Effects of individualized PEEP obtained by two different titration methods on postoperative atelectasis in obese patients: study protocol for a randomized controlled trial

Qing-Yuan Wang, Yu-Wei Ji, Li-Xin An, Lei Cao, Fu-Shan Xue, Qing-Yuan Wang, Yu-Wei Ji, Li-Xin An, Lei Cao, Fu-Shan Xue

Abstract

Background: The incidence of postoperative pulmonary complications (PPCs) is higher in obese patients undergoing general anesthesia and mechanical ventilation due to the reduction of oxygen reserve, functional residual capacity, and lung compliance. Individualized positive end-expiratory pressure (iPEEP) along with other lung-protective strategies is effective in alleviating postoperative atelectasis. Here, we compared the best static lung compliance (Cstat) titration of iPEEP with electrical impedance tomography (EIT) titration to observe their effects on postoperative atelectasis in obese patients undergoing laparoscopic surgery.

Methods: A total number of 140 obese patients with BMI ≥ 32.5kg/m2 undergoing elective laparoscopic gastric volume reduction and at moderate to high risk of developing PPCs will be enrolled and randomized into the optimal static lung compliance-directed iPEEP group and EIT titration iPEEP group. The primary endpoint will be pulmonary atelectasis measured and calculated by EIT immediately after extubation and 2 h after surgery. Secondary endpoints will be intraoperative oxygenation index, organ dysfunction, incidence of PPCs, hospital expenses, and length of hospital stay.

Discussion: Many iPEEP titration methods effective for normal weight patients may not be appropriate for obese patients. Although EIT-guided iPEEP titration is effective in obese patients, its high price and complexity limit its application in many clinical facilities. This trial will test the efficacy of iPEEP via the optimal static lung compliance-guided titration procedure by comparing it with EIT-guided PEEP titration. The results of this trial will provide a feasible and convenient method for anesthesiologists to set individualized PEEP for obese patients during laparoscopic surgery.

Trial registration: ClinicalTrials.gov ChiCTR2000039144 . Registered on October 19, 2020.

Keywords: Atelectasis; Cstat; Electrical impedance tomography; Individualized PEEP; Obesity.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Consolidated Standards of Reporting Trials (CONSORT) diagram for this trial. PEEP positive end-expiratory pressure, iPEEP individual PEEP, COPD chronic obstructive pulmonary disease, ICU intensive care unit, ASA American Society of Anesthesiologists classification, PaO2 partial pressure of arterial oxygen, FiO2 inspiratory fraction of inspired oxygen, EIT electrical impedance tomography, PPCs postoperative pulmonary complications
Fig. 2
Fig. 2
Individualized PEEP and perioperative management process. iPEEP individualized positive end-expiratory pressure, Cstat-iPEEP optimal static lung compliance-directed iPEEP titration group, EIT-iPEEP electrical impedance tomography-guided iPEEP titration group, RM the ventilator-driven alveolar recruitment maneuver
Fig. 3
Fig. 3
The ventilator-driven alveolar recruitment maneuver protocol. Ppeak peak airway pressure. Pplat plateau airway pressure. PEEP positive end-expiratory pressure, Vt tidal volume normalized for adjusted body weight, I:E ratio between inspiratory and expiratory time, RR respiratory rate
Fig. 4
Fig. 4
EIT-guided individualized PEEP titration. Paw airway pressure, Pplat plateau airway pressure, PEEP positive end-expiratory pressure, VT tidal volume normalized for adjusted body weight, RR respiratory rate, RM the ventilator-driven alveolar recruitment maneuver
Fig. 5
Fig. 5
Individualized PEEP titrated by optimal Cstat. Cstat static lung compliance, PEEP positive end-expiratory pressure, iPEEP individualized positive end-expiratory pressure, RM the ventilator-driven alveolar recruitment maneuver

