarez-de-la-rica M Suppan R Teichmann Jmt Guerrero B Thiel R Tolos Gt Altun M Tucci Za Turnbull Z Turudic M Unterberg J Van Limmen Y Van Nieuwenhove J Van Waesberghe M Francisco V Melo B Vitkovic L Vivona M Vizcaychipi Ca Volta A Weber Tn Weingarten J Wittenstein H Wrigge P Wyffels J Yague D Yates A Yavru L Zac J Zhong

subject

Lung Diseases Male medicine.medical_treatment Atelectasis Lung Disease 01 natural sciences Body Mass Index Hypoxemia Positive-Pressure Respiration Postoperative Complications 0302 clinical medicine PEEP postoperative complications obese patients Anesthesia Respiratory function 030212 general & internal medicine Tidal volume General Medicine Middle Aged Pleural Diseases respiratory system Adult; Anesthesia General; Body Mass Index; Female; Humans; Lung Diseases; Male; Middle Aged; Obesity; Pleural Diseases; Positive-Pressure Respiration; Postoperative Complications; Pulmonary Atelectasis; Respiratory Insufficiency; Surgical Procedures Operative; Tidal Volume; Treatment Outcome; Intraoperative Care Operative 3. Good health Treatment Outcome Pneumothorax Surgical Procedures Operative Anesthesia Female medicine.symptom Respiratory Insufficiency psychological phenomena and processes Human circulatory and respiratory physiology Adult Pulmonary Atelectasis Anesthesia General NO 03 medical and health sciences mental disorders Tidal Volume medicine Humans Pleural Disease Obesity 0101 mathematics General Positive end-expiratory pressure Mechanical ventilation Surgical Procedures Intraoperative Care Pulmonary Atelectasi business.industry 010102 general mathematics medicine.disease respiratory tract diseases Respiratory failure Postoperative Complication business

description

Importance: An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain. Objective: To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP. Design, Setting, and Participants: Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018. Interventions: Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H2O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H2O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight. Main Outcomes and Measures: The primary outcome was a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with Spo2 ≤92% for >1 minute). Results: Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, -2.3% [95% CI, -5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P =.23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, -8.6% [95% CI, -11.1% to 6.1%]; P <.001). Conclusions and Relevance: Among obese patients undergoing surgery under general anesthesia, an intraoperative mechanical ventilation strategy with a higher level of PEEP and alveolar recruitment maneuvers, compared with a strategy with a lower level of PEEP, did not reduce postoperative pulmonary complications. Trial Registration: ClinicalTrials.gov Identifier: NCT02148692.

year	journal	country	edition	language
2019-01-01

10.1001/jama.2019.7505 http://hdl.handle.net/11567/959201