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High PEEP with recruitment maneuvers versus Low PEEP During General Anesthesia for Surgery -a Bayesian individual patient data meta-analysis of three randomized clinical trials

  • Guido Mazzinari*
  • , Fernando G. Zampieri
  • , Lorenzo Ball
  • , Niklas S. Campos
  • , Thomas Bluth
  • , Sabrine N. T. Hemmes
  • , Carlos Ferrando
  • , Julian Librero
  • , Marina Soro
  • , Paolo Pelosi
  • , Marcelo Gama de Abreu
  • , Marcus J. Schultz
  • , Ary Serpa Neto
  • , Niklas S. Campos
  • , Thomas Bluth
  • , Sabrine N. T. Hemmes
  • , Marcelo Gama de Abreu
  • , Marcus J. Schultz
  • , Ary Serpa Neto
  • , Niklas S. Campos
  • Thomas Bluth, Sabrine N. T. Hemmes, Julian Librero, Natividad Pozo, Carlos Ferrando, Lorenzo Ball, Guido Mazzinari, Marcelo Gama de Abreu, Marcus J. Schultz, Ary Serpa Neto, Sabrine N. T. Hemmes, Marcelo Gama de Abreu, Paolo Severgnini, Markus W. Hollmann, Jan M. Binnekade, Hermann Wrigge, Jaume Canet, Michael Hiesmayr, Werner Schmid, Edda Tschernko, Samir Jaber, G. ran Hedenstierna, Christian Putensen, Marcus J. Schultz, Agnes Marti, Alessandro Bacuzzi, Alexander Brodhun, Alexandre Molin, Alfred Merten, Ana Parera, Andrea Brunelli, Andrea Cortegiani, Andreas Güldner, Andreas W. Reske, Angelo Gratarola, Antonino Giarratano, Bea Bastin, Bjorn Heyse, Branka Mazul-Sunko, Bruno Amantea, Bruno Barberis, Christian Putensen, Christopher Uhlig, Conrado Minguez Marín, Cristian Celentano, Daniela la Bella, David D'Antini, David Velghe, Demet Sulemanji, Edoardo de Robertis, Eric Hartmann, Francesca Montalto, Francesco Tropea, Gary H. Mills, Gilda Cinnella, Giorgio Della Rocca, Girolamo Caggianelli, Giulia Pellerano, Giuseppina Mollica, Guillermo Bugedo, Hermann Wrigge, Jan-Paul Mulier, Jeroen Vandenbrande, Johann Geib, Jonathan Yaqub, Jorge Florez, Juan F. Mayoral, Juraj Sprung, Jurgen van Limmen, Lieuwe D. J. Bos, Luc de Baerdemaeker, Luc Jamaer, Luigi Spagnolo, Lydia Strys, Manuel Granell Gil, Marcelo Gama de Abreu, Marcos F. Vidal Melo, Marcus J. Schultz, Maria Carmen Unzueta, Maria Victoria Moral, Marion Ferner, Markus W. Hollmann, Martin Weiss, Massimo Vanoni, Maximilian S. Schaefer, Mercè Prieto, Michele Grio, Paolo Severgnini, Peter Markus Spieth, Philipp Simon, Phoebe Bodger, Pilar Sierra, Rita Laufenberg-Feldmann, Roberta Rusca, Rodolfo Proietti, Sabrine N. T. Hemmes, Santi Maurizio Raineri, Santo Caroleo, Sergi Sabaté, Stefan de Hert, Stefano Pezzato, Tanja A. Treschan, Tatjana Goranovic, Thea Koch, Thomas Bluth, Thomas Kiss, Valter Perilli, Virginia Cegarra, Werner Schmid, Carlos Ferrando, Javier Belda, Marina Soro, Jaume Canet, Carmen Unzueta, Fernando Suarez-Sipmann, Julián Librero, Alicia Llombart, Lucas Rovira, Manuel Granell, C. sar Aldecoa, Oscar Diaz-Cambronero, Jaume Balust, Ignacio Garutti, Rafael Gonzalez, Lucia Gallego, Santiago Garcia del Valle, Javier Redondo, David Pestaña, Aurelio Rodríguez, Javier García, Manuel de la Matta, Maite Ibáñez, Francisco Barrios, Samuel Hernández, Vicente Torres, Salvador Peiró, Natividad Pozo, Abigail Villena, Albert Carramiñana, Alberto