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Intraoperative Ventilation of Morbidly Obese Patients Guided by Transpulmonary Pressure

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Abstract

Background

Bariatric surgery has proven a successful approach in the treatment of morbid obesity and its concomitant diseases such as diabetes mellitus and arterial hypertension. Aiming for optimal management of this challenging patient cohort, tailored concepts directly guided by individual patient physiology may outperform standardized care. Implying esophageal pressure measurement and electrical impedance tomography—increasingly applied monitoring approaches to individually adjust mechanical ventilation in challenging circumstances like acute respiratory distress syndrome (ARDS) and intraabdominal hypertension—we compared our institutions standard ventilator regimen with an individually adjusted positive end expiratory pressure (PEEP) level aiming for a positive transpulmonary pressure (P L) throughout the respiratory cycle.

Methods

After obtaining written informed consent, 37 patients scheduled for elective bariatric surgery were studied during mechanical ventilation in reverse Trendelenburg position. Before and after installation of capnoperitoneum, PEEP levels were gradually raised from a standard value of 10 cm H2O until a P L of 0 +/− 1 cm H2O was reached. Changes in ventilation were monitored by electrical impedance tomography (EIT) and arterial blood gases (ABGs) were obtained at the end of surgery and 5 and 60 min after extubation, respectively.

Results

To achieve the goal of a transpulmonary pressure (P L) of 0 cm H2O at end expiration, PEEP levels of 16.7 cm H2O (95% KI 15.6–18.1) before and 23.8 cm H2O (95% KI 19.6–40.4) during capnoperitoneum were necessary. EIT measurements confirmed an optimal PEEP level between 10 and 15 cm H2O before and 20 and 25 cm H2O during capnoperitoneum, respectively. Intra- and postoperative oxygenation did not change significantly.

Conclusion

Patients during laparoscopic bariatric surgery require high levels of PEEP to maintain a positive transpulmonary pressure throughout the respiratory cycle. EIT monitoring allows for non-invasive monitoring of increasing PEEP demand during capnoperitoneum. Individually adjusted PEEP levels did not result in improved postoperative oxygenation.

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References

  1. Arterburn DE, Maciejewski ML, Tsevat J. Impact of morbid obesity on medical expenditures in adults. Int J Obes. 2005;29:334–9.

    Article  CAS  Google Scholar 

  2. Grieve E, Fenwick E, Yang HC, et al. The disproportionate economic burden associated with severe and complicated obesity: a systematic review. Obes Rev. 2013;14:883–94.

    Article  CAS  PubMed  Google Scholar 

  3. Puzziferri N, Roshek 3rd TB, Mayo HG, et al. Long-term follow-up after bariatric surgery: a systematic review. JAMA. 2014;312:934–42.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Dixon JB, Schachter LM, O'Brien PE, et al. Surgical vs conventional therapy for weight loss treatment of obstructive sleep apnea: a randomized controlled trial. JAMA. 308:1142–9.

  5. Reoch J, Mottillo S, Shimony A, et al. Safety of laparoscopic vs open bariatric surgery: a systematic review and meta-analysis. Arch Surg. 2011;146:1314–22.

    Article  PubMed  Google Scholar 

  6. Pelosi P, Croci M, Ravagnan I, et al. Total respiratory system, lung, and chest wall mechanics in sedated-paralyzed postoperative morbidly obese patients. Chest. 1996;109:144–51.

    Article  CAS  PubMed  Google Scholar 

  7. Behazin N, Jones SB, Cohen RI, et al. Respiratory restriction and elevated pleural and esophageal pressures in morbid obesity. J Appl Physiol. 1985;108:212–8.

    Article  Google Scholar 

  8. El-Dawlatly AA, Al-Dohayan A, Abdel-Meguid ME, et al. The effects of pneumoperitoneum on respiratory mechanics during general anesthesia for bariatric surgery. Obes Surg. 2004;14:212–5.

    Article  PubMed  Google Scholar 

  9. Dumont L, Mattys M, Mardirosoff C, et al. Changes in pulmonary mechanics during laparoscopic gastroplasty in morbidly obese patients. Acta Anaesthesiol Scand. 1997;41:408–13.

