Obesity and Weaning from Mechanical Ventilation-An Exploratory Study

Ogugua Ndili Obi, Mark Mazer, Charles Bangley, Zuheir Kassabo, Khalid Saadah, Wayne Trainor, Kenneth Stephens, Patricia L Rice, Robert Shaw, Ogugua Ndili Obi, Mark Mazer, Charles Bangley, Zuheir Kassabo, Khalid Saadah, Wayne Trainor, Kenneth Stephens, Patricia L Rice, Robert Shaw

Abstract

Introduction: Obesity is associated with increased risk of hypercapnic respiratory failure, prolonged duration on mechanical ventilation, and extended weaning periods.

Objective: Pilot study to determine whether morbidly obese adult tracheotomized subjects (body mass index [BMI] ⩾ 40) can be more efficiently weaned from the ventilator by optimizing their positive end-expiratory pressure (PEEP) using either an esophageal balloon or the best achieved static effective compliance.

Methods: We randomly assigned 25 morbidly obese adult tracheotomized subjects (median [interquartile range] BMI 53.4 [26.4]; range 40.4-113.8) to 1 of 2 methods of setting PEEP; using either titration guided by esophageal balloon to overcome negative transpulmonary pressure (Ptp) (goal Ptp 0-5 cmH2O) (ESO group) or titration to maximize static effective lung compliance (Cstat group). Our outcomes of interest were number of subjects weaned by day 30 and time to wean.

Results: At day 30, there was no significant difference in percentage of subjects weaned. 8/13 subjects (62%) in the ESO Group were weaned vs. 9/12(75%) in the Cstat Group (P = 0.67). Among the 17 subjects who weaned, median time to ventilator liberation was significantly shorter in the ESO group: 3.5 days vs Cstat group 14 days (P = .01). Optimal PEEP in the ESO and Cstat groups was similar (ESO mean ± SD = 26.5 ± 5.7 cmH2O and Cstat 24.2 ± 7 cmH2O (P = .38).

Conclusions: Optimization of PEEP using esophageal balloon to achieve positive transpulmonary pressure did not change the proportion of patients weaned. Among patients who weaned, use of the esophageal balloon resulted in faster liberation from mechanical ventilation. There were no adverse consequences of the high PEEP (mean 25.4; range 13-37 cmH2O) used in our study. The study was approved by the Institutional Review Board at our institution (UMCIRB#10-0343) and registered with clinicaltrials.gov (NCT02323009).

Keywords: Morbidly obese; esophageal balloon; positive end-expiratory pressure (PEEP); speaking valve; static compliance (Cstat); tracheotomized; transpulmonary pressure; ventilator weaning.

Conflict of interest statement

Declaration of conflicting interests:The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Image 1.
Image 1.
Serial ventilator screen shots from an esophageal balloon subject adjustment. Note. Panel A shows an airway pressure of 10.1 cmH20 (Paw); An esophageal pressure of 27.5 H20 (Paux). This corresponds to a transpulmonary pressure of -17.4 cmH20 (Paux – Paw). Measurements were made at end-expiration. Panels B through C show increasing PEEP levels from 28 cmH20 in Panel B to 33 cm H20 in Panel C with a corresponding improvement in the transpulmonary pressure until a transpulmonary pressure of zero (0) is achieved in panel C with the final ventilator settings as shown. Please note the significant increase in expired tidal volume from 532cc to 768cc with PEEP adjustment from Panel A to B, necessitating a decrease in applied pressure Support in Panel C. FiO2 was also decreased from 40% to 21% to maintain oxygen saturations of 90% or greater.
Figure 1.
Figure 1.
Box plot comparing number of days to wean in the successfully weaned ESO vs. Cstat subjects.
Figure 2.
Figure 2.
Kaplan-Meier curves showing the time to wean in the entire cohort (N=25).

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