Positive End-expiratory Pressure and Distribution of Ventilation in Pneumoperitoneum Combined with Steep Trendelenburg Position

Shono, Atsuko; Katayama, Nozomi; Fujihara, Tatsuya; Böhm, Stephan H.; Waldmann, Andreas D.; Ugata, Kei; Nikai, Tetsuro; Saito, Yoji

doi:10.1097/aln.0000000000003062

Cited by 58 publications

(64 citation statements)

References 38 publications

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“…Previous pulmonary electrical impedance tomography studies have described the beneficial effect of open-lung ventilation strategies in homogenizing the distribution of pulmonary ventilation. 29,30 However, most of those studies included ARDS or general surgery patients, and data are scant on the impact of open-lung ventilation in patients undergoing open-chest surgery. In this work, we have confirmed that general anesthesia and loss of spontaneous breathing was associated, in semi-sitting patients, with an immediate ventral redistribution of tidal ventilation and a reduction in dorsal lung ventilation.…”

Section: Discussionmentioning

confidence: 99%

Perioperative Open-lung Approach, Regional Ventilation, and Lung Injury in Cardiac Surgery

Lagier¹,

Velly²,

Guinard³

et al. 2020

Anesthesiology

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Background In the Protective Ventilation in Cardiac Surgery (PROVECS) randomized, controlled trial, an open-lung ventilation strategy did not improve postoperative respiratory outcomes after on-pump cardiac surgery. In this prespecified subanalysis, the authors aimed to assess the regional distribution of ventilation and plasma biomarkers of lung epithelial and endothelial injury produced by that strategy. Methods Perioperative open-lung ventilation consisted of recruitment maneuvers, positive end-expiratory pressure (PEEP) = 8 cm H2O, and low-tidal volume ventilation including during cardiopulmonary bypass. Control ventilation strategy was a low-PEEP (2 cm H2O) low-tidal volume approach. Electrical impedance tomography was used serially throughout the perioperative period (n = 56) to compute the dorsal fraction of ventilation (defined as the ratio of dorsal tidal impedance variation to global tidal impedance variation). Lung injury was assessed serially using biomarkers of epithelial (soluble form of the receptor for advanced glycation end-products, sRAGE) and endothelial (angiopoietin-2) lung injury (n = 30). Results Eighty-six patients (age = 64 ± 12 yr; EuroSCORE II = 1.65 ± 1.57%) undergoing elective on-pump cardiac surgery were studied. Induction of general anesthesia was associated with ventral redistribution of tidal volumes and higher dorsal fraction of ventilation in the open-lung than the control strategy (0.38 ± 0.07 vs. 0.30 ± 0.10; P = 0.004). No effect of the open-lung strategy on the dorsal fraction of ventilation was noted at the end of surgery after median sternotomy closure (open-lung = 0.37 ± 0.09 vs. control = 0.34 ± 0.11; P = 0.743) or in extubated patients at postoperative day 2 (open-lung = 0.63 ± 0.18 vs. control = 0.59 ± 0.11; P > 0.999). Open-lung ventilation was associated with increased intraoperative plasma sRAGE (7,677 ± 3,097 pg/ml vs. 6,125 ± 1,400 pg/ml; P = 0.037) and had no effect on angiopoietin-2 (P > 0.999). Conclusions In cardiac surgery patients, open-lung ventilation provided larger dorsal lung ventilation early during surgery without a maintained benefit as compared with controls at the end of surgery and postoperative day 2 and was associated with higher intraoperative plasma concentration of sRAGE suggesting lung overdistension. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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Section: Discussionmentioning

confidence: 99%

Perioperative Open-lung Approach, Regional Ventilation, and Lung Injury in Cardiac Surgery

Lagier¹,

Velly²,

Guinard³

et al. 2020

Anesthesiology

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“…However, surgery was performed in the reverse Trendelenburg position in our study, which is supposed to lower pleural pressure counterbalancing the intraabdominal pressure applied during capnoperitoneum. Even if the effect of capnoperitoneum on pulmonary mechanics seems to be limited in obese patients, 41,42 we cannot exclude the possibility that different PEEP values would have been obtained if PEEP titration had been performed after insufflation of capnoperitoneum. Furthermore, our results cannot be fully transferred to other patient populations or to laparoscopic procedures with different patient positioning, even if a recent publication found that comparable individualized PEEP values are necessary in normal-weight patients undergoing laparoscopic surgery in extreme Trendelenburg positioning.…”

Section: Limitationsmentioning

confidence: 99%

Individualized versus Fixed Positive End-expiratory Pressure for Intraoperative Mechanical Ventilation in Obese Patients: A Secondary Analysis

