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01-10-2005 | Original

Mechanical ventilation strategies and inflammatory responses to cardiac surgery: a prospective randomized clinical trial

Authors: Hermann Wrigge, Ulrike Uhlig, Georg Baumgarten, Jan Menzenbach, Jörg Zinserling, Martin Ernst, Daniel Drömann, Armin Welz, Stefan Uhlig, Christian Putensen

Published in: Intensive Care Medicine | Issue 10/2005

Abstract

Objective

To examine whether postoperative mechanical ventilation with lower tidal volumes (V_T) has protective effects on inflammatory responses induced by cardiopulmonary bypass (CPB) surgery in smokers and nonsmokers.

Design and setting

Prospective, randomized, controlled clinical trial in the intensive care unit of a university hospital.

Patients and participants

We examined 44 patients (22 smokers, 22 nonsmokers) immediately after uncomplicated CPB surgery.

Interventions

Ventilation was applied for 6 h with either V_T of either 6 or 12 ml/kg ideal body weight.

Measurements and results

The time course of serum tumor necrosis factor (TNF) α, interleukin (IL) 6, and IL-8 determined 0, 2, 4, and 6 h after randomization did not differ significantly between the ventilatory strategies. By contrast, in bronchoalveolar lavage fluids sampled after 6 h only TNF-α levels were significantly higher in the high V_T group than the low V_T group (50±111 pg/ml vs. 1±7 pg/ml). IL-6 and IL-8 concentrations did not differ between groups. Subgroup analysis of patients with serum TNF-α level higher than 0 pg/ml after surgery revealed lower TNF-α serum levels during lower V_T ventilation. All observed effects were small, independent of patients’ history of smoking, and were not correlated with duration of ventilation and ICU stay.

Conclusions

Ventilation with lower V_T had no or only minor effect on systemic and pulmonary inflammatory responses in patients with healthy lungs after uncomplicated CPB surgery. Our data do not suggest a clinical benefit of using low V_T ventilation in these selected patients.

Ranieri VM, Suter PM, Tortorella C, De Tullio R, Dayer JM, Brienza A, Bruno F, Slutsky AS (1999) Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial. JAMA 282:54–61CrossRefPubMed

Silverman HJ, Luce JM, Lanken PN, Morris AH, Harabin AL, Oldmixon CF, Thompson BT, Bernard GR (2005) Recommendations for informed consent forms for critical care clinical trials. Crit Care Med 33:867–882CrossRefPubMed

Parsons PE, Eisner MD, Thompson BT, Matthay MA, Ancukiewicz M, Bernard GR, Wheeler AP (2005) Lower tidal volume ventilation and plasma cytokine markers of inflammation in patients with acute lung injury. Crit Care Med 33:1–6CrossRefPubMed

Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 342:1301–1308CrossRefPubMed

Amato MB, Barbas CS, Medeiros DM, Magaldi RB, Schettino GP, Lorenzi FG, Kairalla RA, Deheinzelin D, Munoz C, Oliveira R, Takagaki TY, Carvalho CR (1998) Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 338:347–354CrossRefPubMed

Cremer J, Martin M, Redl H, Bahrami S, Abraham C, Graeter T, Haverich A, Schlag G, Borst HG (1996) Systemic inflammatory response syndrome after cardiac operations. Ann Thorac Surg 61:1714–1720CrossRefPubMed

Kilger E, Weis F, Briegel J, Frey L, Goetz AE, Reuter D, Nagy A, Schuetz A, Lamm P, Knoll A, Peter K (2003) Stress doses of hydrocortisone reduce severe systemic inflammatory response syndrome and improve early outcome in a risk group of patients after cardiac surgery. Crit Care Med 31:1068–1074CrossRefPubMed

Wrigge H, Uhlig U, Zinserling J, Behrends-Callsen E, Ottersbach G, Fischer M, Uhlig S, Putensen C (2004) The effects of different ventilatory settings on pulmonary and systemic inflammatory responses during major surgery. Anesth Analg 98:775–81, tableCrossRefPubMed

Wrigge H, Zinserling J, Stüber F, Spiegel T, Hering R, Wetegrove S, Hoeft A, Putensen C (2000) Effects of mechanical ventilation on release of cytokines into systemic circulation in patients with normal pulmonary function. Anesthesiology 93:1413–1417CrossRefPubMed

10.

