Prolonged postoperative mechanical ventilation is a common complication after major aortic surgery. The relationship between prolonged ventilation and intraoperative variables influenced by anesthesiologists, such as ventilation practices, fluid administration, and blood pressure control during major aortic surgery is unknown. We sought to identify perioperative factors, including intraoperative physiologic and anesthesia-related variables, which are associated with ventilation duration following aortic surgery.

Single-center retrospective observational study.

A tertiary, high-volume cardiac surgery referral center.

Adult patients undergoing major aortic surgery requiring cardiopulmonary bypass (CPB).

None (retrospective observational study).

The primary outcome was the duration of postoperative ventilation (hours). Mixed-effects regression was performed to identify factors associated with the primary outcome. Among the 647 patients included in this study, the median of postoperative mechanical ventilation duration was 9.0 (IQR 6.0, 14.4) hours, with 73 (11.3%) of patients receiving mechanical ventilation for more than 24 hours. Variables significantly associated with the outcome were increases in pre- to post-CPB driving pressure (β = 4.23; 95% CI [0.08, 8.39]; p = 0.04), reduction in pre- to post-CPB end-tidal carbon dioxide partial pressure (β = -5.12; 95% CI [-8.85, -1.39]; p < 0.001), and normalized transfusion volumes (β = 11.14; 95% CI [4.36, 17.91]; p < 0.001). Mechanical power was not associated with postoperative ventilation duration (β = -2.29; 95% CI [-6.48, 1.90]; p = 0.52).

Patients undergoing major aortic surgery are at risk for prolonged mechanical ventilation. Transfusion volume and pre- to post-CPB changes in driving pressures and end-tidal carbon dioxide are significantly associated with postoperative ventilation duration. Intraoperative mechanical ventilator power is not a significant predictor of mechanical ventilation duration after major aortic surgery. These variables are potentially modifiable by anesthesiologists and may be future therapeutic targets.

Ventilator settings and ventilation variables and parameters vary between neurocritical care and non-neurocritical care patients. We aim to compare ventilation management in neurocritical care patients versus non-neurocritical care patients under invasive mechanical ventilation support, and to determine which factors related to ventilatory management have an independent association with outcome in neurocritical patients.

We meta-analyze harmonized individual patient data from three observational studies ('PRactice of VENTilation in critically ill patients without ARDS' [PRoVENT], 'PRactice of VENTilation in critically ill patients in Middle-income Countries' [PRoVENT-iMiC] and 'Extubation strategies and in neuro-intensive care unit patients and associations with outcomes' [ENIO]), pooled into a database named 'PRIME'. The primary endpoint is all cause ICU mortality. Secondary endpoints are key ventilator settings and ventilation variables and parameters. To identify potentially modifiable and non-modifiable factors contributing to ICU mortality, a multivariable model will be built using demographic factors, comorbidities, illness severities, and respiratory and laboratorial variables. In analyses examining the impact of ventilatory variables on outcome, we will estimate the relative risk of ICU mortality for neurocritical and non-neurocritical care patients by dividing the study population based on key ventilator variables and parameters.

This meta-analysis will address a clinically significant research question by comparing neurocritical care with non-neurocritical care patients. As this is a meta-analysis, additional ethical committee approval is not required. Findings will be disseminated to the scientific community through abstracts and original articles in peer-reviewed journals. Furthermore, the PRIME database will be made accessible for further post-hoc analyses.

PROVENT, PROVENT-iMiC and ENIO, and the pooled database PRIME are registered at clinicaltrials.gov (NCT01868321 for PRoVENT, NCT03188770 for PRoVENT-iMiC, and NCT03400904 for ENIO, and for PRIME is pending).

Despite the widespread use of lung-protective ventilation in general anesthesia, the optimal positive end-expiratory pressure (PEEP) remains uncertain. This study aimed to investigate the effects of driving pressure-guided individualized PEEP in patients undergoing robot-assisted laparoscopic radical prostatectomy.

Forty-two male patients undergoing robot-assisted laparoscopic radical prostatectomy were randomized to receive conventional fixed PEEP of 5 cmH2O (n = 21, PEEP5) or driving pressure-guided individualized PEEP (n = 21, PEEPIND). The primary outcome was the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PaO2/FiO2). The secondary outcomes included respiratory mechanics, hemodynamics, optic nerve sheath diameter (ONSD), and the incidence of postoperative delirium (POD) and postoperative pulmonary complications (PPCs) within a 7-day period.

In comparison with the PEEP5 group, the PEEPIND group showed significantly higher (p < 0.001) PEEP values during pneumoperitoneum in the Trendelenburg position (mean [standard deviation], 11.29 cmH2O [1.01 cmH2O]) and after deflation and repositioning to the supine position (mean [standard deviation], 7.05 cmH2O [1.20 cmH2O]). The PaO2/FiO2 values in the PEEPIND group were significantly higher than those in the PEEP5 group 120 min after pneumoperitoneum in the Trendelenburg position (p = 0.023) and at the end of the operation (p = 0.028). The groups showed no differences in ONSD, hemodynamics, and incidence of POD and PPCs (p > 0.05).

In comparison with a fixed PEEP of 5 cmH2O, driving pressure-guided individualized PEEP improves intraoperative respiratory mechanics and oxygenation without causing deterioration in hemodynamics, further escalation in intracranial pressure, or an increase in the incidence of POD. Nevertheless, this procedure requires meticulous monitoring. Unfortunately, individualized PEEP did not result in a reduction in the incidence of PPCs in this study.

http://www.chictr.org.cn, ChiCTR2400081338.

The prone position is commonly used in spinal surgery, but it can lead to decreased lung compliance and increased airway pressure. This study aimed to evaluate the effect of individualized end-inspiratory pause guided by driving pressure on respiratory mechanics in patients undergoing prone spinal surgery.

A randomized controlled trial was conducted from August to October 2023. Patients scheduled for elective prone spinal surgery were randomly assigned to either a study group, receiving individualized end-inspiratory pause, or a control group, receiving a fixed end-inspiratory pause (10% of total inspiratory time). Mechanical ventilation parameters, including tidal volume, plateau pressure, driving pressure, and peak pressure, were recorded at different time points. Arterial blood gases were collected at baseline and at specified intervals.

Data from 36 subjects (18 in each group) were included in the final analysis. The study group exhibited a significant increase in respiratory system compliance (P < 0.05) and improved intraoperative oxygenation (P < 0.05). In addition, the individualized end-inspiratory pause significantly decreased plateau pressure (P < 0.05) and driving pressure (P < 0.05) compared to the control group.

The individualized end-inspiratory pause guided by driving pressure effectively optimized pulmonary compliance and improved oxygenation during prone spinal surgery. These findings suggest that this ventilation strategy may enhance respiratory mechanics and reduce the risk of postoperative pulmonary complications.

Microlaryngeal surgeries require unique considerations for airway management to facilitate patient safety and adequate surgical exposure. Small-diameter endotracheal tubes (ETTs) are widely used but have raised concerns regarding patient safety, including questions about the potential for barotrauma, effective ventilation, and adequate oxygenation. We hypothesize that small ETTs will prove to be safe in a variety of cases.

