Ventilation Strategies During General Anesthesia for Noncardiac Surgery: A Systematic Review and Meta-Analysis

Maria Bolther; Jeppe Henriksen; Mathias J Holmberg; Marie K Jessen; Mikael Valentin; Frederik B Hansen; Johanne M Holst; Andreas Magnussen; Niklas S Hansen; Cecilie M Johannsen; Johannes Enevoldsen; Thomas H Jensen; Lara L Roessler; Peter Carøe Lind; Maibritt P Klitholm; Mark A Eggertsen; Philip Caap; Caroline Boye; Karol M Dabrowski; Lasse Vormfenne; Maria Høybye; Mathias Karlsson; Ida R Balleby; Marie S Rasmussen; Kim Pælestik; Asger Granfeldt; Lars W Andersen

doi:10.1213/ANE.0000000000006106

Ventilation Strategies During General Anesthesia for Noncardiac Surgery: A Systematic Review and Meta-Analysis

Maria Bolther, Jeppe Henriksen, Mathias J Holmberg, Marie K Jessen, Mikael Valentin, Frederik B Hansen, Johanne M Holst, Andreas Magnussen, Niklas S Hansen, Cecilie M Johannsen, Johannes Enevoldsen, Thomas H Jensen, Lara L Roessler, Peter Carøe Lind, Maibritt P Klitholm, Mark A Eggertsen, Philip Caap, Caroline Boye, Karol M Dabrowski, Lasse VormfenneMaria Høybye, Mathias Karlsson, Ida R Balleby, Marie S Rasmussen, Kim Pælestik, Asger Granfeldt, Lars W Andersen^*

^*Corresponding author af dette arbejde

Publikation: Bidrag til tidsskrift/Konferencebidrag i tidsskrift /Bidrag til avis › Review › Forskning › peer review

Abstract

BACKGROUND: The optimal ventilation strategy during general anesthesia is unclear. This systematic review investigated the relationship between ventilation targets or strategies (eg, positive end-expiratory pressure [PEEP], tidal volume, and recruitment maneuvers) and postoperative outcomes.

METHODS: PubMed and Embase were searched on March 8, 2021, for randomized trials investigating the effect of different respiratory targets or strategies on adults undergoing noncardiac surgery. Two investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Meta-analyses were performed for relevant outcomes, and several subgroup analyses were conducted. The certainty of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE).

RESULTS: This review included 63 trials with 65 comparisons. Risk of bias was intermediate for all trials. In the meta-analyses, lung-protective ventilation (ie, low tidal volume with PEEP) reduced the risk of combined pulmonary complications (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.28-0.49; 9 trials; 1106 patients), atelectasis (OR, 0.39; 95% CI, 0.25-0.60; 8 trials; 895 patients), and need for postoperative mechanical ventilation (OR, 0.36; 95% CI, 0.13-1.00; 5 trials; 636 patients). Recruitment maneuvers reduced the risk of atelectasis (OR, 0.44; 95% CI, 0.21-0.92; 5 trials; 328 patients). We found no clear effect of tidal volume, higher versus lower PEEP, or recruitment maneuvers on postoperative pulmonary complications when evaluated individually. For all comparisons across targets, no effect was found on mortality or hospital length of stay. No effect measure modifiers were found in subgroup analyses. The certainty of evidence was rated as very low, low, or moderate depending on the intervention and outcome.

CONCLUSIONS: Although lung-protective ventilation results in a decrease in pulmonary complications, randomized clinical trials provide only limited evidence to guide specific ventilation strategies during general anesthesia for adults undergoing noncardiac surgery.

Originalsprog	Engelsk
Tidsskrift	Anesthesia and Analgesia
Vol/bind	135
Nummer	5
Sider (fra-til)	971-985
Antal sider	15
ISSN	0003-2999
DOI	https://doi.org/10.1213/ANE.0000000000006106
Status	Udgivet - nov. 2022

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Bolther, M., Henriksen, J., Holmberg, M. J., Jessen, M. K., Valentin, M., Hansen, F. B., Holst, J. M., Magnussen, A., Hansen, N. S., Johannsen, C. M., Enevoldsen, J., Jensen, T. H., Roessler, L. L., Carøe Lind, P., Klitholm, M. P., Eggertsen, M. A., Caap, P., Boye, C., Dabrowski, K. M., ... Andersen, L. W. (2022). Ventilation Strategies During General Anesthesia for Noncardiac Surgery: A Systematic Review and Meta-Analysis. Anesthesia and Analgesia, 135(5), 971-985. https://doi.org/10.1213/ANE.0000000000006106

