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Meta-Analysis
. 2023 Dec;131(6):1093-1101.
doi: 10.1016/j.bja.2023.09.011. Epub 2023 Oct 14.

Impact of ventilation strategies on pulmonary and cardiovascular complications in patients undergoing general anaesthesia for elective surgery: a systematic review and meta-analysis

Pasquale Buonanno  1 , Annachiara Marra  2 , Carmine Iacovazzo  2 , Maria Vargas  2 , Antonio Coviello  2 , Francesco Squillacioti  2 , Serena Nappi  2 , Andrea Uriel de Siena  2 , Giuseppe Servillo  2
Affiliations
Meta-Analysis

Impact of ventilation strategies on pulmonary and cardiovascular complications in patients undergoing general anaesthesia for elective surgery: a systematic review and meta-analysis

Pasquale Buonanno et al. Br J Anaesth. 2023 Dec.

Abstract

Background: Many RCTs have evaluated the influence of intraoperative tidal volume (tV), PEEP, and driving pressure on the occurrence of postoperative pulmonary complications, cardiovascular complications, and mortality in adult patients. Our meta-analysis aimed to investigate the association between tV, PEEP, and driving pressure and the above-mentioned outcomes.

Methods: We conducted a systematic review and meta-analysis of RCTs from inception to May 19, 2022. The primary outcome was the incidence of postoperative pulmonary complications; the secondary outcomes were intraoperative cardiovascular complications and 30-day mortality. Primary and secondary outcomes were evaluated stratifying patients in the following groups: (1) low tV (LV, tV 6-8 ml kg-1 and PEEP ≥5 cm H2O) vs high tV (HV, tV >8 ml kg-1 and PEEP=0 cm H2O); (2) higher PEEP (HP, ≥6 cm H2O) vs lower PEEP (LP, <6 cm H2O); and (3) driving pressure-guided PEEP (DP) vs fixed PEEP (FP).

Results: We included 16 RCTs with a total sample size of 4993. The incidence of postoperative pulmonary complications was lower in patients treated with LV than with HV (OR=0.402, CI 0.280-0.577, P<0.001) and lower in DP than in FP group (OR=0.358, CI 0.187-0.684, P=0.002). Postoperative pulmonary complications did not differ between HP and LP groups; the incidence of intraoperative cardiovascular complications was higher in HP group (OR=1.385, CI 1.027-1.867, P=0.002). The 30-day mortality was not influenced by the ventilation strategy.

Conclusions: Optimal intraoperative mechanical ventilation is unclear; however, our meta-analysis showed that low tidal volume and driving pressure-guided PEEP strategies were associated with a reduction in postoperative pulmonary complications.

Keywords: driving pressure; general anaesthesia; positive end-expiratory pressure; postoperative pulmonary complications; ventilation strategy.

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Conflict of interest statement

The authors declare that they have no conflicts of interest.

Figures

Fig 1
Fig 1
PRISMA flowchart.
Fig 2
Fig 2
Risk of bias assessment. HP: higher positive end-expiratory pressure (PEEP); LP: lower PEEP; PPCs: postoperative pulmonary complications; CVCs: cardiovascular complications; M: mortality; LV: low tidal volume (tV) ventilation; HV: high tV ventilation; DP: driving pressure-guided PEEP; FP: fixed PEEP.
Fig 3
Fig 3
Postoperative pulmonary complications among the different ventilation strategies. (a) Comparison between low tidal volume (LV) and high tidal volume (HV) strategies. (b) Comparison between higher PEEP (HP) and lower PEEP (LP) strategies. (c) Comparison between driving pressure-guided PEEP (DP) and fixed PEEP (FP) strategies.
Fig 4
Fig 4
Cardiovascular complications among the different ventilation strategies. (a) Comparison between low tidal volume (LV) and high tidal volume (HV) strategies. (b) Comparison between higher PEEP (HP) and lower PEEP (LP) strategies. (c) Comparison between driving pressure-guided PEEP (DP) and fixed PEEP (FP) strategies.
Fig 5
Fig 5
Mortality among the different ventilation strategies. (a) Comparison between low tidal volume (LV) and high tidal volume (HV) strategies. (b) Comparison between higher PEEP (HP) and lower PEEP (LP) strategies. (c) Comparison between driving pressure-guided PEEP (DP) and fixed PEEP (FP) strategies.
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