We conducted a case series analyzing the safety of 5.0 ETTs in microlaryngeal surgeries at Washington University School of Medicine from November 2020 to November 2023. Outcome measures included intraoperative desaturations (SpO2 < 90% for >2 min), high peak inspiratory pressures (PIPs) (>40 cm H2O), and prolonged extubation times (>15 min). Univariate regression models were used to analyze associations of sociodemographic and clinical variables with these outcome measures.

This study included 76 small-ETT microlaryngeal surgeries. There were 5 instances of desaturations, no reported incidents of barotrauma, and no cases in which intraoperative tube exchange was required due to issues with oxygenation or ventilation. Median PIP was 38 cm H2O, with a range of 17-78 cm H2O. 46% of patients had a PIP above 40 cm H2O. There were prolonged extubation times in 14% of procedures. No association was shown between sociodemographic and clinical variables with risk of desaturations, high PIPs, or prolonged extubation times.

Our study suggests that 5.0 ETTs are safe for microlaryngeal surgery in a variety of patients. Otolaryngologists and anesthesiologists should consider this information when choosing between the multiple available options for airway management during microlaryngeal surgery.

4 Laryngoscope, 135:1451-1454, 2025.

The win ratio analysis method might provide new insight on the impact of positive end-expiratory pressure (PEEP) on clinical outcomes.

The aim is to re-analyse the results of the 'Re-evaluation of the effects of high PEEP with recruitment manoeuvres vs. low PEEP without recruitment manoeuvres during general anaesthesia for surgery' (REPEAT) study using the win ratio analysis.

Individual patient data meta-analysis.

Three international multicentre randomised trials.

Patients undergoing general anaesthesia for surgery.

High vs. low PEEP.

Hierarchical composite endpoint of: all-cause hospital mortality; hospital length of stay; need for postoperative mechanical ventilation; severe pulmonary complications; and mild pulmonary complications.

A total of 3774 patients undergoing general anaesthesia for surgery were included in this analysis. The median (interquartile range [IQR]) age was 57 [45 to 68] years and 2077 (55%) were women. A total of 3 560 720 comparison pairs were produced. The high PEEP group had a higher percentage of losses than wins in hospital mortality (1.1 vs. 0.9%) and hospital length of stay (33.8 vs. 33.2%), comparable percentages of losses and wins in postoperative invasive mechanical ventilation (0.2 vs. 0.2%), a higher percentage of wins in severe complications (2.5 vs. 2.1%) and a higher percentage of ties in mild complications (18.7 vs. 3.9% wins vs. 3.3% losses). The win ratio for high PEEP compared with low PEEP group was 1.00 (95% CI 0.92 to 1.09).

No beneficial effects of high PEEP compared with low PEEP were found in this win ratio analysis.

Clinicaltrials.gov (study identifier NCT03937375).

Placing patients in the steep Trendelenburg position with a pressurised pneumoperitoneum during laparoscopic colorectal surgery increases pulmonary airway pressure, increasing the risks of lung injury and postoperative pulmonary complications, even in patients with healthy lungs.

The aim was to determine whether an integrated anaesthesia protocol was superior to traditional protective ventilation in terms of preventing pulmonary complications.

This study used a randomised, controlled, parallel-group design.

This single-centre trial was conducted at the National Cancer Centre/Cancer Hospital of the Chinese Academy of Medical Sciences from January to May 2023.

A total of 120 patients who underwent laparoscopic surgery for colorectal cancer with intermediate to high risk of pulmonary complications, as determined by the Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score.

Participants were randomly assigned to either lung protective ventilation with a tidal volume of 6 ml kg-1 of predicted body weight + deep neuromuscular block (a train-of-four count of 0 and post tetanic of 1 to 2) + low peritoneal pressure (10 mmHg) or conventional pulmonary ventilation with a tidal volume of 8 ml kg-1 of predicted body weight + moderate neuromuscular block (a train-of-four count of 1 to 2) + standard peritoneal pressure (15 mmHg).

The primary outcome was the incidence of pulmonary complications within 30 postoperative days. The secondary outcomes included serological biomarkers of lung injury.

The lung protective group had a significantly lower incidence of pulmonary complications (15.0%) than the conventional group (38.3%; hazard ratio, 0.332; 95% CI, 0.153 to 0.718; P = 0.003). There were no significant differences in the plasma biomarker levels of soluble receptor for advanced glycation end products and angiopoietin-2 for lung injury between the groups. The treatment-by-covariate interactive analysis revealed that the lung-protective strategy conferred considerable benefits for males and individuals aged 60 years or above. A nomogram that predicted pulmonary complications incorporating four variables exhibited a strong discriminative performance, and the results of the decision curve analysis revealed the potential clinical value of this nomogram.

Compared with traditional strategies, the integrated lung-protective approach may mitigate pulmonary complications without causing lung injury in intermediate to high-respiratory-risk patients undergoing laparoscopic colorectal surgery.

Chinese Clinical Trial Register Identifier: ChiCTR2100054215.

Ventilator-induced lung injury caused by mechanical ventilation under general anesthesia as well as CO2 pneumoperitoneum and special positions for laparoscopy may increase the risk of postoperative pulmonary complications (PPCs). Lung protective ventilation under general anesthesia is advised by the guidelines to lower the risk of PPCs in surgical patients. However, there is considerable controversy about the optimal level of positive end-expiratory pressure (PEEP) and how to set it. Driving pressure reflects the overall respiratory stress and high driving pressure is an independent risk factor for PPCs. The purpose of this study is to explore whether driving pressure-guided individualized PEEP ventilation can lower the incidence of postoperative atelectasis by improving respiratory mechanics during laparoscopic surgery consequently lowering the incidence of PPCs compared with the traditional fixed PEEP ventilation strategy.

The study will be a single-center, prospective, randomized controlled clinical study. A total of 106 adult patients with medium-to-high-risk PPCs undergoing laparoscopic surgery for more than 2 h will be randomly assigned in a 1:1 ratio to receive an individualized PEEP guided by minimum driving pressure (group D) or a fixed PEEP of 5 cmH2O (group C). Patients in group C will maintain a PEEP of 5 cmH2O throughout the whole process, and patients in group D will be administered individualized PEEP after the start of pneumoperitoneum to achieve minimum driving pressure until the end of the operation. The primary outcome is the LUS score at 24 h postoperatively. The secondary outcomes are the LUS scores at other time points, intraoperative respiratory mechanics and oxygenation index, incidence and specific types of PPCs at 7 days postoperatively.

This study will better evaluate the effect of individualized PEEP application guided by driving pressure on the incidence of postoperative atelectasis based on ultrasound assessment consequently the incidence of PPCs in patients undergoing prolonged laparoscopic surgery. The results may provide a clinical evidence for optimizing perioperative lung protection strategies.

www.chictr.org.cn ChiCTR2300079041. Registered on December 25, 2023.

