Intraoperative management of mechanical ventilation in non-cardiothoracic surgery: a national survey in China

Intraoperative management of mechanical ventilation in non-cardiothoracic surgery: a national survey in China | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Intraoperative management of mechanical ventilation in non-cardiothoracic surgery: a national survey in China Qian-Qian Rao, Hong Yu, Si-Yang Wang, Jia-Xin He, Xue-Fei Li, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-1887971/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The current clinical practice regarding intraoperative ventilation management in non-cardiothoracic surgical setting among anesthesia providers in China is unclear. Methods We developed a 25-question anonymous survey which was distributed to anesthesia departments from 81 tertiary/university hospitals in China between August 2021 and September 2021. Information including participant characteristics, ventilatory settings, and opinions on lung-protective ventilation were obtained by electronic survey. Results were reported descriptively. Results The survey was completed by 1089 anesthesiologists from 57 institutions (70% institution response rate). The vast majority of respondents (1010/1089; 92.7%)used low tidal volume (6–8 ml kg − 1 ) ventilation. About three quarters (840/1089; 77.1%) utilized positive end-expiratory pressure, and most anesthesiologists set positive end-expiratory pressure of 1–5 cmH 2 O in either laparoscopic (639/840; 76.1%) or non-laparoscopic surgery (736/840; 87.6%). The majority of respondents (921/1089; 84.6%) performed alveolar recruitment maneuver intraoperatively. Approximate 20% of respondents routinely implemented lung-protective ventilation with bundles of low tidal volume, positive end-expiratory pressure, and alveolar recruitment maneuver. Conclusions We found that heterogeneity exists between individual practices regarding intraoperative ventilation management in the setting of non-cardiothoracic surgery, indicating the potential knowledge-practice gap among Chinese anesthesiologists. Trial registration number: ChiCTR2100047653; Registration date : June 21, 2021 Registry URL : Chictr.org.cn. Anesthesia Surveys and questionnaires Intraoperative Mechanical ventilation Lung-protective ventilation Figures Figure 1 Figure 2 Background Patients undergoing major non-cardiothoracic surgery under general anesthesia and mechanical ventilation may experience postoperative pulmonary complications (PPCs). Prevention of PPCs may in part be achieved by the optimization of intraoperative ventilation management. Over the past two decades, lung-protective ventilation (LPV) containing low tidal volume (V T ), positive end-expiratory pressure (PEEP) and alveolar recruitment maneuvers (ARMs), has been initially implemented in patients with acute respiratory distress syndrome [ 1 ] , and then gradually adopted in surgical settings to decrease the risk of developing adverse pulmonary outcomes [ 2 – 4 ] . Although an 2019 international expert panel–based consensus recommendations suggested LPV for the surgical patient, there are substantial practice pattern variations in intraoperative ventilation management. Several studies indicated that MV practice did not follow current recommendations for lung protection in patients undergoing cardiac and thoracic surgery [ 5 , 6 ] . In addition, little is known about current practice regarding intraoperative ventilation management among anesthesiologists in China. Accordingly, we conducted a nationwide survey to describe the current status in practicing intraoperative ventilation management in non-cardiothoracic surgical setting among Chinese anesthesiologists working in tertiary/university hospitals. We also collect the opinions of anesthesiologists regarding LPV at both practical and theoretical levels. Methods This cross-sectional, self-administered, anonymized, voluntary survey was performed in adhere to the applicable guideline: the strengthening the reporting of observational studies in epidemiology (STROBE) [7] and American Association for Public Opinion Research (AAPOR) reporting guidelines for survey studies [8] . The study was approved by Ethics Committee of West China Hospital of Sichuan University and prospectively registered on Chictr.org.cn (ChiCTR2100047653) on June 21, 2021. The informed consent was obtained from all participants by the recruitment email, available as Additional file 1. Questionnaire Design This survey was developed by an expert panel consisting of 3 members of the Anesthesiology Committee of Sichuan Medical Association (ACSMA). The draft survey was pretested among professors working at the department of anesthesiology in West China Hospital of Sichuan University. We consulted them about the questionnaire logic and the items’ clarity and comprehension. As the final step to assess validity, the revised survey was sent to the second group of 10 experts in the field of LPV from the ACSMA. Again, their comments were used to further modify the survey to assure the validity among the target population. Subsequently, the survey was pilot tested with 44 clinicians to establish administration procedures. Eventually, we developed a 25-item questionnaire, available as Additional file 2, that assessed 3 domains: (1) basic characteristics; (2) MV strategies implemented for adult patients undergoing non-cardiothoracic surgery; (3) understanding and application of the LPV strategy. LPV was defined as low V T ventilation of 6-8 ml kg -1 predicted body weight (PBW) -1 , application of PEEP and ARM [9] . The web-based platform Tencent survey was used. Population The target population of this survey were anesthesiologists working in tertiary general hospitals. The top 100 Chinese hospitals on the ranking list of Fudan were included and special hospitals were excluded. To improve sample representativeness, teaching hospitals were included in the regions where there is no top 100 hospital. Finally, 81 hospitals were eligible, showed in the Additional file 3. Study Procedure On August 11, 2021, recruitment emails were sent to the directors of the department of anesthesiology in the eligible hospitals. The recruitment email, available as Additional file 1, contains survey purpose, voluntary statement, participation anonymity, and online questionnaire link. Participants gave consent by participating in the survey. To indicate this, the following statement was included in the recruitment email: “By completing the survey, you are agreeing to participate in this research.” After the initial e-mail, 2 reminder e-mails were sent to non-responders one week later and telephone calls were made two weeks later. Eventually, 57 directors agreed (institution response rate 70%) to participate . The recruitment email was then distributed to anesthesiologists in these enrolled hospitals. It was required to recycle at least 16 questionnaires including at least 8 questionnaires from attendings or professors and at least 8 questionnaires from residents in each hospital. All surveys were distributed between August 11 th and September 14 th of 2021. Sample Size Calculation In our survey, the response rate of the target population was estimated to be 40% [10] , with a 95% confidence interval (CI) and 5% margin of error. This formula was used to calculate sample size [11] : N = Z 2 α/2 p (1-p) /d 2 (N: minimum sample size; Z α/2 : standard normal variable value at 95% CI, 1.96; p: 0.05; d: margin of error, 5%), which was N=387 for our study. Considering the 40% response rate, the sample size was identified as 968 after being adjusted. Statistical Analysis Responses were summarized using descriptive statistics. We summarized continuous variables as either mean and standard deviation (SD) or median and interquartile range (IQR), and categorical data were displayed as frequency and the proportion of total number (%). Responses to each questionnaire were recorded in a Microsoft Excel database and all statistical analyses were performed using SPSS Statistics 