Gallego-Casilda, Alejandro Duca, Amalia Alcón, Amanda Miñana, Ana Asensio, Ana Colás, Ana Isabel Galve, Ana Izquierdo, Ana Jurado, Ana María Pérez, Ana Mugarra, Ana Parera, Andrea Brunelli, Andrea Gutierrez, Ángeles de Miguel, Angels Lozano, Antonio Katime, Antonio Romero, Beatriz Garrigues, Begoña Ayas, Blanca Arocas, Carlos Delgado, Carmen Fernández, Carolina Romero, Clara Gallego, Cristina Garcés, Cristina Lisbona, Cristina Parrilla, Daniel López-Herrera, Domingo González, Eduardo Llamazares, Elena del Rio, Elena Lozano, Ernesto Pastor, Estefanía Chamorro, Estefanía Gracia, Ester Sánchez, Esther Romero, Fernando Díez, Ferran Serralta, Francisco Daviu, Francisco Sandín, Gerardo Aguilar, Gerardo Tusman, Gonzalo Azparren, Graciela Martínez-Pallí, Guido Mazzinari, Inmaculada Benítez, Inmaculada Hernandéz, Inmaculada India, Irene León, Isabel Fuentes, Isabel Ruiz, Jaume Puig, Javie Ignacio Román, Jesús Acosta, Jesús Rico-Feijoo, Jonathan Olmedo, Jose A. Carbonell, Jose M. Alonso, Jose María Pérez, Jose Miguel Marcos, Jose Navarro, Jose Valdivia, Juan Carrizo, Laura Piqueras, Laura Soriano, Laura Vaquero, Lisset Miguel, Lorena Muñoz, Lucia Valencia, Luis Olmedilla, Ma Justina Etulain, Manuel Tisner, María Barrio, María Dolores Alonso, María García, María J. Hernández, María José Alberola, María Parra, María Pilar Argente, María Vila, Mario de Fez, Marta Agilaga, Marta Gine, Mercedes Ayuso, Mercedes García, Natalia Bejarano, Natalia Peña, Nazario Ojeda, Nilda Martínez, Nuria García, Oto Padrón, Pablo García, Paola Valls, Patricia Cruz, Patricia Piñeiro, Pedro Charco, Rafael Anaya, Ramiro López, Rayco Rodríguez, Rocío Martínez, Roger Pujol, Rosa Dosdá, Rosa Lardies, Ruben Díaz, Rubén Villazala, Sara Zapatero, Sergio Cabrera, Sergio Sánchez, Silvia Martin, Suzana Diaz, Tania Franco, Tania Moreno, Tania Socorro, Vicente Gilabert, Victor Balandrón, Victoria Moral, Virgina Cegarra, Thomas Bluth, Ary Serpa Neto, Ilona Bobek, Jaume Canet, Gilda Cinnella, Luc de Baerdemaeker, Cesare Gregoretti, G. ran Hedenstierna, Sabrine N. T. Hemmes, Michael Hiesmayr, Markus W. Hollmann, Samir Jaber, John Laffey, Marc-Joseph Licker, Klaus Markstaller, Idit Matot, Gary H. Mills, Jan Paul Mulier, Christian Putensen, Rolf Rossaint, Jochen Schmitt, Mert Senturk, Paolo Severgnini, Juraj Sprung, Marcos F. Vidal Melo, Hermann Wrigge, Marcus J. Schultz, Paolo Pelosi, Marcelo Gama de Abreu, Fernando Abelha, S. hayla Abitağaoğlu, Marc Achilles, Afeez Adebesin, Ine Adriaensens, Charles Ahene, Fatima Akbar, Mohammed Al Harbi, Rita Al Khoury Al Kallab, Xavier Albanel, Florence Aldenkortt, Rawan Abdullah Saleh Alfouzan, Reef Alruqaie, Fernando Altermatt, Bruno Luís de Castro Araujo, Genaro Arbesú, Hanna Artsi, Caterina Aurilio, Omer Hilmi Ayanoglu, Alessandro Bacuzzi, Harris Baig, Yolanda Baird, Konstantin Balonov, Jaume Balust, Samantha Banks, Xiaodong Bao, M. lanie Baumgartner, Isabel Belda Tortosa, Alice Bergamaschi, Lars Bergmann, Luca Bigatello, Elena Biosca Pérez, Katja Birr, Thomas Bluth, Elird Bojaxhi, Chiara Bonenti, Iwona Bonney, Elke M. E. Bos, Sara Bowman, Leandro Gobbo Braz, Elisa Brugnoni, Sorin J. Brull, Iole