Measure ID

PUL-02

Domain

Pulmonary

Description

Percentage of cases with median tidal volumes less than or equal to 8 ml/kg.

Measure Type

Process

Rationale

The use of lung protective ventilation techniques (low tidal volumes and positive end-expiratory pressure) should be part of standard anesthetic practice for most cases that require positive pressure ventilation. Several randomized controlled trials, as well as a meta-analysis in 2015 describe the benefit with low vs high tidal volume techniques.^{1-6}

Threshold

90%

Measure Time Period

Case Start to Case End (see other measure build details)

Inclusions

Patients undergoing endotracheal intubation.

Exclusions

- ASA 5 and 6 cases
- Patients < 12 years of age
- Patients <20kg.
- Patients ≥ 18 years old with a height <121.9cm (48 in) OR >213.4cm (84 in)
- Patients 12-17 years old with a height <91.4cm (36 in) or >213.4cm (84 in)
- Cases where Epoprostenol is administered as an inhalational agent
- Cases without a documented sex
- Cases without a documented height
- Cases in which patients are mechanically ventilated for less than 45 cumulative minutes.
- One lung ventilation procedures as indicated by intraoperative notes or note details mapped to one of the following MPOG concepts:
- 50501: Thoracic: Single-lung ventilation
- 50202: Thoracic: Single-lung ventilation, side detail

Success Criteria

Median tidal volume ≤ 8 ml/ kg predicted body weight for the time period between Case Start and Case End.

Other Measure Details

- For a given case, this measure will exclude periods when patients are not under positive pressure ventilation (coded in the measure to exclude minutes where Peak Inspiratory Pressure – PEEP </= 6).
- Peak Inspiratory Pressure determined by values mapped to MPOG Concept 3185. If no PIP documented, PIP is considered null and tidal volume is included.
- PEEP will be determined using values associated with the following variables:
- Use Measured PEEP (MPOG Concept: 3210). If not documented,
- Use Set PEEP (MPOG Concept: 3212). If not documented,
- Assume PEEP = 0.

- For a case to be included for the PUL-02 measure, it must have at least 45 valid values of actual tidal volume or set tidal volume
- In determining median tidal volume, if any value greater than two (2) is documented, it is assumed that tidal volume is documented in milliliters (mL). If all values are less than two (2), tidal volume is assumed to be measured in liters (L).
- For patients ≥18 years old with height>121.9cm (48 in) but <213.4cm (84 in), the following equation is used to determine Predicted Body Weight. For patients less than 5 feet, 5 feet (152.4 cm) will be used for the IBW formula:
- Male patients: 50kg + 0.91kg * (height in cm - 152.4)
- Female patients: 45.5kg + 0.91kg * (height in cm - 152.4)

- For patients 12-17 years old and height > 91.4cm (36 in) but <213.4cm (84 in), the McLaren Method is used to determine Predicted Body Weight. The McLaren Method is the most commonly used method to determine PBW in children and uses growth charts to determine IBW by identifying the 50
^{th}percentile height for age, then using that height to determine 50^{th}percentile weight. This weight is the patient’s Predicted Body Weight (PBW).^{7} - “Actual tidal volume” trumps “set tidal volume” if there are at least 45 valid “actual tidal volume” measurements. If there are no values for “actual tidal volume”, “set tidal volume” is used.

**Algorithm for determining Case Duration**

Case Start:

- Anesthesia Induction End. If not available, then
- Anesthesia Induction Begin. If not available, then
- Procedure Start. If not available, then
- Patient in Room. If not available, then
- Anesthesia Start

Case End:

- Patient Extubated. If not available, then
- Procedure End. If not available, then
- Patient Out of Room. If not available, then
- Anesthesia End.

Provider Attribution

Provider signed in for largest portion of case. See ‘Other Measure Build Details’ section of this specification to view the algorithm used for determining case duration.

**Method for determining Responsible Provider: **

In the event that two or more providers in the same class are signed in for the same duration, all providers signed in for the longest duration will be attributed.

MPOG Concept Used

**Endotracheal Tube**

- 50121 Intubation Endotracheal Tube Stylet Used
- 50122 Intubation Endotracheal Tube Size
- 50123 Intubation Endotracheal Tube Type
- 50124 Intubation Endotracheal Tube Secured Mechanism
- 50125 Intubation Endotracheal Tube Secured Distance
- 50126 Intubation Endotracheal Tube Secured Reference Point
- 50202 Emergence- Patient Extubated
- 50205 Intubation Tube Note
- 50671 Intubation- endotracheal tube in situ

**Tidal Volume**

- 3190 Tidal Volume Actual
- 3192 Tidal Volume Set
- 3185 Peak Inspiratory Pressure
- 3210 Positive End Expiratory Pressure- Measured
- 3212 Positive End Expiratory Pressure- Set

**One-Lung Ventilation**

- 50501 Thoracic-Single lung ventilation
- 50202 Thoracic-Single lung ventilation side detail

**Intraoperative Medication**

- 10473 Epoprostenol
- 2006 Inhalationa

MPOG Phenotypes Used

References

- Brower RG, Matthay MA, Morris A, Schoenfeld D, Thompson BT, Wheeler A. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.
*The New England journal of medicine.*2000;342(18):1301-1308. - Fernandez-Perez ER, Keegan MT, Brown DR, Hubmayr RD, Gajic O. Intraoperative tidal volume as a risk factor for respiratory failure after pneumonectomy.
*Anesthesiology.*2006;105(1):14-18. - Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery.
*The New England journal of medicine.*2013;369(5):428-437. - Guldner A, Kiss T, Serpa Neto A, et al. 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. - Serpa Neto A, Hemmes SN, Barbas CS, et al. Protective versus Conventional Ventilation for Surgery: A Systematic Review and Individual Patient Data Meta-analysis.
*Anesthesiology.*2015;123(1):66-78. - Severgnini P, Selmo G, Lanza C, et al. Protective mechanical ventilation during general anesthesia for open abdominal surgery improves postoperative pulmonary function.
*Anesthesiology.*2013;118(6):1307-1321. - Phillips S, Edlbeck A, Kirby M, Goday P. Ideal body weight in children.
*Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition.*2007;22(2):240-245.

Measure Reviewer(s)

Date Reviewed | QC Presentation | Reviewer | Institution | Summary | QC Vote |
---|---|---|---|---|---|

01/2021 |
01/25/2021 |
Avery Tung, MD Douglas Colqhoun, MD |
University of Chicago University of Michigan |
No Change |

Version

Date | Criteria | Revision |
---|---|---|

None |