ventilation de l’obèse: les 10 points clés
TRANSCRIPT
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Samir JABER
Ventilation de l’obèse:
les 10 points clés
Department of Critical Care Medicine and Anesthesiology (DAR B)
Saint Eloi University Hospital and Montpellier School of Medicine; INSERM U1046 University of Montpellier
80 Avenue Augustin Fliche; 34295 Montpellier. Mail : [email protected] ; Tel : +33 4 67 33 72 71
FRANCE
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1. Background : what every physicians should know about obese patient
2. Preoxygenation and intubation procedures
3. Ventilatory modes
4. Tidal volume
5. Pressures : PEEP, Pplat, Driving Pressure (ΔP); Esophageal (Pes)
6. Recruitment Maneuver
7. Position
8. Weaning : spontaneous breathing trial (SBT) and Extubation
9. Post-extubation period: Ventilatory Support
10. Take home messages
OBJECTIVES. Ventilation in obese patient : 10 Tips
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OBESITE = PATHOLOGIE FREQUENTE
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Obesity : Main impacts on ventilatory system
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Pelosi Anesth Analg 1998
Non aerated tissue (+ 20%) Poorly aerated tissue (+ 70%)
LUNG VOLUMES AND OXYGENATION
Atelectasis
HYPOXEMIA
Volume Pulmonaire (CRF…)
Oxygénation (PaO2/PAO2)
OBESITY
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Effects of anesthesia on lung morphology
in obese patients. Pelosi et al. 2010
Atelectasis
Atelectasis++
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Patient obèse en
Décubitus Dorsal
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1. Background : what every physicians should know about obese patient
2. Preoxygenation and intubation procedures
3. Ventilatory modes
4. Tidal volume
5. Pressures : PEEP, Pplat, Driving Pressure (ΔP); Esophageal (Pes)
6. Recruitment Maneuver
7. Position
8. Weaning : spontaneous breathing trial (SBT) and Extubation
9. Post-extubation period: Ventilatory Support
10. Take home messages
OBJECTIVES. Ventilation in obese patient : 10 Tips
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DIFFICULT MASK VENTILATION AND INTUBATION
Obesity = Risk factor for
Difficult mask ventilation and intubation
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NO DIFFICULT INTUBATION
DIFFICULT INTUBATION 0
10
20
30
40
50
60
Obese patient Non obese
patient Obese patient Non obese
patient INTENSIVE CARE UNIT
OPERATIVE ROOM
2015
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Standard
Preoxygenation
Preoxygenation
CPAP = 6 cmH2O
Prevention of derecruitment (atelectasis) during intubation
Before induction After intubation
Atelectasis +
No atelectasis
Rusca. Anesth Analg 2003
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7/14
1/14
7/14
13/14
0
20
40
60
80
100
Nb
de
pa
tie
nts
(%
)
FeO2 < 95% FeO2 > 95%
VS VNI
80
85
90
95
100
1 min 2 min 3 min 4 min 5 min
FeO
2 (
%)
VS
VNI
* * * *
Facial mask NIV in Pressure Support Ventilation (PSV) mode (8-10 cmH20) with PEEP (6 cmH20) improve preoxygenation before planned intubation in obese patients
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NIV for preoxygenation before intubation in non-selected ICU patients
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Comparative efficacy of different laryngoscopes in obese patients requiring endotracheal intubation: a systematic review and network meta-analysis
Miao Liu1, Zhaodi Zhang2, Guiyue Wang1, Yuhang Li1, Yue Bu1, Hongliang Wang3, Haitao Liu1, Pulin Yu1, Yanji Lv1, Xiaoya Zheng1, Kaili Yu1, Yi Yang4, Fangfang Niu1, Baicheng Zhang1, Qi Chen1,
Yao Wang1, Jinwei Tian4, Kaijiang Yu1*, Changsong Wang1*
Conclusion: Compared with Direct Larynscopy (DL), Videolaryngoscope significantly increased the rate of endotracheal intubation on the first attempt and provided a superior glottis view with no increase in complications.
