- Email: [email protected]
Protective ventilation during cardiac surgery: More than tidal volume?
Accepted Manuscript Title: Protective ventilation during cardiac surgery: more than tidal volume? Author: Benoˆıt Courteille Jennifer Brunet Alexandre Ouattara Franc¸ois St´ephan Jean-Louis G´erard Emmanuel Lorne Marc-Olivier Fischer
S2352-5568(16)30219-3 http://dx.doi.org/doi:10.1016/j.accpm.2016.11.003 ACCPM 210
To appear in: Received date: Revised date: Accepted date:
23-6-2016 3-10-2016 3-11-2016
Please cite this article as: Benoˆıt CourteilleJennifer BrunetAlexandre OuattaraFranc¸ois St´ephanJean-Louis G´erardEmmanuel LorneMarc-Olivier FischerFor the ARCOTHOVA (Anesth´esie-r´eanimation Coeur-Thorax-Vaisseaux), Protective ventilation during cardiac surgery: more than tidal volume? (2016), http://dx.doi.org/10.1016/j.accpm.2016.11.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title page
Protective ventilation during cardiac surgery: more than tidal volume ?
Benoît Courteille, MD 1
François Stéphan, MD, PhD 4 Jean-Louis Gérard, MD, PhD 1
us
Emmanuel Lorne, MD, PhD 5,6
cr
Alexandre Ouattara, MD, PhD 2,3
ip t
Jennifer Brunet, MD 1
Marc-Olivier Fischer, MD, PhD 1,7*
M
1
an
For the ARCOTHOVA
Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre,
Université de Bordeaux, adaptation cardiovasculaire à l'ischémie, U1034, 33600 Pessac,
Ac ce pt e
2
d
CS 30001, F-14000 Caen, France
France; Inserm, adaptation cardiovasculaire à l'ischémie, U1034, F-33600 Pessac, France 3
Service d'anesthésie-réanimation II, maison du Haut-Lévêque, groupe hospitalier Sud, CHU
de Bordeaux, avenue Magellan, F-33600 Pessac, France 4
Service de Réanimation Adulte, Centre Chirurgical Marie Lannelongue, F- 92350 Le Plessis
Robinson, France 5
Anesthesiology and Critical Care Department, Amiens University Medical Center, avenue
René Laennec, F-80054 Amiens, France 6
INSERM U1088, Jules Verne University of Picardy, Centre Universitaire de Recherche en
Santé (CURS), Chemin du Thil, F-80025 Amiens cedex, France 7
EA 4650, Université de Caen-Normandie, Esplanade de la Paix, CS 14 032, F-14000 Caen,
France
Page 1 of 8
Correspondence to: Marc-Olivier Fischer, MD, PhD Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre,
ip t
CS 30001, F-14000 Caen, France. Tel.: +33 231 064 735; Fax: +33 231 065 137, E-mail:
us
cr
[email protected]
an
Acknowledgments: none
Funding: The authors performed the present work in the course of their normal duties as full-
Ac ce pt e
Number of words: 377
d
M
time employees of public-sector healthcare institutions.
The authors declare no conflicts of interest.
Page 2 of 8
*Manuscript (no author information)
1 Letter Protective ventilation during cardiac surgery: more than tidal volume?
Benoît Courteille, MD 1, Jennifer Brunet, MD 1, Alexandre Ouattara, MD, PhD 2,3, François
ip t
Stéphan, MD, PhD 4, Jean-Louis Gérard, MD, PhD 1, Emmanuel Lorne, MD, PhD 5,6, Marc-
cr
Olivier Fischer, MD, PhD 1,7*, For the ARCOTHOVA (Anesthésie-réanimation Coeur-
1
us
Thorax-Vaisseaux)
Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, Avenue de la Côte de Nacre, CS
Université de Bordeaux, adaptation cardiovasculaire à l'ischémie, U1034, 33600 Pessac,
M
2
an
30001, 14000 Caen, France
France; Inserm, adaptation cardiovasculaire à l'ischémie, U1034, 33600 Pessac, France Service d'anesthésie-réanimation II, maison du Haut-Lévêque, groupe hospitalier Sud, CHU
ed
3
de Bordeaux, avenue Magellan, 33600 Pessac, France Service de Réanimation Adulte, Centre Chirurgical Marie Lannelongue, F- 92350 Le Plessis
ce pt
4
Robinson, France 5
Anesthesiology and Critical Care Department, Amiens University Medical Center, avenue
René Laennec, 80054 Amiens, France 6
Ac
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
Inserm U1088, Jules Verne University of Picardy, Centre Universitaire de Recherche en
Santé (CURS), Chemin du Thil, F-80025 Amiens cedex, France 7
EA 4650, Université de Caen-Normandie, Esplanade de la Paix, CS 14 032, 14000 Caen,
France
Correspondence to: Marc-Olivier Fischer, MD, PhD
Page 3 of 8
2 Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000 Caen, France. Tel.: +33 231 064 735; Fax: +33 231 065 137, E-mail: fischer-
ip t
[email protected]
cr
Acknowledgments: none
ce pt
ed
M
The authors declare no conflicts of interest.
