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Table of Contents
Year : 2020  |  Volume : 36  |  Issue : 2  |  Page : 271-272

Is intraoperative low tidal volume ventilation worse in patients with preexisting systemic inflammatory response? Our insights to Chugh et al. study

1 Pulmonology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
2 Department of Anesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
3 Intensive Care and Noninvasive Ventilatory Unit, Hospital Morales Meseguer, Murcia, Spain

Date of Submission26-Feb-2020
Date of Acceptance12-Mar-2020
Date of Web Publication15-Jun-2020

Correspondence Address:
Dr. Gil Goncalves
Pulmonology Department, Centro Hospitalar e Universitário de Coimbra, Praceta, R. Prof. Mota Pinto, 3004-561 Coimbra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/joacp.JOACP_89_20

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How to cite this article:
Goncalves G, Karim HM, Esquinas AM. Is intraoperative low tidal volume ventilation worse in patients with preexisting systemic inflammatory response? Our insights to Chugh et al. study. J Anaesthesiol Clin Pharmacol 2020;36:271-2

How to cite this URL:
Goncalves G, Karim HM, Esquinas AM. Is intraoperative low tidal volume ventilation worse in patients with preexisting systemic inflammatory response? Our insights to Chugh et al. study. J Anaesthesiol Clin Pharmacol [serial online] 2020 [cited 2021 Jun 18];36:271-2. Available from:

Dear Madam,

Low tidal volume, that is, 5–8 mL/kg of ideal body weight (IBW), has been safely used and with better results in patients with or without acute respiratory distress syndrome.[1],[2] In this context, a recently published randomized controlled double-blinded trial by Chugh et al.[3] interested us. The authors aimed to determine whether intraoperative ventilation using high tidal volume (10 mL/kg IBW) versus a lung-protective strategy using low tidal volume (6 mL/kg IBW) along with positive end-expiratory pressure (PEEP) of 10 cmH2O, improves postoperative organ dysfunction in patients suffering from intestinal perforation peritonitis-induced systemic inflammatory response syndrome. They showed that the use of low tidal volume along with PEEP is associated with worse postoperative organ functions as compared to high tidal volume without PEEP, indicated by higher aggregate SOFA score (3 days) as well as the score on the first postoperative day. The result is indeed exciting; however, we found some limitations in this study which are very critical to consider before we apply their results in our clinical practice.

Firstly, the PEEP levels used by the authors need attention. In this study, one group had no PEEP and the other a PEEP of 10 cmH2O. The use of a high PEEP increases abdominal pressure and provokes complications such as intraoperative circulatory depression as evident from the PROVEHILO trial.[4] The PROVEHILO trial compared high(12 cmH2O) versus low (2 cmH2O) PEEP during general anesthesia for open abdominal surgery at the same tidal volume (8 mL/kg IBW) and concluded that an intraoperative protective ventilation strategy should include a low PEEP, without recruitment maneuvers.[4] Therefore, we believe that a lower amount of PEEP was indicated in otherwise non-hypoxemic patients with relatively healthy lungs of the cohort. Further, to minimize this confounder, the two groups should have been compared with the same PEEP. Indeed one parameter of the Chugh et al study should have been similar in both groups to remove confounders.

Secondly, we know that the higher the surgeon experience, the lower is the rate of complications.[5] We could not find information on the surgeon's experience in both groups if in one group, patients were operated by more experienced surgeons, shouldn't it have expected better results? We hope these are taken into account in further studies.

We applaud the authors' work as the study has some important perspectives on the management of abdominal surgical patients, nevertheless, we would like to have our suggestions taken into consideration in the next studies.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Putensen C, Theuerkauf N, Zinserling J, Wrigge H, Pelosi P. Meta-analysis: Ventilation strategies and outcomes of the acute respiratory distress syndrome and acute lung injury. Ann Intern Med 2009;151:897]. Ann Intern Med 2009;151:566-76.  Back to cited text no. 1
Serpa Neto A, Cardoso SO, Manetta JA, Pereira VG, Espósito DC, Pasqualucci Mde O, et al. Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: A meta-analysis. JAMA 2012;308:1651-9.  Back to cited text no. 2
Chugh V, Tyagi A, Arora V, Tyagi A, Das S, Rai G, et al. Low tidal volume ventilation strategy and organ functions in patients with pre-existing systemic inflammatory response. J Anaesthesiol Clin Pharmacol 2019;35:460-7.  Back to cited text no. 3
[PUBMED]  [Full text]  
PROVE Network Investigators for the Clinical Trial Network of the European Society of Anaesthesiology, Hemmes SN, Gama de Abreu M, Pelosi P, Schultz MJ. High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): A multicentre randomised controlled trial. Lancet 2014;384:495-503.  Back to cited text no. 4
Naveiro-Fuentes M, Rodríguez-Oliver A, Fernández-Parra J, González-Paredes A, Aguilar-Romero T, Mozas-Moreno J. Effect of surgeon's experience on complications from laparoscopic hysterectomy. J Gynecol Obstet Hum Reprod 2018;47:63-7.  Back to cited text no. 5


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