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

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  • Maria Bolther, From the *Department of Anesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore; †Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; and ‡Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, University of Copenhagen, Copenhagen, Denmark.
  • ,
  • Jeppe Henriksen, From the *Department of Anesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore; †Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; and ‡Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, University of Copenhagen, Copenhagen, Denmark.
  • ,
  • Mathias J Holmberg
  • Marie K Jessen
  • Frederik B Hansen
  • Johanne M Holst
  • Andreas Magnussen
  • ,
  • Niklas S Hansen, From the *Department of Anesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore; †Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; and ‡Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, University of Copenhagen, Copenhagen, Denmark.
  • ,
  • Cecilie M Johannsen
  • ,
  • Johannes Enevoldsen
  • Thomas H Jensen
  • Lara L Roessler, Clinical Cell Biology, Research Unit of Pathology, Department of Clinical Research, University of Southern Denmark and Department of Pathology, Odense University Hospital, Odense, Denmark; Department of Molecular Medicine, University of Southern Denmark, Odense, Denmark; Clinical Cell Biology, Vejle Hospital - Lillebælt Hospital, University of Southern Denmark, Vejle, Denmark; Department of Forensic Medicine, Aarhus University, Aarhus, Denmark. Electronic address: thomas.levin.andersen@rsyd.dk.
  • ,
  • Peter Carøe Lind
  • Maibritt P Klitholm, From the *Department of Anesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore; †Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; and ‡Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, University of Copenhagen, Copenhagen, Denmark.
  • ,
  • Mark A Eggertsen
  • ,
  • Philip Caap
  • Caroline Boye
  • ,
  • Karol M Dabrowski
  • Lasse Vormfenne, Translational Neuropsychiatry Unit, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Centre for Integrative Sequencing (iSEQ), Aarhus University, Aarhus, Denmark; The Lundbeck Foundation Initiative for Integrative Psychiatric Research, Aarhus University, Aarhus, Denmark; Department of Biomedicine, Aarhus University, Aarhus, Denmark; Psychiatric Department, Aarhus University Hospital, Aarhus, Denmark.
  • ,
  • Maria Høybye
  • Mathias Karlsson, Department of Nephrology, Aalborg Hospital, Aarhus University Hospital, Moelleparkvej 4, 9000 Aalborg, Denmark ; Center for Cardiovascular Research, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark.
  • ,
  • Ida R Balleby, Medical Department, The National Hospital of the Faroe Islands, Torshavn, Faroe Islands.
  • ,
  • Marie S Rasmussen, From the *Department of Anesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore; †Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; and ‡Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, University of Copenhagen, Copenhagen, Denmark., Department of Nephrology, Aalborg Hospital, Aarhus University Hospital, Moelleparkvej 4, 9000 Aalborg, Denmark ; Center for Cardiovascular Research, Aalborg Hospital, Aarhus University Hospital, Aalborg, Denmark.
  • ,
  • Kim Pælestik, From the *Department of Anesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore; †Department of Anesthesiology and Intensive Care Medicine, Aarhus University Hospital, Aarhus, Denmark; and ‡Department of Anesthesiology and Intensive Care Medicine, Zealand University Hospital, University of Copenhagen, Copenhagen, Denmark.
  • ,
  • Asger Granfeldt
  • Lars W Andersen

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.

OriginalsprogEngelsk
TidsskriftAnesthesia and Analgesia
ISSN0003-2999
DOI
StatusE-pub ahead of print - 15 jun. 2022

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