High Positive End-Expiratory Pressure Allows Extubation of an Obese Patient

Abstract

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Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort

“…Second, by increasing end-expiratory lung volume, forcing the diaphragm to operate at a shorter length and thereby impairing diaphragm neuromuscular coupling [ 46 , 47 ], increased PEEP can attenuate the force generated by diaphragmatic contraction [ 48 ]. Indeed, several clinical studies provide indirect evidence to suggest that higher PEEP may render spontaneous effort less injurious in patients with acute respiratory failure before intubation [ 49 ], in patients with ARDS [ 45 , 50 ], and in pediatric patients with lung injury [ 51 ].…”

Preemptive Noninvasive Ventilation to Facilitate Weaning from Mechanical Ventilation in Obese Patients at High Risk of Reintubation

“…440–449 ) report the results of a post hoc analysis of the trial, in which intergroup differences in study outcomes were analyzed after classifying patients according to whether they were obese (BMI ⩾ 30 kg/m 2 ; 206 patients), overweight (25 kg/m 2 ⩽ BMI < 30 kg/m 2 ; 204 patients), or normal/underweight (BMI < 25 kg/m 2 ; 213 patients) ( 10 ). The research question addressing the potential heterogeneity in NIV effects according to different BMI is sound, as obesity significantly interferes with the physiology of respiratory system; this may affect the effect of applied interventions ( 11 , 12 ).…”

“…These results have a robust physiological rationale. Obesity is associated with increased absolute values of pleural pressure, which favors the development of atelectasis; atelectasis yields intrapulmonary shunt and consequent hypoxemia ( 11 ), which is the most frequent cause of extubation failure. Atelectasis may also cause reduction in lung and respiratory system compliance, which increases the muscle workload to generate an adequate V t .…”

“…Atelectasis may also cause reduction in lung and respiratory system compliance, which increases the muscle workload to generate an adequate V t . PEEP, by counterbalancing pleural pressure, maintains positive transpulmonary pressure, prevents atelectasis due to alveolar collapse, and favors a more homogeneous ventilation ( 11 ). Also, airway closure and expiratory flow limitation are magnified in patients who are obese ( 13 , 14 ).…”

“…Finally, patients who are obese may show a lower risk of alveolar overdistension due to high alveolar pressure ( 11 ), which is a major concern when NIV in the pressure support mode is applied in patients with hypoxemia ( 16 ). This may have mitigated the risk of self-inflicted lung injury during NIV.…”