Stewart TE, Meade MO, Cook DJ, Granton JT, Hodder RV, Lapinsky SE, Mazer CD, McLean RF, Rogovein TS, Schouten BD, Todd TR, Slutsky AS (1998) Evaluation of a ventilation strategy to prevent barotrauma in patients at high risk for acute respiratory distress syndrome. Pressure- and Volume-Limited Ventilation Strategy Group. N Engl J Med 338:355–361CrossRefPubMed

11.

Viitanen A, Salmenpera M, Heinonen J (1990) Right ventricular response to hypercarbia after cardiac surgery. Anesthesiology 73:393–400PubMed

12.

Wrigge H, Uhlig U, Menzenbach J, Zinserling J, Uhlig S, Putensen, C (2003) Does postperative ventilatory strategy affect inflammatory response to cardiac surgery in smokers and non-smokers (abstract)? Am J Respir Crit Care Med 167[Suppl]:A905

13.

Wrigge H, Uhlig U, Menzenbach J, Zinserling J, Uhlig S, Putensen, C (2003) Inflammatory effects of conventional and lower tidal volume ventilation after cardiac surgery (abstract). Intensive Care Med 29 [Suppl 1]:S307

14.

Hachenberg T, Tenling A, Nystrom SO, Tyden H, Hedenstierna G (1994) Ventilation-perfusion inequality in patients undergoing cardiac surgery. Anesthesiology 80:509–519PubMed

15.

Hachenberg T, Tenling A, Hansson HE, Tyden H, Hedenstierna G (1997) The ventilation-perfusion relation and gas exchange in mitral valve disease and coronary artery disease. Implications for anesthesia, extracorporeal circulation, and cardiac surgery. Anesthesiology 86:809–817CrossRefPubMed

16.

Boldt J, Osmer C, Linke LC, Dapper F, Hempelmann G (1995) Circulating adhesion molecules in pediatric cardiac surgery. Anesth Analg 81:1129–1135CrossRefPubMed

17.

Nathan N, Denizot Y, Cornu E, Jauberteau MO, Chauvreau C, Feiss P (1997) Cytokine and lipid mediator blood concentrations after coronary artery surgery. Anesth Analg 85:1240–1246CrossRefPubMed

18.

Berendes E, Mollhoff T, Van Aken H, Schmidt C, Erren M, Deng MC, Weyand M, Loick HM (1997) Effects of dopexamine on creatinine clearance, systemic inflammation, and splanchnic oxygenation in patients undergoing coronary artery bypass grafting. Anesth Analg 84:950–957CrossRefPubMed

19.

Gilliland HE, Armstrong MA, McMurray TJ (1999) The inflammatory response to pediatric cardiac surgery: correlation of granulocyte adhesion molecule expression with postoperative oxygenation. Anesth Analg 89:1188–1191CrossRefPubMed

20.

Milot J, Perron J, Lacasse Y, Letourneau L, Cartier PC, Maltais F (2001) Incidence and predictors of ARDS after cardiac surgery. Chest 119:884–888CrossRefPubMed

21.

Koner O, Celebi S, Balci H, Cetin G, Karaoglu K, Cakar N (2004) Effects of protective and conventional mechanical ventilation on pulmonary function and systemic cytokine release after cardiopulmonary bypass. Intensive Care Med 30:620–626CrossRefPubMed

22.

International Consensus Conferences in Intensive Care Medicine (1999) Ventilator-associated lung injury in ARDS. American Thoracic Society, European Society of Intensive Care Medicine, Societe de Reanimation Langue Francaise. Intensive Care Med 25:1444–1452CrossRefPubMed

23.

Miller FG, Silverman HJ (2004) The ethical relevance of the standard of care in the design of clinical trials. Am J Respir Crit Care Med 169:562–564CrossRefPubMed

24.

Brower RG, Bernard G, Morris A (2004) Ethics and standard of care in clinical trials. Am J Respir Crit Care Med 170:198–199PubMed

25.

Montravers P, Gauzit R, Dombret MC, Blanchet F, Desmonts JM (1993) Cardiopulmonary effects of bronchoalveolar lavage in critically ill patients. Chest 104:1541–1547PubMed

26.