23 (IBM SPSS Statistics for Windows, IBM Corp, Armonk, NY, USA). Results A total of 1089 anesthesiologists from 57 institutions responded to the survey. Detailed information about sample characteristics is listed in Table 1. Among respondents, over 2/5 were residents (469/1089; 43.1%) or attendings (457/1089; 41.9%), while 15% (163/1089) of the respondents were professors. Nearly 2/5 (418/1089; 38.4%) had been practicing anesthesia for 0-4 years, 31.2% (340/1089) had been engaged in clinical anesthesia for 5-9 years, and 30.3% (331/1089) for over 10 years. The vast majority of the respondents worked in the teaching hospital (1035/1089; 95%) and practiced in flexible subspecialties (929/1089; 85.3%). V T , PEEP, and ARM The large proportion (1010/1089; 92.7%) of anesthesiologists used low V T ventilation (6-8 ml kg -1 ) which was calculated referring to the PBW (376/1089; 34.5%), actual body weight (ABW) (340/1089; 31.2%) or corrected body weight (347/1089; 31.9%). About three quarters (840/1089; 77.1%) of the respondents applied PEEP. Most of the respondents ventilated patients with a PEEP of 1–5 cmH 2 O in either laparoscopic (639/840; 76.1%) or non-laparoscopic surgery (736/840; 87.6%) (table 2) . Nearly 80% of the anesthesiologists (584/840; 69.5%) set PEEP based on lung compliance (figure 1A) . A total of 84.6% (921/1089) applied intraoperative ARM. The manual ARM was most commonly utilized to recruit the lungs (843/921; 91.5%) (table 2) . 72.5% of the respondents (668/921) applied ARM with oxygen/air mixture, while 22.8% (210/921) and 4.7% (43/921) used pure oxygen and air respectively. ARM was performed regularly at fixed time interval (385/921; 41.8%), when saturation of pulse oxygen (SpO 2 ) dropped (437/921; 47.4%) or before tracheal extubation (623/921; 67.6%) (figure 1B) . LPV practice There were only 208 of 1089 (19.1%) respondents who routinely performed bundles of low V T , PEEP, and ARM (table 2) . Regarding the respondents' opinions on LPV, they preferred to perform LPV in specific patients (figure 1C) and laparoscopic surgery (figure 1D) . The first three most important lung protective ventilatory parameters considered by the respondents were V T (94.7%), PEEP (92.1%), and fraction of inspired oxygen (FiO 2 ) (76.4%) (figure 1E) . The vast majority of respondents (1066/1089; 97.9%) considered bundles of “low V T , PEEP, and ARM” as LPV strategy (figure 1F) . Other ventilatory settings A total of 59.2% (645/1089) respondents in laparoscopic surgery and 81.6% (889/1089) in non-laparoscopic surgery preferred volume-controlled ventilation (VCV) (figure 2A) . It was commonly applied with intraoperative FiO 2 of 40%-60% (485/1089;44.5%) or 60-80% (418/1089; 38.4%) (figure 2B) . Most of the respondents (798/1089; 73.3%) set the inspiratory-to-expiratory ratio (I: E) to 1:2 (figure 2C) . RR was set at 9-12 breaths/min in 66.2% (721/1089) of the respondents and was adjusted to maintain normal E T CO 2 in more than half of the respondents (583/1089; 53.5%) (figure 2D) . The median E T CO 2 was reported to be 50mmHg (interquartile range 45–55) as the acceptable upper limit. Discussion To our knowledge, this is the first nationwide survey among Chinese anesthesiologists that demonstrate considerablely variabe practices with respect to intraoperative ventilation management in non-cardiothoracic surgical setting. The majority of respondents reported applying low V T , PEEP, and ARM separately, while only about a fifth performed LPV with bundles of low V T , PEEP, and ARM. The LPV strategies It has been well established that intraoperative LPV strategies, containing low V T , appropriate PEEP with or without ARMs, could reduce the development of PPCs [12-14] . A retrospective study reported that approximate half of anesthesiologists at U.S. academic medical centers utilized both low V T and PEEP [15] . Our survey showed that only 21.8% routinely applied both low V T and PEEP, although most respondents recognized bundles of “low V T , PEEP, and ARMs” as LPV strategy. This may explained by the knowledge-practice gap among Chinese anesthesiologists. In recent years, some studies have proposed that open-lung ventilation strategy [16] , driving pressure (ΔP) guided ventilation strategy [17, 18] , and mechanical power–guided ventilation strategy [19] may have lung protective effects. However, results remain equivocal regarding their ability to prevent PPCs [20-23] . Low V T and PEEP In our survey, the majority of respondents performed low V T ventilation. The finding was in line with existing literature, which described that the use of low V T had been significantly increased [24, 25] . However, less than half of respondents calculated V T using PBW in accordance with expert recommendation [26] . Two studies found that compared to PBW, calculating V T with ABW would overestimate the target V T and that may expose patients to harmful volutrauma and barotrauma, especially to obese patients [27, 28] . In addition, our survey suggested more than 3/5 respondents set PEEP. While an observational study noted that 80% of patients still were ventilated without PEEP [29] . Reasons for not using PEEP included concerns about potential hemodynamic fluctuations [30] and PEEP not included in the default settings of ventilators [31] . Besides, we found most participants preferred PEEP level at 0-5 cmH 2 O, which was consistent with prior studies [32, 33] . However, a network meta-analysis found that moderate-to-high PEEP (≥5 cmH 2 O) combined with low V T ventilation could reduced the risk of PPCs in surgical patients [14] . By far, there was no consensus on optimal PEEP level, and individualized PEEP according to patients’ lung compliance or ΔP was suggested by several studies [18, 34] . Our findings suggested that most anesthesiologists preferred to set PEEP based on lung compliance. ARMs Our survey showed that more than 60% of anesthesiologists performed ARMs during MV. The results differed from a large observational study, in which less than 1/5 patients received intraoperative ARMs [33] . The implementation of ARMs after intubation was suggested to alleviate the deterioration of functional residual capacity following anesthesia [26] . However, it remains inconsistent regarding the role of ARMs after intubation to prevent PPCs. In our study, only a small number of respondents performed ARMs after tracheal intubation. This might be the result of detrimental effects of ARMs on cardiac output which could aggravate the instability of hemodynamics after induction [35] . Our survey showed that respondents preferred to perform manual ARMs, while ventilator-driven ARMs recommended in the expert consensus were rarely utilized [26] . Other ventilatory settings Our survey suggested that VCV was most commonly used among respondents, which was consistent with the results of two observational studies [36, 37] . Most anesthesiologists preferred FiO 2 at 40%-60%. Until now, the optimal level of FiO 2 remains unknow. Two randomized controlled trials comparing the use of high (80%) versus low (30%) FiO 2 showed no difference in reducing the incidence of PPCs [38, 39] . Expert consensus recommended FiO 2 should be set to ≤ 0.4 with the goal of using the lowest possible FiO 2 to achieve normoxia (or SpO 2 ≥ 94%) and reduce the occurrence of resorption atelectasis [26] . In our survey, a small number of anesthesiologists applied high FiO 2 (>80%) during operation. Limitation Our study has several limitations. Firstly, our survey was only distributed to anesthesiologists of some tertiary/university hospitals in China, and selection bias may exist, which restricts external validity. The results cannot be easily extrapolated to other medical centers in China and other countries. Secondly, our investigation had a 70% institution response rate, possibly introducing nonresponse bias. Nonetheless, a higher response rate does not necessarily improve nonresponse bias regarding demographic and practice variables [ 40 ] . Thirdly, as a general limitation of the survey, we cannot