Positive end-expiratory pressure (PEEP) during anaesthesia for the prevention of mortality and postoperative pulmonary complications.
BACKGROUND
General anaesthesia causes atelectasis which can lead to impaired respiratory function. Positive end-expiratory pressure (PEEP) is a mechanical manoeuvre which increases functional residual capacity (FRC) and prevents collapse of the airways thereby reducing atelectasis. It is not known whether intra-operative PEEP alters the risk of postoperative mortality and pulmonary complications.


OBJECTIVE
To assess the benefits and harms of intraoperative PEEP, for all adult surgical patients, on postoperative mortality and pulmonary outcomes.


METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2009, Issue 4), MEDLINE (via Ovid) (1966 to January 2010), EMBASE (via Ovid) (1980 to January 2010), CINAHL (via EBSCOhost) (1982 to January 2010), ISI Web of Science (1945 to January 2010) and LILACS (via BIREME interface) (1982 to January 2010).


METHODS
We included randomized clinical trials that evaluated the effect of PEEP versus no PEEP, during general anaesthesia, on postoperative mortality and postoperative respiratory complications. We included studies irrespective of language and publication status.


METHODS
Two investigators independently selected papers, extracted data that fulfilled our outcome criteria and assessed the quality of all included trials. We undertook pooled analyses, where appropriate. For our primary outcome (mortality) and two secondary outcomes (respiratory failure and pneumonia), we calculated the number of further patients needed (information size) in order to make reliable conclusions.


RESULTS
We included eight randomized trials with a total of 330 patients. Two trials had a low risk of bias. There was no difference demonstrated for mortality (relative risk (RR) 0.95, 95% CI 0.14 to 6.39). Two statistically significant results were found: the PEEP group had a higher PaO(2)/FiO(2) on day 1 postoperatively (mean difference (MD) 22.98, 95% CI 4.40 to 41.55) and postoperative atelectasis (defined as an area of collapsed lung, quantified by computerized tomography (CT) scan) was less in the PEEP group (SMD -1.2, 95% CI -1.78 to -0.79). There were no adverse events reported in the three trials that adequately measured these outcomes (barotrauma and cardiac complications). Using information size calculations, we estimated that a further 21,200 patients would need to be randomized in order to make a reliable conclusion about PEEP and mortality.


CONCLUSIONS
There is currently insufficient evidence to make conclusions about whether intraoperative PEEP alters the risk of postoperative mortality and respiratory complications among undifferentiated surgical patients.
Imberger
Georgina
G
The Cochrane Anaesthesia Review Group, Rigshospitalet, Blegdamsvej 9,, Afsnit 3342, København, Denmark, 2100.
McIlroy
David
D
Pace
Nathan Leon
NL
Wetterslev
Jørn
J
Brok
Jesper
J
Møller
Ann Merete
AM
D000328:Adult; D000768:Anesthesia, General / Q000009:adverse effects*; D006801:Humans; D011014:Pneumonia / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D011175:Positive-Pressure Respiration / Q000009:adverse effects / Q000379:methods*; D011183:Postoperative Complications / Q000401:mortality / Q000517:prevention & control*; D001261:Pulmonary Atelectasis / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic; D012131:Respiratory Insufficiency / Q000209:etiology / Q000401:mortality / Q000517:prevention & control*