Individualized positive end-expiratory pressure in obese patients during general anaesthesia: a randomized controlled clinical trial using electrical impedance tomography

Nestler, C.; Simon, Philipp; Petroff, David; Hammermüller, Sören; Kamrath, D.; Wolf, Samuel; Dietrich, Arne; Camilo, Luciana Moisés; Beda, Alessandro; Carvalho, Alysson R.; Giannella-Neto, Antonio; Reske, Andreas W.; Wrigge, Hermann

doi:10.1093/bja/aex192

Cited by 158 publications

(241 citation statements)

References 47 publications

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“…In this sense, we report that lung volume exceeds predicted FRC in a significant proportion of patients when PEEP is applied; unfortunately, we cannot clarify the physiological effect of this condition, which has to be addressed in future investigations, especially because such high lung volumes have been documented in a similar setting. 40,41 Preclinical and physiological studies show that, in noninjured lungs, a PEEP-setting strategy aimed at maximising C RS would best compromise between maximising normally aerated areas and minimising hyperinflation. 21,22 This approach, however, has not been shown to be clinically beneficial in a recently published large randomised controlled trial.…”

Section: Discussionmentioning

confidence: 99%

Lung volumes, respiratory mechanics and dynamic strain during general anaesthesia

Grieco

Russo

Romanò

et al. 2018

British Journal of Anaesthesia

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Background: Driving pressure (DP) represents tidal volume normalised to respiratory system compliance (C RS) and is a novel parameter to target ventilator settings. We conducted a study to determine whether C RS and DP reflect aerated lung volume and dynamic strain during general anaesthesia. Methods: Twenty non-obese patients undergoing open abdominal surgery received three PEEP levels (2, 7, or 12 cm H 2 O) in random order with constant tidal volume ventilation. Respiratory mechanics, lung volumes, and alveolar recruitment were measured to assess end-expiratory aerated volume, which was compared with the patient's individual predicted functional residual capacity in supine position (FRCp). Results: C RS was linearly related to aerated volume and DP to dynamic strain at PEEP of 2 cm H 2 O (intraoperative FRC) (r¼0.72 and r¼0.73, both P<0.001). These relationships were maintained with higher PEEP only when aerated volume did not overcome FRCp (r¼0.73, P<0.001; r¼0.54, P¼0.004), with 100 ml lung volume increases accompanied by 1.8 ml cm H 2 O À1 (95% confidence interval [1.1e2.5]) increases in C RS. When aerated volume was greater or equal to FRCp (35% of patients at PEEP 2 cm H 2 O, 55% at PEEP 7 cm H 2 O, and 75% at PEEP 12 cm H 2 O), C RS and DP were independent from aerated volume and dynamic strain, with C RS weakly but significantly inversely related to alveolar dead space fraction (r¼e0.47, P¼0.001). PEEP-induced alveolar recruitment yielded higher C RS and reduced DP only at aerated volumes below FRCp (P¼0.015 and 0.008, respectively). Conclusions: During general anaesthesia, respiratory system compliance and driving pressure reflect aerated lung volume and dynamic strain, respectively, only if aerated volume does not exceed functional residual capacity in supine position, which is a frequent event when PEEP is used in this setting.

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Section: Discussionmentioning

confidence: 99%

Lung volumes, respiratory mechanics and dynamic strain during general anaesthesia

Grieco

Russo

Romanò

et al. 2018

British Journal of Anaesthesia

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“…For example, studies in multiple settings have been unable to show that temporary gains in either lung mechanics or oxygenation extend to the postoperative environment, even when the recruitment maneuver is performed shortly before extubation 7079808182. However, the benefits of recruitment maneuvers may be enhanced or prolonged by the performance of repeated maneuvers 83.…”

Section: Evidence Based Strategies For Perioperative Lung Protective mentioning

confidence: 99%

Perioperative lung protective ventilation

O’Gara

Talmor

2018

BMJ

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Perioperative lung injury is a major source of postoperative morbidity, excess healthcare use, and avoidable mortality. Many potential inciting factors can lead to this condition, including intraoperative ventilator induced lung injury. Questions exist as to whether protective ventilation strategies used in the intensive care unit for patients with acute respiratory distress syndrome are equally beneficial for surgical patients, most of whom do not present with any pre-existing lung pathology. Studied both individually and in combination as a package of intraoperative lung protective ventilation, the use of low tidal volumes, moderate positive end expiratory pressure, and recruitment maneuvers have been shown to improve oxygenation and pulmonary physiology and to reduce postoperative pulmonary complications in at risk patient groups. Further work is needed to define the potential contributions of alternative ventilator strategies, limiting excessive intraoperative oxygen supplementation, use of non-invasive techniques in the postoperative period, and personalized mechanical ventilation. Although the weight of evidence strongly suggests a role for lung protective ventilation in moderate risk patient groups, definitive evidence of its benefit for the general surgical population does not exist. However, given the shift in understanding of what is needed for adequate oxygenation and ventilation under anesthesia, the largely historical arguments against the use of intraoperative lung protective ventilation may soon be outdated, on the basis of its expanding track record of safety and efficacy in multiple settings.

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“…For the original study, the animals were randomly assigned to three different ventilation strategies after induction of the chest trauma: ARDS-Network low-PEEP protocol [ARDSNet [16]], Open-Lung-Concept [OLC, [17]], or an EIT-based ventilation strategy [18,19]. If necessary, ventilator settings were adapted every 4 hours after measuring arterial blood gases and according to the designated strategy.…”

Section: Animal Preparation and Induction Of Chest Traumamentioning

confidence: 99%

Detection of posttraumatic pneumothorax using electrical impedance tomography—An observer-blinded study in pigs with blunt chest trauma

et al. 2020

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Individualized positive end-expiratory pressure in obese patients during general anaesthesia: a randomized controlled clinical trial using electrical impedance tomography

Abstract: German clinical trials register DRKS00004199, www.who.int/ictrp/network/drks2/en/ .

Cited by 158 publications

References 47 publications

Lung volumes, respiratory mechanics and dynamic strain during general anaesthesia

Lung volumes, respiratory mechanics and dynamic strain during general anaesthesia

Perioperative lung protective ventilation

Detection of posttraumatic pneumothorax using electrical impedance tomography—An observer-blinded study in pigs with blunt chest trauma

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