1. Effect of Intraoperative High Positive End-Expiratory Pressure (PEEP) with Recruitment Maneuvers vs Low PEEP on Postoperative Pulmonary Complications in Obese Patients: A Randomized Clinical Trial
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Bluth, T, Neto, As, Schultz, Mj, Pelosi, P, de Abreu MG, Bobek, I, Canet, Jc, de Baerdemaeker, L, Gregoretti, C, Hedenstierna, G, Hemmes, Snt, Hiesmayr, M, Hollmann, M, Jaber, S, Laffey, J, Licker, Mj, Markstaller, K, Matot, I, Mills, G, Mulier, Jp, Putensen, C, Rossaint, R, Schmitt, J, Senturk, M, Severgnini, P, Sprung, J, Melo, Mfv, Wrigge, H, Abelha, F, Abitagaoglu, S, Achilles, M, Adebesin, A, Adriaensens, I, Ahene, C, Akbar, F, Al Harbi, M, al Kallab RA, Albanel, X, Aldenkortt, F, Alfouzan, Ras, Alruqaie, R, Altermatt, F, Araujo, Bld, Arbesu, G, Artsi, H, Aurilio, C, Ayanoglu, Oh, Bacuzzi, A, Baig, H, Baird, Y, Balonov, K, Balust, J, Banks, S, Bao, Xd, Baumgartner, M, Tortosa, Ib, Bergamaschi, A, Bergmann, L, Bigatello, L, Perez, Eb, Birr, K, Bojaxhi, E, Bonenti, C, Bonney, I, Bos, Ee, Bowman, S, Braz, Lg, Brugnoni, E, Brunetti, I, Bruni, A, Buenvenida, Sl, Camerini, Cj, Canet, J, Capatti, B, Carmona, J, Carungcong, J, Carvalho, M, Cattan, A, Cavaleiro, C, Chiumello, D, Ciardo, S, Coburn, M, Colella, U, Contreras, V, Dincer, Pc, Cotter, E, Crovetto, M, Crovetto, W, Darrah, W, Davies, S, De Hert, S, Peces, Ed, Delphin, E, Diaper, J, do Nascimento, P, Donatiello, V, Dong, J, Dourado, Md, Dullenkopf, A, Ebner, F, Elgendy, H, Ellenberger, C, Ari, De, Ermert, T, Farah, F, Fernandez-Bustamante, A, Ferreira, C, Fiore, M, Fonte, A, Palahi, Cf, Galimberti, A, Garofano, N, Giaccari, Lg, Gilsanz, F, Girrbach, F, Gobbi, L, Godfried, Mb, Goettel, N, Goldstein, Pa, Goren, O, Gorlin, A, Gil, Mg, Gratarola, A, Graterol, J, Guyon, P, Haire, K, Harou, P, Helf, A, Hempel, G, Cadiz, Mjh, Heyse, B, Hollmann, Mw, Huercio, I, Ilievska, J, Jakus, L, Jeganath, V, Jelting, Y, Jung, M, Kabon, B, Kacha, A, Ilic, Mk, Karuppiah, A, Kavas, Ad, Barcelos, Gk, Kellogg, Ta, Kemper, J, Kerbrat, R, Khodr, S, Kienbaum, P, Kir, B, Kiss, T, Kivrak, S, Klaric, V, Koch, T, Koksal, C, Kowark, A, Kranke, P, Kuvaki, B, Kuzmanovska, B, Lange, M, de Lemos MF, Lopez-Baamonde, M, Lopez-Hernandez, A, Lopez-Martinez, M, Luise, S, Macgregor, M, Magalhaes, D, Maillard, J, Malerbi, P, Manimekalai, N, Margarson, M, Martin, Dp, Martin, Yn, Martinez-Ocon, J, Martin-Loeches, I, Maseda, E, Mcauliffe, N, Mckenzie, Tj, Medina, P, Meersch, M, Menzen, A, Mertens, E, Meurer, B, Meyer-Treschan, T, Miao, Ch, Micalizzi, C, Milic, M, Modolo, Nsp, Moine, P, Molders, P, Montero-Feijoo, A, Moret, E, Muller, Mk, Murphy, Z, Nalwaya, P, Naumovski, F, Navalesi, P, Lima, Lhne, Adam, Vn, Neumann, C, Newell, C, Nisnevitch, Z, Nizamuddin, J, Novazzi, C, O'Connor, M, Oprea, G, Sungur, Mo, Ozbilgin, S, Pace, Mc, Pacheco, M, Packianathaswamy, B, Gonzalez, Ep, Papaspyros, F, Paredes, S, Passavanti, Mb, Pedemonte, Jc, Peremin, S, Philipsenburg, C, Pinho, D, Pinho, S, Posthuma, Lm, Pota, V, Preckel, B, Priani, P, Rached, Ma, Radoeshki, A, Ragazzi, R, Rajamanickam, T, Rajamohan, A, Ramakrishna, H, Rangarajan, D, Reiterer, C, Renew, Jr, Reynaud, T, Rhys, R, Rivas, E, Robitzky, L, Rubulotta, F, Machado, Hs, Nunes, Cs, Sabbatini, G, Sanahuja, Jm, Sansone, P, Santos, A, Sayedalahl, M, Schaefer, Ms, Scharffenberg, E, Scharffenberg, M, Schiffer, E, Schliewe, N, Schorer, R, Schumann, R, Selmo, G, Sendra, M, Shaw, K, Shosholcheva, M, Sibai, A, Simon, P, Simonassi, F, Sinno, C, Sivrikoz, N, Skandalou, V, Smith, N, Soares, M, Artiles, Ts, Castro, Ds, Sousa, M, Spadaro, S, Stamatakis, E, Steiner, La, Stevenazzi, A, Suarez-de-la-Rica, A, Suppan, M, Teichmann, R, Guerrero, Jmt, Thiel, B, Tolos, R, Altun, Gt, Tucci, M, Turnbull, Za, Turudic, Z, Unterberg, M, Van Limmen, J, Van Nieuwenhove, Y, Van Waesberghe, J, Francisco, M, Melo, V, Vitkovic, B, Vivona, L, Vizcaychipi, M, Volta, Ca, Weber, A, Weingarten, Tn, Wittenstein, J, Wyffels, P, Yague, J, Yates, D, Yavru, A, Zac, L, Zhong, J, Intensive Care Medicine, ACS - Heart failure & arrhythmias, Anesthesiology, ACS - Diabetes & metabolism, APH - Quality of Care, ACS - Pulmonary hypertension & thrombosis, ACS - Microcirculation, Bluth T., Serpa Neto A., Schultz M.J., Pelosi P., Gama de Abreu M., Bobek I., Canet J.C., Cinella G., de Baerdemaeker L., Gregoretti C., Hedenstierna G., Hemmes S.N.T., Hiesmayr M., Hollmann M.W., Jaber S., Laffey J., Licker M.-J., Markstaller K., Matot I., Mills G.H., Mulier J.P., Putensen C., Rossaint R., Schmitt J., Senturk M., Severgnini P., Sprung J., Vidal Melo M.F., Wrigge H., Abelha F., Abitagaoglu S., Achilles M., Adebesin A., Adriaensens I., Ahene C., Akbar F., Harbi M.A., Al Kallab R.A.K., Albanel X., Aldenkortt F., Alfouzan R.A.S., Alruqaie R., Altermatt F., de Castro Araujo B.L., Arbesu G., Artsi H., Aurilio C., Ayanoglu O.H., Bacuzzi A., Baig H., Baird Y., Balonov K., Balust J., Banks S., Bao X., Baumgartner M., Tortosa I.B., Bergamaschi A., Bergmann L., Bigatello L., Perez E.B., Birr K., Bojaxhi E., Bonenti C., Bonney I., Bos E.M.E., Bowman S., Braz L.G., Brugnoni E., Brull S.J., Brunetti I., Bruni A., Buenvenida S.L., Busch C.J., Camerini G., Capatti B., Carmona J., Carungcong J., Carvalho M., Cattan A., Cavaleiro C., Chiumello D., Ciardo S., Coburn M., Colella U., Contreras V., Dincer P.C., Cotter E., Crovetto M., Darrah W., Davies S., De Hert S., Peces E.D.C., Delphin E., Diaper J., Do Nascimento Junior P., Donatiello V., Dong J., Dourado