Background/Objectives: Managing ventilatory strategies in patients with obesity under general anesthesia presents significant challenges due to obesity-related pathophysiological changes. Inverse ratio ventilation (IRV) has emerged as a potential strategy to optimize respiratory mechanics during laparoscopic surgery in this population. The primary outcomes were changes in respiratory mechanics, including peak inspiratory pressure (PPeak), plateau pressure (PPlat), mean airway pressure (PMean), and dynamic compliance (CDyn). Secondary outcomes included gas exchange parameters, hemodynamic measures, inflammatory cytokines, and postoperative complications. Methods: A systematic review and meta-analysis were conducted, searching PubMed, Scopus, EMBASE, and PMC Central. Only English-language randomized controlled trials (RCTs) evaluating the impact of IRV in adult surgical patients with obesity were included. The quality and certainty of evidence were assessed using the Risk of Bias 2 (RoB 2) tool and the Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) framework, respectively. Results: Three RCTs including 172 patients met the inclusion criteria. Compared to conventional ventilation without prolonged inspiratory time or IRV, IRV significantly reduced PPeak (MD [95%CI]: -3.15 [-3.88; -2.42] cmH2O, p < 0.001) and PPlat (MD [95%CI]: -3.13 [-3.80; -2.47] cmH2O, p < 0.001) while increasing PMean (MD [95%CI]: 4.17 [3.11; 5.24] cmH2O, p < 0.001) and CDyn (MD [95%CI]: 2.64 [0.95; 4.22] mL/cmH2O, p = 0.002) during laparoscopy, without significantly affecting gas exchange. IRV significantly reduced mean arterial pressure (MD [95%CI]: -2.93 [-3.95; -1.91] mmHg, p < 0.001) and TNF-α levels (MD [95%CI]: -9.65 [-17.89; -1.40] pg/mL, p = 0.021). Conclusions: IRV optimizes intraoperative respiratory mechanics but has no significant impact on postoperative outcomes, necessitating further research to determine its clinical role.

One-lung ventilation (OLV) in thoracic anesthesia poses dual challenges: preventing hypoxemia and minimizing ventilator-associated lung injury (VALI). Advances such as fiberoptic bronchoscopy and improved anesthetic techniques have reduced hypoxemia, yet optimal management strategies remain uncertain. Protective ventilation, involving low tidal volumes (4-6 mL/kg), individualized PEEP, and selective alveolar recruitment maneuvers (ARM), seek to balance oxygenation and lung protection. However, questions persist regarding the ideal application of PEEP and ARM, as well as their integration into clinical practice. As for PEEP and ARM, further research is needed to address key questions and establish new guidelines.

Current mechanical ventilation practices for patients with acute brain injury (ABI) are poorly defined. This study aimed to describe ventilator settings/parameters used in intensive care units (ICUs) and evaluate their association with clinical outcomes in these patients.

An international, prospective, multicenter, observational study was conducted across 74 ICUs in 26 countries, including adult patients with ABI (e.g., traumatic brain injury, intracranial hemorrhage, subarachnoid hemorrhage, and acute ischemic stroke), who required ICU admission and invasive mechanical ventilation. Ventilatory settings were recorded daily during the first week and on days 10 and 14. ICU and 6-months mortality and 6-months neurological outcome were evaluated.

On admission, 2095 recruited patients (median age 58 [interquartile range 45-70] years, 66.1% male) had a median plateau pressure (Pplat) of 15 (13-18) cmH20, tidal volume/predicted body weight 6.5 (5.7-7.3) mL/Kg, driving pressure 9 (7-12) cmH20, and positive end-expiratory pressure 5 (5-8) cmH20, with no modifications in case of increased intracranial pressure (> 20 mmHg). Significant differences in practices were observed across different countries. The majority of these ventilatory settings were associated with ICU mortality, with the highest hazard ratio (HR) for Pplat (odds ratio 1.50; 95% confidence interval, CI: 1.27-1.78). The results demonstrated consistent association with 6-month mortality; less clear association was observed for neurological outcome.

Protective ventilation strategies are commonly used in ABI patients but with high variability across different countries. Ventilator settings during ICU stay were associated with an increased risk of ICU and 6-month mortality, but not an unfavorable neurological outcome.

With a rapidly aging population and increasing global surgical volumes, managing the elevated risk of perioperative pulmonary complications has become an expanding focus for quality improvement in health care. In this narrative review, we will analyze the evidence-based literature to provide high-quality and actionable management strategies to better detect, stratify risk, optimize, and manage perioperative pulmonary complications in geriatric populations.

Difficulties with mask ventilation and intubation are more prevalent in obese patients. Hence, health care practitioners engaged in airway management of obese individuals must exercise particular vigilance and care. Ventilation strategies can potentially have a detrimental impact on postoperative pulmonary function, prolong hospital stays, and increase costs. As a result, the aim of this review was to investigate airway management technique and ventilation strategies in obese adult patients.

The PubMed, HINARI, Google Scholar, and Cochrane Review databases were searched using appropriate keywords and search engines for adequate evidence from studies meeting the inclusion criteria to reveal the endpoint, which was ventilation strategy and airway management in adult obese patients. Duplicate entries were eliminated through EndNote software. Screening of literature was conducted with proper appraisal checklist. This review was reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses 2020 statement.

The included literature covers a wide range of topics, including preoxygenation, making the patient in a 25° head-up position, use of 10-12cmH2O of positive end-expiratory pressure (PEEP) and continuous positive airway pressure (CPAP) during induction, placing the patient in a ramping posture during intubation, high-flow oxygenation (15 L/min) through the nasopharyngeal airway or nasal cannula during laryngoscopy, using low tidal volume during surgery, a 1:1/1.5:1 I:E ratio, PEEP of 10-20 cmH2O, Fio2 reduced to make SpO2 > 90, pressure-controlled (PC)/volume-controlled (VC) ventilation mode, and recruitment maneuver (RM). Following surgery, it was essential to provide oxygen therapy to maintain preoperative levels, provide CPAP/non-invasive positive pressure ventilation, place patients in semi-sitting positions, and provide thorough postanesthesia care unit monitoring in order to enhance patient outcomes with regard to morbidity and mortality among obese patients. To safely manage and overcome airway challenges in severely obese patients with a suspected difficult airway, awake fiberoptic intubation is recommended.

Positioning the patient in a head-up position (semi-sitting), utilizing CPAP during preoxygenation, and administering oxygen via nasal cannula during intubation to prolong apnoea time and awake fibrotic for suspected difficult airway. Additionally, selecting appropriate ventilation modes (PC/VC), PEEP + RM, and positions during the intraoperative phase is crucial to improving outcomes in obese surgical patients.

Despite the maturity and sophistication of anaesthesia workstations, improvements in our understanding of intraoperative mechanical ventilation, and use of less invasive surgical techniques, postoperative pulmonary complications (PPCs) are still a common problem in surgical patients of all ages. PPCs are associated with a higher incidence of perioperative morbidity and mortality, longer hospital stays, and higher healthcare costs. PPCs are strongly associated with anaesthesia-induced atelectasis, which predisposes to lung damage when partially collapsed lungs are subjected to mechanical ventilation. Lung protective ventilation is thus a modifiable factor that can positively impact the incidence of PPCs after surgery. Intraoperative protective ventilation strategies have been based on two main but intrinsically different hypotheses: one based on sole reduction of tidal volume and pressures, using minimal positive end-expiratory pressure (PEEP), tolerating the presence of lung collapse, and the other also limiting tidal volume and pressures after actively resolving atelectasis by lung recruitment and PEEP individualisation, the individualised open-lung approach. We review the concepts of the individualised open-lung approach, its potential benefits, and outstanding questions. We conclude with a proposal for personalised lung protective ventilation.

