Intraoperative Mechanical Ventilation Strategies in Patients Undergoing One-Lung Ventilation: A Meta-Analysis

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Liu et al.

SpringerPlus (2016) 5:1251


DOI 10.1186/s40064-016-2867-0

RESEARCH Open Access

Intraoperative mechanical ventilation


strategies in patients undergoing one‑lung
ventilation: a meta‑analysis
Zhen Liu1, Xiaowen Liu1,2, Yuguang Huang1 and Jing Zhao1*

Abstract
Background: Postoperative pulmonary complications (PPCs), which are not uncommon in one-lung ventilation, are
among the main causes of postoperative death after lung surgery. Intra-operative ventilation strategies can influence
the incidence of PPCs. High tidal volume (VT) and increased airway pressure may lead to lung injury, while pressure-
controlled ventilation and lung-protective strategies with low VT may have protective effects against lung injury. In
this meta-analysis, we aim to investigate the effects of different ventilation strategies, including pressure-controlled
ventilation (PCV), volume-controlled ventilation (VCV), protective ventilation (PV) and conventional ventilation (CV),
on PPCs in patients undergoing one-lung ventilation. We hypothesize that both PV with low VT and PCV have protec-
tive effects against PPCs in one-lung ventilation.
Methods: A systematic search (PubMed, EMBASE, the Cochrane Library, and Ovid MEDLINE; in May 2015) was
performed for randomized trials comparing PCV with VCV or comparing PV with CV in one-lung ventilation. Meth-
odological quality was evaluated using the Cochrane tool for risk. The primary outcome was the incidence of PPCs.
The secondary outcomes included the length of hospital stay, intraoperative plateau airway pressure (Pplateau), oxygen
index (PaO2/FiO2) and mean arterial pressure (MAP).
Results: In this meta-analysis, 11 studies (436 patients) comparing PCV with VCV and 11 studies (657 patients) com-
paring PV with CV were included. Compared to CV, PV decreased the incidence of PPCs (OR 0.29; 95 % CI 0.15–0.57;
P < 0.01) and intraoperative Pplateau (MD −3.75; 95 % CI −5.74 to −1.76; P < 0.01) but had no significant influence on
the length of hospital stay or MAP. Compared to VCV, PCV decreased intraoperative Pplateau (MD −1.46; 95 % CI −2.54
to −0.34; P = 0.01) but had no significant influence on PPCs, PaO2/FiO2 or MAP.
Conclusions: PV with low VT was associated with the reduced incidence of PPCs compared to CV. However, PCV and
VCV had similar effects on the incidence of PPCs.
Keywords: Protective ventilation, Conventional ventilation, One lung ventilation, Pressure-controlled ventilation,
Volume-controlled ventilation

Background inflammation response in the lung. These changes make


One-lung ventilation, used to isolate and protect the patients susceptible to PPCs (Lohser and Slinger 2015).
lung, has been widely used in thoracic surgery. Nonphys- Various ventilation strategies, such as pressure-controlled
iologic tidal volumes, loss of normal functional residual ventilation (PCV), volume-controlled ventilation (VCV),
capacity and hyperperfusion in the ventilated lung dur- conventional ventilation (CV) and protective ventilation
ing one-lung ventilation result in alveolar damage and (PV), are used in one-lung ventilation. The ideal ventila-
tion strategy should minimize the risk of PPCs while also
*Correspondence: zhaojing1009@aliyun.com
benefitting both gas exchange and pulmonary mechanics.
1
Department of Anesthesiology, Peking Union Medical College Hospital, High tidal volume (VT) is associated with increased
1#Shuai fuyuan, Dongcheng District, Beijing 100730, China areas of overinflation but decreased areas of atelectasis
Full list of author information is available at the end of the article

© 2016 The Author(s). This article is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium,
provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license,
and indicate if changes were made.
Liu et al. SpringerPlus (2016) 5:1251 Page 2 of 12