    Article  CAS  PubMed  Google Scholar 

  10. Futier E, Constantin JM, Pelosi P, et al. Noninvasive ventilation and alveolar recruitment maneuver improve respiratory function during and after intubation of morbidly obese patients: a randomized controlled study. Anesthesiology. 114:1354–63.

  11. Perilli V, Sollazzi L, Modesti C, et al. Comparison of positive end-expiratory pressure with reverse Trendelenburg position in morbidly obese patients undergoing bariatric surgery: effects on hemodynamics and pulmonary gas exchange. Obes Surg. 2003;13:605–9.

    Article  CAS  PubMed  Google Scholar 

  12. Futier E, Constantin JM, Petit A, et al. Positive end-expiratory pressure improves end-expiratory lung volume but not oxygenation after induction of anaesthesia. Eur J Anaesthesiol. 2010;27:508–13.

    PubMed  Google Scholar 

  13. Futier E, Constantin JM, Pelosi P, et al. Intraoperative recruitment maneuver reverses detrimental pneumoperitoneum-induced respiratory effects in healthy weight and obese patients undergoing laparoscopy. Anesthesiology. 2010;113:1310–9.

    Article  PubMed  Google Scholar 

  14. Neligan PJ, Malhotra G, Fraser M, et al. Noninvasive ventilation immediately after extubation improves lung function in morbidly obese patients with obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesth Analg. 2010;110:1360–5.

    Article  PubMed  Google Scholar 

  15. Bardoczky GI, Yernault JC, Houben JJ, et al. Large tidal volume ventilation does not improve oxygenation in morbidly obese patients during anesthesia. Anesth Analg. 1995;81:385–8.

    CAS  PubMed  Google Scholar 

  16. Sutherasan Y, D’Antini D, Pelosi P. Advances in ventilator-associated lung injury: prevention is the target. Expert Rev Respir Med. 8:233–48.

  17. Futier E, Pereira B, Jaber S. Intraoperative low-tidal-volume ventilation. N Engl J Med. 369:1862–3.

  18. Stahl DL, North CM, Lewis A, et al. Case scenario: power of positive end-expiratory pressure: use of esophageal manometry to illustrate pulmonary physiology in an obese patient. Anesthesiology. 2014;121:1320–6.

    Article  PubMed  Google Scholar 

  19. Talmor D, Sarge T, Malhotra A, et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med. 2008;359:2095–104.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Grasso S, Terragni P, Birocco A, et al. ECMO criteria for influenza A (H1N1)-associated ARDS: role of transpulmonary pressure. Intensive Care Med. 2012;38:395–403.

    Article  CAS  PubMed  Google Scholar 

  21. Pelosi P, Luecke T, Rocco PR. Chest wall mechanics and abdominal pressure during general anaesthesia in normal and obese individuals and in acute lung injury. Curr Opin Crit Care. 2011;17:72–9.

    Article  PubMed  Google Scholar 

  22. Sindi A, Piraino T, Alhazzani W, et al. The correlation between esophageal and abdominal pressures in mechanically ventilated patients undergoing laparoscopic surgery. Respir Care. 2013;59:491–6.

    Article  PubMed  Google Scholar 

  23. Cinnella G, Grasso S, Spadaro S, et al. Effects of recruitment maneuver and positive end-expiratory pressure on respiratory mechanics and transpulmonary pressure during laparoscopic surgery. Anesthesiology. 2012;118:114–22.

    Article  Google Scholar 

  24. Erlandsson K, Odenstedt H, Lundin S, et al. Positive end-expiratory pressure optimization using electric impedance tomography in morbidly obese patients during laparoscopic gastric bypass surgery. Acta Anaesthesiol Scand. 2006;50:833–9.

    Article  CAS  PubMed  Google Scholar 

  25. Maracaja-Neto LF, Vercosa N, Roncally AC, et al. Beneficial effects of high positive end-expiratory pressure in lung respiratory mechanics during laparoscopic surgery. Acta Anaesthesiol Scand. 2009;53:210–7.

    Article  CAS  PubMed  Google Scholar 

  26. Valenza F, Vagginelli F, Tiby A, et al. Effects of the beach chair position, positive end-expiratory pressure, and pneumoperitoneum on respiratory function in morbidly obese patients during anesthesia and paralysis. Anesthesiology. 2007;107:725–32.

