Imber David Ae, Pirrone Massimiliano, Zhang Changsheng, Fisher Daniel F, Kacmarek Robert M, Berra Lorenzo
Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.
Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
Respir Care. 2016 Dec;61(12):1681-1692. doi: 10.4187/respcare.04732. Epub 2016 Sep 13.
With a rising incidence of obesity in the United States, anesthesiologists are faced with a larger volume of obese patients coming to the operating room as well as obese patients with ever-larger body mass indices (BMIs). While there are many cardiovascular and endocrine issues that clinicians must take into account when caring for the obese patient, one of the most prominent concerns of the anesthesiologist in the perioperative setting should be the status of the lung. Because the pathophysiology of reduced lung volumes in the obese patient differs from that of the ARDS patient, the best approach to keeping the obese patient's lung open and adequately ventilated during mechanical ventilation is unique. Although strong evidence and research are lacking regarding how to best ventilate the obese surgical patient, we aim with this review to provide an assessment of the small amount of research that has been conducted and the pathophysiology we believe influences the apparent results. We will provide a basic overview of the anatomy and pathophysiology of the obese respiratory system and review studies concerning pre-, intra-, and postoperative respiratory care. Our focus in this review centers on the best approach to keeping the lung recruited through the prevention of compression atelectasis and the maintaining of physiological lung volumes. We recommend the use of PEEP via noninvasive ventilation (NIV) before induction and endotracheal intubation, the use of both PEEP and periodic recruitment maneuvers during mechanical ventilation, and the use of PEEP via NIV after extubation. It is our hope that by studying the underlying mechanisms that make ventilating obese patients so difficult, future research can be better tailored to address this increasingly important challenge to the field of anesthesia.
随着美国肥胖症发病率的上升，麻醉医生面临着越来越多前往手术室的肥胖患者，以及体重指数（BMI）越来越高的肥胖患者。虽然临床医生在护理肥胖患者时必须考虑许多心血管和内分泌问题，但麻醉医生在围手术期最关注的问题之一应该是肺部状况。由于肥胖患者肺容量减少的病理生理学与急性呼吸窘迫综合征（ARDS）患者不同，在机械通气期间保持肥胖患者肺部开放并充分通气的最佳方法是独特的。尽管缺乏关于如何最佳地为肥胖手术患者通气的有力证据和研究，但我们旨在通过本综述对已进行的少量研究以及我们认为影响明显结果的病理生理学进行评估。我们将提供肥胖呼吸系统解剖学和病理生理学的基本概述，并回顾有关术前、术中和术后呼吸护理的研究。本综述的重点是通过预防压迫性肺不张和维持生理肺容量来保持肺复张的最佳方法。我们建议在诱导和气管插管前通过无创通气（NIV）使用呼气末正压（PEEP），在机械通气期间同时使用PEEP和定期复张手法，以及在拔管后通过NIV使用PEEP。我们希望通过研究使肥胖患者通气如此困难的潜在机制，未来的研究能够更好地针对这一麻醉领域日益重要的挑战进行调整。