at end-inspiration (Guldner et al. 2015). Protective ven- was defined as ventilation using VT ≥ 7 ml/kg predicted
tilation with low VT is thought to result in less ventilator- body weight with or without PEEP and without recruit-
induced lung injury and has become a routine strategy in ment maneuvers in one-lung ventilation (Lohser 2008;
patients with ARDS (Petrucci and De Feo 2013). Recent Della Rocca and Coccia 2013).
studies have reported similar results in that low VT pre- The included studies met the following criteria: rand-
vents postoperative complications in surgical patients omized controlled trials of patients aged 18 years or older
(Serpa Neto et al. 2015a, b). However, the effect of low who were undergoing one-lung ventilation during a sur-
VT on patients undergoing one-lung ventilation remains gical procedure. Randomized clinical trials (RCTs) were
unclear. In some studies, PV has been associated with a excluded if they did not involve a surgical procedure, if
decreased oxygenation index and more dead space ventila- they included patients undergoing cardiac surgery, if they
tion without decreases in the incidence of PPCs (Maslow included patients with cardiac diseases, sepsis or ARDS
et al. 2013; Jung et al. 2014; Blank et al. 2016; Neto et al. before surgery, if they were conference abstracts or if full-
2016). In other studies, PV was associated with a lower text articles could not be obtained, if they did not focus
incidence of PPCs and satisfactory gas exchange (Schil- on the comparisons of different ventilation strategies in
ling et al. 2005; Yang et al. 2011; Serpa Neto et al. 2015a, b). the dependent lung, if the intervention group and con-
VCV and PCV are also used in one-lung ventilation. PCV trol group had different ventilation settings during two-
may result in lower airway pressure and a more homoge- lung ventilation (TLV), or if the RCTs did not report any
neous distribution of the tidal volume; PCV also has less outcomes mentioned above. Animal studies were also
of an effect on cardiac function than VCV (Al Shehri et al. excluded.
2014). However, tidal volumes in PCV are highly variable The primary outcome of interest was the development
(Della Rocca and Coccia 2013). The benefits of PCV in of PPCs during follow up, defined as the development of
terms of oxygenation and protection against lung damage atelectasis, lung infiltration, pneumonia or ARDS. The
should be balanced. secondary outcomes included the length of hospital stay,
This meta-analysis aims to investigate the association intraoperative Pplateau, PaO2/FiO2 and MAP. PaO2/FiO2 at
between ventilation strategies and PPCs; the length of 20–40 min in one-lung ventilation in randomized parallel
hospital stay, intraoperative Pplateau, PaO2/FiO2 and MAP studies was included in the analysis of PaO2/FiO2. Cross-
were compared as the secondary outcomes. We hypothe- over studies were not used to evaluate the effect of ven-
size that PV with low VT and PCV have protective effects tilation strategies on PPCs, the length of hospital stay or
on PPCs in one-lung ventilation. PaO2/FiO2.

Methods Information sources


We used the Preferred Reporting Items for Systematic We performed a literature search in PubMed, EMBASE,
Review and Meta-analyses (PRISMA) recommended by the Cochrane Library, and Ovid MEDLINE in May 2015.
the PRISMA working group (http://www.prisma-state- The last search was performed on May 14th, 2015.
ment.org/) in this meta-analysis (Moher et al. 2009). This
meta-analysis was registered on PROSPERO (Prospective Search strategy
Register of Ongoing Systematic Reviews, http://www.crd. The terms ‘anesthesia’, ‘anaesthesia’, ‘surgery’, ‘surgical’,
york.ac.uk/prospero, Registration No. CRD42015022087). ‘operative’, ‘surgical operations’, ‘intra-operative care’,
‘postoperative care’, ‘preoperative care’, ‘perioperative
Eligibility criteria care’, ‘one lung ventilation’, ‘single-lung ventilation’, ‘sin-
We compared 2 types of interventions with 2 control gle-lung ventilations’, ‘lung separation techniques’, ‘lung
groups. In the comparison of PCV and VCV, the inter- separation technique’ were used in various combinations.
vention group was the PCV group and the control group The search was limited to clinical trials. The detailed
was the VCV group. PCV was defined as ventilation search strategy is provided as Additional file 1.
under pressure control with or without PEEP in one-lung
ventilation. VCV was defined as ventilation under vol- Study selection
ume control with or without PEEP in one-lung ventila- Two reviewers (ZL, XWL) conducted the system-
tion. In the comparison of PV and CV, the intervention atic search and independently reviewed the titles and
group was the PV group and the control group was the abstracts of the studies. Only reports meeting the criteria
CV group. According to previous studies, PV was defined listed above were included for data extraction, trial qual-
as ventilation using low VT (VT ≤ 6 ml/kg predicted body ity assessment and the analysis of results. Any disagree-
weight) with or without PEEP and with or without alveo- ments among reviewers was resolved by discussion with
lar recruitment strategies in one-lung ventilation. CV a third author (JZ).
Liu et al. SpringerPlus (2016) 5:1251 Page 3 of 12

