From the Research Group in Perioperative Medicine (G.M., O.D-C., N.G-G., B.A-M., M.P.A.N.) the Department of Anaesthesiology (G.M., O.D-C., J.M.A.-I., N.G-G., B.A-M., M.P.A.N.) the Department of Hepatobiliopancreatic Surgery (J.L.I., J.M.), Hospital Universitario y Politécnico la Fe, Valencia, Spain the Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil (A.S.N.) the Cardio-Pulmonary Department, Pulmonary Division, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil (A.S.N.) the Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands (A.S.N., M.J.S.) Policlinico San Martino Hospital - Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neurosciences, Genoa, Italy (L.B., P.P.) the Department of Surgical Sciences and Integrated Diagnostics, University of Genoa Italy (L.B., P.P.) the Department of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, Technische Universität Dresden, Dresden, Germany (M.G.d.A.) the Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand (M.J.S.) the Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom (M.J.S.).
Anesthesiology. 2020 Apr;132(4):667-677. doi: 10.1097/ALN.0000000000003146.
Pneumoperitoneum for laparoscopic surgery is associated with a rise of driving pressure. The authors aimed to assess the effects of positive end-expiratory pressure (PEEP) on driving pressure at varying intraabdominal pressure levels. It was hypothesized that PEEP attenuates pneumoperitoneum-related rises in driving pressure.
Open-label, nonrandomized, crossover, clinical trial in patients undergoing laparoscopic cholecystectomy. "Targeted PEEP" (2 cm H2O above intraabdominal pressure) was compared with "standard PEEP" (5 cm H2O), with respect to the transpulmonary and respiratory system driving pressure at three predefined intraabdominal pressure levels, and each patient was ventilated with two levels of PEEP at the three intraabdominal pressure levels in the same sequence. The primary outcome was the difference in transpulmonary driving pressure between targeted PEEP and standard PEEP at the three levels of intraabdominal pressure.
Thirty patients were included and analyzed. Targeted PEEP was 10, 14, and 17 cm H2O at intraabdominal pressure of 8, 12, and 15 mmHg, respectively. Compared to standard PEEP, targeted PEEP resulted in lower median transpulmonary driving pressure at intraabdominal pressure of 8 mmHg (7 [5 to 8] vs. 9 [7 to 11] cm H2O; P = 0.010; difference 2 [95% CI 0.5 to 4 cm H2O]); 12 mmHg (7 [4 to 9] vs.10 [7 to 12] cm H2O; P = 0.002; difference 3 [1 to 5] cm H2O); and 15 mmHg (7 [6 to 9] vs.12 [8 to 15] cm H2O; P < 0.001; difference 4 [2 to 6] cm H2O). The effects of targeted PEEP compared to standard PEEP on respiratory system driving pressure were comparable to the effects on transpulmonary driving pressure, though respiratory system driving pressure was higher than transpulmonary driving pressure at all intraabdominal pressure levels.
Transpulmonary driving pressure rises with an increase in intraabdominal pressure, an effect that can be counterbalanced by targeted PEEP. Future studies have to elucidate which combination of PEEP and intraabdominal pressure is best in term of clinical outcomes.
腹腔镜手术中的气腹会导致驱动压升高。作者旨在评估呼气末正压（PEEP）在不同腹腔内压水平下对驱动压的影响。研究假设 PEEP 可减轻气腹引起的驱动压升高。
对行腹腔镜胆囊切除术的患者进行开放标签、非随机、交叉、临床试验。与“标准 PEEP”（腹腔内压高 5cmH2O）相比，比较“目标 PEEP”（腹腔内压高 2cmH2O）在三个预设腹腔内压水平下对跨肺压和呼吸系统驱动压的影响，每个患者在三个腹腔内压水平下以相同的顺序通气两个 PEEP 水平。主要结局为三个腹腔内压水平时目标 PEEP 与标准 PEEP 之间的跨肺驱动压差异。
共纳入 30 例患者并进行分析。腹腔内压为 8、12 和 15mmHg 时，目标 PEEP 分别为 10、14 和 17cmH2O。与标准 PEEP 相比，目标 PEEP 可使腹腔内压为 8mmHg 时的中位跨肺驱动压更低（7[5 至 8] vs.9[7 至 11]cmH2O；P=0.010；差值 2[95%CI 0.5 至 4cmH2O]）；12mmHg 时（7[4 至 9] vs.10[7 至 12]cmH2O；P=0.002；差值 3[1 至 5]cmH2O）；15mmHg 时（7[6 至 9] vs.12[8 至 15]cmH2O；P<0.001；差值 4[2 至 6]cmH2O）。与标准 PEEP 相比，目标 PEEP 对呼吸系统驱动压的影响与对跨肺驱动压的影响相当，尽管在所有腹腔内压水平下，呼吸系统驱动压均高于跨肺驱动压。
随着腹腔内压的升高，跨肺驱动压升高，目标 PEEP 可抵消这种升高。未来的研究必须阐明在临床结局方面，PEEP 和腹腔内压的哪种组合最佳。