verify whether the statement of respondents was truly correct and reflected the current practice in their center. Fourthly, our study remained an observational research. It can only provide limited information about intraoperative ventilator management. It cannot be regarded as a reliable source to make definitive statements. Conclusions In China, intraoperative ventilation management in the setting of non-cardiothoracic surgery varies widely among anesthesiologists. The LPV strategy including low V T , PEEP, and ARMs is generally acknowledged by anesthesiologists, while the implementation rate was low. A knowledge-practice gap may exist among Chinese anesthesia providers, which could be narrowed and further eliminated by interpretation of relevant expert consensus and continuing education. Abbreviations ACSMA, Anesthesiology Committee of Sichuan Medical Association; ARM, alveolar recruitment maneuver; AAPOR, American Association for Public Opinion Research; ABW, actual body weight; BMI, body mass index; CI, confidence interval; EtCO 2 , end-tidal carbon dioxide; FiO 2 , fraction of inspired oxygen; I: E, inspiratory to expiratory ratio; LPV, lung-protective ventilation; MV, mechanical ventilation; OLS, open lung strategy; PBW, predicted body weight; PEEP, positive end-expiratory pressure; PCV, pressure-controlled ventilation; PCV-VG, pressure-controlled-volume guaranteed ventilation; PPCs, postoperative pulmonary complications; QR Code, quick response code; RR, respiratory rate; SpO 2 , saturation of pulse oxygen; STROBE, the strengthening the reporting of observational studies in epidemiology; V T , tidal volume; VCV, volume-controlled ventilation; VILI, ventilator-induced lung injury; ΔP, driving pressure. Declarations Ethics approval and consent to participate The study was approved by Ethics Committee of West China Hospital of Sichuan University and the informed consent was obtained from all participants by the recruitment email. Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding None Authors' contributions Qian-Qian Rao designed the study, analyzed the data, and prepared the manuscript. Hong Yu designed the study, analyzed the data, and prepared the manuscript. Si-Yang Wang analyzed the data and prepared the manuscript. Jia-Xin He collected the data and prepared the manuscript. Xue-Fei Li analyzed the data and prepared the manuscript. Fei Fei collected the data and prepared the manuscript. Kai-Xi Shang collected the data and prepared the manuscript. Hai Yu designed the study and prepared the manuscript. All authors read and approved the final manuscript. Acknowledgments We appreciate the support from every anesthesiologist who participated in this survey and we are grateful to the expert panel for their excellent advice. Collaborators are listed in Additional file 2. References Wang C, Wang X, Chi C, Guo L, Guo L, Zhao N, Wang W, Pi X, Sun B, Lian A et al : Lung ventilation strategies for acute respiratory distress syndrome : a systematic review and network meta - analysis . Sci Rep 2016, 6 :22855. Güldner A, Kiss T, Serpa Neto A, Hemmes SNT, Canet J, Spieth PM, Rocco PRM, Schultz MJ, Pelosi P, Gama de Abreu M: Intraoperative protective mechanical ventilation for prevention of postoperative pulmonary complications: a comprehensive review of the role of tidal volume, positive end-expiratory pressure, and lung recruitment maneuvers . Anesthesiology 2015, 123 (3):692–713. 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Charastiristic N (%) Academic position Resident 469 (43.1) Attending 457 (41.9) Professor 163 (15.0) Years of practice 0-4 418 (38.4) 5-9 340 (31.2) 10-14 195 (17.9) 15-19 68 (6.2) ≥20 68 (6.2) Primary type of practice Flexible subspecialties 929 (85.3) General sugery 41 (3.8) Orthopedics 39 (3.6) Neurosurgery 19 (1.7) Obstetrics and Gynecology 16 (1.5) Otorhinolaryngology 10 (0.9) Urology 8 (0.7) Stomatology 4 (0.4) Ophthalmology 0 (0) Others 23 (2.1) Type of hospital Teaching hospital 1035 (95.0) Non-teaching hospital 54 (5.0) Data are presented as number (percentage). Table 2 Respondents’ Practice Details of LPV Strategy Item Practice N(%) V T <6 28 (2.6) 6-8 (low V T ) 1010 (92.7) 9-10 46 (4.2) others 5 (0.5) PEEP 1-5 639 (58.7) */736 (67.6) † 6-10 198 (18.2) */102 (9.4) † 11-15 3 (0.3) */2 (0.2) † No PEEP 249 (22.9) ARM Manual method 843 (77.4) Progressively increase PEEP 42 (3.9) Progressively increase tidal volume 28 (2.6) Control vital capacity by ventilator 6 (0.6) No ARM 168 (15.4) Low V T +PEEP+ARM Yes 208 (19.1) Low V T +PEEP Yes 237 (21.8) Data are presented as number (percentage). Abbreviations: ARM, Alveolar recruitment maneuvers; LPV, Lung-protective ventilation; PEEP, Positive end-expiratory pressure; V T , Tidal volume. * For laparoscopic surgery; † For non-laparoscopic surgery. Additional Declarations No competing interests reported. Supplementary Files Additionalfile1Recruitmentemail..docx Additionalfile2Questionnaireitems.docx Additionalfile3Listofcollaborators.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1887971","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":123901676,"identity":"db4f35cc-1aee-4d6f-b1a3-f5e1513cc73e","order_by":0,"name":"Qian-Qian Rao","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Qian-Qian","middleName":"","lastName":"Rao","suffix":""},{"id":123901677,"identity":"a6d0c16d-273c-498c-b3a1-e675f4862fe8","order_by":1,"name":"Hong Yu","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hong","middleName":"","lastName":"Yu","suffix":""},{"id":123901678,"identity":"4accb560-2a2e-4e1a-a189-f898e7b3ce34","order_by":2,"name":"Si-Yang Wang","email":"","orcid":"","institution":"Fudan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Si-Yang","middleName":"","lastName":"Wang","suffix":""},{"id":123901679,"identity":"d82fc775-4eab-40c9-b4ef-e37b825483cc","order_by":3,"name":"Jia-Xin He","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Jia-Xin","middleName":"","lastName":"He","suffix":""},{"id":123901680,"identity":"936d7f26-62c4-431d-b6b8-3e946add56bc","order_by":4,"name":"Xue-Fei Li","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xue-Fei","middleName":"","lastName":"Li","suffix":""},{"id":123901681,"identity":"a69eb38a-f406-4a0a-80b0-41b8b0cd5e6e","order_by":5,"name":"Fei Fei","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Fei","middleName":"","lastName":"Fei","suffix":""},{"id":123901682,"identity":"17a696f6-429f-4992-848c-26d6c207c6fe","order_by":6,"name":"Kai-Xi Shang","email":"","orcid":"","institution":"Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kai-Xi","middleName":"","lastName":"Shang","suffix":""},{"id":123901683,"identity":"7597eee6-5f96-4af0-817a-f7151106735b","order_by":7,"name":"Hai Yu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsUlEQVRIiWNgGAWjYFACHgaGhAoIU4IELWdI1sLYRooWgxu5Bz88nFcnb3CA+eBtHga7PCK05CVLJG47bLjhAFuyNQ9DcjERWnIMgFoOJBgc4DGT5mE4kNhAhBbjH4lz6oBa+L8RrcVMIrGBGWQLG3FaJM+8MbNIOHbYcOZhNmPLOQbJhLXwHc8xvvmjpk6e73jzwxtvKuwIa1E4AGMxg91JSD0QyBM0dBSMglEwCkYBACeUO0Iy4BPRAAAAAElFTkSuQmCC","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Hai","middleName":"","lastName":"Yu","suffix":""}],"badges":[],"createdAt":"2022-07-23 09:14:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1887971/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1887971/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":24525872,"identity":"a2b486f7-e791-4976-84f1-bfc2b8014472","added_by":"auto","created_at":"2022-07-29 18:17:13","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":89434,"visible":true,"origin":"","legend":"\u003cp\u003eThe implementation of LPV in non-cardiothoracic surgery. \u003c/p\u003e\u003cp\u003eA, Rationale of setting PEEP \u003c/p\u003e\u003cp\u003eB, Time to use ARMs \u003c/p\u003e\u003cp\u003eC, Patient’s characteristic\u003c/p\u003e\u003cp\u003eD, Type of surgery \u003c/p\u003e\u003cp\u003eE, Parameters considered as LPV\u003c/p\u003e\u003cp\u003eF, Definition of LPV\u003c/p\u003e\u003cp\u003eNumbers in the brackets indicate the percentage of the respondents. Because multiple answers are accepted, percentages do not equal 100%. Abbreviations: ARMs, Alveolar Recruitment Maneuvers; BMI, Body Mass Index; E\u003csub\u003eT\u003c/sub\u003eCO\u003csub\u003e2\u003c/sub\u003e, End-Tidal Carbon Dioxide\u003c/p\u003e\u003cp\u003e; FiO\u003csub\u003e2\u003c/sub\u003e, Fraction of inspired oxygen; LPV, Lung protective ventilation; PEEP, Positive End-Expiratory Pressure; RR, Respiratory rate; SpO\u003csub\u003e2\u003c/sub\u003e, Saturation of Pulse Oxygen; V\u003csub\u003eT\u003c/sub\u003e, Tidal volume.