Data collection process Results


Data were extracted independently by two reviewing Study selection
authors (ZL, XWL). Authors of the original studies were A total of 467 studies were screened and assessed for eli-
contacted to provide additional information if necessary. gibility. Of these, 446 records were excluded for a variety
of reasons as shown in Fig. 1. The remaining 21 rand-
Data items omized controlled trials (reporting on 22 comparisons)
The following information was extracted: study design involving 1083 one-lung ventilation patients undergoing
(randomized parallel studies, randomized cross-over non-cardiac surgery were included in this meta-analysis.
studies), number of patients, ventilation strategies, type Eleven studies including 436 patients compared PCV
of surgery, duration of one-lung ventilation, outcomes with VCV, and 11 studies including 657 patients com-
and preoperative FEV1 (% of predicted). pared PV with CV. Data shown in the histogram were
collected by contacting the corresponding authors by
Risk of bias e-mail for one trial (Jung et al. 2014).
The Cochrane tool for risk of bias was used to assess the
risk of bias for all studies (Higgins et al. 2011). The risk of Study characteristics
bias for random sequence generation, allocation conceal- Eleven of the 21 studies included in this meta-analysis
ment, blinding of participants and personnel, blinding of were randomized parallel studies and 10 studies were
outcome assessment, incomplete outcome data, selec- randomized cross-over studies. The study sample sizes
tive reporting and others was evaluated and classified ranged from 18 to 120 patients. The trials involved both
as “low”, “high”, or “unclear” risk. We used funnel plots open thoracic surgery and video-assisted thoracic sur-
to assess reporting bias, and these plots are available in gery. The duration of one-lung ventilation ranged from
the Additional file 1. The risk of bias evaluation was con- 73.4 to 109 min. The characteristics and risk of bias in
ducted independently by two authors (ZL, XWL). each study are shown in Tables 1 and 2, respectively.

Synthesis of results Results of individual studies and synthesis of results


Review-Manager software (RevMan, version 5.3; The Postoperative pulmonary complications
Cochrane Collaboration, Oxford, UK) was used to con- Two of the 11 studies including 147 patients compar-
duct the data analysis. For binary outcomes, PPCs were ing PCV with VCV reported PPCs as an outcome (Par-
summarized using odds ratios and their 95 % confi- dos et al. 2009; Boules and Ghobrial 2011). Both studies
dence intervals (CIs). Mean difference and 95 % CI were
reported for continuous outcomes. We used I2 to estimate
heterogeneity within the studies (Higgins et al. 2003). A
fixed-effect model was used to analyze the data. If I2 was 672 records identified through
database searching
greater than 50 %, we utilized the random-effects model. 157 from MEDLINE
175 from PubMed
118 from EMBASE
222 from Cochrane library
Additional analysis
When comparing the clinical effect of PCV with VCV, we
467 records after duplicates 443 records excluded after title
performed subgroup analyses to determine if outcomes and abstract screening
could be influenced by the setting of VT or the type of 432, other setting
6, not RCT
PCV. The setting of VT was divided into VT ≤ 6 ml/kg and 2, animal study
467 records screened 2, conference abstracts
VT ≥ 7 ml/kg predicted body weight. The type of PCV was 1, full-text unattainable

divided into conventional pressure-controlled ventilation 3 citations excluded


and PCV-VG. Subgroup analysis was performed only when 1, patients under 18
24 full-text articles assessed years old
for eligibility 1, cardiac surgery with
there were no less than 3 studies providing information for CBP
one outcome. If I2 > 50 %, we performed a sensitivity analy- 1, different TLV settings

sis by removing trials and reanalyzing the remaining studies. 21 studies included in qualitative synthesis

Quality assessment
A Measure Tool to Assess Systematic Reviews 21 studies (22 comparisons) were included in the
meta-analysis
(AMSTAR) was applied to assess the methodologi- 11, comparisons testing pressure controlled ventilation vs
volume controlled ventilation
cal quality. Grading of Recommendations Assessment, 11, comparisons testing protective ventilation vs
conventional ventilation
Development and Evaluation (GRADE) system was used
to assess the evidence quality. Fig. 1 Study flow diagram
Table 1 Characteristics of included studies
Author Year No. of Study Details of VT Age (year), Type of surgery Duration of one- Outcomes Time point Preopera-
patients intervention (ml/kg) and mean (SD) lung ventilation of measure- tive FEV1 (%
PEEP (cmH2O) in each mode ment of out- of predicted)
(min), mean (SD) comes (SD)

Randomized parallel study


Hu et al. 2014 (1) 15 (1) PCV-VG (1) VT = 7 (1) 61 (6) VATS (1) 147(22) Respiratory 15 and 60 min Not reported
(2) 15 (2) VCV PEEP = 0 (2) 62 (7) (2) 154(52) parameters, gas after OLV
(2) VT = 7 exchange, hemo-
dynamics
Liu et al. SpringerPlus (2016) 5:1251