The impact of distinct primary colorectal cancer (CRC) sites on lung injury and complications remains largely unexplored, despite the palpable differences in surgical positions, procedures, and the resulting mechanically induced respiratory pressures at each site.

This study employed a forwards-looking approach utilising the propensity score matching (PSM) method; 300 patients with pathological CRC after laparoscopic surgery from April 2019 to May 2023 were enrolled. Two categories were bifurcated based on their surgical locations: the rectosigmoid colon (RSC) group and the descending/ascending colon (DAC) group, with a 2:1 ratio. The occurrence of postoperative pulmonary complications (PPCs) within a 30-day postoperative period was meticulously evaluated. Additionally, assessments have been performed for plasma biomarkers of immune response dynamics and lung injury (plasma soluble advanced glycation end-product receptor [sRAGE], angiopoietin-2 [ANG-2], interleukin-1β/6 [IL-1β/IL-6]) and other parameters.

Although the increase in postoperative lung epithelial damage, as indicated by the plasma sRAGE levels, was significant in the RSC group (DAC vs. RSC; 1029.6 [576.8-1365.2] vs. 1271.6 [896.3-1587.6]; odds ratio=0.999; 95% CI: 0.998 to 1.000; P=0.007), a significantly increased percentage of PPCs was observed in the DAC group (DAC vs. RSC; hazard ratio=1.669; 95% CI, 1.141 to 2.439; P=0.008). A univariate Cox proportional hazards model revealed that sRAGE, ANG-2, IL-1β, and IL-6 levels were not correlated with the incidence of time-to-PPCs across the two cohorts (P>0.05). Propensity score-weighted Cox regression and causal mediation analysis further demonstrated that the DAC site directly affected the incidence of PPCs, regardless of the other baseline confounders and clinical covariates related to the tumour site and PPCs.

The primary site of CRC is an independent predictor of the development of PPCs. Despite the steep Trendelenburg position of the RSC group inciting more pulmonary stress, inflammation and lung epithelial injury, as indicated by higher sRAGE, it demonstrated a lower PPCs occurrence relative to its DAC counterpart, with a slightly inclined or reversed Trendelenburg position. None of the plasma biomarkers of inflammation or lung injury indicated sufficient prognostic value for PPCs.

Patients at need for ventilation often are at risk of acute respiratory distress syndrome (ARDS). Although lung-protective ventilation strategies, including low driving pressure settings, are well known to improve outcomes, clinical practice often diverges from these strategies. A clinical decision support (CDS) system can improve adherence to current guidelines; moreover, the potential of a CDS to enhance adherence can possibly be further increased by combination with a nudge type intervention.

A prospective cohort trial was conducted in patients at risk of ARDS admitted to an intensive care unit (ICU). Patients were assigned to control or intervention by their date of admission: First, the control group was included without changing anything in clinical practice. Next, the CDS was activated showing an alert in the patient data management system if driving pressure exceeded recommended values; additionally, data on the performance of the wards were sent to the healthcare professionals as the nudge intervention. The main hypothesis was that this combined intervention would lead to a significant decrease in excess driving pressure.

The 472 included patients (230 in the control group and 242 in the intervention group) consisted of 33% females. The median age was 64 years; median Sequential Organ Failure Assessment score was 8. There was a significant reduction in excess driving pressure in the augmented ventilation modes (0.28 ± 0.67 mbar vs. 0.14 ± 0.45 mbar, p = 0.012) but not the controlled mode (0.37 ± 0.83 mbar vs. 0.32 ± 0.8 mbar, p = 0.53). However, there was no significant difference between groups in mechanical power, the number of ventilator-free days, or the percentage of patients showing progression to ARDS. Although there was no difference in progression to ARDS, 28-day mortality was higher in the intervention group. Notably, the mean overall driving pressure across both groups was low (12.02 mbar ± 2.77).

In a population at risk of ARDS, a combined intervention of a clinical decision support system and a nudge intervention was shown to reduce the excessive driving pressure above 15 mbar in augmented but not in controlled modes of ventilation.

Limited information is available regarding the application of lung-protective ventilation strategies during one-lung ventilation (OLV) across mainland China. A nationwide questionnaire survey was conducted to investigate this issue in current clinical practice.

The survey covered various aspects, including respondent demographics, the establishment and maintenance of OLV, intraoperative monitoring standards, and complications associated with OLV.

Five hundred forty-three valid responses were collected from all provinces in mainland China. Volume control ventilation mode, 4 to 6 mL per kilogram of predictive body weight, pure oxygen inspiration, and a low-level positive end-expiratory pressure ≤ 5 cm H2O were the most popular ventilation parameters. The most common thresholds of intraoperative respiration monitoring were peripheral oxygen saturation (SpO2) of 90-94%, end-tidal CO2 of 45 to 55 mm Hg, and an airway pressure of 30 to 34 cm H2O. Recruitment maneuvers were traditionally performed by 94% of the respondents. Intraoperative hypoxemia and laryngeal injury were experienced by 75% and 51% of the respondents, respectively. The proportions of anesthesiologists who frequently experienced hypoxemia during OLV were 19%, 24%, and 7% for lung, cardiovascular, and esophageal surgeries, respectively. Up to 32% of respondents were reluctant to perform lung-protective ventilation strategies during OLV. Multiple regression analysis revealed that the volume-control ventilation mode and an SpO2 intervention threshold of < 85% were independent risk factors for hypoxemia during OLV in lung and cardiovascular surgeries. In esophageal surgery, working in a tier 2 hospital and using traditional ventilation strategies were independent risk factors for hypoxemia during OLV. Subgroup analysis revealed no significant difference in intraoperative hypoxemia during OLV between respondents who performed lung-protective ventilation strategies and those who did not.

Lung-protective ventilation strategies during OLV have been widely accepted in mainland China and are strongly recommended for esophageal surgery, particularly in tier 2 hospitals. Implementing volume control ventilation mode and early management of oxygen desaturation might prevent hypoxemia during OLV.

This study aimed to investigate whether driving pressure-guided ventilation can reduce postoperative pulmonary complications in patients who have undergone heart transplantation. Patients who underwent orthotopic heart transplantation were divided into two groups according to the perioperative ventilation strategy: (1) conventional lung-protective ventilation (group C) and (2) driving pressure-guided ventilation (group D). The primary outcome was the occurrence of postoperative pulmonary complications within 30 days of surgery. Univariate and multivariate logistic regression analyses were performed to evaluate the independent risk factors associated with postoperative pulmonary complications (PPCs). Compared with group C, patients in group D exhibited lower driving pressure. Oxygenation improved significantly in the early period after surgery in patients in group D. Group C exhibited a higher number of patients with postoperative pulmonary complications, especially respiratory infections and atelectasis. Patients in group D experienced a shorter duration of postoperative mechanical ventilation and a shorter stay in the intensive care unit. The conventional ventilation strategy, the high driving pressure level and the low PaO2 value at the end of the surgery were the independent risk factors for PPCs in heart transplantation. Compared with conventional lung-protective ventilation, driving pressure-guided ventilation was associated with improved pulmonary oxygenation and lower incidences of pulmonary complications among patients after heart transplantation.

