Pulmonary complications with individualised vs. fixed positive end‐expiratory pressure in older patients recovering from lung cancer surgery: a randomised trial
W. Wang, K. Liu, Chengya Huang, Qiliang Jiang, Yi Ge, Daniel I. Sessler, Jingxiang Wu
Abstract
Summary Introduction Postoperative pulmonary complications are common after lung cancer surgery in older adults. Individualised positive end‐expiratory pressure may optimise intra‐operative lung mechanics, but its effect on postoperative pulmonary complications is uncertain. We hypothesised that individualised positive end‐expiratory pressure would reduce the incidence of postoperative pulmonary complications compared with a fixed positive end‐expiratory pressure in older patients (age ≥ 60 years) undergoing lung cancer surgery. Methods In total, 400 patients were allocated randomly to individualised positive end‐expiratory pressure (PEEP IND group) or a fixed positive end‐expiratory pressure of 5 cmH 2 O (PEEP 5 group). The primary outcome was the incidence of postoperative pulmonary complications. Secondary outcomes included duration of postoperative hospital stay; extrapulmonary complications; 30‐day postoperative complications; driving pressure; and oxygenation index. Results Median (IQR [range]) individualised positive end‐expiratory pressure was 11 (9–11 [3–13]) cmH 2 O during one‐lung and 9 (7–9 [3–13]) cmH 2 O during two‐lung ventilation. Patients allocated to the PEEP IND group had lower driving pressures during one‐lung (12 (11–14 [4–23]) vs. 15 (13–18 [7–24]) cmH 2 O, p < 0.001) and two‐lung ventilation (9 (7–13 [4–26]) vs. 12 (10–14 [5–26]) cmH 2 O, p < 0.001) and a higher oxygenation index during one‐lung ventilation (26.7 (20.3–34.4 [6.7–55.9]) vs. 22.7 (16.0–29.3 [8.8–58.9]) kPa, p < 0.001) compared with those allocated to the PEEP 5 group. Despite this, the incidence of postoperative pulmonary complications was similar between groups (PEEP IND group 54/195 (28%) vs. PEEP 5 group 50/197 (25%), risk ratio 1.09, 95%CI 0.79–1.52, p = 0.60). Discussion Electrical impedance tomography‐guided individualised positive end‐expiratory pressure reduced driving pressures and improved intra‐operative oxygenation but did not decrease the incidence of postoperative pulmonary complications in older adults undergoing lung cancer surgery.