Brunetti, Andrea Bruni, Shonie L. Buenvenida, Cornelius Johannes Busch, Giovanni Camerini, Jaume Canet, Beatrice Capatti, Javiera Carmona, Jaime Carungcong, Marta Carvalho, Anat Cattan, Carla Cavaleiro, Davide Chiumello, Stefano Ciardo, Mark Coburn, Umberto Colella, Victor Contreras, Pelin Corman Dincer, Elizabeth Cotter, Marcia Crovetto, William Darrah, Simon Davies, Luc de Baerdemaeker, Stefan de Hert, Enrique del Cojo Peces, Ellise Delphin, John Diaper, Paulo do Nascimento Junior, Valerio Donatiello, Jing Dong, Maria do Socorro Dourado, Alexander Dullenkopf, Felix Ebner, Hamed Elgendy, Christoph Ellenberger, Dilek Erdoğan Arı, Thomas Ermert, Fadi Farah, Ana Fernandez-Bustamante, Cristina Ferreira, Marco Fiore, Ana Fonte, Christina Fortià Palahí, Andrea Galimberti, Marcelo Gama de Abreu, Najia Garofano, Luca Gregorio Giaccari, Fernando Gilsanz, Felix Girrbach, Luca Gobbi, Marc Bernard Godfried, Nicolai Goettel, Peter A. Goldstein, Or Goren, Andrew Gorlin, Manuel Granell Gil, Angelo Gratarola, Juan Graterol, Pierre Guyon, Kevin Haire, Philippe Harou, Antonia Helf, Sabrine N. T. Hemmes, Gunther Hempel, María José Hernández Cádiz, Björn Heyse, Markus W. Hollmann, Ivan Huercio, Jasmina Ilievska, Lien Jakus, Vijay Jeganath, Yvonne Jelting, Minoa Jung, Barbara Kabon, Aalok Kacha, Maja Karaman Ilić, Arunthevaraja Karuppiah, Ayse Duygu Kavas, Gleicy Keli Barcelos, Todd A. Kellogg, Johann Kemper, Romain Kerbrat, Suraya Khodr, Peter Kienbaum, Bunyamin Kir, Thomas Kiss, Selin Kivrak, Vlasta Klarić, Thea Koch, Ceren Köksal, Ana Kowark, Peter Kranke, Bahar Kuvaki, Biljana Kuzmanovska, John Laffey, Mirko Lange, Marília Freitas de Lemos, Marc-Joseph Licker, Manuel López-Baamonde, Antonio López-Hernández, Mercedes Lopez-Martinez, Stéphane Luise, Mark MacGregor, Danielle Magalhães, Julien Maillard, Patrizia Malerbi, Natesan Manimekalai, Michael Margarson, Klaus Markstaller, Archer K. Martin, David P. Martin, Yvette N. Martin, Julia Martínez-Ocon, Ignacio Martin-Loeches, Emilio Maseda, Idit Matot, Niamh McAuliffe, Travis J. McKenzie, Paulina Medina, Melanie Meersch, Angelika Menzen, Els Mertens, Bernd Meurer, Tanja Meyer-Treschan, Changhong Miao, Camilla Micalizzi, Morena Milić, Norma Sueli Pinheiro Módolo, Pierre Moine, Patrick Mölders, Ana Montero-Feijoo, Enrique Moret, Markus K. Muller, Zoe Murphy, Pramod Nalwaya, Filip Naumovski, Paolo Navalesi, Lais Helena Navarro e Lima, Višnja Nesek Adam, Claudia Neumann, Christopher Newell, Zoulfira Nisnevitch, Junaid Nizamuddin, Cecilia Novazzi, Michael O'Connor, G. nther Oprea, Mukadder Orhan Sungur, Şule Özbilgin, Maria Caterina Pace, Marcos Pacheco, Balaji Packianathaswamy, Estefania Palma Gonzalez, Fotios Papaspyros, Sebastián Paredes, Maria Beatrice Passavanti, Juan Cristobal Pedemonte, Paolo Pelosi, Sanja Peremin, Christoph Philipsenburg, Daniela Pinho, Silvia Pinho, Linda M. Posthuma, Vincenzo Pota, Benedikt Preckel, Paolo Priani, Christian Putensen, Mohamed Aymen Rached, Aleksandar Radoeshki, Riccardo Ragazzi, Tamilselvan Rajamanickam, Arthi Rajamohan, Harish Ramakrishna, Desikan Rangarajan, Christian Reiterer, J. Ross Renew, Thomas