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Is Protective Lung Ventilation Safe in Morbidly Obese Patients?

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Controversies in the Anesthetic Management of the Obese Surgical Patient

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Abstract

Mechanical ventilation during general anesthesia is mandatory to maintain physiologic gas-exchange. However, recent evidence suggests that mechanical ventilation might also promote ventilator induced lung injury. During general anesthesia obese patients are characterized by a marked reduction in end-expiratory lung volume (70% compared to awake) and increased atelectasis (20–30% of the lung parenchyma). These changes are associated with a reduction in respiratory system compliance and tidal airway closure, which can occur when the closing volume exceeds the end-expiratory lung volume. The opening and closing of atelectatic lung regions as well as collapsed peripheral airways might induce ventilator induced lung injury, with or without major inflammatory response. Experimental studies, as well as retrospective and prospective clinical studies suggest that the use of large tidal volume (Vt) favors the development of lung injury. Side effects associated with the use of lower Vt, like permissive hypercapnia, seem to be minimal. On the other hand, application of moderate positive end-expiratory pressure (PEEP) levels between 5 and 15 cm H2O may decrease airway closure and/or keep open the lung parenchyma, avoiding the ventilator induced lung injury. Before application of PEEP, to effectively reopen atelectatic areas, a recruitment maneuver (RM) at 35–40 cm H2O of plateau pressure, for at least 5 s should be performed. The clinical effectiveness of this ventilatory approach to prevent postoperative pulmonary complications must be investigated in prospective randomized studies. During general anesthesia in morbidly obese patients we recommend the following: (a) Vt reduction to 6–8 ml/kg of ideal body weight, increasing respiratory rate to maintain physiological PaCO2, while avoiding excessive auto-PEEP, (b) PEEP set between 5 and 15 cm H2O, (c) application of a RM before PEEP, and (d) monitoring of auto-PEEP and airway inspiratory pressures.

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Authors and Affiliations

  1. Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy

    Paolo Pelosi & Claudia Brusasco

  2. Department of Anaesthesia and Intensive Care, University Hospital, Uppsala, Sweden

    Henrik Reinius

Authors
  1. Paolo Pelosi
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  2. Claudia Brusasco
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  3. Henrik Reinius
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Correspondence to Paolo Pelosi .

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Editors and Affiliations

  1. Santa Maria degli Angeli Medical Centre, Pordenone, Italy

    Yigal Leykin

  2. Stanford University School of Medicine, Stanford, 94305, California, USA

    Jay B. Brodsky

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Pelosi, P., Brusasco, C., Reinius, H. (2013). Is Protective Lung Ventilation Safe in Morbidly Obese Patients?. In: Leykin, Y., Brodsky, J. (eds) Controversies in the Anesthetic Management of the Obese Surgical Patient. Springer, Milano. https://doi.org/10.1007/978-88-470-2634-6_17

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  • DOI: https://doi.org/10.1007/978-88-470-2634-6_17

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  • Publisher Name: Springer, Milano

  • Print ISBN: 978-88-470-2633-9

  • Online ISBN: 978-88-470-2634-6

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