Protective ventilation measures improve outcomes during major vascular surgery

Background: In major endovascular and open vascular surgery cases, pulmonary complications remain persistently high and the most prevalent. Despite strong evidence from intensive care unit (ICU) practices demonstrating benefits of ventilation management with low tidal volume and high positive end expiratory pressure (PEEP), no consensus exists regarding protective ventilation use intraoperatively. Methods: A single institute, patient and surgeon blinded, prospective, randomized study design was used. Patients undergoing major vascular surgery (vascular surgery scheduled for >120 minutes and requiring general anesthesia) from 2015-2016 were randomized to pre-defined control (n = 14) or intervention (n =19) intraoperative ventilation arms. As described later, intervention consisted of a combination of low tidal volume, optimized positive end expiratory pressure (PEEP) and low intraoperative FiO2. Primary outcomes included all-cause mortality, myocardial infarction (MI) and reintubation within 7 post-operative days (POD). Secondary outcomes included atelectasis, pulmonary function measures, hospital length of stay and post-operative complications of re-intubation, pneumonia, sespsis, unplanned readmission or return to operating room, and/or mortality. Results: The intervention arm had significantly reduced post-operative atelectasis ((p <0.02) and increased post-operative SpO2 (p< 0.02). The intervention arm also had a significantly lower length of hospital stay (6.9±5.5 vs 3.3±1.8, p < 0.016). This was corroborated by a multivariate regression analysis that showed therapy was independently correlated with decreased length of stay (p<0.007). Conclusion: Our data indicate a combination of low tidal volumes, optimized PEEP and low FiO2 improves outcomes of patients undergoing major vascular surgery. Importantly, our study demonstrates that these study parameters for evaluation of intraoperative ventilation management are feasible in a busy academic center and a larger clinical trial is worthy. Protective intraoperative ventilation measures could have significant effects on vascular surgery outcomes.

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Low Tidal Volume and High Positive End-Expiratory Pressure Mechanical Ventilation Results in Increased Inflammation and Ventilator-Associated Lung Injury in Normal Lungs

Anesthesia & Analgesia ◽

10.1213/ane.0b013e3181cfc416 ◽

2010 ◽

Vol 110 (6) ◽

pp. 1652-1660 ◽

Cited By ~ 39

Author(s):

Caron M. Hong ◽

Da-Zhong Xu ◽

Qi Lu ◽

Yunhui Cheng ◽

Vadim Pisarenko ◽

...

Keyword(s):

Mechanical Ventilation ◽

Lung Injury ◽

Tidal Volume ◽

Positive End Expiratory Pressure ◽

Low Tidal Volume ◽

Normal Lungs

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Demographics, management and outcome of females and males with acute respiratory distress syndrome in the LUNG SAFE prospective cohort study

European Respiratory Journal ◽

10.1183/13993003.00609-2019 ◽

2019 ◽

Vol 54 (4) ◽

pp. 1900609 ◽

Cited By ~ 6

Author(s):

Bairbre A. McNicholas ◽

Fabiana Madotto ◽

Tài Pham ◽

Emanuele Rezoagli ◽

Claire H. Masterson ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Length Of Stay ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Tidal Volume ◽

Distress Syndrome ◽

Hospital Length Of Stay ◽

Lower Tidal Volume ◽

Volume Ventilation ◽

To Receive

RationaleWe wished to determine the influence of sex on the management and outcomes in acute respiratory distress syndrome (ARDS) patients in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE).MethodsWe assessed the effect of sex on mortality, intensive care unit and hospital length of stay, and duration of invasive mechanical ventilation (IMV) in patients with ARDS who underwent IMV, adjusting for plausible clinical and geographic confounders.FindingsOf 2377 patients with ARDS, 905 (38%) were female and 1472 (62%) were male. There were no sex differences in clinician recognition of ARDS or critical illness severity profile. Females received higher tidal volumes (8.2±2.1 versus 7.2±1.6 mL·kg−1; p<0.0001) and higher plateau and driving pressures compared with males. Lower tidal volume ventilation was received by 50% of females compared with 74% of males (p<0.0001). In shorter patients (height ≤1.69 m), females were significantly less likely to receive lower tidal volumes. Surviving females had a shorter duration of IMV and reduced length of stay compared with males. Overall hospital mortality was similar in females (40.2%) versus males (40.2%). However, female sex was associated with higher mortality in patients with severe confirmed ARDS (OR for sex (male versus female) 0.35, 95% CI 0.14–0.83).ConclusionsShorter females with ARDS are less likely to receive lower tidal volume ventilation, while females with severe confirmed ARDS have a higher mortality risk. These data highlight the need for better ventilatory management in females to improve their outcomes from ARDS.

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Protective Ventilation Measures Improve Outcomes During Major Vascular Surgery

Journal of Vascular Surgery ◽

10.1016/j.jvs.2020.04.079 ◽

2020 ◽

Vol 72 (1) ◽

pp. e41-e43

Author(s):

Sujata Saha ◽

Mark Bazzell ◽

Randall Dull ◽

Vance Nielsen ◽

Sandipan Bhattacharjee ◽

...

Keyword(s):

Vascular Surgery ◽

Protective Ventilation ◽

Major Vascular Surgery

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Low Tidal Volume Ventilation in Patients without Acute Respiratory Distress Syndrome: A Paradigm Shift in Mechanical Ventilation

Critical Care Research and Practice ◽

10.1155/2012/416862 ◽

2012 ◽

Vol 2012 ◽

pp. 1-12 ◽

Cited By ~ 7

Author(s):

Jed Lipes ◽

Azadeh Bojmehrani ◽

Francois Lellouche

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Lung Injury ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Tidal Volume ◽

Distress Syndrome ◽

Protective Ventilation ◽

Low Tidal Volume ◽

Low Tidal Volume Ventilation ◽

Volume Ventilation

Protective ventilation with low tidal volume has been shown to reduce morbidity and mortality in patients suffering from acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Low tidal volume ventilation is associated with particular clinical challenges and is therefore often underutilized as a therapeutic option in clinical practice. Despite some potential difficulties, data have been published examining the application of protective ventilation in patients without lung injury. We will briefly review the physiologic rationale for low tidal volume ventilation and explore the current evidence for protective ventilation in patients without lung injury. In addition, we will explore some of the potential reasons for its underuse and provide strategies to overcome some of the associated clinical challenges.

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