Reynaud, Rhidian Rhys, Eva Rivas, Luisa Robitzky, Rolf Rossaint, Francesca Rubulotta, S. Humberto Machado, S. Catarina Nunes, Giovanni Sabbatini, Jon D. Samuels, Josep Martí Sanahuja, Pasquale Sansone, Alice Santos, Mohamed Sayedalahl, Maximilian S. Schaefer, Martin Scharffenberg, Eduardo Schiffer, Nadja Schliewe, Raoul Schorer, Marcus J. Schultz, Roman Schumann, Gabriele Selmo, Mar Sendra, Mert Senturk, Paolo Severgnini, Kate Shaw, Mirjana Shosholcheva, Abdulrazak Sibai, Philipp Simon, Francesca Simonassi, Claudia Sinno, Nukhet Sivrikoz, Vasiliki Skandalou, Neil Smith, Maria Soares, Tania Socorro Artiles, Diogo Sousa Castro, Miguel Sousa, Savino Spadaro, Juraj Sprung, Emmanouil Stamatakis, Luzius A. Steiner, Andrea Stevenazzi, Alejandro Suarez-de-la-Rica, M. lanie Suppan, Robert Teichmann, José Maria Tena Guerrero, Bram Thiel, Raquel Tolós, Gulbin Tore Altun, Michelle Tucci, Zachary A. Turnbull, Žana Turudić, Matthias Unterberg, Jurgen van Limmen, Yves van Nieuwenhove, Julia van Waesberghe, Marcos Francisco Vidal Melo, Bibiana Vitković, Luigi Vivona, Marcela Vizcaychipi, Carlo Alberto Volta, Anne Weber, Toby N. Weingarten, Jakob Wittenstein, Hermann Wrigge, Piet Wyffels, Julio Yagüe, David Yates, Ayşen Yavru, REPEATI on behalf of the PROVHILOII, iPROVEIII and PROBESEIV Investigators, and the PROVE Network investigators
*Corresponding author for this work
  • Hospital Universitario La Fe
  • Instituto de Investigación Sanitaria La Fe
  • University of Valencia
  • PROtective VEntilation Network
  • Department of Medicine and Clinical Islet Transplant Program, University of Alberta, Edmonton, AB, Canada
  • San Martino Hospital Genoa
  • University of Genoa
  • Hospital Israelita Albert Einstein
  • Universidade de São Paulo
  • Division of Hematology and Hemostaseology, Department of Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany
  • Hospital Clinic Barcelona
  • Centro de Investigación Biomédica en Red
  • Navarrabiomed
  • Hospital Clinico Universitario de Valencia
  • Cleveland Clinic Foundation
  • Shoklo Malaria Research Unit, Thailand
  • Medical University of Vienna
  • Amsterdam UMC - University of Amsterdam
  • Monash University
  • University of Melbourne
  • University of Amsterdam
  • Instituto de Investigación Sanitaria Fundación Para la Investigación del Hospital Clínico de Valencia - INCLIVA
  • Hospital de Manises, Spain
  • University of Insubria
  • Leipzig University
  • Hospital Universitari Germans Trias i Pujol
  • Hôpital Saint Eloi
  • Uppsala University
  • University of Bonn
  • Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A)
  • Johannes Gutenberg University Mainz
  • Hospital de La Santa Creu I Sant Pau
  • University of Palermo
  • Heinrich Heine University Düsseldorf
  • Ghent University
  • University Hospital Sveti Duh
  • Magna Græcia University
  • Azienda Sanitaria Locale TO3 - Ospedale di Rivoli
  • General Universitario
  • University of Foggia
  • Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
  • Massachusetts General Hospital
  • University of Naples Federico II
  • Sheffield Teaching Hospitals NHS Foundation Trust