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title = "Ventilation Strategies During General Anesthesia for Noncardiac Surgery: A Systematic Review and Meta-Analysis",

abstract = "BACKGROUND: The optimal ventilation strategy during general anesthesia is unclear. This systematic review investigated the relationship between ventilation targets or strategies (eg, positive end-expiratory pressure [PEEP], tidal volume, and recruitment maneuvers) and postoperative outcomes.METHODS: PubMed and Embase were searched on March 8, 2021, for randomized trials investigating the effect of different respiratory targets or strategies on adults undergoing noncardiac surgery. Two investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Meta-analyses were performed for relevant outcomes, and several subgroup analyses were conducted. The certainty of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE).RESULTS: This review included 63 trials with 65 comparisons. Risk of bias was intermediate for all trials. In the meta-analyses, lung-protective ventilation (ie, low tidal volume with PEEP) reduced the risk of combined pulmonary complications (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.28-0.49; 9 trials; 1106 patients), atelectasis (OR, 0.39; 95% CI, 0.25-0.60; 8 trials; 895 patients), and need for postoperative mechanical ventilation (OR, 0.36; 95% CI, 0.13-1.00; 5 trials; 636 patients). Recruitment maneuvers reduced the risk of atelectasis (OR, 0.44; 95% CI, 0.21-0.92; 5 trials; 328 patients). We found no clear effect of tidal volume, higher versus lower PEEP, or recruitment maneuvers on postoperative pulmonary complications when evaluated individually. For all comparisons across targets, no effect was found on mortality or hospital length of stay. No effect measure modifiers were found in subgroup analyses. The certainty of evidence was rated as very low, low, or moderate depending on the intervention and outcome.CONCLUSIONS: Although lung-protective ventilation results in a decrease in pulmonary complications, randomized clinical trials provide only limited evidence to guide specific ventilation strategies during general anesthesia for adults undergoing noncardiac surgery.",

keywords = "Adult, Anesthesia, General/adverse effects, Humans, Lung, Positive-Pressure Respiration/adverse effects, Postoperative Complications/etiology, Pulmonary Atelectasis/etiology, Tidal Volume",

author = "Maria Bolther and Jeppe Henriksen and Holmberg, {Mathias J} and Jessen, {Marie K} and Mikael Valentin and Hansen, {Frederik B} and Holst, {Johanne M} and Andreas Magnussen and Hansen, {Niklas S} and Johannsen, {Cecilie M} and Johannes Enevoldsen and Jensen, {Thomas H} and Roessler, {Lara L} and {Car{\o}e Lind}, Peter and Klitholm, {Maibritt P} and Eggertsen, {Mark A} and Philip Caap and Caroline Boye and Dabrowski, {Karol M} and Lasse Vormfenne and Maria H{\o}ybye and Mathias Karlsson and Balleby, {Ida R} and Rasmussen, {Marie S} and Kim P{\ae}lestik and Asger Granfeldt and Andersen, {Lars W}",

year = "2022",

month = nov,

doi = "10.1213/ANE.0000000000006106",

language = "English",

volume = "135",

pages = "971--985",

journal = "Anesthesia and Analgesia",

issn = "0003-2999",

publisher = "LIPPINCOTT WILLIAMS & WILKINS",

number = "5",

}

Bolther, M, Henriksen, J, Holmberg, MJ , Jessen, MK , Valentin, M , Hansen, FB, Holst, JM, Magnussen, A, Hansen, NS, Johannsen, CM, Enevoldsen, J, Jensen, TH, Roessler, LL, Carøe Lind, P, Klitholm, MP, Eggertsen, MA, Caap, P, Boye, C, Dabrowski, KM, Vormfenne, L, Høybye, M, Karlsson, M, Balleby, IR, Rasmussen, MS, Pælestik, K, Granfeldt, A & Andersen, LW 2022, 'Ventilation Strategies During General Anesthesia for Noncardiac Surgery: A Systematic Review and Meta-Analysis', Anesthesia and Analgesia, bind 135, nr. 5, s. 971-985. https://doi.org/10.1213/ANE.0000000000006106

