Intraoperative Protective Mechanical Ventilation for Prevention of Postoperative Pulmonary Complications: A Comprehensive Review of the Role of Tidal Volume, Positive End-expiratory Pressure, and Lung Recruitment Maneuvers

Postoperative pulmonary complications are associated with increased morbidity, length of hospital stay, and mortality after major surgery. Intraoperative lung-protective mechanical ventilation has the potential to reduce the incidence of postoperative pulmonary complications. This review discusses the relevant literature on definition and methods to predict the occurrence of postoperative pulmonary complication, the pathophysiology of ventilator-induced lung injury with emphasis on the noninjured lung, and protective ventilation strategies, including the respective roles of tidal volumes, positive end-expiratory pressure, and recruitment maneuvers. The authors propose an algorithm for protective intraoperative mechanical ventilation based on evidence from recent randomized controlled trials.

[1]  D. Talmor,et al.  Protective versus Conventional Ventilation for Surgery: A Systematic Review and Individual Patient Data Meta-analysis , 2015, Anesthesiology.

[2]  A. Hoeft,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 , 2015, European journal of anaesthesiology.

[3]  P. Pelosi,et al.  Modulation of Stress versus Time Product during Mechanical Ventilation Influences Inflammation as Well as Alveolar Epithelial and Endothelial Response in Rats , 2015, Anesthesiology.

[4]  S. Ghadiali,et al.  Influence of airway wall compliance on epithelial cell injury and adhesion during interfacial flows. , 2014, Journal of applied physiology.

[5]  P. Pelosi,et al.  Positive end-expiratory pressure during surgery – Authors' reply , 2014, The Lancet.

[6]  P. Pelosi,et al.  High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial , 2014, The Lancet.

[7]  A. Hoeft,et al.  Prospective External Validation of a Predictive Score for Postoperative Pulmonary Complications , 2014, Anesthesiology.

[8]  M. Beaussier,et al.  A Trial of Intraoperative Low-Tidal-Volume Ventilation in Abdominal Surgery , 2014 .

[9]  S. Jaber,et al.  Perioperative Positive Pressure Ventilation: An Integrated Approach to Improve Pulmonary Care , 2014, Anesthesiology.

[10]  A. Goetz,et al.  Mechanotransduction in the lungs. , 2014, Minerva anestesiologica.

[11]  Tilo Winkler,et al.  Effect of Local Tidal Lung Strain on Inflammation in Normal and Lipopolysaccharide-Exposed Sheep* , 2014, Critical care medicine.

[12]  B. Kavanagh,et al.  Lung-protective Ventilation in the Operating Room: Time to Implement? , 2014, Anesthesiology.

[13]  M. Levin,et al.  Low intraoperative tidal volume ventilation with minimal PEEP is associated with increased mortality , 2014, British journal of anaesthesia.

[14]  S. Jaber,et al.  Protective lung ventilation in operating room: a systematic review. , 2014, Minerva anestesiologica.

[15]  D. Talmor,et al.  Predicting Risk of Postoperative Lung Injury in High-risk Surgical Patients: A Multicenter Cohort Study , 2014, Anesthesiology.

[16]  J. Canet,et al.  Predicting postoperative pulmonary complications: implications for outcomes and costs , 2014, Current opinion in anaesthesiology.

[17]  D. Chiumello,et al.  Protective lung ventilation during general anesthesia: is there any evidence? , 2014, Critical Care.

[18]  J. Canet,et al.  Postoperative respiratory failure: pathogenesis, prediction, and prevention , 2014, Current opinion in critical care.

[19]  B. Suki,et al.  Epithelial and endothelial damage induced by mechanical ventilation modes , 2014, Current opinion in critical care.

[20]  S. Bohm,et al.  Noninvasive Monitoring of Lung Recruitment Maneuvers in Morbidly Obese Patients: The Role of Pulse Oximetry and Volumetric Capnography , 2014, Anesthesia and analgesia.

[21]  Hao Wang,et al.  The impact of tidal volume on pulmonary complications following minimally invasive esophagectomy: a randomized and controlled study. , 2013, The Journal of thoracic and cardiovascular surgery.

[22]  R. Hubmayr,et al.  Biophysical determinants of alveolar epithelial plasma membrane wounding associated with mechanical ventilation. , 2013, American journal of physiology. Lung cellular and molecular physiology.

[23]  D. Hess,et al.  A 5-year observational study of lung-protective ventilation in the operating room: a single-center experience. , 2013, Journal of critical care.

[24]  M. Beaussier,et al.  A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. , 2013, The New England journal of medicine.