    Article  PubMed  Google Scholar 

  27. Talab HF, Zabani IA, Abdelrahman HS, et al. Intraoperative ventilatory strategies for prevention of pulmonary atelectasis in obese patients undergoing laparoscopic bariatric surgery. Anesth Analg. 2009;109:1511–6.

    Article  PubMed  Google Scholar 

  28. Schumann R. Anaesthesia for bariatric surgery. Best Pract Res Clin Anaesthesiol. 2011;25:83–93.

    Article  CAS  PubMed  Google Scholar 

  29. Reinius H, Jonsson L, Gustafsson S, et al. Prevention of atelectasis in morbidly obese patients during general anesthesia and paralysis: a computerized tomography study. Anesthesiology. 2009;111:979–87.

    Article  PubMed  Google Scholar 

  30. Almarakbi WA, Fawzi HM, Alhashemi JA. Effects of four intraoperative ventilatory strategies on respiratory compliance and gas exchange during laparoscopic gastric banding in obese patients. Br J Anaesth. 2009;102:862–8.

    Article  CAS  PubMed  Google Scholar 

  31. Futier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Engl J Med. 369:428–37.

  32. Grasso S, Stripoli T, De Michele M, et al. ARDSnet ventilatory protocol and alveolar hyperinflation: role of positive end-expiratory pressure. Am J Respir Crit Care Med. 2007;176:761–7.

    Article  PubMed  Google Scholar 

  33. Rodriguez PO, Bonelli I, Setten M, et al. Transpulmonary pressure and gas exchange during decremental PEEP titration in pulmonary ARDS patients. Respir Care. 2012;58:754–63.

    Google Scholar 

  34. Chiumello D, Carlesso E, Cadringher P, et al. Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. Am J Respir Crit Care Med. 2008;178:346–55.

    Article  PubMed  Google Scholar 

  35. Washko GR, O'Donnell CR, Loring SH. Volume-related and volume-independent effects of posture on esophageal and transpulmonary pressures in healthy subjects. J Appl Physiol. 2006;100:753–8.

    Article  PubMed  Google Scholar 

  36. Pelosi P, Goldner M, McKibben A, et al. Recruitment and derecruitment during acute respiratory failure: an experimental study. Am J Respir Crit Care Med. 2001;164:122–30.

    Article  CAS  PubMed  Google Scholar 

  37. Defresne AA, Hans GA, Goffin PJ, et al. 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. Br J Anaesth. 2014;113(3):501–7.

    Article  CAS  PubMed  Google Scholar 

  38. Lumb AB, Greenhill SJ, Simpson MP, et al. Lung recruitment and positive airway pressure before extubation does not improve oxygenation in the post-anaesthesia care unit: a randomized clinical trial. Br J Anaesth. 2010;104:643–7.

    Article  CAS  PubMed  Google Scholar 

  39. Pok EH, Lee WJ. Gastrointestinal metabolic surgery for the treatment of type 2 diabetes mellitus. World J Gastroenterol. 2014;20:14315–28.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Adams ST, Salhab M, Hussain ZI, et al. Obesity-related hypertension and its remission following gastric bypass surgery—a review of the mechanisms and predictive factors. Blood Press. 2012;22:131–7.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Anesthesiology and Critical Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany

    Lars Eichler, Katarzyna Truskowska, Alwin E. Goetz & Christian Zöllner

  2. Department of General, Visceral, and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

    A. Dupree & P. Busch

Authors
  1. Lars Eichler
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  2. Katarzyna Truskowska
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  3. A. Dupree
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  4. P. Busch
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  5. Alwin E. Goetz
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  6. Christian Zöllner
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Corresponding author

Correspondence to Lars Eichler.

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Conflict of Interest

Lars Eichler, Katarzyna Truskowska, Alwin E. Goetz, and Christian Zöllner report support by Carefusion, Höchberg, Germany, who provided the respirator (Avea™) and esophageal pressure probes and Dräger, Lübeck, Germany, who provided the EIT monitor (Pulmovista 500™).

Anna Dupree and Philipp Busch report no conflict of interest.

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Eichler, L., Truskowska, K., Dupree, A. et al. Intraoperative Ventilation of Morbidly Obese Patients Guided by Transpulmonary Pressure. OBES SURG 28, 122–129 (2018). https://doi.org/10.1007/s11695-017-2794-3

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  • DOI: https://doi.org/10.1007/s11695-017-2794-3

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