\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"Fig1.png","url":"https://assets-eu.researchsquare.com/files/rs-1887971/v1/7308735eb93cb560d8fa61d7.png"},{"id":24525253,"identity":"852e52b1-9824-43be-8add-f76b744252b2","added_by":"auto","created_at":"2022-07-29 18:12:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":66113,"visible":true,"origin":"","legend":"\u003cp\u003eThe implementation of other ventilatory settings in non-cardiothoracic surgery. \u003c/p\u003e\u003cp\u003eA, Ventilation mode \u003c/p\u003e\u003cp\u003eB, Fraction of inspired oxygen\u003c/p\u003e\u003cp\u003eC, Inspiratory to expiratory ratio\u003c/p\u003e\u003cp\u003eD, Respiratory rate \u003c/p\u003e\u003cp\u003eNumbers in the brackets indicate the percentage of the respondent. Because multiple answers are accepted, percentages do not equal 100%. Abbreviations: E\u003csub\u003eT\u003c/sub\u003eCO\u003csub\u003e2\u003c/sub\u003e, End-Tidal Carbon Dioxide; PCV-VG: Pressure-Controlled-Volume Guaranteed Ventilation; PCV, Pressure-Controlled Ventilation; VCV: Volume-Controlled Ventilation.\u003c/p\u003e\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","description":"","filename":"Fig2.png","url":"https://assets-eu.researchsquare.com/files/rs-1887971/v1/e5d61d8e90b40654798a0049.png"},{"id":29151358,"identity":"b3f70f0b-1ba9-4e58-95f8-bcdd26e4e68b","added_by":"auto","created_at":"2022-11-16 18:14:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1615636,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1887971/v1/dd34aa04-4b1e-4804-a157-1c5ff7b1df51.pdf"},{"id":24526039,"identity":"3d5951d7-1af7-4e71-a255-69cee8ecbb68","added_by":"auto","created_at":"2022-07-29 18:22:13","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":53920,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile1Recruitmentemail..docx","url":"https://assets-eu.researchsquare.com/files/rs-1887971/v1/ebbc42905c71e42836a70ef8.docx"},{"id":24525871,"identity":"b58ddf73-0979-4543-a353-86a9920b471c","added_by":"auto","created_at":"2022-07-29 18:17:13","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":26048,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile2Questionnaireitems.docx","url":"https://assets-eu.researchsquare.com/files/rs-1887971/v1/e11d3e0fbb6632bd2d1f660f.docx"},{"id":24525254,"identity":"fbf0fa19-d774-48d5-8f3b-681cb53d203b","added_by":"auto","created_at":"2022-07-29 18:12:13","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":16882,"visible":true,"origin":"","legend":"","description":"","filename":"Additionalfile3Listofcollaborators.docx","url":"https://assets-eu.researchsquare.com/files/rs-1887971/v1/f17c845e68105d2334dfca62.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Intraoperative management of mechanical ventilation in non-cardiothoracic surgery: a national survey in China","fulltext":[{"header":"Background","content":"\u003cp\u003ePatients undergoing major non-cardiothoracic surgery under general anesthesia and mechanical ventilation may experience postoperative pulmonary complications (PPCs). Prevention of PPCs may in part be achieved by the optimization of intraoperative ventilation management. Over the past two decades, lung-protective ventilation (LPV) containing low tidal volume (V\u003csub\u003eT\u003c/sub\u003e), positive end-expiratory pressure (PEEP) and alveolar recruitment maneuvers (ARMs), has been initially implemented in patients with acute respiratory distress syndrome\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e, and then gradually adopted in surgical settings to decrease the risk of developing adverse pulmonary outcomes\u003csup\u003e[\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAlthough an 2019 international expert panel\u0026ndash;based consensus recommendations suggested LPV for the surgical patient, there are substantial practice pattern variations in intraoperative ventilation management. Several studies indicated that MV practice did not follow current recommendations for lung protection in patients undergoing cardiac and thoracic surgery\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. In addition, little is known about current practice regarding intraoperative ventilation management among anesthesiologists in China.\u003c/p\u003e \u003cp\u003eAccordingly, we conducted a nationwide survey to describe the current status in practicing intraoperative ventilation management in non-cardiothoracic surgical setting among Chinese anesthesiologists working in tertiary/university hospitals. We also collect the opinions of anesthesiologists regarding LPV at both practical and theoretical levels.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis cross-sectional, self-administered, anonymized, voluntary survey was performed in adhere to the applicable guideline: the strengthening the reporting of observational studies in epidemiology (STROBE)\u003csup\u003e[7]\u003c/sup\u003e and American Association for Public Opinion Research (AAPOR) reporting guidelines for survey studies \u003csup\u003e[8]\u003c/sup\u003e. The study was approved by Ethics Committee of West China Hospital of Sichuan University and prospectively registered on Chictr.org.cn (ChiCTR2100047653) on June 21, 2021. The informed consent was obtained from all participants by the recruitment email, available as Additional file 1.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eQuestionnaire Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis survey was developed by an expert panel consisting of 3 members of the Anesthesiology Committee of Sichuan Medical Association (ACSMA). The draft survey was pretested among professors working at the department of anesthesiology in West China Hospital of Sichuan University. We consulted them about the questionnaire logic and the items\u0026rsquo; clarity and comprehension. As the final step to assess validity, the revised survey was sent to the second group of 10 experts in the field of LPV from the ACSMA. Again, their comments were used to further modify the survey to assure the validity among the target population. Subsequently, the survey was pilot tested with 44 clinicians to establish administration procedures. Eventually, we developed a 25-item questionnaire, available as Additional file 2, that assessed 3 domains: (1) basic characteristics; (2) MV strategies implemented for adult patients undergoing non-cardiothoracic surgery; (3) understanding and application of the LPV strategy. LPV was defined as low V\u003csub\u003eT\u003c/sub\u003e ventilation of 6-8 ml kg\u003csup\u003e-1\u003c/sup\u003e predicted body weight (PBW)\u003csup\u003e-1\u003c/sup\u003e, application of PEEP and ARM\u003csup\u003e[9]\u003c/sup\u003e. The web-based platform Tencent survey was used.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePopulation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe target population of this survey were anesthesiologists working in tertiary general hospitals. The top 100 Chinese hospitals on the ranking list of Fudan were included and special hospitals were excluded. To improve sample representativeness, teaching hospitals were included in the regions where there is no top 100 hospital. Finally, 81 hospitals were eligible, showed in the Additional file 3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOn August 11, 2021, recruitment emails were sent to the directors of the department of anesthesiology in the eligible hospitals. The recruitment email, available as Additional file 1, contains survey purpose, voluntary statement, participation anonymity, and online questionnaire link. Participants gave consent by participating in the survey. To indicate this, the following statement was included in the recruitment email: \u0026ldquo;By completing the survey, you are agreeing to participate in this research.