Individualized positive end‐expiratory pressure with and without recruitment maneuvers in obese patients during bariatric surgery

Abstract

This study aimed to determine whether regular recruitment maneuvers (RMs) are essential for obese patients (OPs) undergoing elective laparoscopic bariatric surgery (LBS) during intraoperative ventilation with individualized positive end‐expiratory pressure (PEEP). Patients were randomly assigned to two arms: the RM + PEEP−EIT arm consisted of individualized PEEP titrated by electrical impedance tomography (EIT) with two regular RMs and the PEEP−EIT arm consisted of individualized PEEP titrated by EIT without additional RMs. For these two arms together, EIT‐guided PEEP varied among individuals. The partial pressure of oxygen in arterial blood to fractional inspired oxygen (PaO2/FiO2) ratio in the RM + PEEP−EIT arm was higher than that in the PEEP−EIT arm at 1 h after pneumoperitoneum (p = 0.024) and at the end of surgery (p = 0.035). There was no great difference in the PaO2/FiO2 ratio between these two arms when measured 5 min prior to postanesthesia care unit (PACU) departure and on postoperative day 1. Compared with the PEEP−EIT arm, patients in the RM + PEEP−EIT arm had significantly higher intraoperative dynamic respiratory system compliance (p < 0.001) but consumed more vasopressors (p = 0.036). Postoperative pulmonary complications occurred in 1 of 29 patients in the RM + PEEP−EIT arm compared with 2 of 31 patients in the PEEP−EIT arm. Regular lung RMs can improve intraoperative oxygenation and respiratory system compliance among OPs undergoing LBS with EIT‐guided individual PEEP. However, the improvement might disappear before leaving the PACU, and regular RMs resulted in more vasopressor consumption.

Effect of flow-optimized pressure control ventilation-volume guaranteed (PCV-VG) on postoperative pulmonary complications: a consort study

“…The improved lung compliance at T1, T2, and T4 implies fewer PPCs. Furthermore, the PaO 2 /FiO 2 did not improve significantly in the experimental group but was significantly higher at T3 while the total complication rate was significantly reduced, which is consistent with previous reports [ 5 , 13 , 33 ]. The optimizing ventilation strategies during OLV were closely associated with fewer PPCs and better perioperative oxygenation [ 33 ].…”

“…Customized PEEP enhances oxygen levels, end-tidal lung volume (EELV), and respiratory function when ventilating patients during surgery. Nevertheless, these benefits may diminish shortly after removing the endotracheal tube [ 11 – 13 ]. Using driving pressure-guided ventilation during OLV decreases PPCs compared to traditional lung protective ventilation [ 14 ].…”

Setting positive end-expiratory pressure by using electrical impedance tomography

“…In that study, the EIT-guided PEEP level was found to be lower compared with the lower PEEP/F I O 2 table [12 ▪ ]. The same approach was used in a study on obese patients during bariatric surgery with the PEEP set either with or without a preceding recruitment maneuver, showing higher intraoperative C rs in the recruitment group but no differences in the postoperative outcomes [13].…”

“…In that study, the EIT-guided PEEP level was found to be lower compared with the lower PEEP/F I O 2 table [12 & ]. The same approach was used in a study on obese patients during bariatric surgery with the PEEP set either with or without a preceding recruitment maneuver, showing higher intraoperative C rs in the recruitment group but no differences in the postoperative outcomes [13]. Detection of regional respiratory system compliance and its changes as a tool for setting positive end-expiratory pressure When airway pressure is measured in parallel with the EIT examination, regional C rs can be determined from EIT data by dividing the TIV values with the driving pressure.…”