Distribution of ventilation and oxygenation in surgical obese patients ventilated with high versus low positive end-expiratory pressure: A substudy of a randomised controlled trial

Christoph Ellenberger, Paolo Pelosi, Marcelo Gama de Abreu, Hermann Wrigge, John Diaper, Andres Hagerman, Yannick Adam, Marcus J Schultz, Marc Licker, PROBESE investigators, of the PROtective VEntilation Network (PROVEnet); Clinical Trial Network of the European Society of Anaesthesiology and Intensive Care (ESAIC), Christoph Ellenberger, Paolo Pelosi, Marcelo Gama de Abreu, Hermann Wrigge, John Diaper, Andres Hagerman, Yannick Adam, Marcus J Schultz, Marc Licker, PROBESE investigators, of the PROtective VEntilation Network (PROVEnet); Clinical Trial Network of the European Society of Anaesthesiology and Intensive Care (ESAIC)

Abstract

Background: Intra-operative ventilation using low/physiological tidal volume and positive end-expiratory pressure (PEEP) with periodic alveolar recruitment manoeuvres (ARMs) is recommended in obese surgery patients.

Objectives: To investigate the effects of PEEP levels and ARMs on ventilation distribution, oxygenation, haemodynamic parameters and cerebral oximetry.

Design: A substudy of a randomised controlled trial.

Setting: Tertiary medical centre in Geneva, Switzerland, between 2015 and 2018.

Patients: One hundred and sixty-two patients with a BMI at least 35 kg per square metre undergoing elective open or laparoscopic surgery lasting at least 120 min.

Intervention: Patients were randomised to PEEP of 4 cmH 2 O ( n = 79) or PEEP of 12 cmH 2 O with hourly ARMs ( n = 83).

Main outcome measures: The primary endpoint was the fraction of ventilation in the dependent lung as measured by electrical impedance tomography. Secondary endpoints were the oxygen saturation index (SaO 2 /FIO 2 ratio), respiratory and haemodynamic parameters, and cerebral tissue oximetry.

Results: Compared with low PEEP, high PEEP was associated with smaller intra-operative decreases in dependent lung ventilation [-11.2%; 95% confidence interval (CI) -8.7 to -13.7 vs. -13.9%; 95% CI -11.7 to -16.5; P = 0.029], oxygen saturation index (-49.6%; 95% CI -48.0 to -51.3 vs. -51.3%; 95% CI -49.6 to -53.1; P < 0.001) and a lower driving pressure (-6.3 cmH 2 O; 95% CI -5.7 to -7.0). Haemodynamic parameters did not differ between the groups, except at the end of ARMs when arterial pressure and cardiac index decreased on average by -13.7 mmHg (95% CI -12.5 to -14.9) and by -0.54 l min -1 m -2 (95% CI -0.49 to -0.59) along with increased cerebral tissue oximetry (3.0 and 3.2% on left and right front brain, respectively).

Conclusion: In obese patients undergoing abdominal surgery, intra-operative PEEP of 12 cmH 2 O with periodic ARMs, compared with intra-operative PEEP of 4 cmH 2 O without ARMs, slightly redistributed ventilation to dependent lung zones with minor improvements in peripheral and cerebral oxygenation.

Trial registration: NCT02148692, https://clinicaltrials.gov/ct2.

Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the European Society of Anaesthesiology and Intensive Care.

Figures

Fig. 1
Fig. 1
CONSORT flow diagram.
Fig. 2
Fig. 2
Effect of intra-operative high positive end-expiratory pressure with recruitment manoeuvres vs. low PEEP on ventilation of the dependent lung part in obese patients.
Fig. 3
Fig. 3
Effect of intra-operative high positive end-expiratory pressure with recruitment manoeuvres vs. low PEEP on the ratio of pulsed-oxygen saturation (SaO2)/fractional inspired oxygen (FiO2) in obese patients.
Fig. 4
Fig. 4
Intra-operative effects of high positive end-expiratory pressure (PEEP) with recruitment manoeuvres vs. low PEEP on mean arterial blood pressure, cardiac output as well as left and right-sided cerebral near-infrared spectroscopy (NIRS).

