Distribution of ventilation and oxygenation in surgical obese patients ventilated with high versus low positive end-expiratory pressure: A substudy of a randomised controlled trial

Abstract

Background: Intra-operative ventilation using low/physiological tidal volume and positive end-expiratory pressure (PEEP) with periodic alveolar recruitment manoeuvres (ARMs) is recommended in obese surgery patients.

Objectives: To investigate the effects of PEEP levels and ARMs on ventilation distribution, oxygenation, haemodynamic parameters and cerebral oximetry.

Design: A substudy of a randomised controlled trial.

Setting: Tertiary medical centre in Geneva, Switzerland, between 2015 and 2018.

Patients: One hundred and sixty-two patients with a BMI at least 35 kg per square metre undergoing elective open or laparoscopic surgery lasting at least 120 min.

Intervention: Patients were randomised to PEEP of 4 cmH 2 O ( n = 79) or PEEP of 12 cmH 2 O with hourly ARMs ( n = 83).

Main outcome measures: The primary endpoint was the fraction of ventilation in the dependent lung as measured by electrical impedance tomography. Secondary endpoints were the oxygen saturation index (SaO 2 /FIO 2 ratio), respiratory and haemodynamic parameters, and cerebral tissue oximetry.

Results: Compared with low PEEP, high PEEP was associated with smaller intra-operative decreases in dependent lung ventilation [-11.2%; 95% confidence interval (CI) -8.7 to -13.7 vs. -13.9%; 95% CI -11.7 to -16.5; P = 0.029], oxygen saturation index (-49.6%; 95% CI -48.0 to -51.3 vs. -51.3%; 95% CI -49.6 to -53.1; P < 0.001) and a lower driving pressure (-6.3 cmH 2 O; 95% CI -5.7 to -7.0). Haemodynamic parameters did not differ between the groups, except at the end of ARMs when arterial pressure and cardiac index decreased on average by -13.7 mmHg (95% CI -12.5 to -14.9) and by -0.54 l min -1 m -2 (95% CI -0.49 to -0.59) along with increased cerebral tissue oximetry (3.0 and 3.2% on left and right front brain, respectively).

Conclusion: In obese patients undergoing abdominal surgery, intra-operative PEEP of 12 cmH 2 O with periodic ARMs, compared with intra-operative PEEP of 4 cmH 2 O without ARMs, slightly redistributed ventilation to dependent lung zones with minor improvements in peripheral and cerebral oxygenation.

Trial registration: NCT02148692, https://clinicaltrials.gov/ct2.

Fig. 1

CONSORT flow diagram.

Fig. 2

Effect of intra-operative high positive end-expiratory pressure with recruitment manoeuvres vs. low PEEP on ventilation of the dependent lung part in obese patients.

Fig. 3

Effect of intra-operative high positive end-expiratory pressure with recruitment manoeuvres vs. low PEEP on the ratio of pulsed-oxygen saturation (SaO₂)/fractional inspired oxygen (FiO₂) in obese patients.

Fig. 4

Intra-operative effects of high positive end-expiratory pressure (PEEP) with recruitment manoeuvres vs. low PEEP on mean arterial blood pressure, cardiac output as well as left and right-sided cerebral near-infrared spectroscopy (NIRS).