Steinberg KP, Mitchell DR, Maunder RJ, Milberg JA, Whitcomb ME, Hudson LD (1993) Safety of bronchoalveolar lavage in patients with adult respiratory distress syndrome. Am Rev Respir Dis 148:556–561

27.

Krause A, Hohberg B, Heine F, John M, Burmester GR, Witt C (1997) Cytokines derived from alveolar macrophages induce fever after bronchoscopy and bronchoalveolar lavage. Am J Respir Crit Care Med 155:1793–1797PubMed

28.

Pugin J (2002) Is the ventilator responsible for lung and systemic inflammation? Intensive Care Med 28:817–819CrossRefPubMed

29.

Abraham E, Wunderink R, Silverman H, Perl TM, Nasraway S, Levy H, Bone R, Wenzel RP, Balk R, Allred R (1995) Efficacy and safety of monoclonal antibody to human tumor necrosis factor alpha in patients with sepsis syndrome. A randomized, controlled, double-blind, multicenter clinical trial. TNF-alpha MAb Sepsis Study Group. JAMA 273:934–941CrossRefPubMed

30.

Schroeder S, Borger N, Wrigge H, Welz A, Putensen C, Hoeft A, Stüber F (2003) A tumor necrosis factor gene polymorphism influences the inflammatory response after cardiac operation. Ann Thorac Surg 75:534–537CrossRefPubMed

31.

Tomasdottir H, Hjartarson H, Ricksten A, Wasslavik C, Bengtsson A, Ricksten SE (2003) Tumor necrosis factor gene polymorphism is associated with enhanced systemic inflammatory response and increased cardiopulmonary morbidity after cardiac surgery. Anesth Analg 97:944–949CrossRefPubMed

32.

Hickling KG, Henderson SJ (1990) Low mortality associated with low volume pressure limited ventilation with permissive hypercapnia in severe adult respiratory distress syndrome. Intensive Care Med 16:372–377CrossRefPubMed

33.

Stüber F, Wrigge H, Schroeder S, Wetegrove S, Zinserling J, Hoeft A, Putensen C (2002) Kinetic and reversibility of mechanical ventilation-associated pulmonary and systemic inflammatory response in patients with acute lung injury. Intensive Care Med 28:834–841CrossRefPubMed

34.

Johnson MR (1999) Low systemic vascular resistance after cardiopulmonary bypass: are we any closer to understanding the enigma? Crit Care Med 27:1048–1050CrossRefPubMed

35.

Tremblay L, Valenza F, Ribeiro SP, Li J, Slutsky AS (1997) Injurious ventilatory strategies increase cytokines and c-fos m-RNA expression in an isolated rat lung model. J Clin Invest 99:944–952PubMed

36.

Chiumello D, Pristine G, Slutsky AS (1999) Mechanical ventilation affects local and systemic cytokines in an animal model of acute respiratory distress syndrome. Am J Respir Crit Care Med 160:109–116PubMed

37.

Held HD, Boettcher S, Hamann L, Uhlig S (2001) Ventilation-induced chemokine and cytokine release is associated with activation of nuclear factor-kappaB and is blocked by steroids. Am J Respir Crit Care Med 163:711–716PubMed

38.

Laffey JG, O’Croinin D, McLoughlin P, Kavanagh BP (2004) Permissive hypercapnia—role in protective lung ventilatory strategies. Intensive Care Med 30:347–356CrossRefPubMed

Title: Mechanical ventilation strategies and inflammatory responses to cardiac surgery: a prospective randomized clinical trial
Authors: Hermann Wrigge
Ulrike Uhlig
Georg Baumgarten
Jan Menzenbach
Jörg Zinserling
Martin Ernst
Daniel Drömann
Armin Welz
Stefan Uhlig
Christian Putensen
Publication date: 01-10-2005
Publisher: Springer-Verlag
Published in: Intensive Care Medicine / Issue 10/2005
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-005-2767-1

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Mechanical ventilation strategies and inflammatory responses to cardiac surgery: a prospective randomized clinical trial

Abstract

Objective

Design and setting

Patients and participants

Interventions

Measurements and results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Objective

Design and setting

Patients and participants

Interventions

Measurements and results

Conclusions

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