\u0026rdquo; After the initial e-mail, 2 reminder e-mails were sent to non-responders one week later and telephone calls were made two weeks later. Eventually, 57 directors agreed (institution response rate 70%) to participate\u003cstrong\u003e.\u003c/strong\u003e The recruitment email was then distributed to anesthesiologists in these enrolled hospitals. It was required to recycle at least 16 questionnaires including at least 8 questionnaires from attendings or professors and at least 8 questionnaires from residents in each hospital. All surveys were distributed between August 11\u003csup\u003eth\u003c/sup\u003e and September 14\u003csup\u003eth\u003c/sup\u003e of 2021.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample Size Calculation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our survey, the response rate of the target population was estimated to be 40%\u003csup\u003e[10]\u003c/sup\u003e, with a 95% confidence interval (CI) and 5% margin of error. This formula was used to calculate sample size\u003csup\u003e[11]\u003c/sup\u003e: N = Z\u003csup\u003e2\u003c/sup\u003e\u003csub\u003e\u0026alpha;/2\u003c/sub\u003e p (1-p) /d\u003csup\u003e2 \u003c/sup\u003e(N: minimum sample size; Z\u003csub\u003e\u0026alpha;/2\u003c/sub\u003e: standard normal variable value at 95% CI, 1.96; p: 0.05; d: margin of error, 5%), which was N=387 for our study. Considering the 40% response rate, the sample size was identified as 968 after being adjusted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eResponses were summarized using descriptive statistics. We summarized continuous variables as either mean and standard deviation (SD) or median and interquartile range (IQR), and categorical data were displayed as frequency and the proportion of total number (%). Responses to each questionnaire were recorded in a Microsoft Excel database and all statistical analyses were performed using SPSS Statistics 23 (IBM SPSS Statistics for Windows, IBM Corp, Armonk, NY, USA).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 1089 anesthesiologists from 57 institutions responded to the survey. Detailed information about sample characteristics is listed in Table 1. Among respondents, over 2/5 were residents (469/1089; 43.1%) or attendings (457/1089; 41.9%), while 15% (163/1089) of the respondents were professors. Nearly 2/5 (418/1089; 38.4%) had been practicing anesthesia for 0-4 years, 31.2% (340/1089) had been engaged in clinical anesthesia for 5-9 years, and 30.3% (331/1089) for over 10 years. The vast majority of the respondents worked in the teaching hospital (1035/1089; 95%) and practiced in flexible subspecialties (929/1089; 85.3%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eV\u003csub\u003eT\u003c/sub\u003e, PEEP, and ARM \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe large proportion (1010/1089; 92.7%) of anesthesiologists used low V\u003csub\u003eT\u003c/sub\u003e ventilation (6-8 ml kg \u003csup\u003e-1\u003c/sup\u003e) which was calculated referring to the PBW (376/1089; 34.5%), actual body weight (ABW) (340/1089; 31.2%) or corrected body weight (347/1089; 31.9%).\u003c/p\u003e\n\u003cp\u003eAbout three quarters (840/1089; 77.1%) of the respondents applied PEEP. Most of the respondents ventilated patients with a PEEP of 1\u0026ndash;5 cmH\u003csub\u003e2\u003c/sub\u003eO in either laparoscopic (639/840; 76.1%) or non-laparoscopic surgery (736/840; 87.6%) \u003cstrong\u003e(table 2)\u003c/strong\u003e. Nearly 80% of the anesthesiologists (584/840; 69.5%) set PEEP based on lung compliance\u003cstrong\u003e (figure 1A)\u003c/strong\u003e. A total of 84.6% (921/1089) applied intraoperative ARM. The manual ARM was most commonly utilized to recruit the lungs (843/921; 91.5%)\u003cstrong\u003e (table 2)\u003c/strong\u003e. 72.5% of the respondents (668/921) applied ARM with oxygen/air mixture, while 22.8% (210/921) and 4.7% (43/921) used pure oxygen and air respectively. ARM was performed regularly at fixed time interval (385/921; 41.8%), when saturation of pulse oxygen (SpO\u003csub\u003e2\u003c/sub\u003e) dropped (437/921; 47.4%) or before tracheal extubation (623/921; 67.6%) \u003cstrong\u003e(figure 1B)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLPV practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were only 208 of 1089 (19.1%) respondents who routinely performed bundles of low V\u003csub\u003eT\u003c/sub\u003e, PEEP, and ARM \u003cstrong\u003e(table 2)\u003c/strong\u003e. Regarding the respondents' opinions on LPV, they preferred to perform LPV in specific patients \u003cstrong\u003e(figure 1C)\u003c/strong\u003e and laparoscopic surgery \u003cstrong\u003e(figure 1D)\u003c/strong\u003e. The first three most important lung protective ventilatory parameters considered by the respondents were V\u003csub\u003eT\u003c/sub\u003e (94.7%), PEEP (92.1%), and fraction of inspired oxygen (FiO\u003csub\u003e2\u003c/sub\u003e) (76.4%) \u003cstrong\u003e(figure 1E)\u003c/strong\u003e. The vast majority of respondents (1066/1089; 97.9%) considered bundles of \u0026ldquo;low V\u003csub\u003eT\u003c/sub\u003e, PEEP, and ARM\u0026rdquo; as LPV strategy \u003cstrong\u003e(figure 1F)\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOther ventilatory settings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 59.2% (645/1089) respondents \u0026nbsp;in laparoscopic surgery and 81.6% (889/1089) in non-laparoscopic surgery preferred volume-controlled ventilation (VCV)\u003cstrong\u003e (figure 2A)\u003c/strong\u003e. It was commonly applied with intraoperative FiO\u003csub\u003e2\u003c/sub\u003e of 40%-60% (485/1089;44.5%) or 60-80% (418/1089; 38.4%) \u003cstrong\u003e(figure 2B)\u003c/strong\u003e. Most of the respondents (798/1089; 73.3%) set the inspiratory-to-expiratory ratio (I: E) to 1:2 \u003cstrong\u003e(figure 2C)\u003c/strong\u003e. RR was set at 9-12 breaths/min in 66.2% (721/1089) of the respondents and was adjusted to maintain normal E\u003csub\u003eT\u003c/sub\u003eCO\u003csub\u003e2\u003c/sub\u003e in more than half of the respondents (583/1089; 53.5%) \u003cstrong\u003e(figure 2D)\u003c/strong\u003e. The median E\u003csub\u003eT\u003c/sub\u003eCO\u003csub\u003e2\u003c/sub\u003e was reported to be 50mmHg (interquartile range 45\u0026ndash;55) as the acceptable upper limit.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this is the first nationwide survey among Chinese anesthesiologists that demonstrate considerablely variabe practices with respect to intraoperative ventilation management in non-cardiothoracic surgical setting. The majority of respondents reported applying low V\u003csub\u003eT\u003c/sub\u003e, PEEP, and ARM separately, while only about a fifth performed LPV with bundles of low V\u003csub\u003eT\u003c/sub\u003e, PEEP, and ARM.