an
time employees of public-sector healthcare institutions.
us
Funding: The authors performed the present work in the course of their normal duties as full-
Ac
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
Page 4 of 8
3 Extrapolation of the positive results associated with the protective ventilation of critical care patients with acute respiratory distress syndrome has suggested that preventive lungprotective ventilation could improve high-risk surgical patient outcomes [1]. In the IMPROVE study, the authors used an integrated approach to protective ventilation and used
ip t
three items to establish the “protective ventilation” strategy: low tidal volume (6 to 8 mL per kg predicted body weight), positive end-expiratory pressure (PEEP), and repeated recruitment
cr
manoeuvres. However, the respective importance of each item in protective ventilation
us
remains unknown at the present time [2]. The strategy using low tidal volume appears to be the most extensively studied strategy, demonstrating high clinical utility in several surgical
an
procedures [3].
Cardiac surgery is associated with a risk of postoperative respiratory complications [4]. As
M
protective ventilation is an evolving approach and as bedside ventilation strategies have not been extensively reported, we recently conducted a survey of French cardiac
ed
anaesthesiologists concerning their respiratory management strategies [5]. A large proportion of responders, 179 (90%) 95% CI: 87-95, declared that they used a low tidal volume less
ce pt
than 8 mL/kg [5], indicating that most anaesthesiologists are aware of the concept of harmful ventilator-induced lung injury (VILI). Most responders (132 (66%) 95% CI: 60-73) declared that they used tidal volume based on ideal body weight calculated for each patient. The remaining items of the protective ventilation concept appeared to be used less often, as 16%
Ac
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
(31) 95% CI: 11-21 of anaesthesiologists associated the last ‘volume item’ (low tidal volume calculated with ideal body weight) with a PEEP > 5 cmH2O. Finally, a very small proportion of anaesthesiologists (only 15 (8%) 95% CI: 5-12) also used repeated recruitment manoeuvres (Figure 1). Although this mail-based survey presents a number of limitations, including limited accuracy of the conclusions (answers are unverified, and the response rate was 43%) [5], we would like to emphasize that protective ventilation must not be limited to
Page 5 of 8
4 low tidal volume. Firstly, protective ventilation must always be associated with PEEP to limit the risk of alveolar atelectasis. Moreover, these ventilatory settings must be integrated into a multimodal approach, using both adjusted PEEP and repeated recruitment manoeuvres. A recently
ip t
published landmark review article supported this point of view [6]. Secondly, the protective ventilation period should be applied for the longest possible period in
cr
order to increase the duration of prophylactic perioperative positive pressure ventilation (POP
us
ventilation) from preoxygenation in the operating room to postoperative ICU care, as the benefits of intraoperative protective ventilation could be lost during the postoperative period.
an
This concept must be integrated into an individually tailored perioperative management strategy. For example, post-extubation non-invasive ventilation and high flow nasal
M
oxygenation have provided encouraging results after cardiothoracic surgery [7] but further investigations are mandatory before recommending extensive use of this strategy.
ed
Further investigations of this “bundle” perioperative approach (ie from induction of general anaesthesia to postoperative care), including low tidal volumes based on PBW, continuous
surgery patients.
References
ce pt
and moderate PEEP, and repeated recruitment manoeuvres, must be conducted in cardiac
Ac
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
1. Futier E, Constantin JM, Paugam-Burtz C, Pascal J, Eurin M, Neuschwander A, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med 2013;369:428-37. 2. Güldner A, Kiss T, Serpa Neto A, Hemmes SNT, Canet J, Spieth PM, et al. Intraoperative protective mechanical ventilation for prevention of postoperative pulmonary complications: a comprehensive review of the role of tidal volume, positive endexpiratory pressure, and lung recruitment maneuvers. Anesthesiology 2015;123:692-713.