References

    1. Janssen F, Bardoutsos A, Vidra N. Obesity prevalence in the long-term future in 18 European countries and in the USA. Obes Facts 2020; 13:514–527.
    1. Bamgbade OA, Rutter TW, Nafiu OO, Dorje P. Postoperative complications in obese and nonobese patients. World J Surg 2007; 31:556–560.
    1. Choi D, Hendren S, Chang MI, et al. . The impact of obesity and morbid obesity on urgent/emergency colorectal resections: a regional database analysis. Surg Endosc 2022; 36:1876–1886.
    1. Pelosi P, Croci M, Ravagnan I, et al. . Total respiratory system, lung, and chest wall mechanics in sedated-paralyzed postoperative morbidly obese patients. Chest 1996; 109:144–151.
    1. Grassi L, Kacmarek R, Berra L. Ventilatory mechanics in the patient with obesity. Anesthesiology 2020; 132:1246–1256.
    1. Eichler L, Truskowska K, Dupree A, et al. . Intraoperative ventilation of morbidly obese patients guided by transpulmonary pressure. Obes Surg 2018; 28:122–129.
    1. Girrbach F, Petroff D, Schulz S, et al. . Individualised positive end-expiratory pressure guided by electrical impedance tomography for robot-assisted laparoscopic radical prostatectomy: a prospective, randomised controlled clinical trial. Br J Anaesth 2020; 125:373–382.
    1. Nestler C, Simon P, Petroff D, et al. . Individualized positive end-expiratory pressure in obese patients during general anaesthesia: a randomized controlled clinical trial using electrical impedance tomography. Br J Anaesth 2017; 119:1194–1205.
    1. Pelosi P, Ravagnan I, Giurati G, et al. . Positive end-expiratory pressure improves respiratory function in obese but not in normal subjects during anesthesia and paralysis. Anesthesiology 1999; 91:1221–1231.
    1. Schaefer MS, Wania V, Bastin B, et al. . Electrical impedance tomography during major open upper abdominal surgery: a pilot-study. BMC Anesthesiol 2014; 14:51.
    1. Bluth T, Schultz MJ, Pelosi P, et al. . Writing Committee for the PCGotPVNftCTNotESoA. Effect of intraoperative high positive end-expiratory pressure (PEEP) with recruitment maneuvers vs low PEEP on postoperative pulmonary complications in obese patients: a randomized clinical trial. JAMA 2019; 321:2292–2305.
    1. Ding L, Chen DX, Li Q. Effects of electroencephalography and regional cerebral oxygen saturation monitoring on perioperative neurocognitive disorders: a systematic review and meta-analysis. BMC Anesthesiol 2020; 20:254.
    1. Nielsen HB. Systematic review of near-infrared spectroscopy determined cerebral oxygenation during noncardiac surgery. Front Physiol 2014; 5:93.
    1. Canet J, Gallart L, Gomar C, et al. . Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology 2010; 113:1338–1350.
    1. Bluth T, Teichmann R, Kiss T, et al. . Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial. Trials 2017; 18:202.
    1. Pandharipande PP, Shintani AK, Hagerman HE, et al. . Derivation and validation of Spo2/Fio2 ratio to impute for Pao2/Fio2 ratio in the respiratory component of the Sequential Organ Failure Assessment score. Crit Care Med 2009; 37:1317–1321.
    1. Tomicic V, Cornejo R. Lung monitoring with electrical impedance tomography: technical considerations and clinical applications. J Thorac Dis 2019; 11:3122–3135.
    1. Brabant O, Crivellari B, Hosgood G, et al. . Effects of PEEP on the relationship between tidal volume and total impedance change measured via electrical impedance tomography (EIT). J Clin Monit Comput 2022; 36:325–334.
    1. Putensen C, Hentze B, Muenster S, Muders T. Electrical impedance tomography for cardio-pulmonary monitoring. J Clin Med 2019; 8:1176–1198.
    1. Sella N, Pettenuzzo T, Zarantonello F, et al. . Electrical impedance tomography: a compass for the safe route to optimal PEEP. Respir Med 2021; 187:106555.
    1. Karsten J, Luepschen H, Grossherr M, et al. . Effect of PEEP on regional ventilation during laparoscopic surgery monitored by electrical impedance tomography. Acta Anaesthesiol Scand 2011; 55:878–886.
    1. Lagier D, Velly LJ, Guinard B, et al. . Perioperative open-lung approach, regional ventilation, and lung injury in cardiac surgery. Anesthesiology 2020; 133:1029–1045.
    1. Stankiewicz-Rudnicki M, Gaszynski W, Gaszynski T. Assessment of ventilation distribution during laparoscopic bariatric surgery: an electrical impedance tomography study. Biomed Res Int 2016; 2016:7423162.