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe LPV strategies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIt has been well established that intraoperative LPV strategies, containing low V\u003csub\u003eT\u003c/sub\u003e, appropriate PEEP with or without ARMs, could reduce the development of PPCs\u003csup\u003e[12-14]\u003c/sup\u003e. A retrospective study reported that approximate half of anesthesiologists at U.S. academic medical centers utilized both low V\u003csub\u003eT\u003c/sub\u003e and PEEP\u003csup\u003e[15]\u003c/sup\u003e. Our survey showed that only 21.8% routinely applied both low V\u003csub\u003eT\u003c/sub\u003e and PEEP, although most respondents recognized bundles of \u0026ldquo;low V\u003csub\u003eT\u003c/sub\u003e, PEEP, and ARMs\u0026rdquo; as LPV strategy. This may explained by the knowledge-practice gap among Chinese anesthesiologists. In recent years, some studies have proposed that open-lung ventilation strategy\u003csup\u003e[16]\u003c/sup\u003e, driving pressure (\u0026Delta;P) guided ventilation strategy\u003csup\u003e[17, 18]\u003c/sup\u003e, and mechanical power\u0026ndash;guided ventilation strategy\u003csup\u003e[19]\u003c/sup\u003e may have lung protective effects. However, results remain equivocal regarding their ability to prevent PPCs\u003csup\u003e[20-23]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLow V\u003csub\u003eT\u003c/sub\u003e and PEEP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn our survey, the majority of respondents performed low V\u003csub\u003eT\u003c/sub\u003e ventilation. The finding was in line with existing literature, which described that the use of low V\u003csub\u003eT\u003c/sub\u003e had been significantly increased\u003csup\u003e[24, 25]\u003c/sup\u003e. However, less than half of respondents calculated V\u003csub\u003eT\u003c/sub\u003e using PBW in accordance with expert recommendation\u003csup\u003e[26]\u003c/sup\u003e. Two studies found that compared to PBW, calculating V\u003csub\u003eT\u003c/sub\u003e with ABW would overestimate the target V\u003csub\u003eT\u003c/sub\u003e and that may expose patients to harmful volutrauma and barotrauma, especially to obese patients\u003csup\u003e[27, 28]\u003c/sup\u003e. In addition, our survey suggested more than 3/5 respondents set PEEP. While an observational study noted that 80% of patients still were ventilated without PEEP\u003csup\u003e[29]\u003c/sup\u003e. Reasons for not using PEEP included concerns about potential hemodynamic fluctuations \u003csup\u003e[30]\u003c/sup\u003e and PEEP not included in the default settings of ventilators\u003csup\u003e[31]\u003c/sup\u003e. Besides, we found most participants preferred PEEP level at 0-5 cmH\u003csub\u003e2\u003c/sub\u003eO, which was consistent with prior studies \u003csup\u003e[32, 33]\u003c/sup\u003e. However, a network meta-analysis found that moderate-to-high PEEP (\u0026ge;5 cmH\u003csub\u003e2\u003c/sub\u003eO) combined with low V\u003csub\u003eT \u003c/sub\u003eventilation could reduced the risk of PPCs in surgical patients\u003csup\u003e[14]\u003c/sup\u003e. By far, there was no consensus on optimal PEEP level, and individualized PEEP according to patients\u0026rsquo; lung compliance or \u0026Delta;P was suggested by several studies \u003csup\u003e[18, 34]\u003c/sup\u003e. Our findings suggested that most anesthesiologists preferred to set PEEP based on lung compliance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eARMs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur survey showed that more than 60% of anesthesiologists performed ARMs during MV. The results differed from a large observational study, in which less than 1/5 patients received intraoperative ARMs \u003csup\u003e[33]\u003c/sup\u003e. The implementation of ARMs after intubation was suggested to alleviate the deterioration of functional residual capacity following anesthesia\u003csup\u003e[26]\u003c/sup\u003e. However, it remains inconsistent regarding the role of ARMs after intubation to prevent PPCs. In our study, only a small number of respondents performed ARMs after tracheal intubation. This might be the result of detrimental effects of ARMs on cardiac output which could aggravate the instability of hemodynamics after induction\u003csup\u003e[35]\u003c/sup\u003e. Our survey showed that respondents preferred to perform manual ARMs, while ventilator-driven ARMs recommended in the expert consensus were rarely utilized\u003csup\u003e[26]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOther ventilatory settings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur survey suggested that VCV was most commonly used among respondents, which was consistent with the results of two observational studies\u003csup\u003e[36, 37]\u003c/sup\u003e\u003csup\u003e.\u003c/sup\u003e Most anesthesiologists preferred FiO\u003csub\u003e2\u003c/sub\u003e at 40%-60%. Until now, the optimal level of FiO\u003csub\u003e2 \u003c/sub\u003eremains unknow. Two randomized controlled trials comparing the use of high (80%) versus low (30%) FiO\u003csub\u003e2\u003c/sub\u003e showed no difference in reducing the incidence of PPCs\u003csup\u003e[38, 39]\u003c/sup\u003e\u003csup\u003e.\u003c/sup\u003e Expert consensus recommended FiO\u003csub\u003e2\u003c/sub\u003e should be set to \u0026le; 0.4 with the goal of using the lowest possible FiO\u003csub\u003e2\u003c/sub\u003e to achieve normoxia (or SpO\u003csub\u003e2\u003c/sub\u003e \u0026ge; 94%) and reduce the occurrence of resorption atelectasis\u003csup\u003e[26]\u003c/sup\u003e. In our survey, a small number of anesthesiologists applied high FiO\u003csub\u003e2 \u003c/sub\u003e(\u0026gt;80%) during operation.\u003c/p\u003e"},{"header":"Limitation","content":"\u003cp\u003eOur study has several limitations. Firstly, our survey was only distributed to anesthesiologists of some tertiary/university hospitals in China, and selection bias may exist, which restricts external validity. The results cannot be easily extrapolated to other medical centers in China and other countries. Secondly, our investigation had a 70% institution response rate, possibly introducing nonresponse bias. Nonetheless, a higher response rate does not necessarily improve nonresponse bias regarding demographic and practice variables\u003csup\u003e[\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]\u003c/sup\u003e. Thirdly, as a general limitation of the survey, we cannot verify whether the statement of respondents was truly correct and reflected the current practice in their center. Fourthly, our study remained an observational research. It can only provide limited information about intraoperative ventilator management. It cannot be regarded as a reliable source to make definitive statements.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn China, intraoperative ventilation management in the setting of non-cardiothoracic surgery varies widely among anesthesiologists. The LPV strategy including low V\u003csub\u003eT\u003c/sub\u003e, PEEP, and ARMs is generally acknowledged by anesthesiologists, while the implementation rate was low. A knowledge-practice gap may exist among Chinese anesthesia providers, which could be narrowed and further eliminated by interpretation of relevant expert consensus and continuing education.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eACSMA, Anesthesiology Committee of Sichuan Medical Association; ARM, alveolar recruitment maneuver; AAPOR, American Association for Public Opinion Research; ABW, actual body weight; BMI, body mass index; CI, confidence interval; EtCO\u003csub\u003e2\u003c/sub\u003e, end-tidal carbon dioxide; FiO\u003csub\u003e2\u003c/sub\u003e, fraction of inspired oxygen; I: E, inspiratory to expiratory ratio; LPV, lung-protective ventilation; MV, mechanical ventilation; OLS, open lung strategy; PBW, predicted body weight; PEEP, positive end-expiratory pressure; PCV, pressure-controlled ventilation; PCV-VG, pressure-controlled-volume guaranteed ventilation; PPCs, postoperative pulmonary complications; QR Code, quick response code; RR, respiratory rate; SpO\u003csub\u003e2\u003c/sub\u003e, saturation of pulse oxygen; STROBE, the strengthening the reporting of observational studies in epidemiology; V\u003csub\u003eT\u003c/sub\u003e, tidal volume; VCV, volume-controlled ventilation; VILI, ventilator-induced lung injury; \u0026Delta;P, driving pressure.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by Ethics Committee of West China Hospital of Sichuan University and the informed consent was obtained from all participants by the recruitment email.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQian-Qian Rao designed the study, analyzed the data, and prepared the manuscript. Hong Yu designed the study, analyzed the data, and prepared the manuscript. Si-Yang Wang analyzed the data and prepared the manuscript. Jia-Xin He collected the data and prepared the manuscript. Xue-Fei Li analyzed the data and prepared the manuscript. Fei Fei collected the data and prepared the manuscript. Kai-Xi Shang collected the data and prepared the manuscript. Hai Yu designed the study and prepared the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe appreciate the support from every anesthesiologist who participated in this survey and we are grateful to the expert panel for their excellent advice. Collaborators are listed in Additional file 2.