Critical Care Medicine
Adult Critical Care
A Description of Intraoperative Ventilator Management in Patients with Acute Lung Injury and the Use of Lung Protective Ventilation Strategies
Blum JM, Maile M, Park PK, et al (Univ of Michigan Health System, Ann Arbor) Anesthesiology 115:75-82, 2011§
Evidence Ranking
• C
Expert Rating
• 2
Abstract
Background
The incidence of acute lung injury (ALI) in hypoxic patients undergoing surgery is currently unknown. Previous studies have identified lung protective ventilation strategies that are beneficial in the treatment of ALI. The authors sought to determine the incidence and examine the use of lung protective ventilation strategies in patients receiving anesthetics with a known history of ALI.
Methods
The ventilation parameters that were used in all patients were reviewed, with an average preoperative Paco2/Fio2 ratio of ≤300 between January 1, 2005 and July 1, 2009. This dataset was then merged with a dataset of patients screened for ALI. The median tidal volume, positive end-expiratory pressure, peak inspiratory pressures, fraction inhaled oxygen, oxygen saturation, and tidal volumes were compared between groups.
Results
A total of 1,286 patients met criteria for inclusion; 242 had a diagnosis of ALI preoperatively. Comparison of patients with ALI versus those without ALI found statistically yet clinically insignificant differences between the ventilation strategies between the groups in peak inspiratory pressures and positive end-expiratory pressure but no other category. The tidal volumes in cc/kg predicted body weight were approximately 8.7 in both groups. Peak inspiratory pressures were found to be 27.87 cm H2O on average in the non-ALI group and 29.2 in the ALI group.
Conclusion
Similar ventilation strategies are used between patients with ALI and those without ALI. These findings suggest that anesthesiologists are not using lung protective ventilation strategies when ventilating patients with low Paco2/Fio2 ratios and ALI, and instead are treating hypoxia and ALI with higher concentrations of oxygen and peak pressures (Figs 2, Tables 4 and 5).
Figure 2 (A–D) Distribution of ventilator settings by ALI status. (A) cc of ventilation per kg PBW by ALI status. Solid lines represent median values, boxes represent the interquartile range, T bars represent 95% of total sample, 
represent outliers (1.5–3 X box length), * represent extreme outliers (more than 3 X box length). (B) Median positive end-expiratory pressure (PEEP) by ALI status. Solid lines represent median values, boxes represent the interquartile range, T bars represent 95% of total sample, 
represent outliers (1.5–3 X box length), * represent extreme outliers (more than 3 X box length). (C) Median PIP by ALI status. Solid lines represent median values, boxes represent the interquartile range, T bars represent 95% of total sample, 
represent outliers (1.5–3 X box length), * represent extreme outliers (more than three times box length). (D) Median Fio2 by ALI status. Solid lines represent median values, boxes represent the interquartile range, T bars represent 95% of total sample, 
represent outliers (1.5–3 X box length), * represents extreme outliers (more than 3 X box length). ALI = acute lung injury; Fio2 = fraction inspired oxygen; PBW = predicted body weight; PEEP = positive end expiratory pressure; PIP = peak inspiratory pressure. (Reprinted from Blum JM, Maile M, Park PK, et al. A description of intraoperative ventilator management in patients with acute lung injury and the use of lung protective ventilation strategies. Anesthesiology. 2011;115:75-82, with permission from the American Society of Anesthesiologists, Inc.)
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