Page 6 of 8
5 3. Serpa Neto A, Hemmes SNT, Barbas CSV, Beiderlinden M, Biehl M, Binnekade JM, et al. Protective versus Conventional Ventilation for Surgery: A Systematic Review and Individual Patient Data Meta-analysis. Anesthesiology 2015;123:66-78. 4. Lellouche F, Delorme M, Bussières J, Ouattara A. Perioperative ventilatory strategies in cardiac surgery. Best Pract Res Clin Anaesth 2015;29:381-95.
ip t
5. Fischer MO, Courteille B, Guinot P-G, Dupont H, Gérard JL, Hanouz JL, et al. Perioperative Ventilatory Management in Cardiac Surgery: A French Nationwide Survey. Medicine 2016;95:e2655. Futier E, Marret E, Jaber S. Perioperative positive pressure ventilation: an integrated approach to improve pulmonary care. Anesthesiology 2014;121:400-8.
7.
Stéphan F, Barrucand B, Petit P, Rézaiguia-Delclaux S, Médard A, Delannoy B, et al. High-Flow Nasal Oxygen vs Noninvasive Positive Airway Pressure in Hypoxemic Patients After Cardiothoracic Surgery: A Randomized Clinical Trial. JAMA 2015;313:2331-9
an
us
cr
6.
M
Figure 1. Ventilation patterns used during cardiac surgery.
ce pt
ed
PBW: Predicted body weight; PEEP: positive end-expiratory pressure; Vt: tidal volume
Ac
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
Page 7 of 8
cr
i
Figure
M an
us
90%
16%
8%
Ac
ce pt
ed
Incidence of use
66%
TV < 8 mL/kg
Vt < 8 ml/kg
Low TV+IBW
Vt < 8 ml/kg PBW
Low TV+IBW+PEEP>5
Vt < 8 ml/kg PBW PEEP > 5 cmH2O
Protective ventilation
Vt < 8 ml/kg PBW PEEP > 5 cmH2O Recruitment maneuvers Page 8 of 8
S2352-5568(16)30219-3 http://dx.doi.org/doi:10.1016/j.accpm.2016.11.003 ACCPM 210
To appear in: Received date: Revised date: Accepted date:
23-6-2016 3-10-2016 3-11-2016
Please cite this article as: Benoˆıt CourteilleJennifer BrunetAlexandre OuattaraFranc¸ois St´ephanJean-Louis G´erardEmmanuel LorneMarc-Olivier FischerFor the ARCOTHOVA (Anesth´esie-r´eanimation Coeur-Thorax-Vaisseaux), Protective ventilation during cardiac surgery: more than tidal volume? (2016), http://dx.doi.org/10.1016/j.accpm.2016.11.003 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Title page
Protective ventilation during cardiac surgery: more than tidal volume ?
Benoît Courteille, MD 1
François Stéphan, MD, PhD 4 Jean-Louis Gérard, MD, PhD 1
us
Emmanuel Lorne, MD, PhD 5,6
cr
Alexandre Ouattara, MD, PhD 2,3
ip t
Jennifer Brunet, MD 1
Marc-Olivier Fischer, MD, PhD 1,7*
M
1
an
For the ARCOTHOVA
Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre,
Université de Bordeaux, adaptation cardiovasculaire à l'ischémie, U1034, 33600 Pessac,
Ac ce pt e
2
d
CS 30001, F-14000 Caen, France
France; Inserm, adaptation cardiovasculaire à l'ischémie, U1034, F-33600 Pessac, France 3
Service d'anesthésie-réanimation II, maison du Haut-Lévêque, groupe hospitalier Sud, CHU
de Bordeaux, avenue Magellan, F-33600 Pessac, France 4
Service de Réanimation Adulte, Centre Chirurgical Marie Lannelongue, F- 92350 Le Plessis
Robinson, France 5
Anesthesiology and Critical Care Department, Amiens University Medical Center, avenue
René Laennec, F-80054 Amiens, France 6
INSERM U1088, Jules Verne University of Picardy, Centre Universitaire de Recherche en
Santé (CURS), Chemin du Thil, F-80025 Amiens cedex, France 7
EA 4650, Université de Caen-Normandie, Esplanade de la Paix, CS 14 032, F-14000 Caen,
France
Page 1 of 8
Correspondence to: Marc-Olivier Fischer, MD, PhD Pôle Réanimations Anesthésie SAMU/SMUR, CHU de Caen, Avenue de la Côte de Nacre,
ip t
CS 30001, F-14000 Caen, France. Tel.: +33 231 064 735; Fax: +33 231 065 137, E-mail:
us
cr
[email protected]
an
Acknowledgments: none
Funding: The authors performed the present work in the course of their normal duties as full-
Ac ce pt e
Number of words: 377
d
M
time employees of public-sector healthcare institutions.