[25]  A. Anzueto,et al.  Evolution of mortality over time in patients receiving mechanical ventilation. , 2013, American journal of respiratory and critical care medicine.

[26]  A. Maslow,et al.  A randomized comparison of different ventilator strategies during thoracotomy for pulmonary resection. , 2013, The Journal of thoracic and cardiovascular surgery.

[27]  S. Margulies,et al.  Cyclic stretch-induced oxidative stress increases pulmonary alveolar epithelial permeability. , 2013, American journal of respiratory cell and molecular biology.

[28]  D. Hess,et al.  Development and Validation of a Score for Prediction of Postoperative Respiratory Complications , 2013, Anesthesiology.

[29]  P. Pelosi,et al.  Protective Mechanical Ventilation during General Anesthesia for Open Abdominal Surgery Improves Postoperative Pulmonary Function , 2013, Anesthesiology.

[30]  G. Drummond,et al.  III. Tidal volume measurement: OK for science, but too difficult for a workstation standard? , 2013, British journal of anaesthesia.

[31]  L. Bos,et al.  The Extent of Ventilator-Induced Lung Injury in Mice Partly Depends on Duration of Mechanical Ventilation , 2013, Critical care research and practice.

[32]  M. Schultz,et al.  Intraoperative ventilatory strategies to prevent postoperative pulmonary complications: a meta-analysis , 2013, Current opinion in anaesthesiology.

[33]  J. Canet,et al.  Predicting postoperative pulmonary complications in the general population , 2013, Current opinion in anaesthesiology.

[34]  M. Matthay,et al.  Regulation and repair of the alveolar-capillary barrier in acute lung injury. , 2013, Annual review of physiology.

[35]  M. Dambrosio,et al.  Effects of Recruitment Maneuver and Positive End-expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery , 2013, Anesthesiology.

[36]  R. Xu,et al.  [Effect of lung protection mechanical ventilation on respiratory function in the elderly undergoing spinal fusion]. , 2013, Zhong nan da xue xue bao. Yi xue ban = Journal of Central South University. Medical sciences.

[37]  A. Serpa Neto,et al.  Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. , 2012, JAMA.

[38]  M. Beaussier,et al.  A multicentre observational study of intra‐operative ventilatory management during general anaesthesia: tidal volumes and relation to body weight , 2012, Anaesthesia.

[39]  M. Schaefer,et al.  Ventilation with low tidal volumes during upper abdominal surgery does not improve postoperative lung function. , 2012, British journal of anaesthesia.

[40]  Arthur S Slutsky,et al.  Acute Respiratory Distress Syndrome The Berlin Definition , 2012 .

[41]  F. Girardi,et al.  The effect of low versus high tidal volume ventilation on inflammatory markers in healthy individuals undergoing posterior spine fusion in the prone position: a randomized controlled trial. , 2012, Journal of clinical anesthesia.

[42]  M. Protasoni,et al.  Impact of mechanical ventilation and fluid load on pulmonary glycosaminoglycans , 2012, Respiratory Physiology & Neurobiology.

[43]  Shin Kurosawa,et al.  Impact of changes of positive end-expiratory pressure on functional residual capacity at low tidal volume ventilation during general anesthesia , 2012, Journal of Anesthesia.

[44]  F. Lellouche,et al.  High Tidal Volumes in Mechanically Ventilated Patients Increase Organ Dysfunction after Cardiac Surgery , 2012, Anesthesiology.

[45]  P. Pronovost,et al.  Lung protective mechanical ventilation and two year survival in patients with acute lung injury: prospective cohort study , 2012, BMJ : British Medical Journal.

[46]  P. Pelosi,et al.  Pathophysiology of ventilator-associated lung injury , 2012, Current opinion in anaesthesiology.

[47]  A. Koutsoukou,et al.  Plasma membrane disruptions with different modes of injurious mechanical ventilation in normal rat lungs* , 2012, Critical care medicine.

[48]  S. Bohm,et al.  Alveolar recruitment improves ventilation during thoracic surgery: a randomized controlled trial. , 2012, British journal of anaesthesia.

[49]  L. Gattinoni,et al.  Stress and strain within the lung , 2012, Current opinion in critical care.

[50]  Knut Möller,et al.  Adaptive SLICE method: an enhanced method to determine nonlinear dynamic respiratory system mechanics , 2012, Physiological measurement.

[51]  F. Boschetti,et al.  Impact of respiratory pattern on lung mechanics and interstitial proteoglycans in spontaneously breathing anaesthetized healthy rats , 2011, Acta physiologica.

[52]  H. Gehring,et al.  Effect of PEEP on regional ventilation during laparoscopic surgery monitored by electrical impedance tomography , 2011, Acta anaesthesiologica Scandinavica.