Simon¹,

Girrbach²,

Petroff³

et al. 2021

Anesthesiology

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Background General anesthesia may cause atelectasis and deterioration in oxygenation in obese patients. The authors hypothesized that individualized positive end-expiratory pressure (PEEP) improves intraoperative oxygenation and ventilation distribution compared to fixed PEEP. Methods This secondary analysis included all obese patients recruited at University Hospital of Leipzig from the multicenter Protective Intraoperative Ventilation with Higher versus Lower Levels of Positive End-Expiratory Pressure in Obese Patients (PROBESE) trial (n = 42) and likewise all obese patients from a local single-center trial (n = 54). Inclusion criteria for both trials were elective laparoscopic abdominal surgery, body mass index greater than or equal to 35 kg/m2, and Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score greater than or equal to 26. Patients were randomized to PEEP of 4 cm H2O (n = 19) or a recruitment maneuver followed by PEEP of 12 cm H2O (n = 21) in the PROBESE study. In the single-center study, they were randomized to PEEP of 5 cm H2O (n = 25) or a recruitment maneuver followed by individualized PEEP (n = 25) determined by electrical impedance tomography. Primary endpoint was Pao2/inspiratory oxygen fraction before extubation and secondary endpoints included intraoperative tidal volume distribution to dependent lung and driving pressure. Results Ninety patients were evaluated in three groups after combining the two lower PEEP groups. Median individualized PEEP was 18 (interquartile range, 16 to 22; range, 10 to 26) cm H2O. Pao2/inspiratory oxygen fraction before extubation was 515 (individual PEEP), 370 (fixed PEEP of 12 cm H2O), and 305 (fixed PEEP of 4 to 5 cm H2O) mmHg (difference to individualized PEEP, 145; 95% CI, 91 to 200; P < 0.001 for fixed PEEP of 12 cm H2O and 210; 95% CI, 164 to 257; P < 0.001 for fixed PEEP of 4 to 5 cm H2O). Intraoperative tidal volume in the dependent lung areas was 43.9% (individualized PEEP), 25.9% (fixed PEEP of 12 cm H2O) and 26.8% (fixed PEEP of 4 to 5 cm H2O) (difference to individualized PEEP: 18.0%; 95% CI, 8.0 to 20.7; P < 0.001 for fixed PEEP of 12 cm H2O and 17.1%; 95% CI, 10.0 to 20.6; P < 0.001 for fixed PEEP of 4 to 5 cm H2O). Mean intraoperative driving pressure was 9.8 cm H2O (individualized PEEP), 14.4 cm H2O (fixed PEEP of 12 cm H2O), and 18.8 cm H2O (fixed PEEP of 4 to 5 cm H2O), P < 0.001. Conclusions This secondary analysis of obese patients undergoing laparoscopic surgery found better oxygenation, lower driving pressures, and redistribution of ventilation toward dependent lung areas measured by electrical impedance tomography using individualized PEEP. The impact on patient outcome remains unclear. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

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“…However, in our institute, a PEEP of 5 cmH 2 O for patients undergoing robotic-assisted laparoscopic prostatectomy is a common practice. There are a few recommendations stating that the PEEP should be higher than 5 cmH 2 O if the patient is in the Trendelenburg position and/or if there is pneumoperitoneum [29]. A PEEP of 5 cmH 2 O seems to be lower than that reported in the literature.…”

Section: Discussionmentioning

confidence: 95%

Optimal Positive End-Expiratory Pressure Obtained with Titration of Fraction of Inspiratory Oxygen: A Randomized Controlled Clinical Trial

Gao

Yang

Pan

et al. 2021

Preprint

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Background Optimal intraoperative positive end expiratory pressure (PEEP) improves patient outcomes. The pulse-oximetry has been used to determine the lung opening and closing pressures. Therefore, we hypothesized that intraoperative optimal PEEP obtained by titrating inspiratory oxygen fraction (FiO2) guided with pulse-oximetry could improve perioperative oxygenation. Methods Forty-six males undergoing elective robotic assisted laparoscopic prostatectomy were randomly assigned to either optimal PEEP (Group O, n=23) or control with fixed PEEP of 5 cmH2O (Group C, n=23). Optimal PEEP, defined as the PEEP with lowest FiO2 or 0.21 to maintain SpO2≥ 95%, was obtained in both groups after placing the patients in Trendelenburg position and peritoneal insufflation. Patients in Group O maintained the optimal PEEP and in Group C maintained PEEP of 5cmH2O intraoperatively. Both groups were extubated in a sitting position once the extubation criteria met. The primary outcome was the partial arterial oxygen pressure (PaO2)/inspiratory oxygen fraction (FiO2) prior to extubation. Secondary outcome was the incidence of postoperative hypoxemia (SpO2༜92% on room-air after extubation) in post-operative care unit. Results The median optimal PEEP was 16 cm H2O [inter-quartile range, 12-18]. The PaO2/FiO2prior to extubation was significantly higher in Group O than that in Group C (77.0±4.9kPa vs.60.6±5.9kPa, p=0.04); PaO2/FiO2 was also significantly higher in Group O 30minutes after extubation (57.6±1.9 vs. 46.6±1.8kPa, p=0.01). The incidence of hypoxemia on room air in the post-operative care unit was significantly lower in the Group O than in the Group C (1/23, or 4.3% vs. 7/23 or 30.4%, p =0.02). Conclusions Intraoperative optimal PEEP can be achieved by titration of FiO2 guided with SpO2. Maintaining intraoperative optimal PEEP improves intraoperative oxygenation and reduces the incidence of post-operative hypoxemia. Trial registration : Chinese Clinical Trial Registry identifier: ChiCTR2100051010. Prospectively registered on 10 September, 2021

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Positive End-expiratory Pressure and Distribution of Ventilation in Pneumoperitoneum Combined with Steep Trendelenburg Position

Cited by 58 publications

References 38 publications

Perioperative Open-lung Approach, Regional Ventilation, and Lung Injury in Cardiac Surgery

Perioperative Open-lung Approach, Regional Ventilation, and Lung Injury in Cardiac Surgery

Individualized versus Fixed Positive End-expiratory Pressure for Intraoperative Mechanical Ventilation in Obese Patients: A Secondary Analysis

Optimal Positive End-Expiratory Pressure Obtained with Titration of Fraction of Inspiratory Oxygen: A Randomized Controlled Clinical Trial

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