The authors declare no conflicts of interest.
Page 2 of 8
*Manuscript (no author information)
1 Letter Protective ventilation during cardiac surgery: more than tidal volume?
Benoît Courteille, MD 1, Jennifer Brunet, MD 1, Alexandre Ouattara, MD, PhD 2,3, François
ip t
Stéphan, MD, PhD 4, Jean-Louis Gérard, MD, PhD 1, Emmanuel Lorne, MD, PhD 5,6, Marc-
cr
Olivier Fischer, MD, PhD 1,7*, For the ARCOTHOVA (Anesthésie-réanimation Coeur-
1
us
Thorax-Vaisseaux)
Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, Avenue de la Côte de Nacre, CS
Université de Bordeaux, adaptation cardiovasculaire à l'ischémie, U1034, 33600 Pessac,
M
2
an
30001, 14000 Caen, France
France; Inserm, adaptation cardiovasculaire à l'ischémie, U1034, 33600 Pessac, France Service d'anesthésie-réanimation II, maison du Haut-Lévêque, groupe hospitalier Sud, CHU
ed
3
de Bordeaux, avenue Magellan, 33600 Pessac, France Service de Réanimation Adulte, Centre Chirurgical Marie Lannelongue, F- 92350 Le Plessis
ce pt
4
Robinson, France 5
Anesthesiology and Critical Care Department, Amiens University Medical Center, avenue
René Laennec, 80054 Amiens, France 6
Ac
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
Inserm U1088, Jules Verne University of Picardy, Centre Universitaire de Recherche en
Santé (CURS), Chemin du Thil, F-80025 Amiens cedex, France 7
EA 4650, Université de Caen-Normandie, Esplanade de la Paix, CS 14 032, 14000 Caen,
France
Correspondence to: Marc-Olivier Fischer, MD, PhD
Page 3 of 8
2 Pôle Réanimations Anesthésie Samu/Smur, CHU de Caen, Avenue de la Côte de Nacre, CS 30001, 14000 Caen, France. Tel.: +33 231 064 735; Fax: +33 231 065 137, E-mail: fischer-
ip t
[email protected]
cr
Acknowledgments: none
ce pt
ed
M
The authors declare no conflicts of interest.
an
time employees of public-sector healthcare institutions.
us
Funding: The authors performed the present work in the course of their normal duties as full-
Ac
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
Page 4 of 8
3 Extrapolation of the positive results associated with the protective ventilation of critical care patients with acute respiratory distress syndrome has suggested that preventive lungprotective ventilation could improve high-risk surgical patient outcomes [1]. In the IMPROVE study, the authors used an integrated approach to protective ventilation and used
ip t
three items to establish the “protective ventilation” strategy: low tidal volume (6 to 8 mL per kg predicted body weight), positive end-expiratory pressure (PEEP), and repeated recruitment
cr
manoeuvres. However, the respective importance of each item in protective ventilation
us
remains unknown at the present time [2]. The strategy using low tidal volume appears to be the most extensively studied strategy, demonstrating high clinical utility in several surgical
an
procedures [3].