Submitted 2018
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1. Background : what every physicians should know about obese patient
2. Preoxygenation and intubation procedures
3. Ventilatory modes (Volume or Pressure)
4. Tidal volume
5. Pressures : PEEP, Pplat, Driving Pressure (ΔP); Esophageal (Pes)
6. Recruitment Maneuver
7. Position
8. Weaning : spontaneous breathing trial (SBT) and Extubation
9. Post-extubation period: Ventilatory Support
10. Take home messages
OBJECTIVES. Ventilation in obese patient : 10 Tips
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Volume (VCV) = Pressure (PCV) in obese patients
Aldenkortt M. et al. Br J Anaesth. 2012;109(4):493-502
Intraoperative PaO2/FiO2 (kPa)
Intraoperative tidal volume (ml)
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1. Background : what every physicians should know about obese patient
2. Preoxygenation and intubation procedures
3. Ventilatory modes
4. Tidal volume (VT)
5. Pressures : PEEP, Pplat, Driving Pressure (ΔP); Esophageal (Pes).
6. Recruitment Maneuver
7. Position
8. Weaning : spontaneous breathing trial (SBT) and Extubation
9. Post-extubation period: Ventilatory Support
10. Take home messages
OBJECTIVES. Ventilation in obese patient : 10 Tips
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Relationship between BMI and development of ARDS ?
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Development of ARDS increased significantly with increasing weight
« PARADOX » ARDS obese had lower ICU mortality
but this may be due in part to the higher mortality in the underweight patients
Gong. Thorax 2010
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OR for the development of ARDS
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6 mL/kg Ideal Body Weight
Tidal volume (VT) setting
IBW (kg) = Height (cm) -100 man
IBW (kg) = Height (cm) -110 woman
But increase
PEEP
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1. Background : what every physicians should know about obese patient
2. Preoxygenation and intubation procedures
3. Ventilatory modes
4. Tidal volume
5. Pressures : PEEP, Pplat, Driving Pressure (ΔP); Esophageal (Pes)
6. Recruitment Maneuver
7. Position
8. Weaning : spontaneous breathing trial (SBT) and Extubation
9. Post-extubation period: Ventilatory Support
10. Take home messages
OBJECTIVES. Ventilation in obese patient : 10 Tips
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Nestler et al. BJA 2018
Need of an individualized monitoring in the obese patient
1. Electrical Impedance Tomography (EIT)
(Atelectasis visualization)
2. Monitoring of esophageal pressure (calculation of transpulmonary pressure)
Digestive surgery (laparoscopy)
Optimal PEEP= 18 cm H20 More hemodynamic
complications
Bariatric surgery
Optimal PEEP = 17 cmH20 before pneumoperitoneum,
23 cm20 after pneumoperitoneum
No hemodynamic difference
Eichler et al. Obesity surgery 2017
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Optimal PEEP =
20 cmH20
Esophageal Pressure Use
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ICM 2018
Driving pressure (ΔP)= Plateau pressure - PEEP
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NON-OBESE PATIENTS (p=0.02)
OBESE PATIENTS (p= NS)
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1. Background : what every physicians should know about obese patient
2. Preoxygenation and intubation procedures
3. Ventilatory modes
4. Tidal volume
5. Pressures : PEEP, Pplat, Driving Pressure (ΔP); Esophageal (Pes)
6. Recruitment Maneuver
7. Position
8. Weaning : spontaneous breathing trial (SBT) and Extubation
9. Post-extubation period: Ventilatory Support
10. Take home messages
OBJECTIVES. Ventilation in obese patient : 10 Tips
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Awake After induction 5 min 20 min
P E E P
R M
+
P E E P
R E C R U I T M E N T (RM)
?
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1. Background : what every physicians should know about obese patient
2. Preoxygenation and intubation procedures
3. Ventilatory modes
4. Tidal volume
5. Pressures : PEEP, Pplat, Driving Pressure (ΔP); Esophageal (Pes).
6. Recruitment Maneuver
7. Position 8. Weaning : spontaneous breathing trial (SBT) and Extubation
9. Post-extubation period: Ventilatory Support
10. Take home messages
OBJECTIVES. Ventilation in obese patient : 10 Tips
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Positioning at 30-45º promotes better respiratory function (avoid 0º or 90º)
- Burns et al. “Effect of body position on
spontaneous respiratory effort and tidal volume in patients with obesity, abdominal distension and ascites”. Am J Crit Care 1994;3:102-106
- Neill et al.”Effects of sleep posture on
upper airway stability in patients with obstructive sleep apnea”. Am J Respir Crit Care Med 1997;155:199-204
Upright positioning of the patient is strongly recommended so that the excess body tissue on the chest and against the diaphragm is displaced
caudal, which will reduce the WOB and increase the FRC
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Obese – position
Beach chair position improves Respiratory fonction
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+54 % + 88 %
Supine
Position
Supine
Position
Prone
Position
Prone
Position
2013
Prone Position more efficient in obese patient than in non-obese patient
1.Feasibility 2.Safety 3.Efficiency
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Steps of switch from supine to prone position
in an obese patient
1 2 3
4 5 6
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1. Background : what every physicians should know about obese patient
