Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India.
Department of GI Surgery & Liver Transplantation, All India Institute of Medical Sciences, New Delhi, India.
Surgery. 2021 Jul;170(1):277-283. doi: 10.1016/j.surg.2021.01.047. Epub 2021 Mar 24.
As respiratory system compliances are heterogenous, we hypothesized that individualized intraoperative positive end-expiratory pressure titration on the basis of lowest driving pressure can reduce postoperative atelectasis and improve intraoperative oxygenation and postoperative lung functions.
Eighty-two adult patients undergoing major abdominal surgery were recruited in this randomized trial. In the titrated positive end-expiratory pressure group, positive end-expiratory pressure was titrated incrementally until lowest driving pressure was achieved, and the same procedure was repeated in every 2 hours. In the fixed positive end-expiratory pressure group, a positive end-expiratory pressure of 5 cmHO was used throughout the surgery. The primary objective of this study was lung ultrasound score noted at the completion of surgery and 5 minutes after extubation at 12 lung areas bilaterally.
Mean (standard deviation) age of the recruited patients were 43.8 (17.3) years, and 50% of all patients (41 of 82) were women. Lung ultrasound aeration scores were significantly higher in the fixed positive end-expiratory pressure group both before and after extubation (median [interquartile range] 7 [5-8] vs 4 [2-6] before extubation and 8 [6-9] vs 5 [3-7] after extubation; P = .0004 and P = .0011, respectively). Incidence of postoperative pulmonary complications was significantly lower in the titrated positive end-expiratory pressure group (absolute risk difference [95% CI] 17.1% [32.5%-1.7%]; P = .034). The number of patients requiring postoperative supplemental oxygen therapy to maintain SpO >95%, the requirement of intraoperative rescue therapy, and the duration of hospital stay were similar in both of the groups.
Intraoperative titrated positive end-expiratory pressure reduced postoperative lung atelectasis in adult patients undergoing major abdominal surgery. Further large clinical trials are required to know its effect on postoperative pulmonary complications.
由于呼吸系统顺应性存在异质性，我们假设基于最低驱动压的个体化术中呼气末正压滴定可以减少术后肺不张，并改善术中氧合和术后肺功能。
本随机试验纳入了 82 例接受大型腹部手术的成年患者。在滴定呼气末正压组中，逐渐增加呼气末正压直至达到最低驱动压，每 2 小时重复此过程。在固定呼气末正压组中，整个手术过程中使用 5cmH2O 的呼气末正压。本研究的主要观察终点为双侧 12 个肺区术中完成时和拔管后 5 分钟的肺超声评分。
入选患者的平均（标准差）年龄为 43.8（17.3）岁，所有患者中有 50%（41/82）为女性。固定呼气末正压组患者在拔管前（中位数[四分位距] 7 [5-8] vs 4 [2-6]）和拔管后（8 [6-9] vs 5 [3-7]）的肺超声充气评分均显著更高（P<0.0004 和 P=0.0011）。滴定呼气末正压组患者术后肺部并发症的发生率显著更低（绝对风险差异[95%CI] 17.1% [32.5%-1.7%]；P=0.034）。两组患者术后需要补充氧疗以维持 SpO2>95%、需要术中抢救治疗以及住院时间的差异无统计学意义。
在接受大型腹部手术的成年患者中，术中滴定呼气末正压可减少术后肺不张。需要进一步开展大型临床试验来明确其对术后肺部并发症的影响。