PEEP = 0
Qutubet al. 2014 (1) 13 (1) PV 4 (1) VT = 4 (1) 42 (32–54) VATS Not reported Extravascular lung 15, 45 min after (1) 87.1 (3.0)
(2) 13 (2) PV 6 PEEP = 5 (2) 39.5 (31–51) water content OLV; 48 h, 30d (2) 88.4 (2.9)
(3) 13 (3) CV (2) VT = 6 (3) 36 (29–48) index, respiratory post operation (3) 85.8 (4.1)
PEEP = 5 parameters, gas
(3) VT = 8 exchange, clinical
PEEP = 5 outcomes
Jung et al. 2014 (1) 30 (1) PV (1) VT = 6 (1) 35.2 (10.2) VATS Not reported Respiratory param- 5, 15, 30, 45 min Not reported
(2) 30 (2) CV PEEP = 8 (2) 36.3 (9.5) eters after OLV
(2) VT = 10
PEEP = 0
Shen et al. 2013 (1) 53 (1) PV (1) VT = 5 (1) 60.5 (7.3) MIE (1) 72.2 (23.6) Clinical outcomes, 18 h post opera- (1) 92.8 (14.6)
(2) 48 (2) CV PEEP = 5 (2) 57.2 (9.1) (2) 75.0 (18.8) gas exchange, tion, 30d post (2) 87.1 (16.9)
(2) VT = 8 cytokines expres- operation
PEEP = 0 sion
Maslow et al. 2013 (1) 16 (1) PV (1) VT = 5 (1) 62 (14.4) Thoracic surgery (1) 42 (8.3) Respiratory 5, 10, 15, 20, (1) 85.8 (21.7)
(2) 16 (2) CV PEEP = 5 (2) 69.6 (12.9) (2) 46 (9.5) parameters, gas 30 min after (2) 75.4 (16.4)
(2) VT = 10 exchange, hemo- OLV
PEEP = 0 dynamics, clinical
outcomes
Ye and Li 2011 (1) 10 (1) PCV (1) VT = 8 20–65 Thoracic surgery Not reported Respiratory 20, 45 and Not reported
(2) 10 (2) VCV PEEP = 0 parameters, gas 70 min after
(3) 10 (3) PV (2) VT = 8 exchange OLV
PEEP = 0
(3) VT = 6
PEEP = 5
Yang et al. 2011 (1) 50 (1) PV (1) VT = 6 (1) 58 (12) Thoracic surgery (1) 120 (41) Clinical outcomes, 15, 60 min after (1) 105 (9)
(2) 50 (2) CV PEEP = 5 (2) 60 (10) (2) 126 (53) gas exchange, OLV; 2, 72 h (2) 104 (17)
(2) VT = 10 hemodynamics post operation
PEEP = 0
Boules and 2011 (1) 18 (1) PCV-VG (1) VT = 6 (1) 33.4 (6.4) Thoracic surgery (1) 88.7 (42.1) Respiratory 30 min after (1) 73.4 (11.7)
Ghobrial (2) 19 (2) VCV PEEP = 0 (2) 34.7 (7.6) (2) 75.6 (34.7) parameters, gas OLV;72 h post (2) 74.3 (12.5)
(2) VT = 6 exchange, hemo- operation
PEEP = 0 dynamics, clinical
outcomes
Page 4 of 12
Table 1 continued
Author Year No. of Study Details of VT Age (year), Type of surgery Duration of one- Outcomes Time point Preopera-
patients intervention (ml/kg) and mean (SD) lung ventilation of measure- tive FEV1 (%
PEEP (cmH2O) in each mode ment of out- of predicted)
(min), mean (SD) comes (SD)

Pardos et al. 2009 (1) 55 (1) PCV +PEEP (1) VT = 8 (1) 59.5 (13) Thoracic surgery Not reported Respiratory 20, 30 and (1) 91.2 (24)
(2) 55 (2) VCV + PEEP PEEP = 0; (2) 63.9 (11) parameters, gas 40 min after (2) 87.9 (21)
20 min after OLV exchange, clinical OLV; 24 h post
PEEP = 5 outcomes operation; 30d
(2) VT = 8 post operation
Liu et al. SpringerPlus (2016) 5:1251

