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)/FIO2 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.