Open Access

Perioperative Lung Protective Ventilatory Management During Major Abdominal Surgery: A Hungarian Nationwide Survey

Zoltán Ruszkai
Zoltán Ruszkai
, 
Erika Kiss
Erika Kiss
 and 
Zsolt Molnár
Zsolt Molnár
   | Feb 04, 2019
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Article Category: Research Article
Published Online: Feb 04, 2019
Page range: 19 - 27
Received: Sep 20, 2018
Accepted: Dec 10, 2018
DOI: https://doi.org/10.2478/jccm-2019-0002
Keywords
© 2019 Zoltán Ruszkai, Erika Kiss, Zsolt Molnár, published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 License.

Fig. 1

Use of low tidal volume (TV) and ideal body weight (IBW) to determine the appropriate TV are common: 54.9% of respondents apply a low TV of 6 ml/kg or less and 60% of them use IBW. However, applying a TV of 7 ml/kg is also frequent and 38% of respondents use actual or estimated body weight to determine the appropriate TV and 2% of them do not take the patient’s weight into account (RBW).
Use of low tidal volume (TV) and ideal body weight (IBW) to determine the appropriate TV are common: 54.9% of respondents apply a low TV of 6 ml/kg or less and 60% of them use IBW. However, applying a TV of 7 ml/kg is also frequent and 38% of respondents use actual or estimated body weight to determine the appropriate TV and 2% of them do not take the patient’s weight into account (RBW).

Fig. 2

None of the respondents apply zero positive end-expiratory pressure (PEEP) during mechanical ventilation. Half of the respondents commonly use lower levels of PEEP (48.6%), and only 36.1% apply an individually optimal level of PEEP determined during a PEEP titration procedure. In contrast to these results, presumably based on pathophysiological rationality, both moderate (6-10 cmH2O, 37.8%) and individually titrated levels of PEEP (40.5%) are commonly considered appropriate for obese patients (body mass index greater than 30 kg/m2).
None of the respondents apply zero positive end-expiratory pressure (PEEP) during mechanical ventilation. Half of the respondents commonly use lower levels of PEEP (48.6%), and only 36.1% apply an individually optimal level of PEEP determined during a PEEP titration procedure. In contrast to these results, presumably based on pathophysiological rationality, both moderate (6-10 cmH2O, 37.8%) and individually titrated levels of PEEP (40.5%) are commonly considered appropriate for obese patients (body mass index greater than 30 kg/m2).

Fig. 3

Routine and regular use of alveolar recruitment manoeuvres (ARM) is rare after endotracheal intubation (8.1%), during general anaesthesia (10.8%) and prior to extubation procedure (10.8%). Based on our data ARM is a procedure for high-risk patients (33.3%) and usually used during anaesthesia when a decreasing oxygen saturation is detected (32.4%). Approximately 20-30% of respondents never use ARM during any phase of general anaesthesia.
Routine and regular use of alveolar recruitment manoeuvres (ARM) is rare after endotracheal intubation (8.1%), during general anaesthesia (10.8%) and prior to extubation procedure (10.8%). Based on our data ARM is a procedure for high-risk patients (33.3%) and usually used during anaesthesia when a decreasing oxygen saturation is detected (32.4%). Approximately 20-30% of respondents never use ARM during any phase of general anaesthesia.

Fig. 4

Forest plot for the application of the basic elements of lung-protective ventilation. Differences between groups with P values less than 0.05 were considered significant. Despite obvious practice variations were evaluated between trainees and specialist, these differences were not significant statistically.
Forest plot for the application of the basic elements of lung-protective ventilation. Differences between groups with P values less than 0.05 were considered significant. Despite obvious practice variations were evaluated between trainees and specialist, these differences were not significant statistically.

Fig. 5

Forest plot for the application of the other elements of lung-protective ventilation. Differences between groups with P values less than 0.05 were considered significant. Differences in the application of low Pplat and low dPaw between trainees and specialists was statistically significant. Application of these two target parameters are more common among specialists.
Forest plot for the application of the other elements of lung-protective ventilation. Differences between groups with P values less than 0.05 were considered significant. Differences in the application of low Pplat and low dPaw between trainees and specialists was statistically significant. Application of these two target parameters are more common among specialists.

