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. 2014 Jul;113(1):97-108.
doi: 10.1093/bja/aeu054. Epub 2014 Mar 12.

Low intraoperative tidal volume ventilation with minimal PEEP is associated with increased mortality

M A Levin  1 , P J McCormick  1 , H M Lin  2 , L Hosseinian  1 , G W Fischer  3
Affiliations

Low intraoperative tidal volume ventilation with minimal PEEP is associated with increased mortality

M A Levin et al. Br J Anaesth. 2014 Jul.

Abstract

Background: Anaesthetists have traditionally ventilated patients' lungs with tidal volumes (TVs) between 10 and 15 ml kg(-1) of ideal body weight (IBW), without the use of PEEP. Over the past decade, influenced by the results of the Acute Respiratory Distress Syndrome Network trial, many anaesthetists have begun using lower TVs during surgery. It is unclear whether the benefits of low TV ventilation can be extended into the perioperative period.

Methods: We reviewed the records of 29 343 patients who underwent general anaesthesia with mechanical ventilation between January 1, 2008 and December 31, 2011. We calculated TV kg(-1) IBW, PEEP, peak inspiratory pressure (PIP), and dynamic compliance. Cox regression analysis with propensity score matching was performed to examine the association between TV and 30-day mortality.

Results: Median TV was 8.6 [7.7-9.6] ml kg(-1) IBW with minimal PEEP [4.0 (2.2-5.0) cm H2O]. A significant reduction in TV occurred over the study period, from 9 ml kg(-1) IBW in 2008 to 8.3 ml kg(-1) IBW in 2011 (P=0.01). Low TV 6-8 ml kg(-1) IBW was associated with a significant increase in 30-day mortality vs TV 8-10 ml kg(-1) IBW: hazard ratio (HR) 1.6 [95% confidence interval (CI) [1.25-2.08], P=0.0002]. The association remained significant after matching: HR 1.63 [95% CI (1.22-2.18), P<0.001]. There was only a weak correlation between TV kg(-1) IBW and dynamic compliance (r=-0.006, P=0.31) and a weak-to-moderate correlation between TV kg(-1) IBW and PIP (r=0.32 P<0.0001).

Conclusions: Use of low intraoperative TV with minimal PEEP is associated with an increased risk of 30-day mortality.

Keywords: intraoperative care; pulmonary ventilation; tidal volume.

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Conflict of interest statement

None declared.

Figures

Fig 1
Fig 1
The CONSORT style flow diagram showing exclusion criteria.
Fig 2
Fig 2
The relationship between intraoperative airway pressures and tidal volume. Scatterplots with smoothed regression line and 95% CI showing the relationship between several intraoperative ventilator variables and TV normalized by IBW. (a) Dynamic compliance, r=−0.006, P=0.31; (b) PIP, r=0.32, P<0.0001; (c) PEEP, r=0.033, P<0.0001.
Fig 3
Fig 3
The effect of intraoperative tidal volume on 30-day mortality. RCS curve showing the dose–response relationship between median TV per kg IBW and 30-day mortality. Dots show the 5th, 50th, and 95th percentiles of TV per kg IBW. The shaded area shows the 95% CI. The CI >0.00 indicates a significant association between TV per kg IBW <9.7 ml kg−1 and 30-day mortality.
See this image and copyright information in PMC

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