Positive end‐expiratory pressure improves arterial oxygenation during prolonged pneumoperitoneum

Meininger, Dirk; Byhahn, Christian; Mierdl, S.; Westphal, K.; Zwißler, Bernhard

doi:10.1111/j.1399-6576.2005.00713.x

Cited by 96 publications

(75 citation statements)

References 11 publications

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“…9,10 Despite definitive evidences that ventilator-induced lung injury may play a role when ventilating normal lungs (as generally done during anesthesia) are lacking, 11 the hypothesis that a lungprotective ventilatory strategy should be applied during general anesthesia is sound and widely debated. 1,6,7,[12][13][14] Several ventilatory strategies aiming at improving arterial oxygenation and respiratory mechanics during laparoscopic surgery have been investigated: the application of positive end-expiratory pressure (PEEP) has been shown to counterbalance the diaphragm cranial shift increasing functional residual capacity and decreasing respiratory system elastance (E RS ). 12,13,[15][16][17] Recently, translating the concept of lung-protective ventilatory strategy from the adult respiratory distress syndrome context, 9,14,[18][19][20] the application of an "open lung" strategy consisting in a recruiting maneuver (RM) followed by the subsequent application of PEEP has been suggested to effectively reexpand pneumoperitoneum-induced atelectasis and improve oxygenation during laparoscopic surgery.…”

Section: Effects Of Recruitment Maneuver and Positive End-expiratory mentioning

confidence: 99%

Effects of Recruitment Maneuver and Positive End-expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery

et al. 2013

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Background: The authors tested the hypothesis that during laparoscopic surgery, Trendelenburg position and pneumoperitoneum may worsen chest wall elastance, concomitantly decreasing transpulmonary pressure, and that a protective ventilator strategy applied after pneumoperitoneum induction, by increasing transpulmonary pressure, would result in alveolar recruitment and improvement in respiratory mechanics and gas exchange. Methods: In 29 consecutive patients, a recruiting maneuver followed by positive end-expiratory pressure 5 cm H 2 O maintained until the end of surgery was applied after pneumoperitoneum induction. Respiratory mechanics, gas exchange, blood pressure, and cardiac index were measured before (T BSL ) and after pneumoperitoneum with zero positive end-expiratory pressure (T preOLS ), after recruitment with positive end-expiratory pressure (T postOLS ), and after peritoneum desufflation with positive end-expiratory pressure (T end ). Results: Esophageal pressure was used for partitioning respiratory mechanics between lung and chest wall (data are mean ± SD): on T preOLS , chest wall elastance (E cw ) and elastance of the lung (E L ) increased (8.2 ± 0.9 vs. 6.2 ± 1.2 cm H 2 O/L, respectively, on T BSL ; P = 0.00016; and 11.69 ± 1.68 vs. 9.61 ± 1.52 cm H 2 O/L on T BSL ; P = 0.0007). On T postOLS , both chest wall elastance and E L decreased (5.2 ± 1.2 and 8.62 ± 1.03 cm H 2 O/L, respectively; P = 0.00015 vs. T preOLS ), and PaO 2 /inspiratory oxygen fraction improved (491 ± 107 vs. 425 ± 97 on T preOLS; P = 0.008) remaining stable thereafter. Recruited volume (the difference in lung volume for the same static airway pressure) was 194 ± 80 ml. Pplat RS remained stable while inspiratory transpulmonary pressure increased (11.65 + 1.37 cm H 2 O vs. 9.21 + 2.03 on T preOLS ; P = 0.007). All respiratory mechanics parameters remained stable after abdominal desufflation. Hemodynamic parameters remained stable throughout the study. Conclusions:In patients submitted to laparoscopic surgery in Trendelenburg position, an open lung strategy applied after pneumoperitoneum induction increased transpulmonary pressure and led to alveolar recruitment and improvement of E cw and gas exchange. LAPAROSCOPY is a well-established procedure for pelvic gynecologic surgery often performed in Trendelenburg position.1,2 To facilitate laparoscopic surgical manipulation, a pneumoperitoneum is usually induced through carbon dioxide inflation. Both the increase in abdominal pressure as a result of carbon dioxide inflation and the head down body position have been shown to impair the respiratory function during the procedure, mainly inducing atelectasis formation in the dependent lung regions. 1,[3][4][5][6] The resulting decrease in functional residual capacity poses Address correspondence to Dr. Cinnella: Departmentt of Anesthesia and Intensive Care, Policlinico 'Riuniti' -University of Foggia, Viale Pinto 1 -71100 Foggia, Italy. g.cinnella@unifg.it. Information on purchasing reprints may be found at www.anesthesiology.org...