    1. Costa Souza GM, Santos GM, Zimpel SA, Melnik T. Intraoperative ventilation strategies for obese patients undergoing bariatric surgery: systematic review and meta-analysis. BMC Anesthesiol 2020; 20:36.
    1. Reinius H, Jonsson L, Gustafsson S, et al. . Prevention of atelectasis in morbidly obese patients during general anesthesia and paralysis: a computerized tomography study. Anesthesiology 2009; 111:979–987.
    1. Whalen FX, Gajic O, Thompson GB, et al. . The effects of the alveolar recruitment maneuver and positive end-expiratory pressure on arterial oxygenation during laparoscopic bariatric surgery. Anesth Analg 2006; 102:298–305.
    1. Almarakbi WA, Fawzi HM, Alhashemi JA. Effects of four intraoperative ventilatory strategies on respiratory compliance and gas exchange during laparoscopic gastric banding in obese patients. Br J Anaesth 2009; 102:862–868.
    1. Pirrone M, Fisher D, Chipman D, et al. . Recruitment maneuvers and positive end-expiratory pressure titration in morbidly obese ICU patients. Crit Care Med 2016; 44:300–307.
    1. Erlandsson K, Odenstedt H, Lundin S, Stenqvist O. Positive end-expiratory pressure optimization using electric impedance tomography in morbidly obese patients during laparoscopic gastric bypass surgery. Acta Anaesthesiol Scand 2006; 50:833–839.
    1. Simon P, Girrbach F, Petroff D, et al. . Individualized versus fixed positive end-expiratory pressure for intraoperative mechanical ventilation in obese patients: a secondary analysis. Anesthesiology 2021; 134:887–900.
    1. Defresne AA, Hans GA, Goffin PJ, et al. . Recruitment of lung volume during surgery neither affects the postoperative spirometry nor the risk of hypoxaemia after laparoscopic gastric bypass in morbidly obese patients: a randomized controlled study. Br J Anaesth 2014; 113:501–507.
    1. Guay J, Ochroch EA, Kopp S. Intraoperative use of low volume ventilation to decrease postoperative mortality, mechanical ventilation, lengths of stay and lung injury in adults without acute lung injury. Cochrane Database Syst Rev 2018; 7:CD011151.
    1. Meng L, Gelb AW. Regulation of cerebral autoregulation by carbon dioxide. Anesthesiology 2015; 122:196–205.
    1. Mutch WA, Patel SR, Shahidi AM, et al. . Cerebral oxygen saturation: graded response to carbon dioxide with isoxia and graded response to oxygen with isocapnia. PLoS One 2013; 8:e57881.
    1. Li L, Zhao L, Wang T, et al. . Alveolar recruitment maneuver reduces cerebral oxygen saturation and cerebral blood flow velocity in patients during carotid endarterectomy. Med Sci Monit 2021; 27:e930617.
    1. Robba C, Ball L, Battaglini D, et al. . Early effects of ventilatory rescue therapies on systemic and cerebral oxygenation in mechanically ventilated COVID-19 patients with acute respiratory distress syndrome: a prospective observational study. Crit Care 2021; 25:111.
    1. Bein T, Kuhr LP, Bele S, et al. . Lung recruitment maneuver in patients with cerebral injury: effects on intracranial pressure and cerebral metabolism. Intensive Care Med 2002; 28:554–558.
    1. Rupp T, Saugy JJ, Bourdillon N, et al. . Positive expiratory pressure improves arterial and cerebral oxygenation in acute normobaric and hypobaric hypoxia. Am J Physiol Regul Integr Comp Physiol 2019; 317:R754–r762.
    1. Wong ZZ, Chiong XH, Chaw SH, et al. . The use of cerebral oximetry in surgery: a systematic review and meta-analysis of randomized controlled trials. J Cardiothorac Vasc Anesth 2022; 36:2002–2011.
    1. Wittenstein J, Huhle R, Scharffenberg M, et al. . Effects of two stepwise lung recruitment strategies on respiratory function and haemodynamics in anaesthetised pigs: a randomised crossover study. Eur J Anaesthesiol 2021; 38:634–643.
    1. Sud S, Friedrich JO, Adhikari NKJ, et al. . Comparative effectiveness of protective ventilation strategies for moderate and severe acute respiratory distress syndrome. A network meta-analysis. Am J Respir Crit Care Med 2021; 203:1366–1377.
    1. Dianti J, Tisminetzky M, Ferreyro BL, et al. . Association of positive end-expiratory pressure and lung recruitment selection strategies with mortality in acute respiratory distress syndrome: a systematic review and network meta-analysis. Am J Respir Crit Care Med 2022; 205:1300–1310.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj