Individualized PEEP to optimise respiratory mechanics during abdominal surgery: a pilot randomised controlled trial

Ana Fernandez-Bustamante, Juraj Sprung, Robert A Parker, Karsten Bartels, Toby N Weingarten, Carolina Kosour, B Taylor Thompson, Marcos F Vidal Melo, Ana Fernandez-Bustamante, Juraj Sprung, Robert A Parker, Karsten Bartels, Toby N Weingarten, Carolina Kosour, B Taylor Thompson, Marcos F Vidal Melo

Abstract

Background: Higher intraoperative driving pressures (ΔP) are associated with increased postoperative pulmonary complications (PPC). We hypothesised that dynamic adjustment of PEEP throughout abdominal surgery reduces ΔP, maintains positive end-expiratory transpulmonary pressures (Ptp_ee) and increases respiratory system static compliance (Crs) with PEEP levels that are variable between and within patients.

Methods: In a prospective multicentre pilot study, adults at moderate/high risk for PPC undergoing elective abdominal surgery were randomised to one of three ventilation protocols: (1) PEEP≤2 cm H2O, compared with periodic recruitment manoeuvres followed by individualised PEEP to either optimise respiratory system compliance (PEEPmaxCrs) or maintain positive end-expiratory transpulmonary pressure (PEEPPtp_ee). The composite primary outcome included intraoperative ΔP, Ptp_ee, Crs, and PEEP values (median (interquartile range) and coefficients of variation [CVPEEP]).

Results: Thirty-seven patients (48.6% female; age range: 47-73 yr) were assigned to control (PEEP≤2 cm H2O; n=13), PEEPmaxCrs (n=16), or PEEPPtp_ee (n=8) groups. The PEEPPtp_ee intervention could not be delivered in two patients. Subjects assigned to PEEPmaxCrs had lower ΔP (median8 cm H2O [7-10]), compared with the control group (12 cm H2O [10-15]; P=0.006). PEEPmaxCrs was also associated with higher Ptp_ee (2.0 cm H2O [-0.7 to 4.5] vs controls: -8.3 cm H2O [-13.0 to -4.0]; P≤0.001) and higher Crs (47.7 ml cm H2O [43.2-68.8] vs controls: 39.0 ml cm H2O [32.9-43.4]; P=0.009). Individualised PEEP (PEEPmaxCrs and PEEPPtp_ee combined) varied widely (median: 10 cm H2O [8-15]; CVPEEP=0.24 [0.14-0.35]), both between, and within, subjects throughout surgery.

Conclusions: This pilot study suggests that individualised PEEP management strategies applied during abdominal surgery reduce driving pressure, maintain positive Ptp_ee and increase static compliance. The wide range of PEEP observed suggests that an individualised approach is required to optimise respiratory mechanics during abdominal surgery.

Clinical trial registration: NCT02671721.

Keywords: lung compliance; mechanical ventilation; positive end-expiratory pressure; postoperative pulmonary complications; respiratory mechanics; ventilator-induced lung injury.

Copyright © 2020 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.

Figures

Fig 1
Fig 1
CONSORT flow diagram.
Fig 2
Fig 2
PEEP variability. (a) Variability of median PEEP levels between patients receiving a constant PEEP ≤2 cm H2O (control) or individualised PEEP (PEEPmaxCrs or PEEPPtp_ee); and (b) variability of PEEP levels within patients throughout surgery measured by the PEEP coefficient of variation (CVPEEP) for all PEEP levels used for each individual. (∗∗P≤0.01667 in post hoc comparison of respective group compared with control).
Fig 3
Fig 3
Intraoperative respiratory parameters in a subgroup of subjects with end-inspiratory Pes measurements. (a) Driving pressure. (b) Transpulmonary driving pressure. (c) End-inspiratory transpulmonary driving pressure. (d) End-expiratory transpulmonary driving pressure. (e) Respiratory system elastance (ERS). (f) Lung elastance (EL). (g) Correlation between driving pressure and transpulmonary driving pressure. (h) Correlation between respiratory system elastance (Ers) and lung elastance (EL). (Boxplots represent median (Q1, Q3); error bars represent minimum and maximum values; full dots identify outlier values. Results of post hoc comparisons are shown if significant differences observed between the three groups: for post hoc comparisons, P≤0.01667 (=0.05/3) statistically significant. However, we also indicate for completeness all two-group comparisons where 0.01667<P<0.05 as these would be considered significant if we had not adjusted for multiple comparisons. ∗P-value 0.01667<P<0.05 compared with control; ˆP-value 0.01667<P<0.05 PEEPPtp_eevs PEEPmaxCrs ∗∗P≤0.01667 compared with control; ˆˆP≤0.01667 PEEPPtp_eevs PEEPmaxCrs.).
Fig 4
Fig 4
Plasma concentrations of biomarkers of lung injury. Ratios of plasma concentrations of biomarkers of: epithelial injury (club cell protein-16 [CC16] and soluble form of the receptor for advanced glycation end-products [sRAGE]) (a–d); endothelial injury (angiopoietin-2 [Ang-2]) (e–f); inflammation (interleukin [IL]-6 and IL-8) (g–h); and endothelial-derived coagulation activation (plasminogen activator inhibitor-1 [PAI-1]) (i–j) at the end of (Tend) and after 24 h (T24) compared with baseline (T0). (Boxplots represent median (Q1, Q3); error bars represent minimum and maximum values; full dots identify outlier values. Results of post hoc comparisons are shown if significant differences observed between the three groups: for post hoc comparisons, P-values≤ 0.01667 (=0.05/3) statistically significant. However, we also indicate for completeness all two-group comparisons where 0.01667<P<0.05 as these would be considered significant if we had not adjusted for multiple comparisons. ∗P-value 0.01667<P<0.05 compared with control; ˆP-value 0.01667<P<0.05 PEEPPtp_eevs PEEPmaxCrs; ∗∗P≤0.01667 compared with control; ˆˆP≤0.01667 PEEPPtp_eevs PEEPmaxCrs.).

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