References

    1. Writing Committee for the PROBESE Collaborative Group of the PROtective VEntilation Network (PROVEnet) for the Clinical Trial Network of the European Society of Anaesthesiology. Bluth T, Serpa Neto A, Schultz MJ, Pelosi P, Gama de Abreu M, Gregoretti C, et al. 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(23):2292–2305. doi: 10.1001/jama.2019.7505.
    1. Investigators LV. Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: Las Vegas-an observational study in 29 countries. Eur J Anaesthesiol. 2017;34(8):492–507. doi: 10.1097/EJA.0000000000000646.
    1. Fernandez-Bustamante A, Frendl G, Sprung J, Kor DJ, Subramaniam B, Martinez Ruiz R, Lee JW, Henderson WG, Moss A, Mehdiratta N, Colwell MM, Bartels K, Kolodzie K, Giquel J, Vidal Melo MF. Postoperative pulmonary complications, early mortality, and hospital stay following noncardiothoracic surgery: a multicenter study by the perioperative research network investigators. JAMA Surg. 2017;152(2):157–166. doi: 10.1001/jamasurg.2016.4065.
    1. Weiser TG, Haynes AB, Molina G, Lipsitz SR, Esquivel MM, Uribe-Leitz T, et al. Estimate of the global volume of surgery in 2012: an assessment supporting improved health outcomes. Lancet. 2015;385(Suppl 2):S11. doi: 10.1016/S0140-6736(15)60806-6.
    1. Young CC, Harris EM, Vacchiano C, Bodnar S, Bukowy B, Elliott RRD, Migliarese J, Ragains C, Trethewey B, Woodward A, Gama de Abreu M, Girard M, Futier E, Mulier JP, Pelosi P, Sprung J. Lung-protective ventilation for the surgical patient: international expert panel-based consensus recommendations. Br J Anaesth. 2019;123(6):898–913. doi: 10.1016/j.bja.2019.08.017.
    1. Karalapillai D, Weinberg L, Peyton P, Ellard L, Hu R, Pearce B, Tan CO, Story D, O’Donnell M, Hamilton P, Oughton C, Galtieri J, Wilson A, Serpa Neto A, Eastwood G, Bellomo R, Jones DA. Effect of intraoperative low tidal volume vs conventional tidal volume on postoperative pulmonary complications in patients undergoing major surgery: a randomized clinical trial. JAMA. 2020;324(9):848–858. doi: 10.1001/jama.2020.12866.
    1. Ball L, Hemmes SNT, Serpa Neto A, Bluth T, Canet J, Hiesmayr M, Hollmann MW, Mills GH, Vidal Melo MF, Putensen C, Schmid W, Severgnini P, Wrigge H, Gama de Abreu M, Schultz MJ, Pelosi P, LAS VEGAS investigators. PROVE Network. Clinical Trial Network of the European Society of Anaesthesiology Intraoperative ventilation settings and their associations with postoperative pulmonary complications in obese patients. Br J Anaesth. 2018;121(4):899–908. doi: 10.1016/j.bja.2018.04.021.
    1. Nestler C, Simon P, Petroff D, Hammermüller S, Kamrath D, Wolf S, Dietrich A, Camilo LM, Beda A, Carvalho AR, Giannella-Neto A, Reske AW, Wrigge H. 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(6):1194–1205. doi: 10.1093/bja/aex192.
    1. Bluth T, Teichmann R, Kiss T, Bobek I, Canet J, Cinnella G, 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(1):202. doi: 10.1186/s13063-017-1929-0.
    1. Lim JU, Lee JH, Kim JS, Hwang YI, Kim TH, Lim SY, Yoo KH, Jung KS, Kim YK, Rhee CK. Comparison of World Health Organization and Asia-Pacific body mass index classifications in COPD patients. Int J Chron Obstruct Pulmon Dis. 2017;12:2465–2475. doi: 10.2147/COPD.S141295.
    1. Güldner A, Kiss T, Serpa Neto A, Hemmes SN, Canet J, Spieth PM, 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. doi: 10.1097/ALN.0000000000000754.
