Prevention of Atelectasis Formation During the Induction of General Anesthesia in Morbidly Obese Patients

Coussa, M. L.; Proietti, Stefania; Schnyder, P.; Frascarolo, Philippe; Suter, Michel; Spahn, Donat R.; Magnusson, Lennart

doi:10.1213/01.ane.0000111743.61132.99

Cited by 253 publications

(143 citation statements)

References 30 publications

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“…14 Toutefois, plusieurs manoeuvres comme l'utilisation de PEEP et les méthodes de recrutement alvéolaire peuvent être utilisées pendant l'anesthésie et la ventilation mécanique pour limiter l'étendue de ce problème. 14 De plus, l'atélectasie est plus courante en période postopératoire, et elle dépend principalement de l'hypoventilation postopératoire et de la concentration d'oxygène inspirée à la fin de l'anesthésie. Par conséquent, il n'est pas justifié d'éviter la préoxygénation seulement afin d'éviter l'atélectasie.…”

Section: Atélectasieunclassified

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Optimizing preoxygenation in adults

Tanoubi

Drolet

Donati

2009

Can J Anesth/J Can Anesth

182

105

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Purpose Preoxygenation increases oxygen reserves and duration of apnea without desaturation (DAWD), thus it provides valuable additional time to secure the airway. The purpose of this Continuing Professional Development (CPD) module is to examine the various preoxygenation techniques that have been proposed and to assess their effectiveness in healthy adults and in obese, pregnant, and elderly patients. Principal findings The effectiveness of preoxygenation techniques can be evaluated by measuring DAWD, i.e., the time for oxygen saturation to decrease to\90%. Clinically, preoxygenation is considered adequate when end-tidal oxygen fraction is[90%. This is usually achieved with a 3-min tidal volume breathing (TVB) technique. As a rule, asking the patient to take four deep breaths in 30 sec (4 DB 30 sec) yields poorer results. Eight deep breaths in 60 sec (8 DB 60 sec) is equivalent to TVB 3 min. The DAWD is decreased in obese patients, pregnant women, and patients with increased metabolism. Obese patients may benefit from the head-up position and positive pressure breathing. A TVB technique is preferable in the elderly. Failure to preoxygenate is often due to leaks, which commonly occur in edentulous or bearded patients. In cases of difficult preoxygenation, directly applying the circuit to the mouth might be a useful alternative. Supplying extra oxygen in the nasopharynx during apnea might increase DAWD. Conclusion Since ventilation and tracheal intubation difficulties are unpredictable, this CPD module recommends that all patients be preoxygenated. The TVB 3 min and the 8 DB 60 sec techniques are suitable for most patients; however, the 4 DB 30 sec is inadequate. Continuing Professional Development objectivesAfter reading this review, the reader should be able to:• understand the physiological principles of preoxygenation;• describe the slow and fast techniques for preoxygenating patients; • apply the proper techniques in healthy adults with normal weight; • modify these techniques in obese patients, pregnant women, and the elderly; • briefly describe preoxygenation devices other than the face mask.The purpose of preoxygenation is to increase the oxygen reserves of the body, thus preventing hypoxia during a planned or unexpected period of apnea. The term ''denitrogenation'', indicating that nitrogen in the lungs is replaced by oxygen, is sometimes used instead of ''preoxygenation''. However, the latter is generally preferred because the primary goal is to provide oxygen, not to remove nitrogen. With adequate preoxygenation, patients can tolerate a longer period of apnea, and an increased margin of safety is created between induction of anesthesia and the moment the airway is secured. This extra time may prove particularly valuable if mask ventilation is difficult or contraindicated and if laryngoscopy and tracheal intubation are more difficult than expected.The purpose of this Continuing Professional Development (CPD) module is to summarize the physiological principles 123Can J Anesth/J Can Anesth (2009...

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Section: Atélectasieunclassified

“…The presence of 100% oxygen in the lungs favours atelectasis due to oxygen uptake from poorly ventilated alveoli. 3,14 When air is present, nitrogen, which is not taken up or consumed, provides a ''splint'' keeping alveoli open. After induction of anesthesia, positive pressure ventilation via a face mask increases DAWD and prevents atelectasis.…”

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confidence: 99%

Optimizing preoxygenation in adults

Tanoubi

Drolet

Donati

2009

Can J Anesth/J Can Anesth

182

105

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“…The use of 10 cm H 2 O continuous positive airway pressure/positive endexpiratory pressure (CPAP/PEEP) throughout the induction period (CPAP when breathing and PEEP after apnea) has been shown to increase the duration of apnea prior to desaturation by 50% in morbidly obese patients. 36,37 Noninvasive positive pressure ventilation using pressure support ventilation with PEEP via a face mask has also been shown to enhance preoxygenation, achieving a more rapid increase and higher end-tidal O 2 when compared with preoxygenation with spontaneous ventilation. 38 …”

