Recruitment of lung volume during surgery neither affects the postoperative spirometry nor the risk of hypoxaemia after laparoscopic gastric bypass in morbidly obese patients: a randomized controlled study

Defresne, Aline; Hans, Grégory; Goffin, Pierre; Bindelle, Simon; Amabili, Philippe; Deroover, Arnaud; Poirrier, Robert; Brichant, Jean-François; Joris, Jean

doi:10.1093/bja/aeu101

Cited by 44 publications

(33 citation statements)

References 38 publications

(27 reference statements)

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“…Respiratory strategies that increase the pressure of the airways during induction of anesthesia, such as the application of noninvasive ventilation [44], use of PEEP with [45] or without RMs [46], or a combination of all of these [47], seem to be useful for improving the respiratory function of obese patients in the pre- and intraoperative periods [48]. Nevertheless, their effects seem to be short-lived in the postoperative period [49, 50]. To our knowledge, the impact of such strategies on clinically relevant outcome endpoints, such as adverse pulmonary events, has not previously been addressed.…”

Section: Discussionmentioning

confidence: 99%

Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial

Bluth¹,

Teichmann²,

Kiss³

et al. 2017

Trials

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BackgroundPostoperative pulmonary complications (PPCs) increase the morbidity and mortality of surgery in obese patients. High levels of positive end-expiratory pressure (PEEP) with lung recruitment maneuvers may improve intraoperative respiratory function, but they can also compromise hemodynamics, and the effects on PPCs are uncertain. We hypothesized that intraoperative mechanical ventilation using high PEEP with periodic recruitment maneuvers, as compared with low PEEP without recruitment maneuvers, prevents PPCs in obese patients.Methods/designThe PRotective Ventilation with Higher versus Lower PEEP during General Anesthesia for Surgery in OBESE Patients (PROBESE) study is a multicenter, two-arm, international randomized controlled trial. In total, 2013 obese patients with body mass index ≥35 kg/m2 scheduled for at least 2 h of surgery under general anesthesia and at intermediate to high risk for PPCs will be included. Patients are ventilated intraoperatively with a low tidal volume of 7 ml/kg (predicted body weight) and randomly assigned to PEEP of 12 cmH2O with lung recruitment maneuvers (high PEEP) or PEEP of 4 cmH2O without recruitment maneuvers (low PEEP). The occurrence of PPCs will be recorded as collapsed composite of single adverse pulmonary events and represents the primary endpoint.DiscussionTo our knowledge, the PROBESE trial is the first multicenter, international randomized controlled trial to compare the effects of two different levels of intraoperative PEEP during protective low tidal volume ventilation on PPCs in obese patients. The results of the PROBESE trial will support anesthesiologists in their decision to choose a certain PEEP level during general anesthesia for surgery in obese patients in an attempt to prevent PPCs.Trial registrationClinicalTrials.gov identifier: NCT02148692. Registered on 23 May 2014; last updated 7 June 2016.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-017-1929-0) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial

Bluth¹,

Teichmann²,

Kiss³

et al. 2017

Trials

View full text Add to dashboard Cite

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“…Random sequence generation and allocation concealment were correctly described in seven studies [14,17,19,20,22,24,25]. In the blinding of participants and personnel domain all the studies were classified as high risk as the personnel could not be blinded.…”

Section: Risk Of Bias In Included Studiesmentioning

confidence: 99%

“…In the blinding of participants and personnel domain all the studies were classified as high risk as the personnel could not be blinded. Four studies [7,13,17,25] adequately described the blinding of outcome assessment. Eleven studies [7,[14][15][16][17][18][19][20][21]24, 25] did not describe losses or exclusions which could cause imbalance between the groups.…”

Section: Risk Of Bias In Included Studiesmentioning

confidence: 99%

Intraoperative ventilation strategies for obese patients undergoing bariatric surgery: systematic review and meta-analysis

et al. 2020

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Background: Obesity is a global epidemic, and it is widely known that increased Body mass index (BMI) is associated with alterations in respiratory mechanics. Bariatric surgery is established as an effective treatment for this condition. Objective: To assess the safety and effectiveness of different ventilation strategies in obese patients undergoing bariatric surgery. Methods: A systematic review of randomized clinical trials aimed at evaluating ventilation strategies for obese patients was carried out. Primary outcomes: in-hospital mortality, adequacy of gas exchange, and respiration mechanics alterations. Results: Fourteen clinical trials with 574 participants were included. When recruitment maneuvers (RM) vs Positive endexpiratory pressure (PEEP) were compared, RM resulted in better oxygenation p = 0.03 (MD 79.93), higher plateau pressure p < 0.00001 (MD 7.30), higher mean airway pressure p < 0.00001 (MD 6.61), and higher compliance p < 0.00001 (MD 21.00); when comparing RM + Zero end-expiratory pressure (ZEEP) vs RM + PEEP 5 or 10 cmH2O, RM associated with PEEP led to better oxygenation p = 0.001 (MD 167.00); when comparing Continuous Positive Airway Pressure (CPAP) 40 cmH2O + PEEP 10 cmH2O vs CPAP 40 cmH2O + PEEP 15 cmH2O, CPAP 40 + PEEP 15 achieved better gas exchange p = 0.003 (MD 36.00) and compliance p = 0.0003 (MD 3.00). Conclusion: There is some evidence that the alveolar recruitment maneuvers associated with PEEP lead to better oxygenation and higher compliance. There is no evidence of differences between pressure control ventilation (PCV) and Volume control ventilation (VCV).

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“…There were no significant changes in other spirometric data or differences 42 study is the timing of recruitment maneuvers with respect to measurements of lung function. In the Futier et al 42 study, EELV was measured during surgery and at the very end of surgery, in conjunction with the interventions performed, whereas Defresne et al 43 did not measure the effects of the intraoperative interventions interoperatively. It is equally possible that the study group de-recruited after the cessation of PEEP or that the control group regained near-normal lung volumes once extubated and spontaneously breathing.…”

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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Recruitment of lung volume during surgery neither affects the postoperative spirometry nor the risk of hypoxaemia after laparoscopic gastric bypass in morbidly obese patients: a randomized controlled study

Abstract: EudraCT 2011-000999-33.

Cited by 44 publications

References 38 publications

Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial

Protective intraoperative ventilation with higher versus lower levels of positive end-expiratory pressure in obese patients (PROBESE): study protocol for a randomized controlled trial

Intraoperative ventilation strategies for obese patients undergoing bariatric surgery: systematic review and meta-analysis

Respiratory Management of Perioperative Obese Patients

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