  • University of Udine
  • Pontificia Universidad Católica de Chile
  • Department of Urology, AZ Sint-Jan Hospital, Bruges, Belgium
  • Virga Jesse Ziekenhuis
  • Fundacio Puigvert
  • Mayo Clinic Rochester, MN
  • Barts Health NHS Foundation Trust, London, UK
  • Catholic University of the Sacred Heart
  • Hospital Universitari de Bellvitge
  • Hospital Universitario de la Princesa
  • Corachan Clinic
  • Hospital General Universitario de Valencia
  • Hospital Universitario Río Hortega
  • Hospital General Universitario Gregorio Marañon
  • Hospital Universitario de León
  • Hospital Miguel Servet
  • Fundacion Hospital Alcorcon
  • Hospital General Universitario de Ciudad Real
  • Hospital Ramon y Cajal
  • Hospital de Gran Canaria
  • Universidad Autónoma de Madrid
  • Hospital Universitario Virgen del Rocio
  • Hospital Marina Baixa
  • Hospital Universitari Principe de Asturias
  • Hospital Universitario Nuestra Senora de Candelaria
  • Hospital Universitario Son Espases
  • IISLAFE Clinical Research Institute
  • Department of Anesthesiology, Hospital Privado de Comunidad, Mar de Plata, Argentina
  • Semmelweis University
  • University of Toronto
  • University of Geneva
  • Critical Care and Pain Medicine
  • Tel Aviv Sourasky Medical Center
  • University of Sheffield
  • RWTH Aachen University
  • Center for Evidence-Based Healthcare
  • Istanbul University
  • Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital, Halle, Germany
  • University of Porto
  • Centro Hospitalar Universitário de São João
  • Fatih Sultan Mehmet Education and Research Hospital
  • Marienhospital Wesel
  • Imperial College Healthcare NHS Trust
  • University of Antwerp
  • Cleveland Clinic Abu Dhabi
  • Ministry of National Guard – Health Affairs
  • Instituto Nacional de Câncer
  • University of Campania Luigi Vanvitelli
  • Marmara University
  • University of Mississippi
  • University Hospitals Sussex NHS Foundation Trust
  • Tufts Medical Center
  • Royal Cornwall Hospitals NHS Trust
  • Hospital Sagrado Corazon
  • Ruhr University Bochum
  • Boston Medical Center - Brighton
  • Homerton University Hospital NHS Foundation Trust
  • Universidade Estadual Paulista Júlio de Mesquita Filho
  • Mayo Clinic Jacksonville, FL
  • University of Magna
  • Heidelberg University 
  • University of Ferrara
  • Chelsea and Westminster Hospital NHS Foundation Trust
  • University Hospital Center of Santo António
  • University of Milan
  • ASST Santi Paolo e Carlo
  • The University of Chicago
  • NHS Foundation Trust
  • Don Benito-Villanueva Health Area
  • Montefiore Health System
  • Fudan University
  • Associação Hospitalar Beneficente São Vicente de Paulo
  • Institut fuer Anaesthesie und Intensivmedizin, Spital Thurgau, Frauenfeld, Switzerland
  • King Abdullah Medical City
  • Assiut University
  • University of Münster
  • University of Colorado
  • Hospital de São Sebastião – CHEDV
  • Hospital Universitario La Paz
  • Onze Lieve Vrouwe Gasthuis
  • University of Basel
  • Cornell University
  • Mayo Clinic Scottsdale, AZ
  • Polyclinique Montier la Celle