Cardiac surgery is associated with a risk of postoperative respiratory complications [4]. As
M
protective ventilation is an evolving approach and as bedside ventilation strategies have not been extensively reported, we recently conducted a survey of French cardiac
ed
anaesthesiologists concerning their respiratory management strategies [5]. A large proportion of responders, 179 (90%) 95% CI: 87-95, declared that they used a low tidal volume less
ce pt
than 8 mL/kg [5], indicating that most anaesthesiologists are aware of the concept of harmful ventilator-induced lung injury (VILI). Most responders (132 (66%) 95% CI: 60-73) declared that they used tidal volume based on ideal body weight calculated for each patient. The remaining items of the protective ventilation concept appeared to be used less often, as 16%
Ac
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
(31) 95% CI: 11-21 of anaesthesiologists associated the last ‘volume item’ (low tidal volume calculated with ideal body weight) with a PEEP > 5 cmH2O. Finally, a very small proportion of anaesthesiologists (only 15 (8%) 95% CI: 5-12) also used repeated recruitment manoeuvres (Figure 1). Although this mail-based survey presents a number of limitations, including limited accuracy of the conclusions (answers are unverified, and the response rate was 43%) [5], we would like to emphasize that protective ventilation must not be limited to
Page 5 of 8
4 low tidal volume. Firstly, protective ventilation must always be associated with PEEP to limit the risk of alveolar atelectasis. Moreover, these ventilatory settings must be integrated into a multimodal approach, using both adjusted PEEP and repeated recruitment manoeuvres. A recently
ip t
published landmark review article supported this point of view [6]. Secondly, the protective ventilation period should be applied for the longest possible period in
cr
order to increase the duration of prophylactic perioperative positive pressure ventilation (POP
us
ventilation) from preoxygenation in the operating room to postoperative ICU care, as the benefits of intraoperative protective ventilation could be lost during the postoperative period.
an
This concept must be integrated into an individually tailored perioperative management strategy. For example, post-extubation non-invasive ventilation and high flow nasal
M
oxygenation have provided encouraging results after cardiothoracic surgery [7] but further investigations are mandatory before recommending extensive use of this strategy.
ed
Further investigations of this “bundle” perioperative approach (ie from induction of general anaesthesia to postoperative care), including low tidal volumes based on PBW, continuous
surgery patients.
References
ce pt
and moderate PEEP, and repeated recruitment manoeuvres, must be conducted in cardiac
Ac
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
1. Futier E, Constantin JM, Paugam-Burtz C, Pascal J, Eurin M, Neuschwander A, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med 2013;369:428-37. 2. Güldner A, Kiss T, Serpa Neto A, Hemmes SNT, Canet J, Spieth PM, et al. Intraoperative protective mechanical ventilation for prevention of postoperative pulmonary complications: a comprehensive review of the role of tidal volume, positive endexpiratory pressure, and lung recruitment maneuvers. Anesthesiology 2015;123:692-713.
Page 6 of 8
5 3. Serpa Neto A, Hemmes SNT, Barbas CSV, Beiderlinden M, Biehl M, Binnekade JM, et al. Protective versus Conventional Ventilation for Surgery: A Systematic Review and Individual Patient Data Meta-analysis. Anesthesiology 2015;123:66-78. 4. Lellouche F, Delorme M, Bussières J, Ouattara A. Perioperative ventilatory strategies in cardiac surgery. Best Pract Res Clin Anaesth 2015;29:381-95.
ip t
5. Fischer MO, Courteille B, Guinot P-G, Dupont H, Gérard JL, Hanouz JL, et al. Perioperative Ventilatory Management in Cardiac Surgery: A French Nationwide Survey. Medicine 2016;95:e2655. Futier E, Marret E, Jaber S. Perioperative positive pressure ventilation: an integrated approach to improve pulmonary care. Anesthesiology 2014;121:400-8.
7.
Stéphan F, Barrucand B, Petit P, Rézaiguia-Delclaux S, Médard A, Delannoy B, et al. High-Flow Nasal Oxygen vs Noninvasive Positive Airway Pressure in Hypoxemic Patients After Cardiothoracic Surgery: A Randomized Clinical Trial. JAMA 2015;313:2331-9
an
us
cr
6.
M
Figure 1. Ventilation patterns used during cardiac surgery.
ce pt
ed
PBW: Predicted body weight; PEEP: positive end-expiratory pressure; Vt: tidal volume
Ac
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65
Page 7 of 8
cr
i
Figure
M an
us
90%
16%
8%
Ac
ce pt
ed
Incidence of use
66%
TV < 8 mL/kg
Vt < 8 ml/kg
Low TV+IBW
Vt < 8 ml/kg PBW
Low TV+IBW+PEEP>5
Vt < 8 ml/kg PBW PEEP > 5 cmH2O
Protective ventilation
Vt < 8 ml/kg PBW PEEP > 5 cmH2O Recruitment maneuvers Page 8 of 8