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- Title
Effect of Intensive vs Moderate Alveolar Recruitment Strategies Added to Lung-Protective Ventilation on Postoperative Pulmonary Complications: A Randomized Clinical Trial.
- Authors
Costa Leme, Alcino; Tizue Fukushima, Julia; Osawa, Eduardo A.; de Almeida, Juliano Pinheiro; Gerent, Aline Muller; Alves Franco, Rafael; Zanetti Feltrim, Maria Ignez; Nozawa, Emília; de Moraes Coimbra, Vera Regina; de Moraes Ianotti, Rafael; Hashizume, Clarice Shiguemi; Kalil Filho, Roberto; Costa Auler Jr., Jose Otavio; Gomes Galas, Filomena Regina Barbosa; Volpe, Marcia S.; Hajjar, Ludhmila Abrahao; Jatene, Fabio Biscegli; De Santis Santiago, Roberta Ribeiro; Passos Amato, Marcelo Britto; Fukushima, Julia Tizue
- Abstract
<bold>Importance: </bold>Perioperative lung-protective ventilation has been recommended to reduce pulmonary complications after cardiac surgery. The protective role of a small tidal volume (VT) has been established, whereas the added protection afforded by alveolar recruiting strategies remains controversial.<bold>Objective: </bold>To determine whether an intensive alveolar recruitment strategy could reduce postoperative pulmonary complications, when added to a protective ventilation with small VT.<bold>Design, Setting, and Participants: </bold>Randomized clinical trial of patients with hypoxemia after cardiac surgery at a single ICU in Brazil (December 2011-2014).<bold>Interventions: </bold>Intensive recruitment strategy (n=157) or moderate recruitment strategy (n=163) plus protective ventilation with small VT.<bold>Main Outcomes and Measures: </bold>Severity of postoperative pulmonary complications computed until hospital discharge, analyzed with a common odds ratio (OR) to detect ordinal shift in distribution of pulmonary complication severity score (0-to-5 scale, 0, no complications; 5, death). Prespecified secondary outcomes were length of stay in the ICU and hospital, incidence of barotrauma, and hospital mortality.<bold>Results: </bold>All 320 patients (median age, 62 years; IQR, 56-69 years; 125 women [39%]) completed the trial. The intensive recruitment strategy group had a mean 1.8 (95% CI, 1.7 to 2.0) and a median 1.7 (IQR, 1.0-2.0) pulmonary complications score vs 2.1 (95% CI, 2.0-2.3) and 2.0 (IQR, 1.5-3.0) for the moderate strategy group. Overall, the distribution of primary outcome scores shifted consistently in favor of the intensive strategy, with a common OR for lower scores of 1.86 (95% CI, 1.22 to 2.83; P = .003). The mean hospital stay for the moderate group was 12.4 days vs 10.9 days in the intensive group (absolute difference, -1.5 days; 95% CI, -3.1 to -0.3; P = .04). The mean ICU stay for the moderate group was 4.8 days vs 3.8 days for the intensive group (absolute difference, -1.0 days; 95% CI, -1.6 to -0.2; P = .01). Hospital mortality (2.5% in the intensive group vs 4.9% in the moderate group; absolute difference, -2.4%, 95% CI, -7.1% to 2.2%) and barotrauma incidence (0% in the intensive group vs 0.6% in the moderate group; absolute difference, -0.6%; 95% CI, -1.8% to 0.6%; P = .51) did not differ significantly between groups.<bold>Conclusions and Relevance: </bold>Among patients with hypoxemia after cardiac surgery, the use of an intensive vs a moderate alveolar recruitment strategy resulted in less severe pulmonary complications while in the hospital.<bold>Trial Registration: </bold>clinicaltrials.gov Identifier: NCT01502332.
- Subjects
ALVEOLAR process; PULMONARY ventilation-perfusion scans; PERIOPERATIVE care; CARDIAC surgery; CLINICAL trials; HYPOXEMIA; LUNG disease prevention; PULMONARY alveoli; PREVENTION of surgical complications; TREATMENT of surgical complications; ARTIFICIAL respiration; BLOOD pressure; COMPARATIVE studies; CRITICAL care medicine; DECOMPRESSION sickness; HEART beat; LENGTH of stay in hospitals; RESEARCH methodology; MEDICAL cooperation; OXYGEN therapy; RESEARCH; RESPIRATORY measurements; STATISTICAL sampling; EVALUATION research; RANDOMIZED controlled trials; DISEASE incidence; SEVERITY of illness index; HOSPITAL mortality; POSITIVE end-expiratory pressure; PARTIAL pressure; ODDS ratio; PHYSIOLOGY
- Publication
JAMA: Journal of the American Medical Association, 2017, Vol 317, Issue 14, p1422
- ISSN
0098-7484
- Publication type
journal article
- DOI
10.1001/jama.2017.2297