Transhiatal esophagectomy (THE) is used for specific gastroesophageal junction adenocarcinomas. THE is a high-risk surgical procedure. We aimed to assess the impact of postoperative sepsis (sepsis or septic shock) on the 1-year mortality after THE and to determine the risk factors associated with these outcomes. Secondly, we aimed to assess the impact of postoperative sepsis and other risk factors on 1-year cancer recurrence.

A retrospective, observational study was undertaken at the Paoli-Calmettes Institute, Marseille, from January 2012 to March 2022.

Of 118 patients, 24.6% (n = 29) presented with postoperative sepsis. Their 1-year mortality was 11% (n = 13), and their 1-year cancer recurrence was 23.7% (n = 28). In the multivariate analysis, independent factors for 1-year mortality were the following: postoperative sepsis (OR: 7.22 (1.11-47); p = 0.038), number of lymph nodes removed (OR: 0. 78 (0.64-0.95); p = 0.011), recurrence at one year (OR: 9.22 (1.66-51.1); p = 0.011), mediastinitis (OR: 17.7 (1.43-220); p = 0.025) and intraoperative driving pressure (OR: 1.77 (1.17-2.68); p = 0.015). For postoperative sepsis, independent factors were low-dose vasopressors (OR: 0.26; 95% CI: 0.07-0.95; p = 0.049), a cervical abscess (OR: 5.33; 95% CI: 1.5-18.9; p = 0.01), bacterial pneumonia (OR: 11.1; 95% CI: 2.99-41.0; p < 0.001) and a high SOFA score on day 1 (OR: 2.65; 95% CI: 1.36-5.19; p = 0.04). For 1-year cancer recurrence, independent factors were the number of lymph nodes removed (sHR: 0.87; 95% CI: 0.79-0.96; p = 0.005), pTNM stages of III or IV (sHR: 8.29; 95% CI: 2.71-25.32; p < 0.001) and postoperative sepsis (sHR: 6.54; 95% CI: 1.70-25.13; p = 0.005).

Our study indicates that after THE, postoperative sepsis influences survival and cancer recurrence. We identified the associated risk factors, suggesting an early diagnosis might decrease mortality and recurrence.

The effect of different mechanical ventilation modes on pulmonary outcome after abdominal surgery remains unclear. We evaluated the effects of three common ventilation modes on postoperative pulmonary complications (PPCs) among intermediate- to high-risk patients undergoing abdominal surgery.

This randomized clinical trial enrolled adult patients at intermediate or high risk of PPCs who were scheduled for abdominal surgery. Participants were randomized to receive one of three modes of mechanical ventilation modes: volume-controlled ventilation (VCV), pressure-controlled ventilation (PCV), and pressure-control with volume-guaranteed ventilation (PCV-VG). Lung-protective ventilation strategy was implemented in all groups. The primary outcome was the incidence of a composite of pulmonary complications within the first 7 postoperative days. Pulmonary complications within 30 postoperative days, the severity grade of PPCs, and other secondary outcomes were also analyzed.

A total of 1365 patients were randomized and 1349 were analyzed. The primary outcome occurred in 98 (21.8%) in the VCV group, 95 (22.1%) in the PCV group, and 101 (22.5%) in the PCV-VG group (P = 0.865). Additionally, there were no statistically significant differences among the three groups in terms of the incidence of pulmonary complications within postoperative 30 days, severity grade of PPCs, and other secondary outcomes.

In intermediate- to high-risk patients undergoing abdominal surgery, the choice of ventilation mode did not affect the risk of PPCs.

Chinese Clinical Trial Registry, entry ChiCTR1900025880.

Thoracic epidural anesthesia (TEA) is associated with a knowledge gap regarding its mechanisms in lung protection and reduction of postoperative pulmonary complications (PPCs). Driving pressure (ΔP), an alternative indicator of alveolar strain, is closely linked to reduced PPCs with lower ΔP values. We aim to investigate whether TEA contributes to lung protection by lowering ΔP during mechanical ventilation.

In this prospective, randomized, patient and evaluator-blinded parallel study, adult patients scheduled for elective major upper abdominal surgery were assigned to either the TEA group with combined thoracic epidural anesthesia and general anesthesia (TEA-GA) (n = 30) or the control group with only general anesthesia (GA) (n = 30).

The primary outcome was the minimum ΔP determined based on positive end-expiratory pressure (PEEP) after intubation. Secondary outcomes included the incidence of PPCs within seven days, the minimum ΔP at various time points, blood gas analysis, intensive care unit (ICU) admission rates, length of hospital stay, and 30-day mortality rate.

The TEA group had a significantly lower minimum ΔP titrated based on PEEP compared to the control group (11.23 ± 2.19 cmH2O vs. 12.67 ± 2.70 cmH2O; P = 0.028). Multivariate linear regression analysis showed that intraoperative TEA application (compared with its absence; unstandardized beta coefficient (B) = -1.289; P = 0.008) significantly correlated with ΔP. The incidence of PPCs did not differ significantly between the two groups (8 of 30 [26.7%] vs. 12 of 30 [40%]; P = 0.273), but the incidence of atelectasis in the TEA group was significantly lower than in the control group (5 of 30 [16.7%] vs. 12 of 30 [40.7%]; P = 0.012). Multivariate logistic regression analysis indicated that ΔP was the only variable significantly associated with PPCs (Adjusted Odds Ratio [OR] = 2.190; 95% Confidence Interval [CI]: 1.300 to 3.689; P = 0.003).

Compared to GA, TEA-GA can reduce intraoperative ΔP in patients undergoing major upper abdominal surgery, especially those undergoing laparoscopic surgery. However, compared to GA combined with ΔP-guided ventilation, TEA-GA combined with ΔP-guided ventilation does not reduce the risk of PPCs. There was no significant difference in the total use of various vasoactive drugs between the two groups.

This study was registered in the Chinese Clinical Trial Registry (registration number ChiCTR2300068778 date of registration February 28, 2023).

Electrical impedance tomography (EIT) has been used to titrate positive end-expiratory pressure (PEEP). This study aims to develop a comprehensive view of the efficacy and long-term prognosis of EIT-guided PEEP compared to other conventional approaches in various clinical scenarios, including patients with acute respiratory distress syndrome (ARDS), hypoxemic acute respiratory failure (hARF) and patients undergoing surgery under general anesthesia.

The literature search was conducted in PubMed, Web of Science, Embase, and Cochrane Library, from inception to July 30, 2023 (ARDS/hARF) and October 5, 2023 (surgery). The Cochrane risk of bias assessment and the methodological index for non-randomized studies were used for quality appraisal. The main outcomes were PEEP level, PaO2/FiO2 ratio, lung/respiratory system compliance (CL/Crs), driving pressure (ΔP), in-hospital mortality, and postoperative pulmonary complications (PPCs) in surgical studies.