  • University of Würzburg
  • SS Cyril and Methodius University in Skopje
  • Royal Stoke University Hospital Stoke-on-Trent UK
  • General Hospital Sveti Duh
  • Klinička bolnica Dubrava
  • Dokuz Eylul University
  • University Clinic for Traumatology
  • Ashford and St Peters NHS Foundation Trust
  • Department of Surgery, Dublin, Ireland
  • St. Marienhospital Friesoythe gemeinnützige GmbH
  • Intensive Care Unit, Southmead Hospital, Bristol, Bristol, UK
  • Hull University Teaching Hospitals NHS Trust
  • University of Barcelona
  • Universidade Aberta
  • New York Presbyterian Hospital
  • Mansoura University
  • Alexandra Hospital
  • Tel Aviv University

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Abstract

Background: The influence of high positive end-expiratory pressure (PEEP) with recruitment maneuvers on the occurrence of postoperative pulmonary complications after surgery is still not definitively established. Bayesian analysis can help to gain further insights from the available data and provide a probabilistic framework that is easier to interpret. Our objective was to estimate the posterior probability that the use of high PEEP with recruitment maneuvers is associated with reduced postoperative pulmonary complications in patients with intermediate-to-high risk under neutral, pessimistic, and optimistic expectations regarding the treatment effect. Methods: Multilevel Bayesian logistic regression analysis on individual patient data from three randomized clinical trials carried out on surgical patients at Intermediate-to-High Risk for postoperative pulmonary complications. The main outcome was the occurrence of postoperative pulmonary complications in the early postoperative period. We studied the effect of high PEEP with recruitment maneuvers versus Low PEEP Ventilation. Priors were chosen to reflect neutral, pessimistic, and optimistic expectations of the treatment effect. Results: Using a neutral, pessimistic, or optimistic prior, the posterior mean odds ratio (OR) for High PEEP with recruitment maneuvers compared to Low PEEP was 0.85 (95% Credible Interval [CrI] 0.71 to 1.02), 0.87 (0.72 to 1.04), and 0.86 (0.71 to 1.02), respectively. Regardless of prior beliefs, the posterior probability of experiencing a beneficial effect exceeded 90%. Subgroup analysis indicated a more pronounced effect in patients who underwent laparoscopy (OR: 0.67 [0.50 to 0.87]) and those at high risk for PPCs (OR: 0.80 [0.53 to 1.13]). Sensitivity analysis, considering severe postoperative pulmonary complications only or applying a different heterogeneity prior, yielded consistent results. Conclusion: High PEEP with recruitment maneuvers demonstrated a moderate reduction in the probability of PPC occurrence, with a high posterior probability of benefit observed consistently across various prior beliefs, particularly among patients who underwent laparoscopy.
Original languageEnglish
Article number10.1097/ALN.0000000000005170
JournalAnesthesiology
Early online date2024
DOIs
Publication statusE-pub ahead of print - 2024

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