Brief Academy
Critical assessment of the evidence
Henry Oliverosa,
, Fernando Ríosa, Andrés Ruizb
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henry.oliveros@unisabana.edu.co
Corresponding author at: Universidad de la Sabana, Puente del Comun K16, Chia, Colombia.
Corresponding author at: Universidad de la Sabana, Puente del Comun K16, Chia, Colombia.
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=> "henry.oliveros@unisabana.edu.co" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Fernando" "apellidos" => "Ríos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Andrés" "apellidos" => "Ruiz" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Associated Professor, School of Medicine, Universidad de La Sabana, Chia, Colombia" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Resident, Anaesthesia Department, Hospital Militar Central, Bogotá, Colombia" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author at</span>: Universidad de la Sabana, Puente del Comun K16, Chia, Colombia." ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="tb0005"></elsevierMultimedia></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0025" class="elsevierStylePara elsevierViewall">The mechanism of barotrauma and volutrauma has been described since the 70s in patients with acute lung injury and acute respiratory distress syndrome receiving high tidal volume ventilation<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> (10–15<span class="elsevierStyleHsp" style=""></span>ml/kg ideal body weight). This led to the development of controlled clinical trials in an attempt to determine the ideal tidal volume. Different forms of mechanical ventilation were proposed in the 90s using tidal volumes ranging between 3-12<span class="elsevierStyleHsp" style=""></span>ml/kg of the estimated weight.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> However, it was only in 2000 when the ARMA study published by the ARDS Network provided recommendations for low-volume mechanical ventilation (6<span class="elsevierStyleHsp" style=""></span>ml/kg) and airway plateau pressures under 30<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O, leading to a significant reduction in mortality, from 40% down to 31% in patients with ARDS.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a> Since then, the protective ventilation strategy has been broadened to include other types of patients, including those taken to elective surgery, although not taking into consideration the large difference in the pathophysiology of ventilation between diseased and healthy lungs, or the different consequences. Despite this, some clinical trials have found the benefit of low tidal volume ventilation in terms of pulmonary infection and, mortality outcomes.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–10</span></a> However, other studies like ours have shown an increase in 30-day mortality.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,11,12</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Study objective</span><p id="par0030" class="elsevierStylePara elsevierViewall">The objective of this study was to determine whether low tidal volume with minimal PEEP is associated with lower perioperative morbidity and mortality when compared with high volumes in patients taken to surgery under general anaesthesia.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Study design</span><p id="par0095" class="elsevierStylePara elsevierViewall">Retrospective observational study.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results of the study</span><p id="par0035" class="elsevierStylePara elsevierViewall">Overall, 29,343 patients taken to elective surgery were included. Patients of cardiac and thoracic surgery, liver transplant, palliative care, and those who had already received anaesthesia were excluded. Also excluded were all patients ventilated with volumes under 250<span class="elsevierStyleHsp" style=""></span>ml and tidal volumes above 3 or 20<span class="elsevierStyleHsp" style=""></span>ml per kg, or PEEP above 16.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Variables comprised in the ventilator records were determined: end expiratory volume, respiratory rate, peak intraoperative pressure (PIP), peak expiratory pressure, PEEP, inspired fraction and dynamic compliance, and the primary outcomes were 30-day mortality and length of hospital stay.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Comorbidities were assessed using the APR-DRG system in order to adjust 30-day mortality.