TY - JOUR

T1 - Ventilation Strategies During General Anesthesia for Noncardiac Surgery

T2 - A Systematic Review and Meta-Analysis

AU - Bolther, Maria

AU - Henriksen, Jeppe

AU - Holmberg, Mathias J

AU - Jessen, Marie K

AU - Valentin, Mikael

AU - Hansen, Frederik B

AU - Holst, Johanne M

AU - Magnussen, Andreas

AU - Hansen, Niklas S

AU - Johannsen, Cecilie M

AU - Enevoldsen, Johannes

AU - Jensen, Thomas H

AU - Roessler, Lara L

AU - Carøe Lind, Peter

AU - Klitholm, Maibritt P

AU - Eggertsen, Mark A

AU - Caap, Philip

AU - Boye, Caroline

AU - Dabrowski, Karol M

AU - Vormfenne, Lasse

AU - Høybye, Maria

AU - Karlsson, Mathias

AU - Balleby, Ida R

AU - Rasmussen, Marie S

AU - Pælestik, Kim

AU - Granfeldt, Asger

AU - Andersen, Lars W

PY - 2022/11

Y1 - 2022/11

N2 - BACKGROUND: The optimal ventilation strategy during general anesthesia is unclear. This systematic review investigated the relationship between ventilation targets or strategies (eg, positive end-expiratory pressure [PEEP], tidal volume, and recruitment maneuvers) and postoperative outcomes.METHODS: PubMed and Embase were searched on March 8, 2021, for randomized trials investigating the effect of different respiratory targets or strategies on adults undergoing noncardiac surgery. Two investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Meta-analyses were performed for relevant outcomes, and several subgroup analyses were conducted. The certainty of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE).RESULTS: This review included 63 trials with 65 comparisons. Risk of bias was intermediate for all trials. In the meta-analyses, lung-protective ventilation (ie, low tidal volume with PEEP) reduced the risk of combined pulmonary complications (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.28-0.49; 9 trials; 1106 patients), atelectasis (OR, 0.39; 95% CI, 0.25-0.60; 8 trials; 895 patients), and need for postoperative mechanical ventilation (OR, 0.36; 95% CI, 0.13-1.00; 5 trials; 636 patients). Recruitment maneuvers reduced the risk of atelectasis (OR, 0.44; 95% CI, 0.21-0.92; 5 trials; 328 patients). We found no clear effect of tidal volume, higher versus lower PEEP, or recruitment maneuvers on postoperative pulmonary complications when evaluated individually. For all comparisons across targets, no effect was found on mortality or hospital length of stay. No effect measure modifiers were found in subgroup analyses. The certainty of evidence was rated as very low, low, or moderate depending on the intervention and outcome.CONCLUSIONS: Although lung-protective ventilation results in a decrease in pulmonary complications, randomized clinical trials provide only limited evidence to guide specific ventilation strategies during general anesthesia for adults undergoing noncardiac surgery.

AB - BACKGROUND: The optimal ventilation strategy during general anesthesia is unclear. This systematic review investigated the relationship between ventilation targets or strategies (eg, positive end-expiratory pressure [PEEP], tidal volume, and recruitment maneuvers) and postoperative outcomes.METHODS: PubMed and Embase were searched on March 8, 2021, for randomized trials investigating the effect of different respiratory targets or strategies on adults undergoing noncardiac surgery. Two investigators reviewed trials for relevance, extracted data, and assessed risk of bias. Meta-analyses were performed for relevant outcomes, and several subgroup analyses were conducted. The certainty of evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation (GRADE).RESULTS: This review included 63 trials with 65 comparisons. Risk of bias was intermediate for all trials. In the meta-analyses, lung-protective ventilation (ie, low tidal volume with PEEP) reduced the risk of combined pulmonary complications (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.28-0.49; 9 trials; 1106 patients), atelectasis (OR, 0.39; 95% CI, 0.25-0.60; 8 trials; 895 patients), and need for postoperative mechanical ventilation (OR, 0.36; 95% CI, 0.13-1.00; 5 trials; 636 patients). Recruitment maneuvers reduced the risk of atelectasis (OR, 0.44; 95% CI, 0.21-0.92; 5 trials; 328 patients). We found no clear effect of tidal volume, higher versus lower PEEP, or recruitment maneuvers on postoperative pulmonary complications when evaluated individually. For all comparisons across targets, no effect was found on mortality or hospital length of stay. No effect measure modifiers were found in subgroup analyses. The certainty of evidence was rated as very low, low, or moderate depending on the intervention and outcome.CONCLUSIONS: Although lung-protective ventilation results in a decrease in pulmonary complications, randomized clinical trials provide only limited evidence to guide specific ventilation strategies during general anesthesia for adults undergoing noncardiac surgery.

KW - Adult

KW - Anesthesia, General/adverse effects

KW - Humans

KW - Lung

KW - Positive-Pressure Respiration/adverse effects

KW - Postoperative Complications/etiology

KW - Pulmonary Atelectasis/etiology

KW - Tidal Volume

UR - http://www.scopus.com/inward/record.url?scp=85136530233&partnerID=8YFLogxK

U2 - 10.1213/ANE.0000000000006106

DO - 10.1213/ANE.0000000000006106

M3 - Review

C2 - 35703253

SN - 0003-2999

VL - 135

SP - 971

EP - 985

JO - Anesthesia and Analgesia

JF - Anesthesia and Analgesia

IS - 5

ER -

Ventilation Strategies During General Anesthesia for Noncardiac Surgery: A Systematic Review and Meta-Analysis

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