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Observational Study
. 2015 Jul 14:351:h3646.
doi: 10.1136/bmj.h3646.

Intraoperative protective mechanical ventilation and risk of postoperative respiratory complications: hospital based registry study

Karim Ladha  1 , Marcos F Vidal Melo  1 , Duncan J McLean  1 , Jonathan P Wanderer  2 , Stephanie D Grabitz  1 , Tobias Kurth  3 , Matthias Eikermann  4
Affiliations
Observational Study

Intraoperative protective mechanical ventilation and risk of postoperative respiratory complications: hospital based registry study

Karim Ladha et al. BMJ. .

Abstract

Objective: To evaluate the effects of intraoperative protective ventilation on major postoperative respiratory complications and to define safe intraoperative mechanical ventilator settings that do not translate into an increased risk of postoperative respiratory complications.

Design: Hospital based registry study.

Setting: Academic tertiary care hospital and two affiliated community hospitals in Massachusetts, United States.

Participants: 69,265 consecutively enrolled patients over the age of 18 who underwent a non-cardiac surgical procedure between January 2007 and August 2014 and required general anesthesia with endotracheal intubation.

Interventions: Protective ventilation, defined as a median positive end expiratory pressure (PEEP) of 5 cmH2O or more, a median tidal volume of less than 10 mL/kg of predicted body weight, and a median plateau pressure of less than 30 cmH2O.

Main outcome measure: Composite outcome of major respiratory complications, including pulmonary edema, respiratory failure, pneumonia, and re-intubation.

Results: Of the 69,265 enrolled patients 34,800 (50.2%) received protective ventilation and 34,465 (49.8%) received non-protective ventilation intraoperatively. Protective ventilation was associated with a decreased risk of postoperative respiratory complications in multivariable regression (adjusted odds ratio 0.90, 95% confidence interval 0.82 to 0.98, P=0.013). The results were similar in the propensity score matched cohort (odds ratio 0.89, 95% confidence interval 0.83 to 0.97, P=0.004). A PEEP of 5 cmH2O and median plateau pressures of 16 cmH2O or less were associated with the lowest risk of postoperative respiratory complications.

Conclusions: Intraoperative protective ventilation was associated with a decreased risk of postoperative respiratory complications. A PEEP of 5 cmH2O and a plateau pressure of 16 cmH2O or less were identified as protective mechanical ventilator settings. These findings suggest that protective thresholds differ for intraoperative ventilation in patients with normal lungs compared with those used for patients with acute lung injury.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; MFVM has within the last two years received funding from the US National Institutes of Health (grant 1R01HL121228-01) and investigator initiated funding from Merck. TK has within the past two years received investigator initiated research funding from the French National Research Agency and the US National Institutes of Health. Further, he has received honorariums from the BMJ and Cephalalgia for editorial services. JPW is supported by a mentored research training grant in health services research from the Foundation for Anesthesia Education and Research and the Anesthesia Quality Institute. ME has within the past two years received investigator initiated research funding from Masimo, Merck, the ResMed Foundation, and the Buzen’s Foundation. Further, he has received honorariums from Anesthesiology for editorial services. There are no other relationships or activities that could appear to have influenced the submitted work.

Figures

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Fig 1 Flow of patients through study
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Fig 2 Distributions of median positive end expiratory pressure (PEEP), tidal volume, and plateau pressure in full unmatched cohort
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Fig 3 Multivariable logistic regression analysis examining the impact of plateau pressure, positive end expiratory pressure (PEEP), and tidal volume on postoperative pulmonary complications in entire unmatched cohort. Each graph represents a separate regression model adjusting for body mass index, age, sex, American Society of Anesthesiologists classification, score for prediction of postoperative respiratory complications, Charlson comorbidity index, work relative value units, pre-existing chronic pulmonary disease, surgery type, duration of ventilation, epidural placement, units of packed red blood cells, fresh frozen plasma and platelets transfused, ambulatory surgery, urgent/emergent surgery, estimated blood loss, and total fluids administered
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