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ABSTRACT
Historically, mechanical ventilation of the lungs utilizing relatively large tidal volumes was common practice in the operating room and intensive care unit (ICU). The rationale behind this treatment strategy was to yield better patient outcomes, that is, fewer pulmonary complications, and a reduction in morbidity and mortality. As evidence-based practice has evolved, potential harmful effects of traditional, nonphysiological mechanical ventilation (ventilation with larger tidal volumes and the tolerance of high airway pressures) even in shortterm treatment have been shown to correlate with systemic inflammation and the development of ventilator-associated lung injury. Lung-protective ventilation principles using more physiological tidal volumes, avoiding high inspiratory plateau pressures, along with appropriate levels of positive end-expiratory pressure have been shown to decrease pulmonary complications and improve outcomes in patients with acute respiratory distress syndrome requiring ongoing ventilatory support in the ICU. In addition, current research is beginning to validate the benefit of providing more physiologic ventilator support in the operating room, particularly for high-risk patients undergoing major abdominal surgery, in minimizing acute lung injury. A review of lung-protective ventilation measures including benefits and potential side effects is presented. Additional treatment modalities and therapeutic considerations are offered for inclusion in optimal patient management.
INTRODUCTION
Pulmonary complications, such as acute lung injury, atelectasis, pneumonia, and infection, associated with mechanically ventilated patients, remain a major contributor to increased patient morbidity and mortality (Esteban et al., 2013; Gu, Wang, & Liu, 2015). Significant postoperative pulmonary complications, occurring in approximately 5% of patients (Canet et al., 2010) are the second most common perioperative problem following wound infection (Khuri et al., 2005). Consequences of these pulmonary complications are an increased length of hospital stay, morbidity, and mortality (Canet et al., 2010; Mazo et al., 2014). The contributory role of mechanical ventilation to negative patient outcomes has been reassessed to determine whether modification in our traditional ventilatory management of the patient might translate into realized benefits and improved patient care. Conventional ventilatory parameters consisted of employing relatively large tidal volumes (VT), in the range of 12 to 15 mL/kg of predicted body weight (PBW), with the belief that these larger breaths were safe, would prevent atelectasis, improve ventilation-perfusion mismatch, and reduce the need for high inspired oxygen concentrations. Positive end-expiratory pressure (PEEP) was not used...