Four randomized controlled trials (RCTs), one historical control study, and six before-after studies of ARDS/hARF, as well as eight surgical RCTs, were retrieved. Subgroup analysis has been carried out and analysis of before-after studies was performed separately. Diverse PEEP strategies were adopted in the included studies, such as low/high PEEP-FiO2-table of ARDS-net, pressure-volume loop, and transpulmonary pressure. In ARDS/hARF studies, the EIT strategy did not result in considerably enhanced respiratory system mechanics, including comparable PaO2/FiO2 ratios, comparable ΔP, and increased CL/Crs. As for long-term prognosis, the rough overall meta-analysis showed decreased in-hospital mortality (risk ratio RR = 1.54, 95% CI = (1.09, 2.18), P = 0.01). In patients undergoing general anesthesia surgery, the EIT group demonstrated increased PaO2/FiO2 ratio, CL/Crs, and decreased ΔP versus the fixed 4 or 5 cmH2O PEEP. In postoperative prognosis, incidence of PPCs was generally comparable between the two groups.

The EIT-derived PEEP setting strategy might be associated with potential benefits in respiratory outcomes and prognosis in ARDS/hARF and surgical patients. Current data is insufficient to provide solid evidence.

Postoperative pulmonary complications (PPCs) are common in patients undergoing general anesthesia, with atelectasis being a key contributor that increases postoperative mortality and prolongs hospitalization. Our research hypothesis is that ultrasound-guided individualized PEEP titration can reduce postoperative atelectasis. This single-center randomized controlled trial recruited elderly patients for laparoscopic surgery. Patients were randomly assigned to two group: the study group (individualized PEEP groups, PEEP Ind group) and the control group (Fixed PEEP group, PEEP 5 group). All patients in these two groups received volume-controlled ventilation during general anesthesia. Patients in the study group were given ultrasound-guided PEEP, while those in the control group were given a fixed 5 cmH2O PEEP. Bedside ultrasound assessed lung ventilation. The primary outcome was the severity of atelectasis within seven days post-surgery. Eighty-nine patients scheduled for elective laparoscopic radical surgery for colorectal cancer were enrolled in our study. Lung ultrasound scores (LUSs) in the study group during postoperative seven days was significantly decreased compared with that in the control group (P < 0.05). The severity of postoperative atelectasis in the study group was significantly improved. The incidence of PPCs during postoperative 7 days in the study group was significantly less than that in the control group (48.6% vs. 77.8%; RR = 0.625; CI = 0.430-0.909; P = 0.01). In elderly patients undergoing laparoscopic radical resection, lung ultrasound-guided individualized PEEP can alleviate the severity of postoperative atelectasis.Clinical trial number and registry URL: No. ChiCTR2200062979 ( https://www.chictr.org.cn ).

Background: Progressive atelectasis regularly occurs during general anaesthesia; hence, positive end-expiratory pressure (PEEP) is often applied. Individualised PEEP titration may reduce the incidence of postoperative pulmonary complications (PPCs) and improve oxygenation as compared to fixed PEEP settings; however, evidence is lacking. Methods: This systematic review and meta-analysis was registered on PROSPERO (CRD42021282228). A systematic search in four databases (MEDLINE Via PubMed, EMBASE, CENTRAL, and Web of Science) was performed on 14 October 2021 and updated on 26 April 2024. We searched for randomised controlled trials comparing the effects of individually titrated versus fixed PEEP strategies during abdominal surgeries. The primary endpoint was the incidence of PPCs. The secondary endpoints included the PaO2/FiO2 at the end of surgery, individually set PEEP value, vasopressor requirements, and respiratory mechanics. Results: We identified 30 trials (2602 patients). The incidence of PPCs was significantly lower among patients in the individualised group (RR = 0.70, CI: 0.58-0.84). A significantly higher PaO2/FiO2 ratio was found in the individualised group as compared to controls at the end of the surgery (MD = 55.99 mmHg, 95% CI: 31.78-80.21). Individual PEEP was significantly higher as compared to conventional settings (MD = 6.27 cm H2O, CI: 4.30-8.23). Fewer patients in the control group needed vasopressor support; however, this result was non-significant. Lung-function-related outcomes showed better respiratory mechanics in the individualised group (Cstat: MD = 11.92 cm H2O 95% CI: 6.40-17.45). Conclusions: Our results show that individually titrated PEEP results in fewer PPCs and better oxygenation in patients undergoing abdominal surgery.

Background: This study aimed to investigate the associations between dyscapnia, ventilatory variables, and mortality. We hypothesized that the association between mechanical power or ventilatory ratio and survival is mediated by dyscapnia. Methods: Patients with moderate or severe acute respiratory distress syndrome (ARDS), who received mechanical ventilation within the first 48 h after admission to the intensive care unit for at least 48 h, were included in this retrospective single-center study. Values of arterial carbon dioxide (PaCO2) were categorized into "hypercapnia" (PaCO2 ≥ 50 mm Hg), "normocapnia" (PaCO2 36-49 mmHg), and "hypocapnia" (PaCO2 ≤ 35 mm Hg). We used path analyses to assess the associations between ventilatory variables (mechanical power and ventilatory ratio) and mortality, where hypocapnia or hypercapnia were included as mediating variables. Results: Between December 2017 and April 2021, 435 patients were included. While there was a significant association between mechanical power and hypercapnia (BEM = 0.24 [95% CI: 0.15; 0.34], P < .01), there was no significant association between mechanical power or hypercapnia and ICU mortality. The association between mechanical power and intensive care unit (ICU) mortality was fully mediated by hypocapnia (BEM = -0.10 [95% CI: -0.19; 0.00], P = .05; BMO = 0.38 [95% CI: 0.13; 0.63], P < .01). Ventilatory ratio was significantly associated with hypercapnia (B = 0.23 [95% CI: 0.14; 0.32], P < .01). There was no significant association between ventilatory ratio, hypercapnia, and mortality. There was a significant effect of ventilatory ratio on mortality, which was fully mediated by hypocapnia (BEM = -0.14 [95% CI: -0.24; -0.05], P < .01; BMO = 0.37 [95% CI: 0.12; 0.62], P < .01). Conclusion: In mechanically ventilated patients with moderate or severe ARDS, the association between mechanical power and mortality was fully mediated by hypocapnia. Likewise, there was a mediating effect of hypocapnia on the association between ventilatory ratio and ICU mortality. Our results indicate that the debate on dyscapnia and outcome after ARDS should consider the impact of ventilatory variables.

A low dynamic driving pressure during mechanical ventilation for general anesthesia has been associated with a lower risk of postoperative respiratory complications (PRC), a key driver of healthcare costs. It is, however, unclear whether maintaining low driving pressure is clinically relevant to measure and contain costs. We hypothesized that a lower dynamic driving pressure is associated with lower costs.

Multicenter retrospective cohort study.

Two academic healthcare networks in New York and Massachusetts, USA.

46,715 adult surgical patients undergoing general anesthesia for non-ambulatory (inpatient and same-day admission) surgery between 2016 and 2021.

The primary exposure was the median intraoperative dynamic driving pressure.

