Intraoperative protective mechanical ventilation and risk of postoperative respiratory complications: hospital based registry study.
Intraoperative protective mechanical ventilation and risk of postoperative respiratory complications: hospital based registry study.
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DOI：
10.1136/bmj.h3646
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发表时间：
2015-07-14
期刊：
影响因子：
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通讯作者：
Eikermann M
中科院分区：
文献类型：
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作者：
Ladha K;Vidal Melo MF;McLean DJ;Wanderer JP;Grabitz SD;Kurth T;Eikermann M
目的 评估术中保护性通气对主要术后呼吸系统并发症的影响，并确定不会增加术后呼吸系统并发症风险的安全术中机械呼吸机设置。设计基于医院的登记研究。在美国马萨诸塞州设有学术三级护理医院和两家附属社区医院。参与者 69~265 名连续入组的 18 岁以上患者，他们在 2007 年 1 月至 2014 年 8 月期间接受了非心脏外科手术，需要气管插管全身麻醉。干预措施 保护性通气，定义为中位呼气末正压 (PEEP) 为 5 cmH2O 或以上，中位潮气量小于 10 mL/kg 预计体重，中位平台压小于 30 cmH2O。主要结局指标 主要呼吸系统并发症的综合结局，包括肺水肿、呼吸衰竭、肺炎和重新插管。结果 69~265 例入组患者中，术中 34~800 例（50.2%）接受保护性通气，34~465 例（49.8%）接受非保护性通气。多变量回归显示，保护性通气与术后呼吸系统并发症风险降低相关（调整后优势比 0.90，95% 置信区间 0.82 至 0.98，P=0.013）。倾向评分匹配队列的结果相似（比值比 0.89，95% 置信区间 0.83 至 0.97，P=0.004）。 5 cmH2O 的 PEEP 和 16 cmH2O 或更低的中位平台压与术后呼吸系统并发症的风险最低相关。结论 术中保护性通气与术后呼吸系统并发症风险降低相关。 5 cmH2O 的 PEEP 和 16 cmH2O 或更低的平台压被确定为保护性机械呼吸机设置。这些发现表明，与急性肺损伤患者相比，正常肺部患者术中通气的保护阈值有所不同。
Objective To evaluate the effects of intraoperative protective ventilation on major postoperative respiratory complications and to define safe intraoperative mechanical ventilator settings that do not translate into an increased risk of postoperative respiratory complications. Design Hospital based registry study. Setting Academic tertiary care hospital and two affiliated community hospitals in Massachusetts, United States. Participants 69 265 consecutively enrolled patients over the age of 18 who underwent a non-cardiac surgical procedure between January 2007 and August 2014 and required general anesthesia with endotracheal intubation. Interventions Protective ventilation, defined as a median positive end expiratory pressure (PEEP) of 5 cmH2O or more, a median tidal volume of less than 10 mL/kg of predicted body weight, and a median plateau pressure of less than 30 cmH2O. Main outcome measure Composite outcome of major respiratory complications, including pulmonary edema, respiratory failure, pneumonia, and re-intubation. Results Of the 69 265 enrolled patients 34 800 (50.2%) received protective ventilation and 34 465 (49.8%) received non-protective ventilation intraoperatively. Protective ventilation was associated with a decreased risk of postoperative respiratory complications in multivariable regression (adjusted odds ratio 0.90, 95% confidence interval 0.82 to 0.98, P=0.013). The results were similar in the propensity score matched cohort (odds ratio 0.89, 95% confidence interval 0.83 to 0.97, P=0.004). A PEEP of 5 cmH2O and median plateau pressures of 16 cmH2O or less were associated with the lowest risk of postoperative respiratory complications. Conclusions Intraoperative protective ventilation was associated with a decreased risk of postoperative respiratory complications. A PEEP of 5 cmH2O and a plateau pressure of 16 cmH2O or less were identified as protective mechanical ventilator settings. These findings suggest that protective thresholds differ for intraoperative ventilation in patients with normal lungs compared with those used for patients with acute lung injury.