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Predictor variables included ASA classification, age, gender, race, body mass index, laparoscopic vs. open surgery, type of surgery, PIP, and dynamic compliance.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Tidal volume was adjusted according to body mass index in order to classify the patients as those ventilated with volumes ranging between 3 and 6, 6 and 8, 10 and 12, and 12 and 20<span class="elsevierStyleHsp" style=""></span>ml/kg of ideal body weight (kg<span class="elsevierStyleSup">−1</span> IBW), compared to patients ventilated with a tidal volume ranging between 8 and 10<span class="elsevierStyleHsp" style=""></span>ml/kg of ideal body weight (kg<span class="elsevierStyleSup">−1</span> IBW). In order to determine 30-day mortality and length of stay, simple and adjusted Hazard Ratios were used in order to account for potential confounding variables in a Cox regression model; and in order to diminish selection bias, the propensity index was used to match each of the mechanical ventilation volume categories with the same probability. For probability determinations, variables such as ASA, gender, race, urgent surgery, use of steroids, surgical specialty, laparoscopic surgery, PAR-DRG score, physical fitness, ideal body weight, and body mass index were used.</p><p id="par0060" class="elsevierStylePara elsevierViewall">A 30-day mortality HR of 1.6 [95% CI) [1.25–2.08] was found for the group with volumes of 6–8<span class="elsevierStyleHsp" style=""></span>ml/kg of ideal body weight. These values were adjusted for pre-operative risk using the comorbidity score APRG DRG, aside from ASA and BMI.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Level of evidence</span><p id="par0065" class="elsevierStylePara elsevierViewall">Grade IV.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Comments from the reviewers</span><p id="par0070" class="elsevierStylePara elsevierViewall">The propensity score methodology<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a> has been used over the past two decades for reducing selection bias in observational studies, and eliminating a large proportion of the underlying differences found between the comparison groups. This is achieved by determining the probability of assigning patients to one or the other therapy as a function of explanatory variables and then comparing the groups in terms of outcomes, taking into consideration similar probability of assignment to each of the groups or therapies. This is a way to simulate a clinical trial despite the limitations of not having considered all the variables that may have influenced assignment to one or another group. In this study, the finding of increased mortality in the group of patients ventilated with 6–8<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span> compared with volumes of 8–10<span class="elsevierStyleHsp" style=""></span>mL<span class="elsevierStyleHsp" style=""></span>kg<span class="elsevierStyleSup">−1</span> does not reflect a response gradient with smaller volumes, as is to be expected. On the other hand, the mortality outcome is not limited to pneumonia-related mortality. Another limitation of this study is not having determined the plateau pressure, a measurement which would have reflected the true impact on overstretching and would have helped determine whether the anaesthetists could have used that variable to base their decision of adjusting the volume. From the pathophysiological point of view, the ventilation-associated injury will depend on the stress and tension to which the lung parenchyma is subjected as a result of tidal volume, respiratory rate, flow, inspiration time, PEEP, volume and recruitment manoeuvres. To this date, the variable that best evaluates lung overstretching is transpulmonary pressure.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">Finally, the results of this study are the opposite of those presented in the meta-analysis by Ary Serpa et al., who identified nine studies with 1077 patients which explored the association between low volumes and the mortality outcome and found a RR (95% CI)<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.64 (0.46–086).<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> In the same meta-analysis, no differences were found when clinical trials and observational studies were analysed separately, showing consistency in the results.