2. Preoxygenation and intubation procedures
3. Ventilatory modes
4. Tidal volume
5. Pressures : PEEP, Pplat, Driving Pressure (ΔP); Esophageal (Pes).
6. Recruitment Maneuver
7. Position
8. Weaning : Spontaneous Breathing Trial (SBT) and Extubation
9. Post-extubation period: Ventilatory Support
10. Take home messages
OBJECTIVES. Ventilation in obese patient : 10 Tips
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37
Avril 2005 Budapest (Hongrie)
No specificities about obese patient
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How to perform Spontaneous Breathing Trial
in obese patients ?
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Ventilator Experimental bench Esophageal tube
Pneumotachograph
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Inspiratory effort
PSV+7 PEEP+7 AI 0 PEEP 0
T-Tube
Post Extubation
VE
(L/s)
Poes
(cmH2O)
Paw
(cmH2O)
Pga
(cmH2O)
Pdi
(cmH2O)
PSV+0 PEEP+7
PSV+7 PEEP+0
PSV+7 PEEP+0
PSV+0 PEEP+0
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0
10
20
30
40
PSV 7 PEEP 7 PSV 0 PEEP 7 PSV 7 PEEP 0 PSV 0 PEEP 0 T PIECE AFTER EXTUBATION
Swin
g P
es (
cmH
2O
)
Esophageal pressure Swing
SBT
A
* * *
_ mean
Post Extubation
p < 0.001 NS
= =
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Obese SBT-extubation ?
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Alveolar collapse during airways aspiration
Courtesy Dr. Strang
EXTUBATION PROCEDURE (tube remove) at the end of a maximal inspiration
(auto-recruitment)
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6%
15%
3%
15%
0
2
4
6
8
10
12
14
16
Intubation
difficile
Stridor
post-
extubation
Non-Obese (n=124)
Obese (n=82)
* *
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1. Background : what every physicians should know about obese patient
2. Preoxygenation and intubation procedures
3. Ventilatory modes
4. Tidal volume
5. Pressures : PEEP, Pplat, Driving Pressure (ΔP); Esophageal (Pes)
6. Recruitment Maneuver
7. Position
8. Weaning : spontaneous breathing trial (SBT) and Extubation
9. Post-extubation period: Ventilatory Support
10. Take home messages
OBJECTIVES. Ventilation in obese patient : 10 Tips
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“Preventive” High flow nasal cannula (HFNC) oxygen therapy, noninvasive ventilation (NIV) and obesity ?
Stephan et al. Respiratory Care 2017 - Prevention acute respiratory failure following thoracic surgery - No difference NIV vs HFNC
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Perioperative noninvasive ventilation (NIV) in obese pts:
a qualitative review and meta-analysis.
Carron M et al. Surg Obes Relat Dis. 2015 Dec 10.
• 768 patients included
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Impact of PEEP on :
1. Lung
2. Upper Airway
↑ airway obstruction in SAOS – obese patients
Impact of CPAP ?
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NIV in Upright position
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0
5
10
15
20
25
30
Détresse
respiratoire (%)
Réintubation
(%)
Durée séjour
réa (j)
Standard (n=62)
VNI préventive (n=62)
P= 0,14
P= 0,03
P < 0,001
NIV Curative
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COMPRESSION PNEUMATIQUE INTERMITTENTE
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Androïde (tronc) Gynoïde
(hanches, cuisses, Fesses)
Il n’y a pas « une obésité » mais « des obésités » = possible explication des résultats controversés d’études sur les patients obèses = médecine « personnalisée »
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1. Background : what every physicians should know about obese patient
2. Preoxygenation and intubation procedures
3. Ventilatory modes
4. Tidal volume
5. Pressures : PEEP, Pplat, Driving Pressure (ΔP); Esophageal (Pes)
6. Recruitment Maneuver
7. Position
8. Weaning : spontaneous breathing trial (SBT) and Extubation
9. Post-extubation period: Ventilatory Support
10.Take home messages
OBJECTIVES. Ventilation in obese patient : 10 Tips
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1. Difficult intubation: anticipate and optimize (NIV…)
2. Volume=Pressure at similar assistance level
3. Tidal Volume set according Predicted Body Weight
4. « High PEEP »
5. SBT= T-tube or PSV=0+PEEP=0
6. Post-extubation : at risk for acute airway obstruction
7. CPAP-NIV post-extubation++
Take Home Messages
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Thanks for the attention