Ventilatory inequality in the operating room. Gender differences in intraoperative mechanical ventilation guidelines

Matías Aguilera, A.; Alday Muñoz, E.; Muñoz de Nova, J.L.; Planas Roca, A.
doi:10.1016/j.redare.2022.08.009
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In the context of a recent dissertation&#44; we performed a cross-sectional observational study that analysed the extent to which anaesthesiologists from a tertiary University Hospital adhere to the consensus-based recommendations on intraoperative mechanical ventilation &#40;MV&#41; published in 2019 by Young et al&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> According to these guidelines&#44; patients should initially be ventilated using a tidal volume &#40;Vt&#41; of 6&#8211;8&#160;ml kg predicted body weight&#44; PEEP&#160;&#8805;&#160;5&#160;cm H2O and FiO<span class="elsevierStyleInf">2</span>&#160;&#8804;&#160;0&#46;6&#44; and alveolar recruitment manoeuvres &#40;ARM&#41; should be performed in case of hypoxaemia&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">After obtaining the informed consent of the treating anaesthesiologist&#44; we collected data during anaesthesia maintenance in the operating room&#46; We recorded the ventilator settings and collected patient data from their clinical history and anaesthesia chart&#46; We used the <span class="elsevierStyleItalic">ARDSNet</span><a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> protocol to calculate weight&#58; men&#58; 50&#160;&#43;&#160;0&#46;91&#160;&#215;&#160;&#40;height in cm - 152&#46;4&#41;&#59; women&#58; 45&#46;5&#160;&#43;&#160;0&#46;91&#160;&#215;&#160;&#40;height in cm - 152&#46;4&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The study was approved by the Research Ethics Committees of the Hospital Universitario La Princesa&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The estimated sample size was 65 patients &#40;95&#37; confidence level&#44; 10&#37; precision&#44; and 50&#37; estimated adherence&#44; which maximized the sample size&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">We recruited a total of 73 patients &#40;42 men and 31 women&#41;&#44; and found a 50&#37; rate of adherence to recommendations &#40;95&#37; CI 39&#8211;61&#41;&#46; In 40&#37; of patients&#44; lack of adherence was due to the programmed Vt exceeding 8&#160;ml&#47;kg of predicted weight&#46; Significantly&#44; 71&#37; of women in the sample were ventilated with Vt&#160;&#62;&#160;8&#160;ml&#47;kg compared to 16&#37; of men&#44; showing that women were 3 times more likely to be ventilated using a higher-than-recommended Vt&#46; Regarding the other parameters analysed&#44; Vt&#160;&#62;&#160;8&#160;ml&#47;kg was also more likely to be used in obese &#40;body mass index&#160;&#62;&#160;30&#41; patients&#44; although this difference was not statistically significant&#44; and recommendations were more likely to be followed when an anaesthesiology resident was present in the operating room &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Our results show the existence of gender inequality in the application of lung protective recommendations in intraoperative MV&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Swart et al&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> also found differences between the Vt used in men and women admitted to intensive care units&#46; In their prospective observational study&#44; they analysed MV Vt settings in in critically ill patients from 2001 to 2015&#44; and found that the Vt used gradually decreased over time&#44; although the use of Vt&#160;&#60;&#160;8&#160;ml&#47;kg increased from 12&#37; to 78&#37; in men and from 5&#37; to only 50&#37; in women&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Low Vt ventilation &#40;6&#8722;8&#160;ml&#47;kg of predicted weight&#41; is the cornerstone of lung protective ventilation&#46; According to Severgnini et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> low Vt together with PEEP&#160;&#8805;&#160;5 or adjusted for ARM can reduce systemic and local inflammation&#44; the rate of postoperative pulmonary complications&#44; and hospital length of stay&#46; Our results show that women are at higher risk of overventilation-related perioperative injury for several reasons&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0045" class="elsevierStylePara elsevierViewall">First&#44; the default Vt setting on anaesthesia ventilators is 500&#160;ml&#44; which means ventilating female patients measuring least 171&#160;cm in height with a Vt of 8&#160;ml&#47;kg of predicted weight&#44; and overventilating any female patient under this height&#46; According to the Spanish <span class="elsevierStyleItalic">National Statistics Institute</span> &#40;<span class="elsevierStyleItalic">INE&#44;</span> in its Spanish acronym&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> the average height of women in Europe is 163&#160;cm&#44; and 85&#37; of women are under 171&#160;cm tall&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0050" class="elsevierStylePara elsevierViewall">Secondly&#44; the recommended <span class="elsevierStyleItalic">ARDSNet</span> protocol for calculating predicted weight is complex and infeasible in normal practice&#44; unless it is built into the ventilator&#46; Formulas based directly on height&#44; subtracting 100 or 110&#160;cm depending on sex&#44; are useful in our opinion&#44; since in most patients they correlate with the <span class="elsevierStyleItalic">ARSDNet</span> formula&#44; except in women measuring under 150&#160;cm and in men measuring over 190&#160;cm&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0055" class="elsevierStylePara elsevierViewall">Finally&#44; according to the <span class="elsevierStyleItalic">European Health Survey 2020 in Spain</span>&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> 16&#46;5&#37; of men and 15&#46;5&#37; of women have a BMI&#160;&#62;&#160;30&#46; In these patients&#44; the use of actual weight to calculate intraoperative Vt will increase the risk of overventilation in both men and women&#46;</p></li></ul></p><p id="par0060" class="elsevierStylePara elsevierViewall">In view of the results obtained&#44; we believe that adherence to recommendations for intraoperative MV can be improved by&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1</span><p id="par0065" class="elsevierStylePara elsevierViewall">Raising awareness of existing gender differences in order to promote the practice of calculating Vt based on predicted weight&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2</span><p id="par0070" class="elsevierStylePara elsevierViewall">Encouraging ventilator manufacturers to factor in gender and height in addition to age and weight in their automatic calculation of Vt settings&#46; The interface can also report Vt based on predicted weight&#44; including an alarm&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">3</span><p id="par0075" class="elsevierStylePara elsevierViewall">Reduce default Vt to 400&#160;ml on ventilators&#46; Based on the foregoing calculations and the average height according to the INE&#44; this would reduce the percentage of women at risk of being ventilated with Vt greater than 8&#160;ml&#47;kg from 85&#37; to less than 15&#37;&#46;</p></li></ul></p></span>"
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Female&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;63&#8722;5&#46;06&nbsp;\t\t\t\t\t\t\n
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