The primary outcome was direct perioperative healthcare-associated costs, which were matched with data from the Healthcare Cost and Utilization Project-National Inpatient Sample (HCUP-NIS) to report absolute differences in total costs in United States Dollars (US$). We assessed effect modification by patients' baseline risk of PRC (score for prediction of postoperative respiratory complications [SPORC] ≥ 7) and effect mediation by rates of PRC (including post-extubation saturation < 90%, re-intubation or non-invasive ventilation within 7 days) and other major complications.

The median intraoperative dynamic driving pressure was 17.2cmH2O (IQR 14.0-21.3cmH2O). In adjusted analyses, every 5cmH2O reduction in dynamic driving pressure was associated with a decrease of -0.7% in direct perioperative healthcare-associated costs (95%CI -1.3 to -0.1%; p = 0.020). When a dynamic driving pressure below 15cmH2O was maintained, -US$340 lower total perioperative healthcare-associated costs were observed (95%CI -US$546 to -US$132; p = 0.001). This association was limited to patients at high baseline risk of PRC (n = 4059; -US$1755;97.5%CI -US$2495 to -US$986; p < 0.001), where lower risks of PRC and other major complications mediated 10.7% and 7.2% of this association (p < 0.001 and p = 0.015, respectively).

Intraoperative mechanical ventilation targeting low dynamic driving pressures could be a relevant measure to reduce perioperative healthcare-associated costs in high-risk patients.

Long-term pulmonary complications have been reported after a coronavirus disease-2019 (COVID-19). We hypothesized that a history of COVID-19 is associated with a measurable decrease in baseline respiratory system compliance in patients undergoing general anesthesia.

In this hospital registry study, we included adult patients undergoing general anesthesia between January 2020 and March 2022 at a tertiary health care network in Massachusetts. We excluded patients with an American Society of Anesthesiologists physical status >IV, laryngoscopic surgeries, and patients who arrived intubated. The primary exposure was a history of COVID-19. The primary outcome was baseline respiratory system compliance (mL/cmH 2 O). Effects of severity of infection, surges (Alpha 1 , Alpha 2 , Delta, and Omicron), patient demographics, and time between infection and assessment of compliance were investigated.

A total of 19,921 patients were included. Approximately 1386 (7.0%) patients had a history of COVID-19. A history of COVID-19 at any time before surgery was associated with a measurably lower baseline respiratory system compliance (ratio of means adj = 0.96; 95% confidence interval [CI], 0.94-0.97; P < .001; adjusted compliance difference: -1.6 mL/cmH 2 O). The association was more pronounced in patients with a severe form of COVID-19 (ratio of means adj = 0.95; 95% CI, 0.90-0.99; P = .02, adjusted compliance difference: -2 mL/cmH 2 O). Alpha 1 , Alpha 2 , and Delta surges, but not Omicron, led to a lower baseline respiratory system compliance ( P < .001, P = .02, and P < .001). The Delta surge effect was magnified in Hispanic ethnicity ( P -for-interaction = 0.003; ratio of means adj = 0.83; 95% CI, 0.74-0.93; P = .001; adjusted compliance difference: -4.6 mL/cmH 2 O).

A history of COVID-19 infection during Alpha 1 , Alpha 2 , and Delta surges was associated with a measurably lower baseline respiratory system compliance.

The reduction in functional residual capacity (FRC) is a significant pathological factor in the development of postoperative pulmonary complications. Appropriate positive end-expiratory pressure (PEEP) is critical to preserve FRC during mechanical ventilation. Our previous study suggests that using driving pressure-guided PEEP can reduce postoperative pulmonary complications. In this study, we hypothesize that individualized PEEP can increase immediate postoperative FRC and improve lung ventilation.

This single-centered, randomized controlled trial included a total of 91 patients scheduled for laparoscopic surgery for colorectal carcinoma. Patients were randomly assigned to receive individualized PEEP guided by minimum driving pressure or a fixed PEEP of six cmH2O. The primary outcome was postoperative FRC. Secondary outcomes included the incidence of postoperative pulmonary complications, postoperative Oxygenation Index, alveolar-arterial oxygen tension difference (PA-aO2), intrapulmonary shunt (QS/QT), and Respiratory Index, as well as lung ventilation measured by electrical impedance tomography.

The median value of PEEP in the individualized group was 14 cmH2O, with an interquartile range of 12-14 cmH2O. The postoperative FRC was significantly higher in the individualized PEEP group than that in the PEEP six cmH2O group (32.8 [12.8] vs. 25.0 [12.6] mL/kg, P=0.004). Patients receiving driving pressure-guided PEEP also had significantly higher Oxygenation Index, better ventilation distribution, and lower PA-aO2, QS/QT, and Respiratory Index.

Driving pressure-guided PEEP can preserve postoperative FRC and provide better ventilation and oxygenation for patients undergoing laparoscopic colorectal surgery.

Preterm infants close to viability commonly require mechanical ventilation (MV) for respiratory distress syndrome. Despite commonly used lung-sparing ventilation techniques, rapid lung expansion during MV induces lung injury, a risk factor for bronchopulmonary dysplasia. This study investigates whether ventilation with optimized lung expansion is feasible and whether it can further minimize lung injury. Therefore, optimized lung expansion ventilation (OLEV) was compared to conventional volume targeted ventilation.

Twenty preterm lambs were surgically delivered after 132 days of gestation. Nine animals were randomized to receive OLEV for 24 h, and seven received standard MV. Four unventilated animals served as controls (NV). Lungs were sampled for histological analysis at the end of the experimental period.

Ventilation with OLEV was feasible, resulting in a significantly higher mean ventilation pressure (0.7-1.3 mbar). Temporary differences in oxygenation between OLEV and MV did not reach clinically relevant levels. Ventilation in general tended to result in higher lung injury scores compared to NV, without differences between OLEV and MV. While pro-inflammatory tumor necrosis factor-α messenger RNA (mRNA) levels increased in both ventilation groups compared to NV, only animals in the MV group showed a higher number of CD45-positive cells in the lung. In contrast, mean (standard deviations) surfactant protein-B mRNA levels were significantly lower in OLEV, 0.63 (0.38) compared to NV 1.03 (0.32) (p = .023, one-way analysis of variance).

In conclusion, a small reduction in pulmonary inflammation after 24 h of support with OLEV suggests potential to reduce preterm lung injury.

Intraoperative driving pressure (ΔP) has an independent association with the development of postoperative pulmonary complications (PPCs) in patients receiving ventilation during general anesthesia for major surgery. Ventilation with high intraoperative positive end-expiratory pressure (PEEP) with recruitment maneuvers (RMs) that result in a low ΔP has the potential to prevent PPCs. This trial tests the hypothesis that compared to standard low PEEP without RMs, an individualized high PEEP strategy, titrated to the lowest ΔP, with RMs prevents PPCs in patients receiving intraoperative protective ventilation during anesthesia for minimally invasive abdominal surgery.

