Comparison of Volume-Guaranteed or -Targeted, Pressure-Controlled Ventilation with Volume-Controlled Ventilation during Elective Surgery: A Systematic Review and Meta-Analysis

Volker Schick, Fabian Dusse, Ronny Eckardt, Steffen Kerkhoff, Simone Commotio, Jochen Hinkelbein, Alexander Mathes, Volker Schick, Fabian Dusse, Ronny Eckardt, Steffen Kerkhoff, Simone Commotio, Jochen Hinkelbein, Alexander Mathes

Abstract

For perioperative mechanical ventilation under general anesthesia, modern respirators aim at combining the benefits of pressure-controlled ventilation (PCV) and volume-controlled ventilation (VCV) in modes typically named "volume-guaranteed" or "volume-targeted" pressure-controlled ventilation (PCV-VG). This systematic review and meta-analysis tested the hypothesis that PCV-VG modes of ventilation could be beneficial in terms of improved airway pressures (Ppeak, Pplateau, Pmean), dynamic compliance (Cdyn), or arterial blood gases (PaO2, PaCO2) in adults undergoing elective surgery under general anesthesia. Three major medical electronic databases were searched with predefined search strategies and publications were systematically evaluated according to the Cochrane Review Methods. Continuous variables were tested for mean differences using the inverse variance method and 95% confidence intervals (CI) were calculated. Based on the assumption that intervention effects across studies were not identical, a random effects model was chosen. Assessment for heterogeneity was performed with the χ2 test and the I2 statistic. As primary endpoints, Ppeak, Pplateau, Pmean, Cdyn, PaO2, and PaCO2 were evaluated. Of the 725 publications identified, 17 finally met eligibility criteria, with a total of 929 patients recruited. Under supine two-lung ventilation, PCV-VG resulted in significantly reduced Ppeak (15 studies) and Pplateau (9 studies) as well as higher Cdyn (9 studies), compared with VCV [random effects models; Ppeak: CI -3.26 to -1.47; p < 0.001; I2 = 82%; Pplateau: -3.12 to -0.12; p = 0.03; I2 = 90%; Cdyn: CI 3.42 to 8.65; p < 0.001; I2 = 90%]. For one-lung ventilation (8 studies), PCV-VG allowed for significantly lower Ppeak and higher PaO2 compared with VCV. In Trendelenburg position (5 studies), this effect was significant for Ppeak only. This systematic review and meta-analysis demonstrates that volume-targeting, pressure-controlled ventilation modes may provide benefits with respect to the improved airway dynamics in two- and one-lung ventilation, and improved oxygenation in one-lung ventilation in adults undergoing elective surgery.

Keywords: PCV-VG; anesthesia; auto-flow; perioperative; pressure controlled ventilation; surgery; volume controlled ventilation; volume guarantee; volume target.

Conflict of interest statement

The authors declare no conflict of interest.

Figures

Figure 1
Figure 1
Flow chart of study selection.
Figure 2
Figure 2
Risk of bias traffic light plot.
Figure 3
Figure 3
Risk of bias summary plot.
Figure 4
Figure 4
Peak airway pressure (Ppeak): supine, two-lung ventilation. The green center of each square represents the weighted mean difference for individual trials, and the corresponding horizontal line stands for a 95% confidence interval. The diamonds represent pooled results.
Figure 5
Figure 5
Plateau airway pressure (Pplateau): supine, two-lung ventilation. The green center of each square represents the weighted mean difference for individual trials, and the corresponding horizontal line stands for a 95% confidence interval. The diamonds represent pooled results.
Figure 6
Figure 6
Mean airway pressure (Pmean): supine, two-lung ventilation. The green center of each square represents the weighted mean difference for individual trials, and the corresponding horizontal line stands for a 95% confidence interval. The diamonds represent pooled results.
Figure 7
Figure 7
Dynamic compliance (Cdyn): supine, two-lung ventilation. The green center of each square represents the weighted mean difference for individual trials, and the corresponding horizontal line stands for a 95% confidence interval. The diamonds represent pooled results.
Figure 8
Figure 8
Arterial oxygen pressure (PaO2): supine, two-lung ventilation. The green center of each square represents the weighted mean difference for individual trials, and the corresponding horizontal line stands for a 95% confidence interval. The diamonds represent pooled results.
Figure 9
Figure 9
Arterial carbon dioxide pressure (PaCO2): supine, two-lung ventilation. The green center of each square represents the weighted mean difference for individual trials, and the corresponding horizontal line stands for a 95% confidence interval. The diamonds represent pooled results.
Figure 10
Figure 10
Peak airway pressure (Ppeak): after 20–60 min of one-lung ventilation. The green center of each square represents the weighted mean difference for individual trials, and the corresponding horizontal line stands for a 95% confidence interval. The diamonds represent pooled results.
Figure 11
Figure 11
Arterial oxygen pressure (PaO2): after 20–60 min of one-lung ventilation. The green center of each square represents the weighted mean difference for individual trials, and the corresponding horizontal line stands for a 95% confidence interval. The diamonds represent pooled results.
Figure 12
Figure 12
Peak airway pressure (Ppeak): after 60 min of Trendelenburg position. The green center of each square represents the weighted mean difference for individual trials, and the corresponding horizontal line stands for a 95% confidence interval. The diamonds represent pooled results.

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