PEEP = 0;
20 min after OLV
PEEP = 5
Lin et al. 2008 (1) 20 (1) PV (1) VT = 5–6 (1) 55 Thoracic surgery Not reported Cytokines expres- 120 min after Not reported
(2) 20 (2) CV PEEP = 3–5 (2) 54 sion, respiratory OLV, 24 h post
(2) VT = 10 PEEP parameters, gas operation
unclear exchange
Michelet et al. 2006 (1) 26 (1) PV (1) VT = 5 (1) 61 (10) Thoracic surgery (1) 85 (29) Cytokines expres- 15 min after OLV; (1) 93 (19)
(2) 26 (2) CV PEEP = 5 (2) 60 (8.5) (2) 89 (29) sion, respiratory at the end of (2) 96 (18)
(2) VT = 9 parameters, gas OLV; 1,18 h
PEEP = 0 exchange, clinical post operation
outcomes
Randomized cross-over study
Song et al. 2014 27 (1) PCV-VG (1) VT = 8 63.6 (9.7) Thoracic surgery (1) 30 Respiratory 30 min after OLV 107.3 (33.1)
(2) VCV PEEP = 0 (2) 30 parameters, gas in each mode
(2) VT = 8 exchange, hemo-
PEEP = 0 dynamics
Pu et al. 2014 20 (1) PCV-VG (1) VT = 8–10 PEEP 59.8 (unclear) Thoracic surgery (1) 30 Respiratory 30 min after OLV Not reported
(2) VCV unclear (2) 30 parameters, gas in each mode
(2) VT = 8–10 PEEP exchange, hemo-
unclear dynamics
Al Shehri et al. 2014 28 (1) PCV (1) VT = 6 (1) 37.4 (11.51) Thoracic surgery (1) 30 Right ventricular 30 min after OLV 84.5 (10.8)
(2)VCV PEEP = 5 (2) 39.1 (13.93) (2) 30 function, gas in each mode
(2) VT = 6 exchange, hemo-
PEEP = 5 dynamics
Végh et al. 2013 100 (1) PV (1) VT = 5 (1) 64 (12) Thoracic surgery (1) 30 Respiratory 30 min after OLV 91.5
(2) CV PEEP = 5 (2) 63 (12) (2) 30 parameters, gas in each mode (14.0)
(2) VT = 10 exchange, hemo-
PEEP = 0 dynamics
Roze et al. 2012 82 (1) PV (1) VT = 5 (1) 62 (10) Thoracic surgery (1) 10 Respiratory 10 min after OLV Not reported
(2) CV PEEP = 9 (1) (2) 60 (10) (2) 10 parameters, Gas in each mode
(2) VT = 8 exchange, hemo-
PEEP = 5 dynamics
Sungur Ulke 2011 31 (1) PV (1) VT = 6 58.3 (7.2) Thoracic surgery (1) 20 Respiratory 20 min after OLV 75 (14.7)
et al. (2) CV PEEP = 5 (2) 20 parameters, gas in each mode
(2) VT = 8 exchange, hemo-
PEEP = 0 dynamics
Page 5 of 12
Liu et al. SpringerPlus (2016) 5:1251

Table 1 continued
Author Year No. of Study Details of VT Age (year), Type of surgery Duration of one- Outcomes Time point Preopera-
patients intervention (ml/kg) and mean (SD) lung ventilation of measure- tive FEV1 (%
PEEP (cmH2O) in each mode ment of out- of predicted)
(min), mean (SD) comes (SD)

Montes et al. 2010 41 (1) PCV (1) VT = 6 (1) 59.1 (16) Thoracic surgery (1) 30 Respiratory 30 min after OLV 91.2 (19.3)
(2)VCV PEEP = 5 (2) 56.1 (17) (2) 30 parameters, gas in each mode
(2) VT = 6 exchange
PEEP = 5
Choi et al. 2009 18 (1) PCV (1) VT = 8 61.4 (10.3) Robot-assisted (1) 30 Respiratory 30 min after OLV 109.1 (21.2)
(2) VCV PEEP = 0 esophagectomy (2) 30 parameters, gas in each mode
(2) VT = 9 exchange, hemo-
PEEP = 0 dynamics
Unzueta et al. 2007 57 (1) PCV (1) VT = 9 (1) 58.25 (15.15) Thoracic surgery (1) 30 Respiratory 30 min after OLV 82.2 (17.5)
(2) VCV PEEP = 0 (2) 54.75 (13.91) (2) 30 parameters, gas in each mode
(2) VT = 9 exchange
PEEP = 0
Tugrul et al. 1997 48 (1) PCV (1) VT = 10 PEEP 56.4 Thoracic surgery (1) 30 Respiratory 30 min after OLV 76.8 (14)
(2) VCV unclear (2) 30 parameters, gas in each mode
(2) VT = 10 PEEP exchange, hemo-
unclear dynamics
ARS alveolar recruitment strategy, CV conventional ventilation, MIE minimally invasive esophagectomy, PCV pressure-controlled ventilation, PCV-VG volume guaranteed pressure-controlled ventilation, PV protective
ventilation, VATS video-assisted thoracoscopic surgery, VCV volume-controlled ventilation
Page 6 of 12
Liu et al. SpringerPlus (2016) 5:1251 Page 7 of 12

