CRIT CLOUD

  • Summaries & Reviews
    • Airway
    • Cardiovascular
    • Controversies
    • Endocrinology
    • Fluids
    • Guidelines
    • Infections
    • Neurology
    • Nutrition
    • Pharmacology
    • Procedures
    • Radiology
    • Renal
    • Resuscitiation
    • Respiratory
    • Sedation
    • Sepsis
    • Transfusion
  • World of Foam
  • FOAM.education
  • Education
    • ACLS Training ICU Lindenhofspital
    • Download Presentations
    • Download CME Galway Clinic 🔒
    • Download CME Lindenhof Hospital 🔒
    • Echo 🔒
    • Presentations🔒
    • Multimedia
  • About Us
    • Contact
  • Summaries & Reviews
    • Airway
    • Cardiovascular
    • Controversies
    • Endocrinology
    • Fluids
    • Guidelines
    • Infections
    • Neurology
    • Nutrition
    • Pharmacology
    • Procedures
    • Radiology
    • Renal
    • Resuscitiation
    • Respiratory
    • Sedation
    • Sepsis
    • Transfusion
  • World of Foam
  • FOAM.education
  • Education
    • ACLS Training ICU Lindenhofspital
    • Download Presentations
    • Download CME Galway Clinic 🔒
    • Download CME Lindenhof Hospital 🔒
    • Echo 🔒
    • Presentations🔒
    • Multimedia
  • About Us
    • Contact

Reviews and Summaries

PROVHILO - Why Is PEEP Never Adjusted to Weight while Tidal Volumes Are?

19/6/2014

 
Picture
The Lancet has now published the multi-centre study (PROVHILO) which has looked at the role of positive end-expiratory pressure (PEEP) for mechanical ventilation during general anaesthesia. For that reason the PROVE network investigators have included almost 900 patients in a randomised controlled trial who were planned for open abdominal surgery. All patients were ventilated with a tidal volume (Vt) of 8ml/kg. One group received a PEEP of 12 cmH2O and recruitement maneuvres while the other group got alomst no PEEP (<2 cmH2O) and no recruitement maneuvres. Primary endpoint were pulmonary compications on day 5 postoperatively. They found no difference in pulmonary complications but significantly more introperative hypotension and use of vasoactive agents in the higher PEEP group.
So the investigators conclude that a higher level of PEEP and recruitment maneuvres do not protect against postoperative pulmonary complications. They actually advise to use low tidal volumes and very low PEEP for intraoperative ventilation.

The multicenter study is well designed and performed but some questions remain:

Why is PEEP never adjusted to weight?
One striking feature is that we all use tidal volumes according to the patients body weight, but interestingly nobody seems to use this adjustement for weight when it comes to PEEP. Using a PEEP of 12 in a small and slim 50kg patient has a different impact compared to a massively obese patient.

Is 12 cmH2O too high?
A PEEP of 12 can be considered generally high and is not used by most anaesthetists in their daily practice anyway. There was no third arm using intermediate levels of PEEP to answer the question on how these patient might have performed.

Why did other trial find differing conclusions?
The aspect of different levels of PEEP is interesting as previous studies actually were able to show improved outcome with 'protective' mechanical ventilation. The IMPROVE trial in the NEJM from Augut 2013 compared patients for abdominal surgery ventilated with Vt of 10-12ml/kg and 0 cmH2O of PEEP to patients ventilated with Vt of 6-8ml/kg and 6-10 cmH2O of PEEP. In this multicenter, double blind trial with 400 patients improved outcome and reduced health care utilazation were found in the group 'protectively' ventilated.

In june 2013 Anaesthesiology published a prospective randomized small trial with 56 patients undergoing open abdominal surgery for more than 2 hours. This time they compared Vt of 9ml/kg and O PEEP to Vt of 7ml/kg and 10 PEEP. This time 'protective' ventilation with PEEP improved respiratory function but did not affect length of hospital stay.


Taking these fact into account I think we remain with following conclusions:

- The PROVHILO trial is not reason enough to abandon PEEP for anaesthetic ventilation in theatre

- Instead we might have to consider adjusting PEEP to the patients clinical condition (e.g. weight)

- There is no evidence currently to recommend routine recruitment maneuvers in theatre



The Prove Network Investigators, The Lancet, Early Online Publication, 1 June 2014


Comments are closed.

    Search


    ​Translate

    Select your language above. Beware: Google Translate is often imprecise and might result in incorrect phrases!

    Picture


    ​Categories

    All
    Airway
    Cardiovascular
    Controversies
    Endocrinology
    Fluids
    For A Smile ; )
    Guidelines
    Infections
    Meducation
    Neurology
    Nutrition
    Pharmacology
    Procedures
    Radiology
    Renal
    Respiratory
    Resuscitation
    SARS CoV 2
    SARS-CoV-2
    Sedation
    Sepsis
    Transfusion

    Archives

    January 2021
    September 2020
    March 2020
    February 2020
    January 2020
    December 2019
    November 2019
    July 2019
    May 2019
    March 2019
    February 2019
    January 2019
    December 2018
    January 2018
    October 2017
    August 2017
    June 2017
    March 2017
    February 2017
    January 2017
    October 2016
    July 2016
    June 2016
    April 2016
    February 2016
    December 2015
    October 2015
    September 2015
    August 2015
    July 2015
    June 2015
    May 2015
    April 2015
    March 2015
    January 2015
    December 2014
    November 2014
    October 2014
    September 2014
    August 2014
    July 2014
    June 2014
    May 2014
    April 2014
    March 2014
    February 2014
    January 2014
    December 2013
    November 2013

    Author

    Timothy Aebi

    RSS Feed

ABOUT US

The Crit ☁​ supports free access medical education. The content of this website can be used and reproduced by stating a reference to our site.
Read our statements here

SEARCH US

CONTACT US

If you have any interesting article or news to be posted on this website, please contact us here
​

FOLLOW US

TRUST US

TWEET US

This website is certified by Health On the Net Foundation. Click to verify. This site complies with the HONcode standard for trustworthy health information:
verify here.

Picture
Follow @BIJCorg

DISCOVER THE WORLD OF #FOAMed HERE
Picture