Effect of Intensive vs Moderate Alveolar Recruitment Strategies Added to Lung-Protective Ventilation on Postoperative Pulmonary Complications: A Randomized Clinical Trial.
Perioperative lung-protective ventilation has been recommended to reduce pulmonary complications after cardiac surgery. The protective role of a small tidal volume (VT) has been established, whereas the added protection afforded by alveolar recruiting strategies remains controversial.



To determine whether an intensive alveolar recruitment strategy could reduce postoperative pulmonary complications, when added to a protective ventilation with small VT.



Randomized clinical trial of patients with hypoxemia after cardiac surgery at a single ICU in Brazil (December 2011-2014).



Intensive recruitment strategy (n=157) or moderate recruitment strategy (n=163) plus protective ventilation with small VT.



Severity of postoperative pulmonary complications computed until hospital discharge, analyzed with a common odds ratio (OR) to detect ordinal shift in distribution of pulmonary complication severity score (0-to-5 scale, 0, no complications; 5, death). Prespecified secondary outcomes were length of stay in the ICU and hospital, incidence of barotrauma, and hospital mortality.



All 320 patients (median age, 62 years; IQR, 56-69 years; 125 women [39%]) completed the trial. The intensive recruitment strategy group had a mean 1.8 (95% CI, 1.7 to 2.0) and a median 1.7 (IQR, 1.0-2.0) pulmonary complications score vs 2.1 (95% CI, 2.0-2.3) and 2.0 (IQR, 1.5-3.0) for the moderate strategy group. Overall, the distribution of primary outcome scores shifted consistently in favor of the intensive strategy, with a common OR for lower scores of 1.86 (95% CI, 1.22 to 2.83; P = .003). The mean hospital stay for the moderate group was 12.4 days vs 10.9 days in the intensive group (absolute difference, -1.5 days; 95% CI, -3.1 to -0.3; P = .04). The mean ICU stay for the moderate group was 4.8 days vs 3.8 days for the intensive group (absolute difference, -1.0 days; 95% CI, -1.6 to -0.2; P = .01). Hospital mortality (2.5% in the intensive group vs 4.9% in the moderate group; absolute difference, -2.4%, 95% CI, -7.1% to 2.2%) and barotrauma incidence (0% in the intensive group vs 0.6% in the moderate group; absolute difference, -0.6%; 95% CI, -1.8% to 0.6%; P = .51) did not differ significantly between groups.



Among patients with hypoxemia after cardiac surgery, the use of an intensive vs a moderate alveolar recruitment strategy resulted in less severe pulmonary complications while in the hospital.



clinicaltrials.gov Identifier: NCT01502332.
Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
Alcino
A
Costa Leme
Cardio-Pulmonary Department, Heart Division, Heart Institute (Incor), Hospital Das Clínicas da FMUSP - University of São Paulo, São Paulo, Brazil.
Ludhmila Abrahao
LA
Hajjar
Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil3Departament of Applied Physiotherapy, Federal University of Triângulo Mineiro, Uberaba, Brazil.
Marcia S
MS
Volpe
Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
Julia Tizue
JT
Fukushima
Cardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
Roberta Ribeiro
RR
De Santis Santiago
Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
Eduardo A
EA
Osawa
Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
Juliano
J
Pinheiro de Almeida
Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
Aline Muller
AM
Gerent
Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
Rafael Alves
RA
Franco
Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
Maria Ignez
MI
Zanetti Feltrim
Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
Emília
E
Nozawa
Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
Vera Regina
VR
de Moraes Coimbra
Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
Rafael
R
de Moraes Ianotti
Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
Clarice Shiguemi
CS
Hashizume
Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
Roberto
R
Kalil Filho
Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
Jose Otavio Costa
JO
Auler
Cardio-Pulmonary Department, Heart Division, Heart Institute (Incor), Hospital Das Clínicas da FMUSP - University of São Paulo, São Paulo, Brazil.
Fabio Biscegli
FB
Jatene
Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
Filomena Regina Barbosa
FR
Gomes Galas
Cardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
Marcelo Britto Passos
MB
Amato
D000368:Aged; D001469:Barotrauma / Q000453:epidemiology; D001794:Blood Pressure / Q000502:physiology; D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D003422:Critical Care / Q000706:statistics & numerical data; D005260:Female; D006339:Heart Rate / Q000502:physiology; D017052:Hospital Mortality; D006801:Humans; D000860:Hypoxia / Q000209:etiology / Q000628:therapy*; D015994:Incidence; D007902:Length of Stay; D008171:Lung Diseases / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010102:Oxygen Inhalation Therapy / Q000379:methods* / Q000706:statistics & numerical data; D010313:Partial Pressure; D011175:Positive-Pressure Respiration / Q000379:methods; D011183:Postoperative Complications / Q000517:prevention & control / Q000628:therapy*; D011650:Pulmonary Alveoli / Q000502:physiology*; D012121:Respiration, Artificial / Q000379:methods*; D012720:Severity of Illness Index; D013990:Tidal Volume