Brazilian Journal of Anesthesiology
https://app.periodikos.com.br/journal/rba/article/doi/10.1016/j.bjane.2026.844814
Brazilian Journal of Anesthesiology
Special Article

Consensus recommendations on perioperative mechanical ventilation strategies: an evidence-based guideline by the Brazilian Society of Anesthesiology

Recomendações de consenso sobre estratégias de ventilação mecânica perioperatória: uma diretriz baseada em evidências da Sociedade Brasileira de Anestesiologia

João Manoel Silva Jr, Talison Silas Pereira, Luiz Fernando dos Reis Falcão, Ricardo Esper Treml, Alexandre Marini Isola, Alexandre Goulart Pustilnik, Anacleto Gabriel de Alcântara, André Prato Schmidt, Antonio Carlos Aguiar Brandão, Arthur Caus de Morais, Bruna Silveira Ferreira Klauck, Bruno Campostrini Sily, Bruno Francisco de Freitas Tonelotto, Carlos Gustavo dos Santos Silva, Carmen Sílvia Valente Barbas, Claudia Marquez Simões, Daniel da Escóssia Melo Sousa, Fábio Barlem Hohmann, Fábio Luis Ferrari Regatieri, Germano Pinheiro Medeiros, Gutenberg Diniz Borborema, Maisa Ribeiro Araújo, Marcelo Ramalho Fernandes, Marcelo Tabary de Oliveira Carlucci, Matheus Faccini Vane, Neymar Elias de Oliveira, Plínio da Cunha Leal, Roberta Figueiredo Vieira, Rodrigo Leal Alves, Rodrigo Pereira Diaz André, Saullo Queiroz Silveira, Victor Sampaio de Almeida, Vinícius Caldeira Quintão, Leandro Gobbo Braz, Luiz Marcelo Sá Malbouisson

http://dx.doi.org/10.1016/j.bjane.2026.844814 Braz J Anesthesiol, vol.76, n5, 844814, 2026
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Abstract

Background

Postoperative Pulmonary Complications (PPCs) are a leading cause of morbidity, mortality, and prolonged hospitalization in surgical patients. Intraoperative mechanical ventilation plays a critical role in mitigating these risks, yet clinical practices remain heterogeneous and often not guided by evidence-based standards.

Objective

To develop evidence-based recommendations on perioperative mechanical ventilation strategies for surgical patients, aiming to optimize respiratory care, reduce PPCs, and standardize practice in Brazil.

Methods

This guideline was developed under the coordination of the Brazilian Society of Anesthesiology (SBA) by a panel of anesthesiologists and intensivists from multiple institutions. Seventeen clinical questions were structured in the PICO format (Population, Intervention, Comparison, Outcome). Systematic literature searches were conducted in PubMed, Embase, Cochrane Library, and Scopus up to July 2025. The strength of recommendations and certainty of evidence were assessed using the GRADE methodology. A modified Delphi process was applied to obtain agreement among collaborators, and consensus was discussed only when the predefined threshold of at least 80% agreement was not achieved. All recommendations were standardized in a uniform format.

Results

Seventeen thematic chapters were developed, covering topics from respiratory physiology and the definition of PPCs to advanced intraoperative monitoring, special populations (obese, pediatric, thoracic and cardiac surgery), and patients with or without acute lung injury. Key recommendations include the routine use of lung-protective strategies low tidal volumes of 6–8 mL.kg⁻¹ PBW in patients without ARDS and 4–8 mL.kg⁻¹ PBW in patients with ARDS, Positive End-Expiratory Pressure [PEEP] titrated to physiology, driving pressure ΔP ≤ 15 cm H2O, and Plateau Pressure [Pplat] ≤ 30 cm H2O), individualized approaches in high-risk patients, avoidance of unnecessary high fraction of inspired oxygen (FiO2), and selective use of recruitment maneuvers. Standardized definitions of PPCs and structured monitoring were emphasized as essential to improving patient outcomes.

Conclusion

These consensus-based recommendations provide clinicians with a practical, evidence-informed framework for perioperative mechanical ventilation. Adoption of protective strategies and standardized definitions is expected to improve respiratory outcomes and reduce variability in perioperative care.

Keywords

Anesthesia; GRADE; Mechanical ventilation; Perioperative care; Protective ventilation; Pulmonary complications

Resumo

Introdução

As complicações pulmonares pós-operatórias (CPPOs) são uma das principais causas de morbidade, mortalidade e internação prolongada em pacientes cirúrgicos. A ventilação mecânica intraoperatória desempenha um papel crítico na mitigação desses riscos; no entanto, as práticas clínicas permanecem heterogêneas e frequentemente não são guiadas por padrões baseados em evidências. O objetivo desta diretriz foi desenvolver recomendações baseadas em evidências sobre estratégias de ventilação mecânica perioperatória para pacientes cirúrgicos, visando otimizar a assistência respiratória, reduzir as CPPOs e padronizar a prática no Brasil.

Métodos

Esta diretriz foi desenvolvida sob a coordenação da Sociedade Brasileira de Anestesiologia (SBA) por um painel de anestesiologistas e intensivistas de múltiplas instituições. Dezessete perguntas clínicas foram estruturadas no formato PICO (População, Intervenção, Comparação, Desfecho). Foram realizadas buscas sistemáticas na literatura nas bases de dados PubMed, Embase, Cochrane Library e Scopus até julho de 2025. A força das recomendações e a certeza da evidência foram avaliadas utilizando a metodologia GRADE. Um processo Delphi modificado foi aplicado para obter consenso entre os colaboradores, e o consenso foi debatido apenas quando o limite predefinido de pelo menos 80% de concordância não foi alcançado. Todas as recomendações foram padronizadas em um formato uniforme.

Resultados

Foram desenvolvidos dezessete capítulos temáticos, abrangendo desde a fisiologia respiratória e a definição de CPPOs até o monitoramento intraoperatório avançado, populações especiais (obesos, pediatria, cirurgia torácica e cardíaca) e pacientes com ou sem lesão pulmonar aguda. As principais recomendações incluem o uso rotineiro de estratégias de ventilação protetora (baixos volumes correntes de 6–8 mL.kg⁻¹ de peso corporal predito [PCP], pressão positiva expiratória final [PEEP] titulada de acordo com a fisiologia, pressão de condução [driving pressure] ΔP ≤ 15 cm H₂O e pressão de pico/platô [Plateau pressure, Pplat] < 30 cm H₂O), abordagens individualizadas em pacientes de alto risco, prevenção do uso desnecessário de frações inspiradas de oxigênio (FiO₂) elevadas e uso seletivo de manobras de recrutamento. Definições padronizadas de CPPOs e monitoramento estruturado foram enfatizados como essenciais para melhorar os desfechos dos pacientes.

Conclusão

Estas recomendações baseadas em consenso fornecem aos clínicos uma estrutura prática e fundamentada em evidências para a ventilação mecânica perioperatória. Espera-se que a adoção de estratégias protetoras e definições padronizadas melhore os desfechos respiratórios e reduza a variabilidade na assistência perioperatória.

Palavras-chave

Anestesia; GRADE; Ventilação mecânica; Assistência perioperatória; Ventilação protetora; Complicações pulmonares

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Submitted date:
07/10/2025

Accepted date:
09/06/2026

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