Demographic data and respondents’ professional details

n (=111)%
Type of institution
University medical centre2421.6
Hospital in capital3027.1
County hospital4439.6
Other hospitals1311.7
Respondents’ post
Specialist candidate (trainees)2219.8
Specialist5852.3
Chief medical officer3127.9
Length of practice in anaesthesia
< 5 yrs2018.0
5 – 10 yrs2118.9
> 10 yrs7063.1
The annual number of major abdominal surgery per centre
< 10065.4
100 – 200119.9
200 – 3002219.8
300 – 4001210.8
> 4006054.1

Availability of perioperative breathing and intraoperative LPV protocols

Other hospitalsUniversity Medical Centres
n (=87)%n (=24)%OR (95% CI)p
Availability of perioperative breathing protocols1011.5833.30.39(0.14 – 1.10)0.0747
The absence of perioperative breathing protocols7990.81875.00.42(0.14 – 1.28)0.1262
Availability of intraoperative LPV protocols66.928.30.82(0.15 – 4.32)0.8099
The absence of intraoperative LPV protocols8193.12291.71.22(0.25 – 6.07)0.8062

Preoperative assessment: examinations and prescribed interventions

PhysiotherapyChest X-raySpirometryABGAPPPVS
Always3(2.7)46(41.1)0(0)7(6.3)0(0)
In patients with COPD49(43.8)44(39.3)101(90.2)63(56.3)8(7.1)
In patients with bronchial asthma25(22.3)30(26.8)84(75.0)22(19.6)3(2.7)
Inactive smokers18(16.1)22(19.6)18(16.1)10(8.9)0(0)
In case of actual intermittent respiratory disease11(9.8)38(33.9)30(26.8)25(22.3)5(4.5)
In patients with abnormal chest X-ray or lung CT scan17(15.2)n/a47(42.0)24(21.4)2(1.8)
If low SpO2 (< 96%) is observed during an assessment20(17.9)41(36.6)46(41.1)63(56.3)7(6.3)
Prior to acute or vital surgeryn/a16(14.3)n/a45(40.2)7(6.3)
Never prescribed56(50)9(8)6(5.4)9(8.0)96(85.7)

Opinions about the risk factors of postoperative pulmonary complications

Risk factors of PPCConsidered as important RF
n (=111)%95% CI
Thoracic surgery10392.884.1 – 124.9
Major abdominal surgery10090.181.4 – 121.6
COPD10998.990.4 – 132.6
Obesity9787.478.7 – 118.3
Residual neuromuscular blockade after surgery10695.586.8 – 128.2
Transplant surgery4237.830.3 – 56.8
Intracranial surgery3833.326.1 – 51.0
Chronic malnutrition3935.828.6 – 54.5
Anaemia3733.723.5 – 47.5
Prolonged use of NGT after surgery2825.317.8 – 39.3

Use of the basic elements of lung protective ventilation

TraineesSpecialists
n (=22)%n (=89)%OR (95% CI)p
Low TV (≤ 6 mL/kg)836.45359.62.58(0.98 – 6.77)0.0549
Applies IBW1150.05662.91.70(0.66 – 4.34)0.2701
PEEP < 6 cmH2O1254.54247.20.74(0.29 – 1.90)0.5374
Never applies a PEEP titration procedure1254.54550.60.85(0.33 – 2.17)0.7380
Never applies ARM after intubation418.22123.61.39(0.42 – 4.56)0.5874
Never applies ARM during anaesthesia418.21820.21.14(0.34 – 3.79)0.8297
Never applies ARM before extubation836.42730.30.76(0.29 – 2.03)0.5866
Applies ARM regularly during anaesthesia29.11011.21.27(0.26 – 6.24)0.7721
Targeted ARM (if SpO2 < 96%) during anaesthesia836.42831.50.80(0.30 – 2.13)0.6604
Applies the entire LPV concept627.32426.91.01(0.36 – 2.89)0.9769

Use of other elements of lung protective ventilation

TraineesSpecialists
n (=22)%n (=89)%OR (95% CI)p
Use of permissive hypercapnia1463.65258.40.80(0.31 – 2.11)0.6562
Appropriate RR based on EtCO21777.36977.51.01(0.33 – 3.09)0.9795
Pplat < 25 cmH2O418.24651.74,81(1.51 – 15.36)0.0079
dPaw < 20 cmH2O418.22528.14,50(1.69 – 11.99)0.0026
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