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Section: Effects Of Recruitment Maneuver and Positive End-expiratory mentioning

confidence: 99%

Effects of Recruitment Maneuver and Positive End-expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery

et al. 2013

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“…A 5-cmH2O PEEP diminishes intrapulmonary shunt and improves oxygenation in the presence of pneumoperitoneum (71). EIT confirmed that PEEP augments ventilation in the dependent lung zones during pneumoperitoneum (30,72).…”

Section: Alveolar Recruitment and Peepmentioning

confidence: 57%

Artificial ventilation during pneumoperitoneum

Comuzzi¹

2014

SOB

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the complications pertaining to pneumoperitoneum to solve them quickly, paying particular attention to the patients at higher risk, such as elderly, obese, and those with cardiopulmonary disease. KEY WORDS: pneumoperitoneum, artificial ventilation, obesity, laparoscopy, anesthesia. IntroductionLaparoscopic surgery has been increasingly employed in various surgical subspecialties because of its innumerous benefits. These are evident during the post-operative period and result from the less important organ/tissue trauma caused by laparoscopic approaches than those triggered by open surgery. The main advantages of laparoscopic surgery are: reduction of the inflammatory and metabolic responses (1-3), reduced post-operative pain and analgesic consumption (2, 3), smaller incidence of respiratory complications (2), faster resolution of post-operative ileum and recovery (1). Taken together, these outcomes reduce hospital stay, promote a quicker return to normal daily activities (2-4), and reduce the cost of the treatment (4). On the other hand, laparoscopic surgery presents some challenges regarding the intra-operative anesthesia management, since there are respiratory and hemodynamic changes pertaining to the general anesthesia itself, to the abdominal insufflation, and to the intra-operative positioning of the patient (5). These issues become even more evident in patients with cardiopulmonary disease or obesity (6). This review focuses on the intra-operative respiratory alterations caused by laparoscopy and on the ventilatory strategies that are prone to minimize the modifications evoked by the technique. Alterations of the respiratory systemIn order to allow an adequate observation of the surgical field, laparoscopic surgery requires controlled gas insufflation into the peritoneal cavity (pneumoperitoneum). For this purpose, carbon dioxide is regularly used under a pressure of 10-15 mmHg. Naturally, respiratory issues related to mechanics and CO2 overload SummaryLaparoscopic surgery has been increasingly used in many surgical subspecialties, due to its various post-operative benefits. On the other hand, it presents intra-operative challenges to the anesthesia management. The inflation of the abdominal cavity with carbon dioxide leads to hemodynamic changes, mechanical respiratory system derangements (increased elastance, resistance and airway pressure), augmented V'CO2, and alterations of the V'/Q' ratio and of the PaCO2-PetCO2 gradient. All these changes may be influenced by other factors, such as body position and baseline characteristics of the patient. To minimize the negative consequences of these modifications a protective ventilation strategy with the use of low tidal volumes and PEEP, eventually associated with recruitment maneuvers, is suggested. No ventilatory mode or anesthetic drug has been proven better than the others. It has been suggested that the use of supraglotic devices may be a safe alternative to endotracheal intubation during laparoscopic surgery. It is important that the anesthetist be aware ...