M.D.S., Dullenkopf A., Ebner F., Elgendy H., Ellenberger C., Erdogan Ari D., Ermert T., Farah F., Fernandez-Bustamante A., Ferreira C., Fiore M., Fonte A., Palahi C.F., Galimberti A., Garofano N., Giaccari L.G., Gilsanz F., Girrbach F., Gobbi L., Godfried M.B., Goettel N., Goldstein P.A., Goren O., Gorlin A., Gil M.G., Gratarola A., Graterol J., Guyon P., Haire K., Harou P., Helf A., Hempel G., Cadiz M.J.H., Heyse B., Huercio I., Ilievska J., Jakus L., Jeganath V., Jelting Y., Jung M., Kabon B., Kacha A., Ilic M.K., Karuppiah A., Kavas A.D., Barcelos G.K., Kellogg T.A., Kemper J., Kerbrat R., Khodr S., Kienbaum P., Kir B., Kiss T., Kivrak S., Klaric V., Koch T., Koksal C., Kowark A., Kranke P., Kuvaki B., Kuzmanovska B., Lange M., de Lemos M.F., Lopez-Baamonde M., Lopez-Hernandez A., Lopez-Martinez M., Luise S., Macgregor M., Magalhaes D., Maillard J., Malerbi P., Manimekalai N., Margarson M., Martin A.K., Martin D.P., Martin Y.N., Martinez-Ocon J., Martin-Loeches I., Maseda E., McAuliffe N., McKenzie T.J., Medina P., Meersch M., Menzen A., Mertens E., Meurer B., Meyer-Treschan T., Miao C., Micalizzi C., Milic M., Modolo N.S.P., Moine P., Molders P., Montero-Feijoo A., Moret E., Muller M.K., Murphy Z., Nalwaya P., Naumovski F., Navalesi P., Navarro E Lima L.H., Adam V.N., Neumann C., Newell C., Nisnevitch Z., Nizamuddin J., Novazzi C., O'connor M., Oprea G., Sungur M.O., Ozbilgin S., Pace M.C., Pacheco M., Packianathaswamy B., Gonzalez E.P., Papaspyros F., Paredes S., Passavanti M.B., Pedemonte J.C., Peremin S., Philipsenburg C., Pinho D., Pinho S., Posthuma L.M., Pota V., Preckel B., Priani P., Rached M.A., Radoeshki A., Ragazzi R., Rajamanickam T., Rajamohan A., Ramakrishna H., Rangarajan D., Reiterer C., Ross Renew J., Reynaud T., Rhys R., Rivas E., Robitzky L., Rubulotta F., Machado H.S., Nunes C.S., Sabbatini G., Samuels J.D., Sanahuja J.M., Sansone P., Santos A., Sayedalahl M., Schaefer M.S., Scharffenberg M., Schiffer E., Schliewe N., Schorer R., Schumann R., Selmo G., Sendra M., Shaw K., Shosholcheva M., Sibai A., Simon P., Simonassi F., Sinno C., Sivrikoz N., Skandalou V., Smith N., Soares M., Artiles T.S., Castro D.S., Sousa M., Spadaro S., Stamatakis E., Steiner L.A., Stevenazzi A., Suarez-De-la-rica A., Suppan M., Teichmann R., Guerrero J.M.T., Thiel B., Tolos R., Altun G.T., Tucci M., Turnbull Z.A., Turudic Z., Unterberg M., Van Limmen J., Van Nieuwenhove Y., Van Waesberghe J., Vitkovic B., Vivona L., Vizcaychipi M., Volta C.A., Weber A., Weingarten T.N., Wittenstein J., Wyffels P., Yague J., Yates D., Yavru A., Zac L., Zhong J., Bluth, T., Serpa Neto, A., Schultz, M. J., Pelosi, P., Gama De Abreu, M., Aurilio, C., Pace, M. C., Passavanti, M. B., Pota, V., and Sansone, P.