Table 2 Risk of bias in included studies


Author Year Random Allocation Blinding Blinding Incomplete Selective Other bias
sequence concealment of participants of outcome outcome data reporting
generation and personnel assessment

Randomized parallel study


Hu et al. 2014 Low High Low Low Unclear Unclear Low
Qutub et al. 2014 Unclear Unclear Low Low Low Low Low
Jung et al. 2014 Low High Low Low Unclear Unclear Low
Shen et al. 2013 Low Unclear Low Unclear Low High Low
Maslow et al. 2013 Unclear Unclear Low Unclear Low Unclear Low
Yang et al. 2011 Low Low Low Low Low Unclear Low
Ye and Li 2011 Unclear Unclear Low Low Unclear Unclear Low
Boules and 2011 Low Unclear Low Unclear Unclear Unclear Low
Ghobrial
Pardos et al. 2009 Unclear High Low Unclear Unclear Unclear Low
Lin et al. 2008 Unclear Unclear Low Low Unclear Unclear Low
Michelet et al. 2006 Low Low Low Unclear Low Unclear High
Randomized cross-over study
Song et al. 2014 Low Unclear Low Low Unclear Unclear Low
Pu et al. 2014 Unclear Unclear Low Low Unclear Unclear Low
Al Shehri et al. 2014 Low Low Low Low Unclear Low High
Végh et al. 2013 Low Unclear Low Low Unclear Low Low
Roze et al. 2012 Low Unclear Low Low Low Low Low
Sungur Ulke 2011 Low Unclear Low Low Unclear Unclear Low
et al.
Montes et al. 2010 Low Unclear Low Low Low Unclear Low
Choi et al. 2009 Low Unclear Low Low Low Unclear Low
Unzueta et al. 2007 Low Unclear Low Low Low Unclear Low
Tugrul et al. 1997 Unclear Unclear Low Low Unclear Unclear Low

found that PCV did not have any advantages over VCV in et al. 1997; Unzueta et al. 2007; Choi et al. 2009; Par-
terms of decreased incidence of PPCs (OR 1.05; 95 % CI dos et al. 2009; Montes et al. 2010; Boules and Ghobrial
0.25–4.34; I2 = 0; P = 0.95) (Fig. 2a). 2011; Al Shehri et al. 2014; Pu et al. 2014). PCV showed
Four of the 12 studies including 285 patients compar- decreased Pplateau compared to VCV (MD −1.46; 95 % CI
ing PV with CV reported PPCs as an outcome (Michelet −2.58 to −0.34; I2 = 72 %; P = 0.01) (Fig. 4a).
et al. 2006; Yang et al. 2011; Maslow et al. 2013; Shen Eight of the 12 studies including 497 patients compar-
et al. 2013). PV showed a protective effect over CV on ing PV with CV reported Pplateau as an outcome (Michelet
respiratory complications after one-lung ventilation (OR et al. 2006; Lin et al. 2008; Sungur Ulke et al. 2011;
0.29; 95 % CI 0.15–0.57; I2 = 0; P < 0.01) (Fig. 2b). Yang et al. 2011; Roze et al. 2012; Maslow et al. 2013;
Végh et al. 2013; Jung et al. 2014). PV decreased Pplateau
Length of hospital stay compared to CV (MD −3.57; 95 % CI −5.74 to −1.76;
Four studies including 272 patients comparing PV with I2 = 94 %; P < 0.01) (Fig. 4b).
CV reported the length of hospital stay as an outcome
(Yang et al. 2011; Maslow et al. 2013; Shen et al. 2013; PaO2/FiO2
Qutub et al. 2014). No advantages in terms of the length Three randomized parallel trials including 167 patients
of hospital stay were found in the PV group (MD −0.65; comparing PCV and VCV reported PaO2/FiO2 at
95 % CI −1.59 to 0.30; I2 = 27 %; P = 0.18) (Fig. 3). 20–30 min after OLV as an outcome (Pardos et al. 2009;
Boules and Ghobrial 2011; Ye and Li 2011). No differ-
Plateau airway pressure ences in PaO2/FiO2 were found in those 2 groups (MD
Eight of the 11 studies including 359 patients comparing 47.56; 95 % CI −7.67 to 102.79; I2 = 91 %; P = 0.09)
PCV with VCV reported Pplateau as an outcome (Tugrul (Fig. 5).
Liu et al. SpringerPlus (2016) 5:1251 Page 8 of 12

