Respiratory Management of Perioperative Obese Patients.
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.
Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.|Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
David Ae
DA
Imber
Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.|Dipartimento di Anestesiologia, Terapia Intensiva e Scienze Dermatologiche, Università degli Studi di Milano, Milan, Italy.
Massimiliano
M
Pirrone
Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts.|Anesthesia and Operation Center, Chinese PLA General Hospital, Beijing, China.
Changsheng
C
Zhang
Department of Respiratory Care, Massachusetts General Hospital, Boston, Massachusetts.
Daniel F
DF
Fisher
Harvard Medical School and the Department of Respiratory Care, Massachusetts General Hospital, Boston, Massachusetts.
Robert M
RM
Kacmarek
Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts. lberra@mgh.harvard.edu.|Harvard Medical School, Boston, Massachusetts.
Lorenzo
L
Berra
D000328:Adult; D015992:Body Mass Index; D006801:Humans; D008168:Lung / Q000503:physiopathology; D063087:Noninvasive Ventilation / Q000379:methods*; D009765:Obesity / Q000503:physiopathology* / Q000601:surgery*; D019990:Perioperative Care / Q000379:methods*; D011175:Positive-Pressure Respiration / Q000379:methods; D001261:Pulmonary Atelectasis / Q000209:etiology / Q000517:prevention & control; D012121:Respiration, Artificial / Q000379:methods*; D013990:Tidal Volume
PEEP; atelectasis; mechanical ventilation; noninvasive ventilation; obesity; recruitment maneuver