title: Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: a meta-analysis of individual patient data.
abstract: Protective mechanical ventilation strategies using low tidal volume or high levels of positive end-expiratory pressure (PEEP) improve outcomes for patients who have had surgery. The role of the driving pressure, which is the difference between the plateau pressure and the level of positive end-expiratory pressure is not known. We investigated the association of tidal volume, the level of PEEP, and driving pressure during intraoperative ventilation with the development of postoperative pulmonary complications.
  
  
  
  We did a meta-analysis of individual patient data from randomised controlled trials of protective ventilation during general anesthaesia for surgery published up to July 30, 2015. The main outcome was development of postoperative pulmonary complications (postoperative lung injury, pulmonary infection, or barotrauma).
  
  
  
  We included data from 17 randomised controlled trials, including 2250 patients. Multivariate analysis suggested that driving pressure was associated with the development of postoperative pulmonary complications (odds ratio [OR] for one unit increase of driving pressure 1·16, 95% CI 1·13-1·19; p<0·0001), whereas we detected no association for tidal volume (1·05, 0·98-1·13; p=0·179). PEEP did not have a large enough effect in univariate analysis to warrant inclusion in the multivariate analysis. In a mediator analysis, driving pressure was the only significant mediator of the effects of protective ventilation on development of pulmonary complications (p=0·027). In two studies that compared low with high PEEP during low tidal volume ventilation, an increase in the level of PEEP that resulted in an increase in driving pressure was associated with more postoperative pulmonary complications (OR 3·11, 95% CI 1·39-6·96; p=0·006).
  
  
  
  In patients having surgery, intraoperative high driving pressure and changes in the level of PEEP that result in an increase of driving pressure are associated with more postoperative pulmonary complications. However, a randomised controlled trial comparing ventilation based on driving pressure with usual care is needed to confirm these findings.
  
  
  