Fig. 2 Effect of ventilation strategies on postoperative pulmonary complications. a PCV versus VCV; b PV versus CV

Fig. 3 Effect of ventilation strategies on length of hospital stay (days)

Mean arterial pressure VT 6 ml/kg predicted body weight compared to VCV. In


Six of the 11 studies including 181 patients comparing the groups with VT ≥ 7 ml/kg, no significant benefit was
PCV and VCV reported MAP as an outcome (Tugrul found in patients undergoing PCV compared to VCV
et al. 1997; Choi et al. 2009; Boules and Ghobrial 2011; Al (MD −0.58; 95 % CI −1.37–0.20) (Table 3).
Shehri et al. 2014; Hu et al. 2014; Pu et al. 2014). No dif- Subgroup analysis on the type of PCV showed
ferences in MAP were found in those 2 groups (MD 0.26; decreases in Pplateau (MD −2.78; 95 % CI −4.21 to
95 % CI −2.28–2.79; I2 = 0; P = 0.84) (Fig. 6a). −1.35; I2 = 0 %; P < 0.01) in patients undergoing vol-
Four of the 12 studies including 222 patients compar- ume guaranteed pressure-controlled ventilation (PCV-
ing PV and CV reported MAP as an outcome (Michelet VG) compared to VCV, while traditional PCV showed
et al. 2006; Sungur Ulke et al. 2011; Végh et al. 2013; no significant benefits in Pplateau (MD −1.06; 95 % CI
Qutub et al. 2014). No differences in MAP were found in −2.37–0.24; I2 = 75 %; P = 0.11). With respect to MAP,
those 2 groups (MD −0.89; 95 % CI −3.20 to 1.41; I2 = 0; no significant differences or heterogeneity were found in
P = 0.45) (Fig. 6b). the subgroup analysis.
Sensitivity analyses of Pplateau and PaO2/FiO2 were also
Subgroup analysis performed. When comparing PCV with VCV, heteroge-
Subgroup analysis regarding the volume of VT showed a neity in Pplateau could be resolved by excluding the study
decrease in Pplateau (MD −2.58; 95 % CI −4.74 to −0.43; by Al Shehri et al. (2014) (MD −0.89; 95 % CI −1.50 to
I2 = 85 %; P = 0.02) in patients undergoing PCV with −0.28; I2 = 37 %; P < 0.01). This change had no effect
Liu et al. SpringerPlus (2016) 5:1251 Page 9 of 12

Fig. 4 Effect of ventilation strategies on plateau airway pressure. a PCV versus VCV; b PV versus CV

Fig. 5 Effect of ventilation strategies on PaO2/FiO2

on the final result. Heterogeneity in PaO2/FiO2 could be that PCV-VG (but not traditional PCV) can decrease
resolved by excluding the study by Pardos et al. (Pardos Pplateau. Currently available data are insufficient to iden-
et al. 2009) (MD 74.01; 95 % CI 60.04–87.98; I2 = 0 %; tify differences between PV and CV or PCV and VCV on
P < 0.01). This change affected the final result and showed the length of hospital stay, PaO2/FiO2 or MAP.
PCV benefited PaO2/FiO2 in comparison with VCV. In Our result suggesting that PV with low VT can protect
the comparison of PV with CV on Pplateau, heterogeneity surgical patients from PPCs is consistent with recently pub-
and the final result could not be resolved by the exclusion lished studies (Hemmes et al. 2015, Serpa Neto et al. 2015a,
of any study involved in this meta-analysis. b). However, the definition of PV in these studies is venti-
lation with VT ≤ 8 ml/kg, and they also include all surgi-
Discussion cal patients under general anesthesia (Hemmes et al. 2015).
This meta-analysis suggests that PV but not PCV can The definition of VT and the conclusions from these studies
decrease the incidence of PPCs. Although both PV and might not be suitable in one-lung ventilation. Our results
PCV can decrease the Pplateau, subgroup analyses show suggest that PV with VT ≤ 6 ml/kg can benefit surgical
Liu et al. SpringerPlus (2016) 5:1251 Page 10 of 12

Fig. 6 Effect of ventilation strategies on mean arterial pressure. a PCV versus VCV; b PV versus CV

Table 3 Subgroup analyses of patients undergoing one-lung ventilation with PCV and VCV
Volume of VT Type of PCV
≤6 ml/kg ≥7 ml/kg Traditional PCV PCV-VG

