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Preliminary Communication
Caring for the Critically Ill Patient
April 11, 2017

Effect of Intensive vs Moderate Alveolar Recruitment Strategies Added to Lung-Protective Ventilation on Postoperative Pulmonary ComplicationsA Randomized Clinical Trial

Author Affiliations
  • 1Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil
  • 2Cardio-Pulmonary Department, Heart Division, Heart Institute (Incor), Hospital Das Clínicas da FMUSP - University of São Paulo, São Paulo, Brazil
  • 3Departament of Applied Physiotherapy, Federal University of Triângulo Mineiro, Uberaba, Brazil
  • 4Cardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil
JAMA. 2017;317(14):1422-1432. doi:10.1001/jama.2017.2297
Key Points

Question  Is there any extra benefit to applying more intensive alveolar recruitment strategies for high-risk surgical patients already receiving perioperative small tidal volumes and protective lung ventilation?

Findings  An intensive recruitment strategy compared with a moderate recruitment strategy to treat patients with hypoxemia after cardiac surgery resulted in significantly lower severity of pulmonary complications during the hospital stay. The strategy caused a consistent shift to lower scores that favored use of an intensive recruitment strategy.

Meaning  A more intensive alveolar recruitment strategy applied postoperatively may reduce the severity of pulmonary complications in patients with hypoxemia after cardiac surgery.

Abstract

Importance  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.

Objective  To determine whether an intensive alveolar recruitment strategy could reduce postoperative pulmonary complications, when added to a protective ventilation with small VT.

Design, Setting, and Participants  Randomized clinical trial of patients with hypoxemia after cardiac surgery at a single ICU in Brazil (December 2011-2014).

Interventions  Intensive recruitment strategy (n=157) or moderate recruitment strategy (n=163) plus protective ventilation with small VT.

Main Outcomes and Measures  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.

Results  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.

Conclusions and Relevance  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.

Trial Registration  clinicaltrials.gov Identifier: NCT01502332

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