Editorial

Intraoperative Protective Mechanical Ventilation: Fact or

Fiction?
Guido Musch, M.D., M.B.A., Marcos F. Vidal Melo, M.D., Ph.D.

P ositive pressure ventilation lung injury.The results instead show

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gained widespread clinical no meaningful clinical or statistical
acceptance during the Danish polio difference among the four studied
epidemic of 1952,1 when it dra- groups in oxygenation within the
matically reduced the mortality of first postoperative hour, oxygen-
respiratory failure, and it has saved ation later on the ward, frequency of
countless lives in ensuing years by postoperative pulmonary complica-
enabling modern critical care and tions, or duration of hospitalization.
the safe practice of surgery under It is important to note that the
general anesthesia. Nonetheless, authors did not use excessively
evidence emerged in the 1970s high or low tidal volumes4,5 and
that positive pressure ventilation PEEP, but instead values consid-
can itself cause lung injury.2 Since ered acceptable in current clinical
then, two fundamental facts have practice.4–6 Accordingly, two main
been established. First, large tidal inferences can be drawn. First, in a
lung excursions are detrimental if cohort of patients with a low preva-
they lead to end-inspiratory overd- “When is protective intraopera- lence of lung disease and borderline
istension and/or cyclical alveolar or obesity undergoing nonabdominal
bronchiolar derecruitment–recruit- tive ventilation most beneficial?” surgery of moderate duration (about
ment between breaths. Second, the lungs of patients during 3.5 h) and without major physiologic impact (e.g., blood loss),
general anesthesia or with acute respiratory distress syndrome low tidal volumes as well as higher acceptable tidal volumes
are functionally smaller: functional residual capacity is reduced (10 ml/kg)4,5 with higher PEEP were well tolerated. It is inter-
because some of the airspaces become atelectatic, consolidated, esting that a tidal volume of 6 ml/kg did not result in lower
or flooded with edema. A corollary of these facts has been the oxygenation even at the lower PEEP, given that atelectasis is
quest to restore the relationship between tidal volume and usually considered the main downside of low tidal volume.
functional residual capacity either by decreasing the former or These results suggest that relatively healthy lungs in the stud-
increasing the latter. This concept represents the physiologic ied conditions can withstand a few hours of low tidal volume
underpinning of all “protective” ventilation strategies. ventilation during nonabdominal surgery without developing
Such framework is helpful to analyze the study by Turan significant atelectasis even at low PEEP. Higher PEEP and tidal
and colleagues3 in this issue of Anesthesiology. In this large volume did not seem to compromise postoperative lung func-
factorial crossover cluster trial, adults undergoing orthopedic tion either. Second, these results release the cognitive anchor
surgery during general anesthesia (approximately 50% also to a single optimal PEEP or tidal volume, at least in this patient
with regional block and slightly more than 50% undergoing population, and instead portray a range of equally acceptable
arthroplasty) were allocated to two levels of tidal volume (6 and values, consistent with a range—not merely a point—of max-
10 ml/kg of predicted body weight) and of positive end-ex- imal compliance in the pressure–volume curve of a healthy
piratory pressure (PEEP, 5 and 8 cm H2O). Presumably, ven- lung. This message is important because it argues against the
tilation with lower tidal volume and higher PEEP could lead transposition without qualification of inferences and values
to better postoperative oxygenation and lower incidence of derived from critical care studies to the operating room.
respiratory complications, because such a strategy would limit So, is intraoperative protective ventilation all fic-
both end-inspiratory overdistension and end-expiratory dere- tion? Substantive observational evidence has identified
cruitment, the two biophysical triggers of ventilator-induced tidal volume as a risk factor for postoperative pulmonary

Image: A. Johnson, Vivo Visuals Studio.

This editorial accompanies the article on p. 406. This article has a related Infographic on p. A19. This article has an audio podcast.
Accepted for publication August 19, 2022.
Guido Musch, M.D., M.B.A.; Department of Anesthesiology and Perioperative Medicine, UMass Chan Medical School, Worcester, Massachusetts.
Marcos F. Vidal Melo, M.D., Ph.D.; Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York.
Copyright © 2022, the American Society of Anesthesiologists. All Rights Reserved. Anesthesiology 2022; 137:381–3. DOI: 10.1097/ALN.0000000000004366

ANESTHESIOLOGY, V 137 • NO 4 October 2022 381

Copyright © 2022, the American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
<zdoi;. DOI: 10.1097/ALN.0000000000004366>
 Editorial

complications after general anesthesia.7,8 These studies indi- they did not necessarily provide the best or single setting of
cated that “protective” ventilation (generally defined as the variable of interest to achieve that effect.
lower tidal volume plus PEEP and/or recruitment maneu- The hemodynamic impact of mechanical ventilation is fre-
vers) may reduce such complications4,8 that are associated quently a concern.A clinically meaningful finding by Turan and
with increased mortality, intensive care unit admission, and colleagues3 in this regard was the similar intraoperative use of
length of stay.7 The Intraoperative Protective Ventilation vasopressors and incidence of hypotension in all combinations
(IMPROVE) trial confirmed a marked beneficial effect of of PEEP and tidal volume. This finding reinforces the con-
protective ventilation on major abdominal surgery.6 cept that the mild-to-moderate range of ventilatory settings
Yet, as with Turan’s trial, several trials on protective venti- explored does not usually result in major hemodynamic effects.

