Intraoperative ventilation strategies to prevent postoperative pulmonary complications: Systematic review, meta-analysis, and trial sequential analysis

For many years, mechanical ventilation with high tidal volumes (VT) was common practice in operating theaters because this strategy recruits collapsed lung tissue, improves ventilation–perfusion mismatch, and thus decreases the need for high oxygen fractions. Positive end-expiratory pressure (PEEP) was seldom used because it could cause cardiac compromise. Increasing advances in the understanding of the mechanisms of ventilator-induced lung injury from animal studies and randomized controlled trials in patients with uninjured lungs in intensive care unit and operation room have pushed anesthesiologists to consider lung-protective strategies during intraoperative ventilation. These strategies at least include the use of low VT, and perhaps also the use of PEEP, which when compared to high VT with low PEEP may prevent the occurrence of postoperative pulmonary complications (PPCs). Such protective effects, however, are likely ascribed to low VT rather than to PEEP. In fact, at least in nonobese patients undergoing open abdominal surgery, high PEEP does not protect against PPCs, and it can impair the hemodynamics. Further studies shall determine whether a strategy consisting of low VT combined with PEEP and recruitment maneuvers reduces PPCs in obese patients and other types of surgery (e.g., laparoscopic and thoracic), compared to low VT with low PEEP. Furthermore, the role of driving pressure for titrating ventilation settings in patients with uninjured lungs shall be investigated.