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Christoph Boesing, Laura Schaefer, Marvin Hammel, Mirko Otto, Susanne Blank, Paolo Pelosi, Patricia R M Rocco, Thomas Luecke, Joerg Krebs
Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany; Theodor-Kutzer-Ufer 1-3, Mannheim, Germany.
Department of Surgery, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Mannheim, Germany; Theodor-Kutzer-Ufer 1-3, Mannheim, Germany.
Anesthesiology. 2023 Sep 1;139(3):249-261. doi: 10.1097/ALN.0000000000004631.
Superobesity and laparoscopic surgery promote negative end-expiratory transpulmonary pressure that causes atelectasis formation and impaired respiratory mechanics. The authors hypothesized that end-expiratory transpulmonary pressure differs between fixed and individualized positive end-expiratory pressure (PEEP) strategies and mediates their effects on respiratory mechanics, end-expiratory lung volume, gas exchange, and hemodynamic parameters in superobese patients.
In this prospective, nonrandomized crossover study including 40 superobese patients (body mass index 57.3 ± 6.4 kg/m2) undergoing laparoscopic bariatric surgery, PEEP was set according to (1) a fixed level of 8 cm H2O (PEEPEmpirical), (2) the highest respiratory system compliance (PEEPCompliance), or (3) an end-expiratory transpulmonary pressure targeting 0 cm H2O (PEEPTranspul) at different surgical positioning. The primary endpoint was end-expiratory transpulmonary pressure at different surgical positioning; secondary endpoints were respiratory mechanics, end-expiratory lung volume, gas exchange, and hemodynamic parameters.
Individualized PEEPCompliance compared to fixed PEEPEmpirical resulted in higher PEEP (supine, 17.2 ± 2.4 vs. 8.0 ± 0.0 cm H2O; supine with pneumoperitoneum, 21.5 ± 2.5 vs. 8.0 ± 0.0 cm H2O; and beach chair with pneumoperitoneum; 15.8 ± 2.5 vs. 8.0 ± 0.0 cm H2O; P < 0.001 each) and less negative end-expiratory transpulmonary pressure (supine, -2.9 ± 2.0 vs. -10.6 ± 2.6 cm H2O; supine with pneumoperitoneum, -2.9 ± 2.0 vs. -14.1 ± 3.7 cm H2O; and beach chair with pneumoperitoneum, -2.8 ± 2.2 vs. -9.2 ± 3.7 cm H2O; P < 0.001 each). Titrated PEEP, end-expiratory transpulmonary pressure, and lung volume were lower with PEEPCompliance compared to PEEPTranspul (P < 0.001 each). Respiratory system and transpulmonary driving pressure and mechanical power normalized to respiratory system compliance were reduced using PEEPCompliance compared to PEEPTranspul.
In superobese patients undergoing laparoscopic surgery, individualized PEEPCompliance may provide a feasible compromise regarding end-expiratory transpulmonary pressures compared to PEEPEmpirical and PEEPTranspul, because PEEPCompliance with slightly negative end-expiratory transpulmonary pressures improved respiratory mechanics, lung volumes, and oxygenation while preserving cardiac output.
超级肥胖和腹腔镜手术会导致呼气末跨肺压呈负向，从而导致肺不张形成和呼吸力学受损。作者假设，在超级肥胖患者中，呼气末跨肺压在固定和个体化呼气末正压（PEEP）策略之间存在差异，并介导它们对呼吸力学、呼气末肺容量、气体交换和血流动力学参数的影响。
在这项包括 40 名超级肥胖患者（体重指数 57.3±6.4kg/m2）的前瞻性、非随机交叉研究中，根据（1）固定的 8cmH2O（PEEPEmpirical），（2）最高呼吸系统顺应性（PEEPCompliance）或（3）呼气末跨肺压目标为 0cmH2O（PEEPTranspul），分别设置 PEEP。主要终点是不同手术体位下的呼气末跨肺压；次要终点是呼吸力学、呼气末肺容量、气体交换和血流动力学参数。
与固定的 PEEPEmpirical 相比，个体化的 PEEPCompliance 导致更高的 PEEP（仰卧位，17.2±2.4 比 8.0±0.0cmH2O；仰卧位加气腹，21.5±2.5 比 8.0±0.0cmH2O；和加气腹的沙滩椅位，15.8±2.5 比 8.0±0.0cmH2O；P<0.001 各体位）和更低的呼气末跨肺压（仰卧位，-2.9±2.0 比-10.6±2.6cmH2O；仰卧位加气腹，-2.9±2.0 比-14.1±3.7cmH2O；和加气腹的沙滩椅位，-2.8±2.2 比-9.2±3.7cmH2O；P<0.001 各体位）。与 PEEPTranspul 相比，滴定的 PEEP、呼气末跨肺压和肺容量在 PEEPCompliance 时较低（P<0.001 各体位）。与 PEEPTranspul 相比，使用 PEEPCompliance 时呼吸系统和跨肺驱动压以及机械功率与呼吸系统顺应性的比值降低。
在接受腹腔镜手术的超级肥胖患者中，与 PEEPEmpirical 和 PEEPTranspul 相比，个体化的 PEEPCompliance 可能在呼气末跨肺压方面提供一种可行的折衷方案，因为带有轻微负呼气末跨肺压的 PEEPCompliance 改善了呼吸力学、肺容量和氧合，同时保持心输出量。