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWang C, Wang X, Chi C, Guo L, Guo L, Zhao N, Wang W, Pi X, Sun B, Lian A \u003cem\u003eet al\u003c/em\u003e: \u003cb\u003eLung ventilation strategies for acute respiratory distress syndrome\u003c/b\u003e: \u003cb\u003ea systematic review and network meta\u003c/b\u003e-\u003cb\u003eanalysis\u003c/b\u003e. \u003cem\u003eSci Rep\u003c/em\u003e 2016, \u003cb\u003e6\u003c/b\u003e:22855.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eG\u0026uuml;ldner A, Kiss T, Serpa Neto A, Hemmes SNT, Canet J, Spieth PM, Rocco PRM, Schultz MJ, Pelosi P, Gama de Abreu M: \u003cb\u003eIntraoperative protective mechanical ventilation for prevention of postoperative pulmonary complications: a comprehensive review of the role of tidal volume, positive end-expiratory pressure, and lung recruitment maneuvers\u003c/b\u003e. 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Respir Care 2018, \u003cb\u003e63\u003c/b\u003e(9):1079\u0026ndash;1084.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaber S, Coisel Y, Chanques G, Futier E, Constantin JM, Michelet P, Beaussier M, Lefrant JY, Allaouchiche B, Capdevila X \u003cem\u003eet al\u003c/em\u003e: \u003cb\u003eA multicentre observational study of intra-operative ventilatory management during general anaesthesia: tidal volumes and relation to body weight\u003c/b\u003e. Anaesthesia 2012, \u003cb\u003e67\u003c/b\u003e(9).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHemmes SNT, Gama de Abreu M, Pelosi P, Schultz MJ: \u003cb\u003eHigh versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): a multicentre randomised controlled trial\u003c/b\u003e. Lancet 2014, \u003cb\u003e384\u003c/b\u003e(9942):495\u0026ndash;503.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiao SS, Colquhoun DA, Naik BI, Ma JZ, Nemergut EC, Durieux ME, Blank RS, Forkin KT: \u003cb\u003eChanging Default Ventilator Settings on Anesthesia Machines Improves Adherence to Lung-Protective Ventilation Measures\u003c/b\u003e. Anesthesia and analgesia 2018, \u003cb\u003e126\u003c/b\u003e(4):1219\u0026ndash;1222.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLadha K, Vidal Melo MF, McLean DJ, Wanderer JP, Grabitz SD, Kurth T, Eikermann M: \u003cb\u003eIntraoperative protective mechanical ventilation and risk of postoperative respiratory complications: hospital based registry study\u003c/b\u003e. BMJ 2015, \u003cb\u003e351\u003c/b\u003e:h3646.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEpidemiology, \u003cb\u003epractice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications\u003c/b\u003e: \u003cb\u003eLAS VEGAS\u003c/b\u003e - \u003cb\u003ean observational study in 29 countries\u003c/b\u003e. \u003cem\u003eEur J Anaesthesiol\u003c/em\u003e 2017, \u003cb\u003e34\u003c/b\u003e(8):492\u0026ndash;507.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cb\u003eDriving Pressure During General Anesthesia for Open Abdominal Surgery (DESIGNATION): study protocol of a randomized clinical trial\u003c/b\u003e. Trials 2020, \u003cb\u003e21\u003c/b\u003e(1):198.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDas A, Haque M, Chikhani M, Cole O, Wang W, Hardman JG, Bates DG: \u003cb\u003eHemodynamic effects of lung recruitment maneuvers in acute respiratory distress syndrome\u003c/b\u003e. BMC Pulm Med 2017, \u003cb\u003e17\u003c/b\u003e(1):34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKaralapillai D, Weinberg L, Galtieri J, Glassford N, Eastwood G, Darvall J, Geertsema J, Bangia R, Fitzgerald J, Phan T \u003cem\u003eet al\u003c/em\u003e: \u003cb\u003eCurrent ventilation practice during general anaesthesia: a prospective audit in Melbourne, Australia\u003c/b\u003e. BMC anesthesiology 2014, \u003cb\u003e14\u003c/b\u003e:85.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilcox SR, Richards JB, Fisher DF, Sankoff J, Seigel TA: \u003cb\u003eInitial mechanical ventilator settings and lung protective ventilation in the ED\u003c/b\u003e. Am J Emerg Med 2016, \u003cb\u003e34\u003c/b\u003e(8):1446\u0026ndash;1451.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi X-F, Jiang D, Jiang Y-L, Yu H, Zhang M-Q, Jiang J-L, He L-L, Yu H: \u003cb\u003eComparison of low and high inspiratory oxygen fraction added to lung-protective ventilation on postoperative pulmonary complications after abdominal surgery: A randomized controlled trial\u003c/b\u003e. J Clin Anesth 2020, \u003cb\u003e67\u003c/b\u003e:110009.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerrando C, Aldecoa C, Unzueta C, Belda FJ, Librero J, Tusman G, Suarez-Sipmann F, Peiro S, Pozo N, Brunelli A \u003cem\u003eet al\u003c/em\u003e: \u003cb\u003eEffects of oxygen on post-surgical infections during an individualised perioperative open-lung ventilatory strategy: a randomised controlled trial\u003c/b\u003e. Br J Anaesth 2020, \u003cb\u003e124\u003c/b\u003e(1):110\u0026ndash;120.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScott A, Jeon S-H, Joyce CM, Humphreys JS, Kalb G, Witt J, Leahy A: \u003cb\u003eA randomised trial and economic evaluation of the effect of response mode on response rate, response bias, and item non-response in a survey of doctors\u003c/b\u003e. BMC Med Res Methodol 2011, \u003cb\u003e11\u003c/b\u003e:126.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"418\"\u003e\n\u003cp\u003e\u003cstrong\u003eTable1 Sample Characteristics in this survey. \u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" width=\"418\"\u003e\n\u003cp\u003eCharastiristic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003eN (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\n\u003cp\u003eAcademic position\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eResident\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e469 (43.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eAttending\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e457 (41.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eProfessor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e163 (15.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\n\u003cp\u003eYears of practice\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003e0-4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e418 (38.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003e5-9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e340 (31.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003e10-14\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e195 (17.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003e15-19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e68 (6.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003e\u0026ge;20\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e68 (6.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\n\u003cp\u003ePrimary type of practice\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eFlexible subspecialties\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e929 (85.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eGeneral sugery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e41 (3.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eOrthopedics\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e39 (3.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eNeurosurgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e19 (1.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eObstetrics and Gynecology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e16 (1.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eOtorhinolaryngology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e10 (0.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eUrology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e8 (0.