  None.
authors.affiliation: Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands; Program of Post-Graduation, Research and Innovation, Faculdade de Medicina do ABC, Santo André, Brazil; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil. Electronic address: aryserpa@terra.com.br.
authors.forename: Ary Serpa
authors.initials: AS
authors.lastname: Neto
authors.affiliation: Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.
authors.forename: Sabrine N T
authors.initials: SN
authors.lastname: Hemmes
authors.affiliation: Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.
authors.forename: Carmen S V
authors.initials: CS
authors.lastname: Barbas
authors.affiliation: Department of Anaesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany; Department of Anaesthesiology, Marienhospital Osnabrück, Osnabrück, Germany.
authors.forename: Martin
authors.initials: M
authors.lastname: Beiderlinden
authors.affiliation: Department of Anesthesiology, University of Colorado, Aurora, CO, USA.
authors.forename: Ana
authors.initials: A
authors.lastname: Fernandez-Bustamante
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Estaing University Hospital, Clermont-Ferrand, France.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Futier
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA.
authors.forename: Ognjen
authors.initials: O
authors.lastname: Gajic
authors.affiliation: Department of Cardiothoracic Anaesthesia & Surgical Intensive Care, King Fahd Hospital, University of Dammam, Dammam, Saudi Arabia.
authors.forename: Mohamed R
authors.initials: MR
authors.lastname: El-Tahan
authors.affiliation: Department of Anesthesiology, King Fahd Hospital, University of Dammam, Dammam, Saudi Arabia.
authors.forename: Abdulmohsin A Al
authors.initials: AA
authors.lastname: Ghamdi
authors.affiliation: Department of Chest Diseases, Research Unit INSERM U1046, Montpellier, France.
authors.forename: Ersin
authors.initials: E
authors.lastname: Günay
authors.affiliation: Department of Critical Care Medicine and Anesthesiology, Saint Eloi University Hospital, Research Unit INSERM U1046, Montpellier, France.
authors.forename: Samir
authors.initials: S
authors.lastname: Jaber
authors.affiliation: Department of Anaesthesiology and Reanimation, Research Unit INSERM U1046, Montpellier, France.
authors.forename: Serdar
authors.initials: S
authors.lastname: Kokulu
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.
authors.forename: Alf
authors.initials: A
authors.lastname: Kozian
authors.affiliation: Department of Anaesthesiology, Pharmacology and Intensive Care, Faculty of Medicine, University Hospital of Geneva, Geneva, Switzerland.
authors.forename: Marc
authors.initials: M
authors.lastname: Licker
authors.affiliation: State Key Laboratory of Oncology of South China, Sun Yat-sen University Cancer Center, Guangzhou, Guangdong, China.
authors.forename: Wen-Qian
authors.initials: WQ
authors.lastname: Lin
authors.affiliation: Department of Anesthesiology, The Warren Alpert School of Brown University, Providence, RI, USA.
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Maslow
authors.affiliation: Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA.
authors.forename: Stavros G
authors.initials: SG
authors.lastname: Memtsoudis
authors.affiliation: Department of Intensive Care, Erasmus University Medical Center, Rotterdam, Netherlands.
authors.forename: Dinis
authors.initials: D
authors.lastname: Reis Miranda
authors.affiliation: Department of Anesthesiology, University of Colorado, Aurora, CO, USA.
authors.forename: Pierre
authors.initials: P
authors.lastname: Moine
authors.affiliation: Department of Surgery, The Warren Alpert School of Brown University, Providence, RI, USA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Ng
authors.affiliation: Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari Aldo Moro, Bari, Italy.
authors.forename: Domenico
authors.initials: D
authors.lastname: Paparella
authors.affiliation: Department of Anesthesia and Intensive Care Medicine, Rome, Italy; Sapienza University of Rome, Rome, Italy; Policlinico Umberto I Hospital, Rome, Italy.
authors.forename: V Marco
authors.initials: VM
authors.lastname: Ranieri
authors.affiliation: Department of Anesthesiology and Anesthesia Clinical Research Unit, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA.
authors.forename: Federica
authors.initials: F
authors.lastname: Scavonetto
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Schilling
authors.affiliation: Department Biotechnology and Sciences of Life, Azienda Ospedaliera Fondazione Macchi, University of Insubria, Varese, Italy.
authors.forename: Gabriele
authors.initials: G
authors.lastname: Selmo
authors.affiliation: Department Biotechnology and Sciences of Life, Azienda Ospedaliera Fondazione Macchi, University of Insubria, Varese, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Severgnini
authors.affiliation: Department of Anesthesiology and Anesthesia Clinical Research Unit, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA.
authors.forename: Juraj
authors.initials: J
authors.lastname: Sprung
authors.affiliation: Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
authors.forename: Sugantha
authors.initials: S
authors.lastname: Sundar
authors.affiliation: Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Talmor
authors.affiliation: Department of Anaesthesiology, Düsseldorf University Hospital, Heinrich-Heine University, Düsseldorf, Germany.
authors.forename: Tanja
authors.initials: T
authors.lastname: Treschan
authors.affiliation: Department of Anaesthesiology, Hospital de Sant Pau, Barcelona, Spain.
authors.forename: Carmen
authors.initials: C
authors.lastname: Unzueta
authors.affiliation: Department of Anesthesiology and Anesthesia Clinical Research Unit, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN, USA.
authors.forename: Toby N
authors.initials: TN
authors.lastname: Weingarten
authors.affiliation: Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.
authors.forename: Esther K
authors.initials: EK
authors.lastname: Wolthuis
authors.affiliation: Department of Anaesthesiology and Intensive Care Medicine, University of Hospital Leipzig, Leipzig, Germany.
authors.forename: Hermann
authors.initials: H
authors.lastname: Wrigge
authors.affiliation: Cardio-Pulmonary Department, Pulmonary Division, Heart Institute, University of São Paulo, São Paulo, Brazil.
authors.forename: Marcelo B P
authors.initials: MB
authors.lastname: Amato
authors.affiliation: Cardio-Pulmonary Department, Pulmonary Division, Heart Institute, University of São Paulo, São Paulo, Brazil; Research and Education Institute, Hospital Sirio-Libanês, São Paulo, Brazil.
authors.forename: Eduardo L V
authors.initials: EL
authors.lastname: Costa
authors.affiliation: Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
authors.forename: Marcelo Gama
authors.initials: MG
authors.lastname: de Abreu
authors.affiliation: Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST, University of Genoa, Genoa, Italy.
authors.forename: Paolo
authors.initials: P
authors.lastname: Pelosi
authors.affiliation: Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands; Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands.
authors.forename: Marcus J
authors.initials: MJ
authors.lastname: Schultz
mesh_terms: D000328:Adult; D000368:Aged; D000768:Anesthesia, General / Q000009:adverse effects* / Q000379:methods; D005260:Female; D006801:Humans; D007432:Intraoperative Period; D008171:Lung Diseases / Q000209:etiology*; D008297:Male; D008875:Middle Aged; D011175:Positive-Pressure Respiration / Q000009:adverse effects* / Q000379:methods; D011183:Postoperative Complications / Q000209:etiology*; D016032:Randomized Controlled Trials as Topic; D013990:Tidal Volume