Dipartimento Ambiente, Salute e Sicurezza, Università degli Studi dell'Insubria, Varese: Servizio di Anestesia e Rianimazione B, Ospedale di Circolo, Fondazione Macchi, Viale Borri 57, 21100, Varese, Italy.
Best Pract Res Clin Anaesthesiol. 2010 Jun;24(2):211-25. doi: 10.1016/j.bpa.2010.02.001.
Obesity is a metabolic disease that is on the increase all over the world. Up to 35% of the population in North America and 15-20% in Europe can be considered obese. Since these patients are characterised by several systemic physiopathological alterations, the perioperative management may present some problems, mainly related to their respiratory system. Body mass is an important determinant of respiratory function before and during anaesthesia not only in morbidly but also in moderately obese patients. These can manifest as (a) reduced lung volume with increased atelectasis; (b)derangements in respiratory system, lung and chest wall compliance and increased resistance; and (c) moderate to severe hypoxaemia. These physiological alterations are more marked in obese patients with hypercapnic syndrome or obstructive sleep apnoea syndrome. The suggested perioperative ventilation management includes (a) awake and/or facilitated endotracheal intubation by using a video-laryngoscope; (b) tidal volume of 6-10 ml kg(-1) ideal body weight, increasing respiratory rate to maintain physiological PaCO2, while avoiding intrinsic positive end-expiratory pressure (PEEPi); and (c) a recruitment manoeuvre (35-55 cmH2O for 6 s) followed by the application of an end-expiratory pressure (PEEP) of 10 cmH2O. The recruitment manoeuvre should always be performed only when a volemic and haemodynamic stabilisation is reached after induction of anaesthesia. In the postoperative period, beach chair position, aggressive physiotherapy, noninvasive respiratory support and short-term recovery in intermediate critical care units with care of fluid management and pain may be useful to reduce pulmonary complications.
肥胖是一种代谢性疾病，在全球范围内呈上升趋势。北美高达 35%的人口，欧洲 15-20%的人口可以被认为是肥胖。由于这些患者存在多种全身病理生理改变，围手术期管理可能会出现一些问题，主要与呼吸系统有关。体重是麻醉前和麻醉期间呼吸系统功能的重要决定因素，不仅在病态肥胖患者中，在中度肥胖患者中也是如此。这些患者可能表现为（a）肺容量减少伴肺不张增加；（b）呼吸系统、肺和胸壁顺应性改变以及阻力增加；和（c）中度至重度低氧血症。这些生理改变在伴有高碳酸血症或阻塞性睡眠呼吸暂停综合征的肥胖患者中更为明显。建议的围手术期通气管理包括（a）使用视频喉镜清醒和/或辅助气管插管；（b）6-10 ml kg(-1)理想体重的潮气量，增加呼吸频率以维持生理 PaCO2，同时避免内源性呼气末正压（PEEPi）；和（c）复张手法（35-55 cmH2O 持续 6 s），然后应用呼气末正压（PEEP）10 cmH2O。复张手法仅应在麻醉诱导后达到容量和血流动力学稳定时进行。在术后期间，沙滩椅体位、积极的物理治疗、无创性呼吸支持和短期入住中级危重症监护病房恢复，注意液体管理和疼痛管理，可能有助于减少肺部并发症。