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eStomatology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e4 (0.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eOphthalmology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e0 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eOthers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e23 (2.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\n\u003cp\u003eType of hospital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eTeaching hospital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e1035 (95.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"170\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"248\"\u003e\n\u003cp\u003eNon-teaching hospital\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"124\"\u003e\n\u003cp\u003e54 (5.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"541\"\u003e\n\u003cp\u003eData are presented as number (percentage).\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable width=\"0\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"605\"\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2 Respondents\u0026rsquo; Practice Details of LPV Strategy\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u003cstrong\u003eItem\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"246\"\u003e\n\u003cp\u003e\u003cstrong\u003ePractice\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"179\"\u003e\n\u003cp\u003e\u003cstrong\u003eN(%)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003eV\u003csub\u003eT\u003c/sub\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"246\"\u003e\n\u003cp\u003e\u0026lt;6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"179\"\u003e\n\u003cp\u003e28 (2.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"246\"\u003e\n\u003cp\u003e6-8 (low V\u003csub\u003eT\u003c/sub\u003e)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"179\"\u003e\n\u003cp\u003e1010 (92.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"246\"\u003e\n\u003cp\u003e9-10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"179\"\u003e\n\u003cp\u003e46 (4.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"246\"\u003e\n\u003cp\u003eothers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"179\"\u003e\n\u003cp\u003e5 (0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003ePEEP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"246\"\u003e\n\u003cp\u003e1-5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"179\"\u003e\n\u003cp\u003e639 (58.7) */736 (67.6) \u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"246\"\u003e\n\u003cp\u003e6-10\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"179\"\u003e\n\u003cp\u003e198 (18.2) */102 (9.4) \u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"246\"\u003e\n\u003cp\u003e11-15\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"179\"\u003e\n\u003cp\u003e3 (0.3) */2 (0.2) \u0026dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd width=\"246\"\u003e\n\u003cp\u003eNo PEEP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"179\"\u003e\n\u003cp\u003e249 (22.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003eARM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"246\"\u003e\n\u003cp\u003eManual method\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"179\"\u003e\n\u003cp\u003e843 (77.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"246\"\u003e\n\u003cp\u003eProgressively increase PEEP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"179\"\u003e\n\u003cp\u003e42 (3.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"246\"\u003e\n\u003cp\u003eProgressively increase tidal volume\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"179\"\u003e\n\u003cp\u003e28 (2.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"246\"\u003e\n\u003cp\u003eControl vital capacity by ventilator\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"179\"\u003e\n\u003cp\u003e6 (0.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"246\"\u003e\n\u003cp\u003eNo ARM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"179\"\u003e\n\u003cp\u003e168 (15.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003eLow V\u003csub\u003eT \u003c/sub\u003e+PEEP+ARM\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"246\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"179\"\u003e\n\u003cp\u003e208 (19.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"180\"\u003e\n\u003cp\u003eLow V\u003csub\u003eT \u003c/sub\u003e+PEEP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"246\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"179\"\u003e\n\u003cp\u003e237 (21.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"605\"\u003e\n\u003cp\u003eData are presented as number (percentage).\u003c/p\u003e\n\u003cp\u003eAbbreviations: ARM, Alveolar recruitment maneuvers; LPV, Lung-protective ventilation; PEEP, Positive end-expiratory pressure; V\u003csub\u003eT\u003c/sub\u003e, Tidal volume.\u003c/p\u003e\n\u003cp\u003e* For laparoscopic surgery; \u0026nbsp;\u0026dagger; For non-laparoscopic surgery.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e "}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Anesthesia, Surveys and questionnaires, Intraoperative, Mechanical ventilation, Lung-protective ventilation\t ","lastPublishedDoi":"10.21203/rs.3.rs-1887971/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1887971/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe current clinical practice regarding intraoperative ventilation management in non-cardiothoracic surgical setting among anesthesia providers in China is unclear.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe developed a 25-question anonymous survey which was distributed to anesthesia departments from 81 tertiary/university hospitals in China between August 2021 and September 2021. Information including participant characteristics, ventilatory settings, and opinions on lung-protective ventilation were obtained by electronic survey. Results were reported descriptively.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe survey was completed by 1089 anesthesiologists from 57 institutions (70% institution response rate). The vast majority of respondents (1010/1089; 92.7%)used low tidal volume (6\u0026ndash;8 ml kg \u003csup\u003e\u0026minus;\u0026thinsp;1\u003c/sup\u003e) ventilation. About three quarters (840/1089; 77.1%) utilized positive end-expiratory pressure, and most anesthesiologists set positive end-expiratory pressure of 1\u0026ndash;5 cmH\u003csub\u003e2\u003c/sub\u003eO in either laparoscopic (639/840; 76.1%) or non-laparoscopic surgery (736/840; 87.6%). The majority of respondents (921/1089; 84.6%) performed alveolar recruitment maneuver intraoperatively. Approximate 20% of respondents routinely implemented lung-protective ventilation with bundles of low tidal volume, positive end-expiratory pressure, and alveolar recruitment maneuver.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe found that heterogeneity exists between individual practices regarding intraoperative ventilation management in the setting of non-cardiothoracic surgery, indicating the potential knowledge-practice gap among Chinese anesthesiologists.\u003c/p\u003e\u003ch2\u003eTrial registration number:\u003c/h2\u003e \u003cp\u003eChiCTR2100047653; \u003cb\u003eRegistration date\u003c/b\u003e: June 21, 2021 \u003cb\u003eRegistry URL\u003c/b\u003e: Chictr.org.cn.\u003c/p\u003e","manuscriptTitle":"Intraoperative management of mechanical ventilation in non-cardiothoracic surgery: a national survey in China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-07-29 18:12:11","doi":"10.21203/rs.3.rs-1887971/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d2d64369-f91b-46da-b1d6-49cf0d22d319","owner":[],"postedDate":"July 29th, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-11-16T18:14:15+00:00","versionOfRecord":[],"versionCreatedAt":"2022-07-29 18:12:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1887971","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1887971","identity":"rs-1887971","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}