Section: Positioning and Preoxygenationmentioning

confidence: 99%

“…Il a été démontré que le recours à une ventilation en pression positive continue / pression positive télé-expiratoire de 10 cm H 2 O (CPAP / PEEP) tout au long de la période d'induction (CPAP lors de la respiration et PEEP après l'apnée) augmentait la durée de l'apnée avant désaturation de 50 % chez les patients obèses morbides. 36,37 En outre, il a également été démontré que la ventilation en pression positive non effractive utilisant une aide inspiratoire et une PEEP via un masque facial améliorait la préoxygénation, résultant en une augmentation plus rapide et un O 2 télé-expiratoire plus élevé comparativement à une préoxygénation en ventilation spontanée. 38 …”

Section: Positionnement Et Préoxygénationunclassified

Airway management and oxygenation in obese patients

Murphy

Wong

2013

Can J Anesth/J Can Anesth

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“…Important limitations of this study were the absence of ventilation between the onset of apnea and intubation, and the relative brevity of the pre-oxygenation (only 3 minutes). Later studies, however, showed a benefi t of applying CPAP with oxygen during pre-oxygenation in morbidly obese patients [18], [19]. Compared to O 2 alone, CPAP of 10 cmH 2 O + O 2 for 5 min increased the time to desaturate and reduced the amount of atelectasis following intubation [18], [19].…”

Section: Non-invasive Ventilation With Positive Pressurementioning

confidence: 99%

Intubation in the ICU: We Could Improve our Practice

Jong¹,

Jung²,

Jaber³

2014

Annual Update in Intensive Care and Emergency Medicine 2014

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Airway management is a commonly performed procedure in the intensive care unit (ICU). Hypoxemia and cardiovascular collapse represent the initial and most serious life-threatening complications associated with diffi cult airway access, both in emergency intubation in the critically ill [1]- [4] and in planned intubations (e. g., scheduled surgery or invasive procedures) [5]. To prevent and limit the incidence of life-threatening complications following intubation, several pre-oxygenation techniques and intubation algorithms have been entertained.Th e objectives of the present chapter are to: 1) describe new tools (e. g., the MACOCHA Score) to better identify patients at high-risk of diffi cult intubation and related complications; 2) describe new strategies for improving pre-oxygenation before intubation (e. g., continuous positive airway pressure [CPAP] or non-invasive ventilation [NIV]); 3) propose an intubation bundle (the Montpellier-ICU intubation algorithm) to limit complications related to the intubation procedure; 4) report recent data on the role of videolaryngoscopes in the ICU; and, fi nally, 5) propose an algorithm for secure airway management in the ICU (Th e Montpellier-airway ICU algorithm). Which patients are 'at risk' of complications during intubation?All ICU patients could be considered at risk of complications during intubation. How to identify risk factors for diffi cult intubation in the ICU?Although several predictive risk factors and scores for diffi cult intubation have been identifi ed in anesthesia practice, until recently no (a priori) clinical score had been developed for ICU patients. However, a recent study assessed risk factors for diffi cult intubation in the ICU [3] and developed a predictive score of diffi cult intubation, the MACOCHA score, which was then externally validated. Th e main predictors of diffi cult intubation were related to the patient (Mallampati score III or IV, obstructive sleep apnea syndrome, reduced mobility of cervical spine, limited mouth opening), the pathology (coma, severe hypoxia) and the operator (nonanesthesiologist) (Table 1). By optimizing the discrimination threshold, the discriminative ability of the score is high. In order to reject diffi cult intubation with certainty, a cut-off of 3 or greater seems appropriate, providing an optimal negative predictive value (97 % and 98 % in the original and validation cohorts, respectively) and sensitivity (76 % and 73 % in the original and validation cohorts, respectively). Th e MACOCHA score enables patients at risk of diffi cult intubation to be identifi ed and further studies are needed to determine whether calculating this score before each intubation could help

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Prevention of Atelectasis Formation During the Induction of General Anesthesia in Morbidly Obese Patients

Abstract: Application of positive end-expiratory pressure during induction of general anesthesia in morbidly obese patients prevents atelectasis formation and improves oxygenation. Therefore, this technique should be considered for anesthesia induction in morbidly obese patients.

Cited by 253 publications

References 30 publications

Optimizing preoxygenation in adults

Optimizing preoxygenation in adults

Airway management and oxygenation in obese patients

Intubation in the ICU: We Could Improve our Practice

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