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Lung Diseases ,Male ,medicine.medical_treatment ,Atelectasis ,Lung Disease ,01 natural sciences ,Body Mass Index ,Hypoxemia ,Positive-Pressure Respiration ,Postoperative Complications ,0302 clinical medicine ,PEEP, postoperative complications, obese patients ,Anesthesia ,Respiratory function ,030212 general & internal medicine ,Tidal volume ,General Medicine ,Middle Aged ,Pleural Diseases ,respiratory system ,Adult ,Anesthesia, General ,Female ,Humans ,Obesity ,Pulmonary Atelectasis ,Respiratory Insufficiency ,Surgical Procedures, Operative ,Tidal Volume ,Treatment Outcome ,Intraoperative Care ,Operative ,3. Good health ,Pneumothorax ,medicine.symptom ,psychological phenomena and processes ,Human ,circulatory and respiratory physiology ,NO ,03 medical and health sciences ,mental disorders ,medicine ,Pleural Disease ,0101 mathematics ,General ,Positive end-expiratory pressure ,Mechanical ventilation ,Surgical Procedures ,Pulmonary Atelectasi ,business.industry ,010102 general mathematics ,medicine.disease ,respiratory tract diseases ,Respiratory failure ,Postoperative Complication ,business - Abstract
Importance: An intraoperative higher level of positive end-expiratory positive pressure (PEEP) with alveolar recruitment maneuvers improves respiratory function in obese patients undergoing surgery, but the effect on clinical outcomes is uncertain. Objective: To determine whether a higher level of PEEP with alveolar recruitment maneuvers decreases postoperative pulmonary complications in obese patients undergoing surgery compared with a lower level of PEEP. Design, Setting, and Participants: Randomized clinical trial of 2013 adults with body mass indices of 35 or greater and substantial risk for postoperative pulmonary complications who were undergoing noncardiac, nonneurological surgery under general anesthesia. The trial was conducted at 77 sites in 23 countries from July 2014-February 2018; final follow-up: May 2018. Interventions: Patients were randomized to the high level of PEEP group (n = 989), consisting of a PEEP level of 12 cm H2O with alveolar recruitment maneuvers (a stepwise increase of tidal volume and eventually PEEP) or to the low level of PEEP group (n = 987), consisting of a PEEP level of 4 cm H2O. All patients received volume-controlled ventilation with a tidal volume of 7 mL/kg of predicted body weight. Main Outcomes and Measures: The primary outcome was a composite of pulmonary complications within the first 5 postoperative days, including respiratory failure, acute respiratory distress syndrome, bronchospasm, new pulmonary infiltrates, pulmonary infection, aspiration pneumonitis, pleural effusion, atelectasis, cardiopulmonary edema, and pneumothorax. Among the 9 prespecified secondary outcomes, 3 were intraoperative complications, including hypoxemia (oxygen desaturation with Spo2 ≤92% for >1 minute). Results: Among 2013 adults who were randomized, 1976 (98.2%) completed the trial (mean age, 48.8 years; 1381 [69.9%] women; 1778 [90.1%] underwent abdominal operations). In the intention-to-treat analysis, the primary outcome occurred in 211 of 989 patients (21.3%) in the high level of PEEP group compared with 233 of 987 patients (23.6%) in the low level of PEEP group (difference, -2.3% [95% CI, -5.9% to 1.4%]; risk ratio, 0.93 [95% CI, 0.83 to 1.04]; P =.23). Among the 9 prespecified secondary outcomes, 6 were not significantly different between the high and low level of PEEP groups, and 3 were significantly different, including fewer patients with hypoxemia (5.0% in the high level of PEEP group vs 13.6% in the low level of PEEP group; difference, -8.6% [95% CI, -11.1% to 6.1%]; P
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- 2019