"DrivinG prEssure duriNg gEneRal AnesThesia fOr minimally invasive abdominal suRgery (GENERATOR)" is an international, multicenter, two-group, patient and outcome-assessor blinded randomized clinical trial. In total, 1806 adult patients scheduled for minimally invasive abdominal surgery and with an increased risk of PPCs based on (i) the ARISCAT risk score for PPCs (≥ 26 points) and/or (ii) a combination of age > 40 years and scheduled surgery lasting > 2 h and planned to receive an intra-arterial catheter for blood pressure monitoring during the surgery will be included. Patients are assigned to either an intraoperative ventilation strategy with individualized high PEEP, titrated to the lowest ΔP, with RMs or one with a standard low PEEP of 5 cm H2O without RMs. The primary outcome is a collapsed composite endpoint of PPCs until postoperative day 5.

GENERATOR will be the first adequately powered randomized clinical trial to compare the effects of individualized high PEEP with RMs versus standard low PEEP without RMs on the occurrence of PPCs after minimally invasive abdominal surgery. The results of the GENERATOR trial will support anesthesiologists in their decisions regarding PEEP settings during minimally invasive abdominal surgery.

GENERATOR is registered at ClinicalTrials.gov (study identifier: NCT06101511) on 26 October 2023.

Objective: To explore the complications of long-term placement of Montgomery T silicone stent (T-tube) in the treatment of subglottic benign airway stenosis (SBAS) and the timing of successful T-tube removal. Methods: We retrospectively collected the clinical data of 32 patients with SBAS who underwent the treatment of T-tube and analyzed their placement and successful removal of the T-tube. Results: There were 22 males and 10 females, aged from 21 to 79 years (60.9 ± 13.7 years). The T-tubes were successfully placed in all 32 patients, and 6 patients (18.8%) with mild stenosis were placed by the intravenous conscious sedation. The longest follow-up period was 60.4 months, and 17 patients (53.1%) had the T-tubes for more than 12 months; 5 patients (15.6%) were changed to the tracheostomy cannula after unplanned removal of the T-tubes for various reasons; the T-tubes were successfully removed in 9 patients (28.1%), and the duration of T-tubes placement was 5.2-22.7 months (12.1 ± 6.3 months), among them anatomical stenosis in 9 patients (100%). Secretion retention was observed in 32 patients (100%), granulation tissue hyperplasia was observed in 9 patients (28.1%), and the normal ventilation was not affected in most patients by bronchoscopic treatment and follow-up; the T-tubes were removed in 3 patients due to severe complications. There was no significant difference in the incidences of secretion retention and granulation tissue hyperplasia between the time point at 1 week, 1 month, 3 months, and 12 months, p > 0.05. In patients with T-tube more than 12 months, the severity of secretion retention at 1 week, 1 month, 3 months, and 12 months was significantly different, p < 0.05, however, there was no significant difference in the severity of granulation tissue hyperplasia, p > 0.05. Conclusions: T-tube is safe and effective in the treatment of SBAS. The severity of secretion retention increased in patients with long-term placement of the T-tube. For patients with mild stenosis and anatomical stenosis, the T-tube removal can be attempted at about 1 year of follow-up.

Robotic-assisted laparoscopic radical prostatectomy (RALP) requires pneumoperitoneum and steep Trendelenburg position. Our aim was to investigate the influence of the combination of pneumoperitoneum and Trendelenburg position on mechanical power and its components during RALP.

Sixty-one prospectively enrolled patients scheduled for RALP were studied in supine position before surgery, during pneumoperitoneum and Trendelenburg position and in supine position after surgery at constant ventilatory setting. In a subgroup of 17 patients the response to increasing positive end-expiratory pressure (PEEP) from 5 to 10 cmH2O was studied.

The application of pneumoperitoneum and Trendelenburg position increased the total mechanical power (13.8 [11.6 - 15.5] vs 9.2 [7.5 - 11.7] J/min, p < 0.001) and its elastic and resistive components compared to supine position before surgery. In supine position after surgery the total mechanical power and its elastic component decreased but remained higher compared to supine position before surgery. Increasing PEEP from 5 to 10 cmH2O within each timepoint significantly increased the total mechanical power (supine position before surgery: 9.8 [8.4 - 10.4] vs 12.1 [11.4 - 14.2] J/min, p < 0.001; pneumoperitoneum and Trendelenburg position: 13.8 [12.2 - 14.3] vs 15.5 [15.0 - 16.7] J/min, p < 0.001; supine position after surgery: 10.2 [9.4 - 10.7] vs 12.7 [12.0 - 13.6] J/min, p < 0.001), without affecting respiratory system elastance.

Mechanical power in healthy patients undergoing RALP significantly increased both during the pneumoperitoneum and Trendelenburg position and in supine position after surgery. PEEP always increased mechanical power without ameliorating the respiratory system elastance.

Intraoperative bleeding is one of the major challenges in rhinoplasty.

This study aimed to evaluate the effect of pressure-controlled ventilation (PCV) versus volume-controlled ventilation (VCV) modes on intraoperative bleeding during rhinoplasty.

In a double-blinded randomized clinical trial, 58 candidates for rhinoplasty were randomly assigned to the PCV or VCV groups. Anesthesia was induced and maintained using the same total intravenous anesthesia (TIVA) method in both groups. The amount of bleeding was assessed by counting blood-soaked gauze and measuring the content of the suctioned fluid. Additionally, bleeding in the surgical field was assessed by the surgeon using the Boezaart criterion.

The mean intraoperative bleeding volume was 30 ± 45 mL in the PCV group and 100 ± 120 mL in the VCV group (P < 0.001). According to logistic regression analysis, the odds of experiencing moderately severe or severe bleeding in the VCV group were 5.4 times higher than in the PCV group. After adjusting for confounding variables, the odds ratio increased to 26.8 (95% CI = 1.2, 59.3).

The results of the study suggest that the pressure-controlled mode may lead to lower intraoperative bleeding compared to the volume-controlled mode. The decrease in peak airway pressure is likely a contributing factor to this observation.

Postoperative pulmonary complications (PPCs) vary amongst different surgical techniques. We aim to compare the incidence of PPCs after laparoscopic non-robotic versus laparoscopic robotic abdominal surgery.

LapRas (Risk Factors for PPCs in Laparoscopic Non-robotic vs Laparoscopic robotic abdominal surgery) incorporates harmonized data from 2 observational studies on abdominal surgery patients and PPCs: 'Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS), and 'Assessment of Ventilation during general AnesThesia for Robotic surgery' (AVATaR). The primary endpoint is the occurrence of one or more PPCs in the first five postoperative days. Secondary endpoints include the occurrence of each individual PPC, hospital length of stay and in-hospital mortality. Logistic regression models will be used to identify risk factors for PPCs in laparoscopic non-robotic versus laparoscopic robotic abdominal surgery. We will investigate whether differences in the occurrence of PPCs between the two groups are driven by differences in duration of anesthesia and/or the intensity of mechanical ventilation.

This analysis will address a clinically relevant research question comparing laparoscopic and robotic assisted surgery. No additional ethical committee approval is required for this metanalysis. Data will be shared with the scientific community by abstracts and original articles submitted to peer-reviewed journals.

The registration of this post-hoc analysis is pending; individual studies that were merged into the used database were registered at clinicaltrials.gov: LAS VEGAS with identifier NCT01601223, AVATaR with identifier NCT02989415.