title: Efficacy of a Low-Tidal Volume Ventilation Strategy to Prevent Reperfusion Lung Injury after Pulmonary Thromboendarterectomy.
abstract: BACKGROUND
  Reperfusion lung injury is a postoperative complication of pulmonary thromboendarterectomy that can significantly affect morbidity and mortality. Studies in other postoperative patient populations have demonstrated a reduction in acute lung injury with the use of a low-tidal volume (Vt) ventilation strategy. Whether this approach benefits patients undergoing thromboendarterectomy is unknown.
  
  
  OBJECTIVE
  We sought to determine if low-Vt ventilation reduces reperfusion lung injury in patients with chronic thromboembolic pulmonary hypertension undergoing thromboendarterectomy.
  
  
  METHODS
  Patients undergoing thromboendarterectomy at one center were randomized to receive either low (6 ml/kg predicted body weight) or usual care Vts (10 ml/kg) from the initiation of mechanical ventilation in the operating room through Postoperative Day 3. The primary endpoint was the onset of reperfusion lung injury. Secondary outcomes included severity of hypoxemia, days on mechanical ventilation, and intensive care unit and hospital lengths of stay.
  
  
  RESULTS
  A total of 128 patients were enrolled and included in the analysis; 63 were randomized to the low-Vt group and 65 were randomized to the usual care group. There was no statistically significant difference in the incidence of reperfusion lung injury between groups (32%, n=20 in the low-Vt group vs. 23%, n=15 in the usual care group; P=0.367). Although differences were noted in plateau pressures (17.9 cm H2O vs. 20.1 cm H2O, P<0.001) and peak inspiratory pressures (20.4 cm H2O vs. 23.0 cm H2O, P<0.001) between the low-Vt and usual care groups, respectively, mean airway pressures, PaO2/FiO2, days on mechanical ventilation, and ICU and hospital lengths of stay were all similar between groups.
  
  
  CONCLUSIONS
  In patients with chronic thromboembolic pulmonary hypertension undergoing pulmonary thromboendarterectomy, intra- and postoperative ventilation using low Vts (6 mg/kg) compared with usual care Vts (10 mg/kg) does not reduce the incidence of reperfusion lung injury or improve clinical outcomes. Clinical trial registered with www.clinicaltrials.gov (NCT00747045).
authors.affiliation: 1 Division of Pulmonary, Critical Care, and Sleep Medicine.
authors.forename: Dina M
authors.initials: DM
authors.lastname: Bates
authors.affiliation: 1 Division of Pulmonary, Critical Care, and Sleep Medicine.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Fernandes
authors.affiliation: 1 Division of Pulmonary, Critical Care, and Sleep Medicine.
authors.forename: Beau V
authors.initials: BV
authors.lastname: Duwe
authors.affiliation: 1 Division of Pulmonary, Critical Care, and Sleep Medicine.
authors.forename: Bryan O
authors.initials: BO
authors.lastname: King
authors.affiliation: 2 Department of Anesthesiology, and.
authors.forename: Dalia A
authors.initials: DA
authors.lastname: Banks
authors.affiliation: 3 Division of Pulmonary and Critical Care Medicine, Texas Tech University School of Medicine, Lubbock, Texas.
authors.forename: Victor J
authors.initials: VJ
authors.lastname: Test
authors.affiliation: 1 Division of Pulmonary, Critical Care, and Sleep Medicine.
authors.forename: Peter F
authors.initials: PF
authors.lastname: Fedullo
authors.affiliation: 1 Division of Pulmonary, Critical Care, and Sleep Medicine.
authors.forename: Nick H
authors.initials: NH
authors.lastname: Kim
authors.affiliation: 4 Division of Cardiovascular and Thoracic Surgery, University of California, San Diego, La Jolla, California; and.
authors.forename: Michael M
authors.initials: MM
authors.lastname: Madani
authors.affiliation: 4 Division of Cardiovascular and Thoracic Surgery, University of California, San Diego, La Jolla, California; and.
authors.forename: Stuart W
authors.initials: SW
authors.lastname: Jamieson
authors.affiliation: 1 Division of Pulmonary, Critical Care, and Sleep Medicine.
authors.forename: William R
authors.initials: WR
authors.lastname: Auger
authors.affiliation: 1 Division of Pulmonary, Critical Care, and Sleep Medicine.
authors.forename: Kim M
authors.initials: KM
authors.lastname: Kerr
mesh_terms: D055371:Acute Lung Injury / Q000517:prevention & control*; D000328:Adult; D000368:Aged; D004691:Endarterectomy; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008168:Lung / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011182:Postoperative Care; D011183:Postoperative Complications / Q000517:prevention & control*; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000379:methods*; D012720:Severity of Illness Index; D013990:Tidal Volume
keywords: adult respiratory distress syndrome; mechanical ventilators; postoperative care; pulmonary hypertension; ventilator-induced lung injury