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,10,20–25</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Suggested articles for review</span><p id="par0080" class="elsevierStylePara elsevierViewall">Rocco PR et al.<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a>.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Serpa Neto et al.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a>.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Hemmes et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a>.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Funding</span><p id="par0105" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Conflicts of interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Study objective" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design" ] 3 => array:2 [ "identificador" => "sec0025" "titulo" => "Results of the study" ] 4 => array:2 [ "identificador" => "sec0030" "titulo" => "Level of evidence" ] 5 => array:2 [ "identificador" => "sec0035" "titulo" => "Comments from the reviewers" ] 6 => array:2 [ "identificador" => "sec0040" "titulo" => "Suggested articles for review" ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-10-08" "fechaAceptado" => "2015-02-23" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Oliveros H, Ríos F, Ruiz A. Apreciación crítica de la evidencia. Rev Colomb Anestesiol. 2015;43:160–162.</p>" ] ] "multimedia" => array:1 [ 0 => array:5 [ "identificador" => "tb0005" "tipo" => "MULTIMEDIATEXTO" "mostrarFloat" => false "mostrarDisplay" => true "texto" => array:1 [ "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0010" class="elsevierStylePara elsevierViewall">Levin MA, McCormick PJ, Lin HM, Hosseinian L, Fischer GW. Low intraoperative tidal volume ventilation with minimal PEEP is associated with increased mortality. Br J Anaesth. 2014;113:97–108. <span class="elsevierStyleInterRef" id="intr0005" href="doi:10.1093/bja/aeu0541">http://dx.doi.org/10.1093/bja/aeu0541</span></p></span>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:28 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Low intraoperative tidal volume ventilation with minimal PEEP is associated with increased mortality" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.A. Levin" 1 => "P.J. McCormick" 2 => "H.M. Lin" 3 => "L. Hosseinian" 4 => "G.W. 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| 2022 January | 4 | 5 | 9 |
| 2021 December | 8 | 7 | 15 |
| 2021 November | 6 | 7 | 13 |
| 2021 October | 4 | 11 | 15 |
| 2021 September | 5 | 7 | 12 |
| 2021 August | 6 | 3 | 9 |
| 2021 July | 5 | 6 | 11 |
| 2021 June | 6 | 8 | 14 |
| 2021 May | 5 | 8 | 13 |
| 2021 April | 4 | 5 | 9 |
| 2021 March | 3 | 7 | 10 |
| 2021 February | 1 | 3 | 4 |
| 2021 January | 4 | 10 | 14 |
| 2020 December | 4 | 8 | 12 |
| 2020 November | 1 | 6 | 7 |
| 2020 October | 4 | 2 | 6 |
| 2020 September | 6 | 6 | 12 |
| 2020 August | 5 | 5 | 10 |
| 2020 July | 7 | 2 | 9 |
| 2020 June | 1 | 1 | 2 |
| 2020 May | 6 | 6 | 12 |
| 2020 April | 1 | 3 | 4 |
| 2020 March | 4 | 6 | 10 |
| 2020 February | 4 | 2 | 6 |
| 2020 January | 3 | 3 | 6 |
| 2019 December | 9 | 7 | 16 |
| 2019 November | 3 | 0 | 3 |
| 2019 October | 1 | 2 | 3 |
| 2019 September | 1 | 0 | 1 |
| 2019 August | 4 | 1 | 5 |
| 2019 July | 1 | 3 | 4 |
| 2019 June | 1 | 2 | 3 |
| 2019 May | 1 | 7 | 8 |
| 2018 September | 1 | 0 | 1 |
| 2018 June | 1 | 2 | 3 |
| 2018 May | 14 | 7 | 21 |
| 2018 April | 21 | 8 | 29 |
| 2018 March | 12 | 6 | 18 |
| 2018 February | 14 | 8 | 22 |
| 2018 January | 29 | 5 | 34 |
| 2017 December | 15 | 6 | 21 |
| 2017 November | 18 | 7 | 25 |
| 2017 October | 17 | 11 | 28 |
| 2017 September | 19 | 9 | 28 |
| 2017 August | 29 | 7 | 36 |
| 2017 July | 31 | 5 | 36 |
| 2017 June | 32 | 11 | 43 |
| 2017 May | 35 | 9 | 44 |
| 2017 April | 36 | 12 | 48 |
| 2017 March | 17 | 8 | 25 |
| 2017 February | 12 | 4 | 16 |
| 2017 January | 12 | 5 | 17 |
| 2016 December | 24 | 15 | 39 |
| 2016 November | 21 | 11 | 32 |
| 2016 October | 17 | 7 | 24 |
| 2016 September | 24 | 6 | 30 |
| 2016 August | 22 | 9 | 31 |
| 2016 July | 12 | 5 | 17 |
| 2016 June | 0 | 13 | 13 |
| 2016 May | 2 | 25 | 27 |
| 2016 April | 0 | 14 | 14 |
| 2016 March | 2 | 19 | 21 |
| 2016 February | 0 | 24 | 24 |
| 2016 January | 1 | 0 | 1 |
| 2015 December | 7 | 11 | 18 |
| 2015 November | 21 | 1 | 22 |
| 2015 October | 26 | 18 | 44 |
| 2015 September | 43 | 8 | 51 |
| 2015 August | 34 | 10 | 44 |
| 2015 July | 31 | 10 | 41 |
| 2015 June | 39 | 10 | 49 |
| 2015 May | 66 | 12 | 78 |
| 2015 April | 47 | 16 | 63 |
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