[53]  Ognjen Gajic,et al.  Derivation and Diagnostic Accuracy of the Surgical Lung Injury Prediction Model , 2011, Anesthesiology.

[54]  Alessandro Santini,et al.  Lung stress and strain during mechanical ventilation: any safe threshold? , 2011, American journal of respiratory and critical care medicine.

[55]  V. Novack,et al.  Influence of low tidal volume ventilation on time to extubation in cardiac surgical patients. , 2011, Anesthesiology.

[56]  G. Hedenstierna,et al.  Ventilatory protective strategies during thoracic surgery: effects of alveolar recruitment maneuver and low-tidal volume ventilation on lung density distribution. , 2011, Anesthesiology.

[57]  M. Vavilala,et al.  Intraoperative adherence to a low tidal volume ventilation strategy in critically ill patients with preexisting acute lung injury. , 2011, Journal of critical care.

[58]  Ognjen Gajic,et al.  Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study. , 2011, American journal of respiratory and critical care medicine.

[59]  Carmen Gomar,et al.  Prediction of Postoperative Pulmonary Complications in a Population-based Surgical Cohort , 2010, Anesthesiology.

[60]  V. Herasevich,et al.  Acute lung injury prediction score: derivation and validation in a population-based sample , 2010, European Respiratory Journal.

[61]  E. Deitch,et al.  Low Tidal Volume and High Positive End-Expiratory Pressure Mechanical Ventilation Results in Increased Inflammation and Ventilator-Associated Lung Injury in Normal Lungs , 2010, Anesthesia and analgesia.

[62]  S. Jaber,et al.  Positive end-expiratory pressure improves end-expiratory lung volume but not oxygenation after induction of anaesthesia , 2010, European journal of anaesthesiology.

[63]  Matthias Briel,et al.  Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. , 2010, JAMA.

[64]  D. Schroeder,et al.  Comparison of two ventilatory strategies in elderly patients undergoing major abdominal surgery. , 2010, British journal of anaesthesia.

[65]  P. Pelosi,et al.  Prevention of Atelectasis in Morbidly Obese Patients during General Anesthesia and Paralysis: A Computerized Tomography Study , 2009, Anesthesiology.

[66]  C. Putensen,et al.  Meta-analysis: Ventilation Strategies and Outcomes of the Acute Respiratory Distress Syndrome and Acute Lung Injury , 2009, Annals of Internal Medicine.

[67]  J. Tschopp,et al.  Impact of intraoperative lung-protective interventions in patients undergoing lung cancer surgery , 2009, Critical care.

[68]  V. Ranieri,et al.  Pulmonary atelectasis during low stretch ventilation: “Open lung” versus “lung rest” strategy* , 2009, Critical care medicine.

[69]  M. Schultz,et al.  Mechanical ventilation using non-injurious ventilation settings causes lung injury in the absence of pre-existing lung injury in healthy mice , 2009, Critical care.

[70]  S. Rugonyi,et al.  The biophysical function of pulmonary surfactant , 2008, Respiratory Physiology & Neurobiology.

[71]  C. Vachon,et al.  Intraoperative ventilator settings and acute lung injury after elective surgery: a nested case control study , 2008, Thorax.

[72]  Massimo Cressoni,et al.  Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. , 2008, American journal of respiratory and critical care medicine.

[73]  X. Bai,et al.  [Effects of the lung protective ventilatory strategy on proinflammatory cytokine release during one-lung ventilation]. , 2008, Ai zheng = Aizheng = Chinese journal of cancer.

[74]  S. Bohm,et al.  Compliance and Dead Space Fraction Indicate an Optimal Level of Positive End-Expiratory Pressure After Recruitment in Anesthetized Patients , 2008, Anesthesia and analgesia.

[75]  T. van der Poll,et al.  Mechanical Ventilation with Lower Tidal Volumes and Positive End-expiratory Pressure Prevents Pulmonary Inflammation in Patients without Preexisting Lung Injury , 2008, Anesthesiology.

[76]  A. Koutsoukou,et al.  Cytokine release, small airway injury, and parenchymal damage during mechanical ventilation in normal open-chest rats. , 2008, Journal of applied physiology.

[77]  P. Pelosi,et al.  Effects of mechanical ventilation on the extracellular matrix , 2008, Intensive Care Medicine.

[78]  L. Bouadma,et al.  Mechanical ventilation and hemorrhagic shock-resuscitation interact to increase inflammatory cytokine release in rats* , 2007, Critical care medicine.

[79]  V. Ottani,et al.  Proteoglycan fragmentation and respiratory mechanics in mechanically ventilated healthy rats. , 2007, Journal of applied physiology.

