Recruitment Maneuvers and Positive End-Expiratory Pressure Titration in Morbidly Obese ICU Patients

Pirrone, Massimiliano; Fisher, Daniel F.; Chipman, Daniel; Imber, David A.; Corona, J Negrete; Mietto, Cristina; Kacmarek, Robert M.; Berra, Lorenzo

doi:10.1097/ccm.0000000000001387

Cited by 108 publications

(110 citation statements)

References 24 publications

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“…The implications of obesity on respiratory system mechanics are well known: chest wall mechanics are impaired, and respiratory system compliance is reduced. Obese patients have an increased risk for early expiratory alveolar collapse and potential consecutive atelectrauma [3,5,17,19,20] and thus for decreased functional residual capacity and expiratory reserve volume [5,13,21,22]. Values are stated as mean ± SD.…”

Section: Discussionmentioning

confidence: 99%

“…Therefore, besides low tidal volume and optional recruitment maneuvers, lung-protective ventilation strategies include the application of adequate PEEP in these patients. However, the ideal adjustment of applied tidal volume, and PEEPwith respect to the potential injurious effects of alveolar overdistensionin obese patients still remain obscure [20]. In this regard, FCV improved lung recruitment without modifying PEEP or tidal volume.…”

Section: Discussionmentioning

confidence: 99%

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Flow-controlled ventilation (FCV) improves regional ventilation in obese patients – a randomized controlled crossover trial

et al. 2020

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Background: In obese patients, high closing capacity and low functional residual capacity increase the risk for expiratory alveolar collapse. Constant expiratory flow, as provided by the new flow-controlled ventilation (FCV) mode, was shown to improve lung recruitment. We hypothesized that lung aeration and respiratory mechanics improve in obese patients during FCV. Methods:We compared FCV and volume-controlled (VCV) ventilation in 23 obese patients in a randomized crossover setting. Starting with baseline measurements, ventilation settings were kept identical except for the ventilation mode related differences (VCV: inspiration to expiration ratio 1:2 with passive expiration, FCV: inspiration to expiration ratio 1:1 with active, linearized expiration). Primary endpoint of the study was the change of endexpiratory lung volume compared to baseline ventilation. Secondary endpoints were the change of mean lung volume, respiratory mechanics and hemodynamic variables.Results: The loss of end-expiratory lung volume and mean lung volume compared to baseline was lower during FCV compared to VCV (end-expiratory lung volume: FCV, − 126 ± 207 ml; VCV, − 316 ± 254 ml; p < 0.001, mean lung volume: FCV, − 108.2 ± 198.6 ml; VCV, − 315.8 ± 252.1 ml; p < 0.001) and at comparable plateau pressure (baseline, 19.6 ± 3.7; VCV, 20.2 ± 3.4; FCV, 20.2 ± 3.8 cmH 2 O; p = 0.441), mean tracheal pressure was higher (baseline, 13.1 ± 1.1; VCV, 12.9 ± 1.2; FCV, 14.8 ± 2.2 cmH 2 O; p < 0.001). All other respiratory and hemodynamic variables were comparable between the ventilation modes.Conclusions: This study demonstrates that, compared to VCV, FCV improves regional ventilation distribution of the lung at comparable PEEP, tidal volume, P Plat and ventilation frequency. The increase in end-expiratory lung volume during FCV was probably caused by the increased mean tracheal pressure which can be attributed to the linearized expiratory pressure decline.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Flow-controlled ventilation (FCV) improves regional ventilation in obese patients – a randomized controlled crossover trial

et al. 2020

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“…Recently, Pirrone et al 46 conducted a study in which mechanically ventilated morbidly obese ICU subjects (BMI 50.7 Ϯ 16.0 kg/m 2 ) underwent recruitment maneuvers and PEEP titration using both esophageal manometry and a best decremental PEEP trial. Both methods for PEEP titration were used in each study subject.…”

Section: Recruitment Maneuversmentioning

confidence: 99%

Respiratory Management of Perioperative Obese Patients

et al. 2016

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SummaryWith a rising incidence of obesity in the United States, anesthesiologists are faced with a larger volume of obese patients coming to the operating room as well as obese patients with ever-larger body mass indices (BMIs). While there are many cardiovascular and endocrine issues that clinicians must take into account when caring for the obese patient, one of the most prominent concerns of the anesthesiologist in the perioperative setting should be the status of the lung. Because the pathophysiology of reduced lung volumes in the obese patient differs from that of the ARDS patient, the best approach to keeping the obese patient's lung open and adequately ventilated during mechanical ventilation is unique. Although strong evidence and research are lacking regarding how to best ventilate the obese surgical patient, we aim with this review to provide an assessment of the small amount of research that has been conducted and the pathophysiology we believe influences the apparent results. We will provide a basic overview of the anatomy and pathophysiology of the obese respiratory system and review studies concerning pre-, intra-, and postoperative respiratory care. Our focus in this review centers on the best approach to keeping the lung recruited through the prevention of compression atelectasis and the maintaining of physiological lung volumes. We recommend the use of PEEP via noninvasive ventilation (NIV) before induction and endotracheal intubation, the use of both PEEP and periodic recruitment maneuvers during mechanical ventilation, and the use of PEEP via NIV after extubation. It is our hope that by studying the underlying mechanisms that make ventilating obese patients so difficult, future research can be better tailored to address this increasingly important challenge to the field of anesthesia.

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“…O baixo volume respiratório é ainda mais evidente no período noturno, condicionando a diminuição da concentração de oxigênio no sangue arterial, com alterações da estrutura e fases do sono e da sonolência diurna 14 . Um recente estudo indicou que o é necessário utilizar técnicas de pressão positiva em pacientes obesos, para melhor recrutamento pulmonar e manter os alvéolos abertos 13,15 . Esta é uma característica muito comum dos pacientes com SAHOS, e neste acompanhamento, apesar de relato da melhora no sono, os pacientes permaneceram com sobrepeso/obesidade durante os 5 anos.…”

Section: Discussionunclassified

Qualidade do sono em pacientes com apneia obstrutiva após cinco anos de uso de CPAP

2017

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Recruitment Maneuvers and Positive End-Expiratory Pressure Titration in Morbidly Obese ICU Patients

Cited by 108 publications

References 24 publications

Flow-controlled ventilation (FCV) improves regional ventilation in obese patients – a randomized controlled crossover trial

Flow-controlled ventilation (FCV) improves regional ventilation in obese patients – a randomized controlled crossover trial

Respiratory Management of Perioperative Obese Patients

Qualidade do sono em pacientes com apneia obstrutiva após cinco anos de uso de CPAP

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