• Costa LemeAlcinoADepartment of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil., Ludhmila Abrahao Hajjar, Marcia S Volpe, Julia Tizue Fukushima, Roberta Ribeiro De Santis Santiago, Eduardo A Osawa, Juliano Pinheiro de Almeida, Aline Muller Gerent, Rafael Alves Franco, Zanetti FeltrimMaria IgnezMIDepartment of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil., Emília Nozawa, Vera Regina de Moraes Coimbra, de Moraes IanottiRafaelRDepartment of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil., Clarice Shiguemi Hashizume, Roberto Kalil Filho, Jose Otavio Costa Auler, Fabio Biscegli Jatene, Gomes GalasFilomena Regina BarbosaFRDepartment of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil., and AmatoMarcelo Britto PassosMBCardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil..
• Department of Anesthesia and Intensive Care, Heart Institute (InCor), Hospital Das Clínicas da FMUSP, University of São Paulo, São Paulo, Brazil.
• JAMA. 2017 Apr 11; 317 (14): 1422-1432.

ImportancePerioperative lung-protective ventilation has been recommended to reduce pulmonary complications after cardiac surgery. The protective role of a small tidal volume (VT) has been established, whereas the added protection afforded by alveolar recruiting strategies remains controversial.ObjectiveTo determine whether an intensive alveolar recruitment strategy could reduce postoperative pulmonary complications, when added to a protective ventilation with small VT.Design, Setting, And ParticipantsRandomized clinical trial of patients with hypoxemia after cardiac surgery at a single ICU in Brazil (December 2011-2014).InterventionsIntensive recruitment strategy (n=157) or moderate recruitment strategy (n=163) plus protective ventilation with small VT.Main Outcomes And MeasuresSeverity of postoperative pulmonary complications computed until hospital discharge, analyzed with a common odds ratio (OR) to detect ordinal shift in distribution of pulmonary complication severity score (0-to-5 scale, 0, no complications; 5, death). Prespecified secondary outcomes were length of stay in the ICU and hospital, incidence of barotrauma, and hospital mortality.ResultsAll 320 patients (median age, 62 years; IQR, 56-69 years; 125 women [39%]) completed the trial. The intensive recruitment strategy group had a mean 1.8 (95% CI, 1.7 to 2.0) and a median 1.7 (IQR, 1.0-2.0) pulmonary complications score vs 2.1 (95% CI, 2.0-2.3) and 2.0 (IQR, 1.5-3.0) for the moderate strategy group. Overall, the distribution of primary outcome scores shifted consistently in favor of the intensive strategy, with a common OR for lower scores of 1.86 (95% CI, 1.22 to 2.83; P = .003). The mean hospital stay for the moderate group was 12.4 days vs 10.9 days in the intensive group (absolute difference, -1.5 days; 95% CI, -3.1 to -0.3; P = .04). The mean ICU stay for the moderate group was 4.8 days vs 3.8 days for the intensive group (absolute difference, -1.0 days; 95% CI, -1.6 to -0.2; P = .01). Hospital mortality (2.5% in the intensive group vs 4.9% in the moderate group; absolute difference, -2.4%, 95% CI, -7.1% to 2.2%) and barotrauma incidence (0% in the intensive group vs 0.6% in the moderate group; absolute difference, -0.6%; 95% CI, -1.8% to 0.6%; P = .51) did not differ significantly between groups.Conclusions And RelevanceAmong patients with hypoxemia after cardiac surgery, the use of an intensive vs a moderate alveolar recruitment strategy resulted in less severe pulmonary complications while in the hospital.Trial Registrationclinicaltrials.gov Identifier: NCT01502332.

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