[80]  L. Joosten,et al.  Mechanical Ventilation in Healthy Mice Induces Reversible Pulmonary and Systemic Cytokine Elevation with Preserved Alveolar Integrity: An In Vivo Model Using Clinical Relevant Ventilation Settings , 2007, Anesthesiology.

[81]  R. Lachmann,et al.  High positive end-expiratory pressure levels promote bacterial translocation in experimental pneumonia , 2007, Intensive Care Medicine.

[82]  L. Neumayer,et al.  Multivariable predictors of postoperative respiratory failure after general and vascular surgery: results from the patient safety in surgery study. , 2007, Journal of the American College of Surgeons.

[83]  H. Cai,et al.  Effect of low tidal volume ventilation on atelectasis in patients during general anesthesia: a computed tomographic scan. , 2007, Journal of clinical anesthesia.

[84]  E. d’Angelo,et al.  Closing volume: a reappraisal (1967–2007) , 2007, European Journal of Applied Physiology.

[85]  L. Papazian,et al.  Protective Ventilation Influences Systemic Inflammation after Esophagectomy: A Randomized Controlled Study , 2006, Anesthesiology.

[86]  Robert M Kacmarek,et al.  Reversibility of lung collapse and hypoxemia in early acute respiratory distress syndrome. , 2006, American journal of respiratory and critical care medicine.

[87]  V. Lawrence,et al.  Preoperative Pulmonary Risk Stratification for Noncardiothoracic Surgery: Systematic Review for the American College of Physicians , 2006, Annals of Internal Medicine.

[88]  F. Jardin.  Tidal volume reduction in patients with acute lung injury when plateau pressures are not high. , 2006, American journal of respiratory and critical care medicine.

[89]  A. Bogers,et al.  Ventilation according to the open lung concept attenuates pulmonary inflammatory response in cardiac surgery. , 2005, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[90]  T. Welte,et al.  The Pulmonary Immune Effects of Mechanical Ventilation in Patients Undergoing Thoracic Surgery , 2005, Anesthesia and analgesia.

[91]  M. Ernst,et al.  Mechanical ventilation strategies and inflammatory responses to cardiac surgery: a prospective randomized clinical trial , 2005, Intensive Care Medicine.

[92]  V. Ranieri,et al.  Mechanical ventilation affects inflammatory mediators in patients undergoing cardiopulmonary bypass for cardiac surgery: a randomized clinical trial. , 2005, The Journal of thoracic and cardiovascular surgery.

[93]  R. Hubmayr,et al.  Cellular stress failure in ventilator-injured lungs. , 2005, American journal of respiratory and critical care medicine.

[94]  Arthur S Slutsky,et al.  Ventilator-induced lung injury: from the bench to the bedside , 2005, Intensive Care Medicine.

[95]  Marek Ancukiewicz,et al.  Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. , 2009, The New England journal of medicine.

[96]  A. V. van Kaam,et al.  Reducing atelectasis attenuates bacterial growth and translocation in experimental pneumonia. , 2004, American journal of respiratory and critical care medicine.

[97]  C. Putensen,et al.  The Effects of Different Ventilatory Settings on Pulmonary and Systemic Inflammatory Responses During Major Surgery , 2004, Anesthesia and analgesia.

[98]  G. Çetin,et al.  Effects of protective and conventional mechanical ventilation on pulmonary function and systemic cytokine release after cardiopulmonary bypass , 2004, Intensive Care Medicine.

[99]  P. Schnyder,et al.  Prevention of Atelectasis Formation During Induction of General Anesthesia , 2003, Anesthesia and analgesia.

[100]  Arthur S Slutsky,et al.  Injurious mechanical ventilation and end-organ epithelial cell apoptosis and organ dysfunction in an experimental model of acute respiratory distress syndrome. , 2003, JAMA.

[101]  M. Heintz,et al.  One-Lung Ventilation with High Tidal Volumes and Zero Positive End-Expiratory Pressure Is Injurious in the Isolated Rabbit Lung Model , 2003, Anesthesia and analgesia.

[102]  S. Uhlig.  Ventilation-induced lung injury and mechanotransduction: stretching it too far? , 2002, American journal of physiology. Lung cellular and molecular physiology.

[103]  William Henderson,et al.  Development and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery , 2001, Annals of Internal Medicine.

[104]  S. Margulies,et al.  Role of stretch on tight junction structure in alveolar epithelial cells. , 2001, American journal of respiratory cell and molecular biology.

[105]  P. Pelosi,et al.  Recruitment and derecruitment during acute respiratory failure: an experimental study. , 2001, American journal of respiratory and critical care medicine.