    1. Pereira SM, Tucci MR, Morais CCA, Simões CM, Tonelotto BFF, Pompeo MS, Kay FU, Pelosi P, Vieira JE, Amato MBP. Individual positive end-expiratory pressure settings optimize intraoperative mechanical ventilation and reduce postoperative atelectasis. Anesthesiology. 2018;129(6):1070–1081. doi: 10.1097/ALN.0000000000002435.
    1. NCD-Risk Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19.2 million participants. Lancet. 2016;387(10026):1377–1396. doi: 10.1016/S0140-6736(16)30054-X.
    1. Fumagalli J, Berra L, Zhang C, Pirrone M, Santiago RRS, Gomes S, et al. Transpulmonary pressure describes lung morphology during decremental positive end-expiratory pressure trials in obesity. Crit Care Med. 2017;45(8):1374–1381. doi: 10.1097/CCM.0000000000002460.
    1. Reinius H, Jonsson L, Gustafsson S, Sundbom M, Duvernoy O, Pelosi P, Hedenstierna G, Fredén F. Prevention of atelectasis in morbidly obese patients during general anesthesia and paralysis: a computerized tomography study. Anesthesiology. 2009;111(5):979–987. doi: 10.1097/ALN.0b013e3181b87edb.
    1. Ortiz VE, Vidal-Melo MF, Walsh JL. Strategies for managing oxygenation in obese patients undergoing laparoscopic surgery. Surg Obes Relat Dis. 2015;11(3):721–728. doi: 10.1016/j.soard.2014.11.021.
    1. Futier E, Constantin JM, Pelosi P, Chanques G, Kwiatkoskwi F, Jaber S, Bazin JE. Intraoperative recruitment maneuver reverses detrimental pneumoperitoneum-induced respiratory effects in healthy weight and obese patients undergoing laparoscopy. Anesthesiology. 2010;113(6):1310–1319. doi: 10.1097/ALN.0b013e3181fc640a.
    1. Wang C, Zhao N, Wang W, Guo L, Guo L, Chi C, Wang X, Pi X, Cui Y, Li E. Intraoperative mechanical ventilation strategies for obese patients: a systematic review and network meta-analysis. Obes Rev. 2015;16(6):508–517. doi: 10.1111/obr.12274.
    1. Pirrone M, Fisher D, Chipman D, Imber DA, Corona J, Mietto C, et al. Recruitment maneuvers and positive end-expiratory pressure titration in morbidly obese ICU patients. Crit Care Med. 2016;44(2):300–307. doi: 10.1097/CCM.0000000000001387.
    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;2016:7423162–7423167. doi: 10.1155/2016/7423162.
    1. Ruszkai Z, Kiss E, László I, Bokrétás GP, Vizserálek D, Vámossy I, Surány E, Buzogány I, Bajory Z, Molnár Z. Effects of intraoperative positive end-expiratory pressure optimization on respiratory mechanics and the inflammatory response: a randomized controlled trial. J Clin Monit Comput. 2020;35(3):1–14. doi: 10.1007/s10877-020-00519-6.
    1. Kallet RH. Should PEEP titration be based on chest mechanics in patients with ARDS? Respir Care. 2016;61(6):876–890. doi: 10.4187/respcare.04657.
    1. Frerichs I, Amato MB, van Kaam AH, Tingay DG, Zhao Z, Grychtol B, et al. Chest electrical impedance tomography examination, data analysis, terminology, clinical use and recommendations: consensus statement of the TRanslational EIT developmeNt stuDy group. Thorax. 2017;72(1):83–93. doi: 10.1136/thoraxjnl-2016-208357.
    1. Zhao Z, Chang MY, Chang MY, Gow CH, Zhang JH, Hsu YL, Frerichs I, Chang HT, Möller K. Positive end-expiratory pressure titration with electrical impedance tomography and pressure-volume curve in severe acute respiratory distress syndrome. Ann Intensive Care. 2019;9(1):7. doi: 10.1186/s13613-019-0484-0.
    1. Zhu C, Yao JW, An LX, Bai YF, Li WJ. Effects of intraoperative individualized PEEP on postoperative atelectasis in obese patients: study protocol for a prospective randomized controlled trial. Trials. 2020;21(1):618. doi: 10.1186/s13063-020-04565-y.

Source: PubMed

Спонсоры и соавторы

Заболевания

Медикаментозные вмешательства

Подписаться