Effect of Intensive vs Moderate Alveolar Recruitment Strategies Added to Lung-Protective Ventilation on Postoperative Pulmonary Complications: A Randomized Clinical Trial

JAMA. 2017 Apr 11;317(14):1422-1432. doi: 10.1001/jama.2017.2297.


Importance: Perioperative lung-protective ventilation has been recommended to reduce pulmonary complications after cardiac surgery. The protective role of a small tidal volume (VT) has been established, whereas the added protection afforded by alveolar recruiting strategies remains controversial.

Objective: To determine whether an intensive alveolar recruitment strategy could reduce postoperative pulmonary complications, when added to a protective ventilation with small VT.

Design, setting, and participants: Randomized clinical trial of patients with hypoxemia after cardiac surgery at a single ICU in Brazil (December 2011-2014).

Interventions: Intensive recruitment strategy (n=157) or moderate recruitment strategy (n=163) plus protective ventilation with small VT.

Main outcomes and measures: Severity of postoperative pulmonary complications computed until hospital discharge, analyzed with a common odds ratio (OR) to detect ordinal shift in distribution of pulmonary complication severity score (0-to-5 scale, 0, no complications; 5, death). Prespecified secondary outcomes were length of stay in the ICU and hospital, incidence of barotrauma, and hospital mortality.

Results: All 320 patients (median age, 62 years; IQR, 56-69 years; 125 women [39%]) completed the trial. The intensive recruitment strategy group had a mean 1.8 (95% CI, 1.7 to 2.0) and a median 1.7 (IQR, 1.0-2.0) pulmonary complications score vs 2.1 (95% CI, 2.0-2.3) and 2.0 (IQR, 1.5-3.0) for the moderate strategy group. Overall, the distribution of primary outcome scores shifted consistently in favor of the intensive strategy, with a common OR for lower scores of 1.86 (95% CI, 1.22 to 2.83; P = .003). The mean hospital stay for the moderate group was 12.4 days vs 10.9 days in the intensive group (absolute difference, -1.5 days; 95% CI, -3.1 to -0.3; P = .04). The mean ICU stay for the moderate group was 4.8 days vs 3.8 days for the intensive group (absolute difference, -1.0 days; 95% CI, -1.6 to -0.2; P = .01). Hospital mortality (2.5% in the intensive group vs 4.9% in the moderate group; absolute difference, -2.4%, 95% CI, -7.1% to 2.2%) and barotrauma incidence (0% in the intensive group vs 0.6% in the moderate group; absolute difference, -0.6%; 95% CI, -1.8% to 0.6%; P = .51) did not differ significantly between groups.

Conclusions and relevance: Among patients with hypoxemia after cardiac surgery, the use of an intensive vs a moderate alveolar recruitment strategy resulted in less severe pulmonary complications while in the hospital.

Trial registration: clinicaltrials.gov Identifier: NCT01502332.

Publication types

  • Randomized Controlled Trial

MeSH terms

  • Aged
  • Barotrauma / epidemiology
  • Blood Pressure / physiology
  • Cardiac Surgical Procedures / adverse effects*
  • Critical Care / statistics & numerical data
  • Female
  • Heart Rate / physiology
  • Hospital Mortality
  • Humans
  • Hypoxia / etiology
  • Hypoxia / therapy*
  • Incidence
  • Length of Stay
  • Lung Diseases / prevention & control
  • Male
  • Middle Aged
  • Odds Ratio
  • Oxygen Inhalation Therapy / methods*
  • Oxygen Inhalation Therapy / statistics & numerical data
  • Partial Pressure
  • Positive-Pressure Respiration / methods
  • Postoperative Complications / prevention & control
  • Postoperative Complications / therapy*
  • Pulmonary Alveoli / physiology*
  • Respiration, Artificial / methods*
  • Severity of Illness Index*
  • Tidal Volume

Associated data

  • ClinicalTrials.gov/NCT01502332
  • ClinicalTrials.gov/NCT01502332