[106]  J. Wetterslev,et al.  Optimizing peroperative compliance with PEEP during upper abdominal surgery: effects on perioperative oxygenation and complications in patients without preoperative cardiopulmonary dysfunction , 2001, European journal of anaesthesiology.

[107]  A. Hoeft,et al.  Effects of Mechanical Ventilation on Release of Cytokines into Systemic Circulation in Patients with Normal Pulmonary Function , 2000, Anesthesiology.

[108]  S. Yuan,et al.  Myosin light chain kinase transference induces myosin light chain activation and endothelial hyperpermeability. , 2000, American journal of physiology. Cell physiology.

[109]  W. Henderson,et al.  Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery , 2000, Annals of surgery.

[110]  D. Schoenfeld,et al.  Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. , 2000, The New England journal of medicine.

[111]  R. Albert,et al.  The prone position eliminates compression of the lungs by the heart. , 2000, American journal of respiratory and critical care medicine.

[112]  P. Pelosi,et al.  Positive end-expiratory pressure improves respiratory function in obese but not in normal subjects during anesthesia and paralysis. , 1999, Anesthesiology.

[113]  G. Hedenstierna,et al.  Dynamics of re-expansion of atelectasis during general anaesthesia. , 1999, British journal of anaesthesia.

[114]  C. Joyce,et al.  Kinetics of absorption atelectasis during anesthesia: a mathematical model. , 1999, Journal of applied physiology.

[115]  G. Hedenstierna,et al.  Positive end‐expiratory pressure prevents atelectasisduring general anaesthesia even in the presence of a high inspired oxygen concentration , 1999, Acta anaesthesiologica Scandinavica.

[116]  J. Sznajder,et al.  Ventilator-associated lung injury decreases lung ability to clear edema in rats. , 1999, American journal of respiratory and critical care medicine.

[117]  N. Farman,et al.  Hypoxia downregulates expression and activity of epithelial sodium channels in rat alveolar epithelial cells. , 1997, American journal of respiratory cell and molecular biology.

[118]  M. Corada,et al.  Polymorphonuclear leukocyte adhesion triggers the disorganization of endothelial cell-to-cell adherens junctions , 1996, The Journal of cell biology.

[119]  G. Hedenstierna,et al.  CT-Assessment of Dependent Lung Densities in Man during General Anaesthesia , 1995, Acta radiologica.

[120]  G. Hedenstierna,et al.  Influence of Gas Composition on Recurrence of Atelectasis after a Reexpansion Maneuver during General Anesthesia , 1995, Anesthesiology.

[121]  G. Hedenstierna,et al.  Re-expansion of atelectasis during general anaesthesia: a computed tomography study. , 1993, British journal of anaesthesia.

[122]  J. West,et al.  Stress failure in pulmonary capillaries. , 1991, Journal of applied physiology.

[123]  K. Peevy,et al.  Lung edema caused by high peak inspiratory pressures in dogs. Role of increased microvascular filtration pressure and permeability. , 1990, The American review of respiratory disease.

[124]  G. Hedenstierna,et al.  Pulmonary Densities during Anesthesia with Muscular Relaxation—A Proposal of Atelectasis , 1985, Anesthesiology.

[125]  E. d’Angelo.  Factors affecting the distribution of transpulmonary pressure in animals and in man. , 1984, Bulletin europeen de physiopathologie respiratoire.

[126]  N. A. Bergman,et al.  Contribution of the Closure of Pulmonary Units to Impaired Oxygenation during Anesthesia , 1983, Anesthesiology.

[127]  E. Egan.  Lung inflation, lung solute permeability, and alveolar edema. , 1982, Journal of applied physiology: respiratory, environmental and exercise physiology.

[128]  R. Albert,et al.  Increased surface tension favors pulmonary edema formation in anesthetized dogs' lungs. , 1979, The Journal of clinical investigation.

[129]  H. Marsh,et al.  Closing capacity in awake and anesthetized-paralyzed man. , 1978, Journal of applied physiology: respiratory, environmental and exercise physiology.

[130]  S. F. Sullivan,et al.  The surface tension of tracheobronchial secretions during general anesthesia. , 1972, Anesthesiology.

[131]  J. Mead,et al.  Stress distribution in lungs: a model of pulmonary elasticity. , 1970, Journal of applied physiology.

[132]  M. B. Laver,et al.  IMPAIRED OXYGENATION IN SURGICAL PATIENTS DURING GENERAL ANESTHESIA WITH CONTROLLED VENTILATION. A CONCEPT OF ATELECTASIS. , 1963, The New England journal of medicine.