Plateau airway pressure [MD (95 % CI)] −2.58 (−4.74, −0.43) −0.58 (−1.37, 0.20) −1.06 (−2.37, 0.24) −2.78 (−4.21, −1.35)
Mean arterial pressure [MD (95 % CI)] −2.17 (−7.25, 2.91) 1.06 (−1.87, 3.99) 0.04 (−3.12, 3.20) 0.64 (−3.62, 4.91)

patients in one-lung ventilation. A high quality retrospec- identify any difference between PCV and VCV on PPCs.
tive study published recently found that low VT does not It should be noted that Pplateau in PV is lower than Pplateau
prevent PPCs, which contradicts our results (Blank et al. in PCV on average (Choi et al. 2009; Sungur Ulke et al.
2016). In this retrospective study, fewer than half (47 %) of 2011). Differences in Pplateau may be caused by the differ-
the patients received PEEP ≥ 5 cmH2O (Blank et al. 2016). ences in VT. The VT in PCV is usually 8 ml/kg or higher,
Atelectasis should be considered in all general anesthe- while the VT in PV is no more than 6 ml/kg (Michelet
tized patients. And it is of great importance to avoiding the et al. 2006; Jung et al. 2014; Pu et al. 2014). PCV-VG is a
occurrence of atelectasis during OLV (Lohser and Slinger novel mode of ventilation which has been used in recent
2015). Low VT with low PEEP can cause increased amounts years. Although present data suggest that PCV-VG can
of atelectasis (Guldner et al. 2015). Only one study with a decrease Pplateau, more studies are still needed.
sample size of 40 patients used PV with PEEP ≤ 5 cmH2O A combination of low VT and PEEP is generally used in
(Lin et al. 2008). In this study performed by Lin et al., PPCs PV. PEEP can cause cardiac compromise, which can be
were not included in the outcomes (Lin et al. 2008). To reflected by MAP. Low VT may induce hypoxemia. In this
achieve a protective effect on PPCs, PEEP ≥ 5 cmH2O may meta-analysis, the effects of different ventilation strate-
be necessary when PV is used in surgical patients undergo- gies on PaO2/FiO2 and MAP were compared. Decreasing
ing one-lung ventilation. alveolar oxygen tension could induce HPV and resulted
Pplateau is part of the driving pressure and contributes in the redistribution of pulmonary blood flow (Moudgil
to ventilator-induced lung injury (Neto et al. 2016). Our et al. 2005). HPV had a rapid-onset phase and a delayed
results suggest that PV has lower Pplateau compared to CV, phase in response to alveolar hypoxia. The rapid-onset
which might explain the mechanism of decreased PPCs phase reached a plateau at 20–40 min. The delayed phase
in the PV group. Although PCV can also decrease the begins at 40 min and takes more than 2 h to reverse
Pplateau compared to VCV, current data are insufficient to (Lumb and Slinger 2015). PaO2/FiO2 can be affected by
Liu et al. SpringerPlus (2016) 5:1251 Page 11 of 12

HPV. Because most thoracic surgery can be completed in Authors’ contributions


ZL helped design the study, conduct the study, analyze the data, and write
2 h, only the results of PaO2/FiO2 at 20 to 40 min after the manuscript. XL helped conduct the study and analyze the data. YH helped
one-lung ventilation are compared in this meta-analysis. conduct the study. JZ helped design the study, conduct the study, and write
Our results suggest that there is no difference between the manuscript. All authors read and approved the final manuscript.
PV and CV or PCV and VCV on PaO2/FiO2 and MAP. Author details
This result is consistent with clinical studies published 1
Department of Anesthesiology, Peking Union Medical College Hospital,
previously (Boules and Ghobrial 2011; Qutub et al. 2014). 1#Shuai fuyuan, Dongcheng District, Beijing 100730, China. 2 Department
of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical
The studies included in this meta-analysis are all RCTs Sciences and Peking Union Medical College, 33# Shijingshan District, Bei-
and the overall quality of their reporting is good. Ran- jing 100144, China.
dom sequence generation and allocation concealment
Acknowledgements
are utilized in most studies. This meta-analysis is of high We thank the authors of all the studies included in this meta-analysis.
methodological quality assessed by AMSTAR. However,
limited by the number of patients, the overall strength Competing interests
The authors declare that they have no competing interests.
of the evidence provided by this meta-analysis is moder-
ate (Additional file 2). Received: 2 December 2015 Accepted: 19 July 2016
This meta-analysis has some limitations. First, PPCs
include a combination of various lung injuries after sur-
gery. The incidence of atelectasis, volutrauma, barotrauma
and ARDS may not be the same with different ventilation
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