Transpulmonary Pressure Describes Lung Morphology During Decremental Positive End-Expiratory Pressure Trials in Obesity*

Fumagalli, Jacopo; Berra, Lorenzo; Zhang, Changsheng; Pirrone, Massimiliano; Santiago, Roberta Ribeiro De Santis; Gomes, Susimeire; Magni, Federico; Santos, Glaucia A. B. dos; Bennett, Desmond J; Torsani, Vinícius; Fisher, Daniel F.; Morais, Caio C. A.; Amato, Marcelo B. P.; Kacmarek, Robert M.

doi:10.1097/ccm.0000000000002460

Cited by 90 publications

(90 citation statements)

References 28 publications

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“…Our recent studies confirm that pleural pressure in patients with class III obesity is higher than in patients with lean body habitus [16][17][18][19]. Increased pleural pressure significantly reduces lung volume (especially functional residual capacity) and leads to formation of atelectasis, which is associated with shunting and hypoxemia [17][18][19].…”

Section: Introductionsupporting

confidence: 67%

“…To our knowledge, our observational study is the first to investigate the effects on survival of an alternative individualized and physiologically driven approach of care, rather than use of ARDSnet protocols in patients with class III obesity and ARDS. In the absence of definitive guidance, over the past years we have meticulously studied pulmonary physiology and hemodynamics in mechanically ventilated patients with obesity [17][18][19].…”

Section: Major Findingsmentioning

confidence: 99%

“…ARDS patients are often said to have a "baby lung," a reduced lung volume but with a highly variable amount of recruitable lung parenchyma [29]. The increased pleural pressure in patients with class III obesity [16][17][18][19] causes atelectasis of > 40% of lung parenchyma. Atelectasis in patients with class III obesity can easily be recruited [17,19].…”

Section: Major Findingsmentioning

confidence: 99%

“…Increased pleural pressure significantly reduces lung volume (especially functional residual capacity) and leads to formation of atelectasis, which is associated with shunting and hypoxemia [17][18][19]. Patients with obesity often have highly recruitable lungs, and common PEEP levels used in the ICU are not sufficient to prevent atelectasis [17][18][19]. As a result, in this population, only an individualized physiological titration of PEEP with a LRM is effective to counter the detrimental effects of increased pleural pressure, resulting in lung re-expansion [17][18][19].…”

Section: Introductionmentioning

confidence: 99%

“…Patients with obesity often have highly recruitable lungs, and common PEEP levels used in the ICU are not sufficient to prevent atelectasis [17][18][19]. As a result, in this population, only an individualized physiological titration of PEEP with a LRM is effective to counter the detrimental effects of increased pleural pressure, resulting in lung re-expansion [17][18][19].…”

Section: Introductionmentioning

confidence: 99%

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A lung rescue team improves survival in obesity with acute respiratory distress syndrome

et al. 2020

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Background: Limited data exist regarding ventilation in patients with class III obesity [body mass index (BMI) > 40 kg/m 2 ] and acute respiratory distress syndrome (ARDS). The aim of the present study was to determine whether an individualized titration of mechanical ventilation according to cardiopulmonary physiology reduces the mortality in patients with class III obesity and ARDS. Methods: In this retrospective study, we enrolled adults admitted to the ICU from 2012 to 2017 who had class III obesity and ARDS and received mechanical ventilation for > 48 h. Enrolled patients were divided in two cohorts: one cohort (2012-2014) had ventilator settings determined by the ARDSnet table for lower positive end-expiratory pressure/higher inspiratory fraction of oxygen (standard protocol-based cohort); the other cohort (2015-2017) had ventilator settings determined by an individualized protocol established by a lung rescue team (lung rescue team cohort). The lung rescue team used lung recruitment maneuvers, esophageal manometry, and hemodynamic monitoring. Results: The standard protocol-based cohort included 70 patients (BMI = 49 ± 9 kg/m 2 ), and the lung rescue team cohort included 50 patients (BMI = 54 ± 13 kg/m 2 ). Patients in the standard protocol-based cohort compared to lung rescue team cohort had almost double the risk of dying at 28 days [31% versus 16%, P = 0.012; hazard ratio (HR) 0.32; 95% confidence interval (CI95%) 0.13-0.78] and 3 months (41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16-0.74), and this effect persisted at 6 months and 1 year (incidence of death unchanged 41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16-0.74). Conclusion: Individualized titration of mechanical ventilation by a lung rescue team was associated with decreased mortality compared to use of an ARDSnet table.

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Section: Introductionsupporting

confidence: 67%

Section: Major Findingsmentioning

confidence: 99%

Section: Major Findingsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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A lung rescue team improves survival in obesity with acute respiratory distress syndrome

et al. 2020

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Strategies to Adjust Positive End-Expiratory Pressure in Patients With ARDS—Reply

Beitler

Talmor

2019

JAMA

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

Wang

Fan

et al. 2022

The Kaohsiung J of Med Scie

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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.

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Transpulmonary Pressure Describes Lung Morphology During Decremental Positive End-Expiratory Pressure Trials in Obesity*

Cited by 90 publications

References 28 publications

A lung rescue team improves survival in obesity with acute respiratory distress syndrome

A lung rescue team improves survival in obesity with acute respiratory distress syndrome

Strategies to Adjust Positive End-Expiratory Pressure in Patients With ARDS—Reply

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

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