title: Effect of positive end-expiratory pressure on pulmonary shunt and dynamic compliance during abdominal surgery.
abstract: BACKGROUND
  General anaesthesia decreases pulmonary compliance and increases pulmonary shunt due to the development of atelectasis. The presence of capnoperitoneum during laparoscopic surgery may further decrease functional residual capacity, promoting an increased amount of atelectasis compared with laparotomy. The aim of this study was to evaluate the effects of different levels of positive end-expiratory pressure (PEEP) in both types of surgery and to investigate whether higher levels of PEEP should be used during laparoscopic surgery.
  
  
  METHODS
  This prospective observational study included 52 patients undergoing either laparotomy or laparoscopic surgery. Three levels of PEEP were applied in random order: (1) zero (ZEEP), (2) 5 cmH2O and (3) 10 cmH2O. Pulmonary shunt and ventilation/perfusion mismatch were assessed by the automatic lung parameter estimator system.
  
  
  RESULTS
  Pulmonary shunt was similar in both groups. However, in laparotomy, a PEEP of 5 cmH2O significantly decreased shunt when compared with ZEEP (12 vs 6%; P=0.001), with additional PEEP having no further effect. In laparoscopic surgery, a significant reduction in shunt (13 vs 6%; P=0.001) was obtained only at a PEEP of 10 cmH2O. Although laparoscopic surgery was associated with a lower pulmonary compliance, increasing levels of PEEP were able to ameliorate it in both groups.
  
  
  CONCLUSIONS
  Both surgeries have similar negative effects on pulmonary shunt, while the presence of capnoperitoneum reduced only the pulmonary compliance. It appears that a more aggressive PEEP level is required to reduce shunt and to maximize compliance in case of laparoscopic surgery.
authors.affiliation: Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant'Anna, University of Ferrara, Aldo 8, Aldo Moro, Ferrara 44121, Italy savinospadaro@gmail.com.
authors.forename: S
authors.initials: S
authors.lastname: Spadaro
authors.affiliation: Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
authors.forename: D S
authors.initials: DS
authors.lastname: Karbing
authors.affiliation: Dipartimento di Anestesia, Rianimazione (Intensiva e Subintensiva) e Terapia del Dolore, Fondazione IRCCS, Ospedale Maggiore Policlinico, Mangiagalli, Regina Elena di Milano, Milan, Italy.
authors.forename: T
authors.initials: T
authors.lastname: Mauri
authors.affiliation: Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant'Anna, University of Ferrara, Aldo 8, Aldo Moro, Ferrara 44121, Italy.
authors.forename: E
authors.initials: E
authors.lastname: Marangoni
authors.affiliation: Dipartimento di Scienze Clinico-chirurgiche, Diagnostiche e Pediatriche, Sezione di Anestesia Rianimazione e Terapia Antalgica, Università degli Studi di Pavia, SC Anestesia e Rianimazione, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy.
authors.forename: F
authors.initials: F
authors.lastname: Mojoli
authors.affiliation: Statistic and Research Innovative office, Sant'Anna University Hospital of Ferrara, Ferrara, Italy.
authors.forename: G
authors.initials: G
authors.lastname: Valpiani
authors.affiliation: Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant'Anna, University of Ferrara, Aldo 8, Aldo Moro, Ferrara 44121, Italy.
authors.forename: C
authors.initials: C
authors.lastname: Carrieri
authors.affiliation: Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant'Anna, University of Ferrara, Aldo 8, Aldo Moro, Ferrara 44121, Italy.
authors.forename: R
authors.initials: R
authors.lastname: Ragazzi
authors.affiliation: Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant'Anna, University of Ferrara, Aldo 8, Aldo Moro, Ferrara 44121, Italy.
authors.forename: M
authors.initials: M
authors.lastname: Verri
authors.affiliation: Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark.
authors.forename: S E
authors.initials: SE
authors.lastname: Rees
authors.affiliation: Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Arcispedale Sant'Anna, University of Ferrara, Aldo 8, Aldo Moro, Ferrara 44121, Italy.
authors.forename: C A
authors.initials: CA
authors.lastname: Volta
mesh_terms: D000005:Abdomen / Q000601:surgery*; D000368:Aged; D000768:Anesthesia, General; D005260:Female; D006801:Humans; D007431:Intraoperative Complications / Q000517:prevention & control; D010535:Laparoscopy / Q000379:methods / Q000592:standards; D007813:Laparotomy; D008170:Lung Compliance; D008297:Male; D008875:Middle Aged; D011175:Positive-Pressure Respiration / Q000009:adverse effects*; D011446:Prospective Studies; D001261:Pulmonary Atelectasis / Q000517:prevention & control; D012121:Respiration, Artificial
keywords: end-expiratory pressure, positive; laparoscopic surgery; laparotomy; pulmonary compliance; shunt