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lation did not demonstrate a difference between groups.5,9,10 The study opens several questions. Many patients were
What could explain these inconsistencies, and when is pro- excluded by anesthesiologists, or due to comorbidities, insta-
tective intraoperative ventilation most beneficial? It has been bility, or other reasons. Such subset of potentially higher-risk
increasingly recognized that the ratio of tidal volume to patients could represent those patients who would most benefit
end-expiratory lung volume, proportional to the driving pres- from specific ventilatory interventions. Although the primary
sure and a surrogate for lung strain, is the biophysical mediator outcome of Spo2/Fio2 in the first hour is a sensitive marker of
of the effects of tidal volume and PEEP on ventilator-induced oxygenation impairment, it could be affected predominantly
lung injury.4 In fact, the potential of different tidal volumes to by factors other than ventilatory settings.The absence of differ-
reduce postoperative pulmonary complications depends on the ences in the ward reinforces that any influence of intraoperative
patient’s respiratory compliance.11 This physiologic individuality settings on postoperative oxygenation was unlikely. Also, even if
may be a reason for discrepancies. Patient population is another there was an intraoperative effect of the interventions, this could
factor. The IMPROVE trial targeted a high-risk population be lost at extubation, without subsequent benefit. Finally, the
for pulmonary complications6 (major open abdominal surgery, reported rate of pulmonary complications was quite low, imply-
pre-existent respiratory risk factors), whereas Turan and col- ing a low-risk group and the potential risk for false negatives,
leagues studied a population at lower risk3 based on the Assess given that the occurrence of those complications derived from
Respiratory Risk in Surgical Patients in Catalonia risk score.12 registry and billing data not from prospective collection.
There is evidence that pulmonary outcomes are less likely to Such limitations will deserve future exploration to advance
depend on PEEP in nonabdominal/noncardiothoracic surgery, this relevant area. For now, Turan and colleagues provide evi-
e.g., neurologic versus abdominal surgery.13 This also implies dence that mild-to-moderate differences in key ventilator
that Turan’s results should not be extrapolated to abdominal or settings—tidal volume and PEEP—within currently accepted
cardiothoracic surgery, when additional injury mechanisms are ranges do not result in substantial differential effects on post-
present and, consequently, the effects of different ventilatory set- operative oxygenation and other pulmonary outcomes during
tings could be more evident.13 Time may also be an important orthopedic surgery. Mechanical ventilation in the operating
variable. Normal lungs show only limited inflammation after room requires its own specific set of knowledge, with ranges
2 h of ventilation even at high driving pressures.14 Sixteen to different from those of patients with acute respiratory distress
24 h were necessary for a significant pulmonary inflammatory syndrome in intensive care units. Protective ventilation is not
response and mechanical deterioration to develop in experi- defined by single arbitrary numbers, but by ranges of venti-
ments applying clinical tidal volumes (6 to 8 ml/kg) in initially latory settings that likely differ in distinct conditions and in
uninjured lungs.15–17 Finally, the separation between ventilator relation to patient-specific physiopathologic features.
settings is relevant.The IMPROVE trial acted on multiple vari- Research Support
ables (tidal volume, PEEP, recruitment maneuvers) setting them
apart enough (tidal volumes of 6 to 8 ml/kg with PEEP = 6 to Dr. Vidal Melo was supported by National Institutes of
8 cm H2O versus 10 to 12 ml/kg with PEEP = 0 cm H20) that, Health-National Heart, Lung, and Blood Institute (Bethesda,
presumably, the effect could be detected in contrast to current Maryland) grants UH3HL140177 and R01HL121228.
practice used by Turan and colleagues.3
If there is a range of equally acceptable values for ventila- Competing Interests
tory settings, it may be hard to show an effect, especially when The authors declare no competing interests.
clinical practice has already converged toward such a range.
Turan and colleagues studied a large population and observed Correspondence
a smaller SD for the primary outcome than that initially pre-
sumed, which ultimately yielded a high power to detect the Address correspondence to Dr. Vidal Melo: mv2869@
predefined mean effect.The 97.5% CIs for the effect estimates cumc.colmbia.edu
were a time-weighted average Spo2/Fio2 of –0.4 to 7.3% for
tidal volume and –4.0 to 3.6% for PEEP, numbers that con- References
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382 Anesthesiology 2022; 137:381–3 G. Musch and M. F. Vidal Melo

Copyright © 2022, the American Society of Anesthesiologists. All Rights Reserved. Unauthorized reproduction of this article is prohibited.
 Editorial

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G. Musch and M. F. Vidal Melo Anesthesiology 2022; 137:381–3 383

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