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“…The importance of PEEP application for maintaining adequate gas exchange while preventing ventilator-induced lung injury is especially emphasized (7,10,22,23). Many studies suggested that PEEP and the alveolar recruitment maneuver application improved ventilation-perfusion and gas exchange (7,24,25).…”

Section: Discussionmentioning

confidence: 99%

“…In the literature, several ventilation strategies including volume control ventilation, pressure control ventilation, recruitment maneuvers, and PEEP application are discussed for the management of ventilation and oxygenation problems caused by increased intraabdominal pressure and head-down position (19)(20)(21)(22)(23). The importance of PEEP application for maintaining adequate gas exchange while preventing ventilator-induced lung injury is especially emphasized (7,10,22,23).…”

Section: Discussionmentioning

confidence: 99%

Effects of positive end-expiratory pressure on intracranial pressure during pneumoperitoneum and Trendelenburg position in a porcine model*

Bedirli¹,

Emmez²,

Ünal³

et al. 2017

Turk J Med Sci

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IntroductionRobot-assisted laparoscopic surgery has developed greatly and is becoming a standard technique for radical prostatectomy. It is widely preferred for pelvic surgeries because of its important advantages that minimize postoperative morbidity and mortality. Robotic surgeries in the pelvic region, including radical prostatectomy, rectum resection, and gynecologic procedures, usually require a steep Trendelenburg position and carbon dioxide pneumoperitoneum to secure the surgical field. Pneumoperitoneum combined with steep Trendelenburg position may cause significant changes in cardiovascular, respiratory, and neurophysiological parameters (1,2). Both the increase in abdominal pressure as a result of carbon dioxide insufflation and the head-down position have been shown to impair respiratory functions during the procedure by pushing the diaphragm upward and reducing lung volume and respiratory compliance, thus inducing atelectasis formation (3,4).Background/aim: This study was undertaken to evaluate the effects of positive end-expiratory pressure (PEEP) levels on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) and to determine the appropriate PEEP level during steep Trendelenburg position combined with pneumoperitoneum. Materials and methods:Ten pigs were included in this study. Pneumoperitoneum and Trendelenburg position were maintained and PEEP titration was initiated. Arterial pressure, heart rate, arterial blood gas, ICP, and CPP were recorded at the following time points: baseline (T0), 30 min after positioning and pneumoperitoneum (T1), PEEP 5 (T2), PEEP 10 (T3), PEEP 15 (T4), and PEEP 20 (T5).Results: MAP significantly increased at T1 compared to T0 and decreased at T4 and T5 compared to T1. ICP was 9.5 mmHg and CPP was 69.3 mmHg at T0. CO 2 insufflation and steep Trendelenburg position did not cause any significant difference in ICP and CPP. ICP increased and CPP decreased significantly at T4 and T5 compared to both T0 and T1. PaO 2 and PaO 2 /FiO 2 decreased significantly at T1 and T2 compared to T0, while both increased significantly at T3, T4, and T5 compared to T1. Conclusion:PEEP of 10 cmH 2 O was effective for providing oxygenation while preserving hemodynamic stability, ICP, and CPP in this model.

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Positive end‐expiratory pressure improves arterial oxygenation during prolonged pneumoperitoneum

Abstract: The application of a constant positive airway pressure of 5 cmH(2)O preserves arterial oxygenation during prolonged pneumoperitoneum.

Cited by 96 publications

References 11 publications

Effects of Recruitment Maneuver and Positive End-expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery

Effects of Recruitment Maneuver and Positive End-expiratory Pressure on Respiratory Mechanics and Transpulmonary Pressure during Laparoscopic Surgery

Artificial ventilation during pneumoperitoneum

Effects of positive end-expiratory pressure on intracranial pressure during pneumoperitoneum and Trendelenburg position in a porcine model*

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