Ventilation de l obèse: les 10 points clés
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1 Ventilation de l obèse: les 10 points clés Samir JABER 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; Montpellier. Mail : s-jaber@chu-montpellier.fr ; Tel : FRANCE
2 OBJECTIVES. Ventilation in obese patient : 10 Tips 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
3 OBESITE = PATHOLOGIE FREQUENTE
4 Obesity : Main impacts on ventilatory system
5 LUNG VOLUMES AND OXYGENATION Volume Pulmonaire (CRF ) OBESITY Oxygénation (PaO2/PAO2) Atelectasis Non aerated tissue (+ 20%) Poorly aerated tissue (+ 70%) HYPOXEMIA Pelosi Anesth Analg 1998
6 Effects of anesthesia on lung morphology in obese patients. Pelosi et al Atelectasis Atelectasis++
7 Patient obèse en Décubitus Dorsal
8 OBJECTIVES. Ventilation in obese patient : 10 Tips 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
9 DIFFICULT MASK VENTILATION AND INTUBATION Obesity = Risk factor for Difficult mask ventilation and intubation
10 DIFFICULT INTUBATION Obese patient Non obese patient INTENSIVE CARE UNIT Obese patient OPERATIVE ROOM Non obese patient NO DIFFICULT INTUBATION
11
12 Prevention of derecruitment (atelectasis) during intubation Before induction After intubation Standard Preoxygenation Atelectasis + Preoxygenation CPAP = 6 cmh 2 O No atelectasis Rusca. Anesth Analg 2003
13
14 Nb de patients (%) FeO2 (%) / * * * * 60 7/14 7/ /14 85 VS 0 FeO2 < 95% FeO2 > 95% 80 VNI VS VNI 1 min 2 min 3 min 4 min 5 min Facial mask NIV in Pressure Support Ventilation (PSV) mode (8-10 cmh20) with PEEP (6 cmh20) improve preoxygenation before planned intubation in obese patients
15 NIV for preoxygenation before intubation in non-selected ICU patients
16 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
17 OBJECTIVES. Ventilation in obese patient : 10 Tips 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
18 Volume (VCV) = Pressure (PCV) in obese patients Aldenkortt M. et al. Br J Anaesth. 2012;109(4): Intraoperative PaO2/FiO2 (kpa) Intraoperative tidal volume (ml)
19 OBJECTIVES. Ventilation in obese patient : 10 Tips 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
20 Relationship between BMI and development of ARDS?
21 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
22 OR for the development of ARDS
23 Tidal volume (VT) setting 6 ml/kg Ideal Body Weight But increase PEEP IBW (kg) = Height (cm) -100 man IBW (kg) = Height (cm) -110 woman
24 OBJECTIVES. Ventilation in obese patient : 10 Tips 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
25 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 Nestler et al. BJA 2018 Eichler et al. Obesity surgery 2017
26 Esophageal Pressure Use Optimal PEEP = 20 cmh20
27 Driving pressure (ΔP)= Plateau pressure - PEEP ICM 2018
28 NON-OBESE PATIENTS (p=0.02) OBESE PATIENTS (p= NS)
29 OBJECTIVES. Ventilation in obese patient : 10 Tips 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
30 P E E P R M + P E E P? R E C R U I T M E N T (RM) Awake After induction 5 min 20 min
31 OBJECTIVES. Ventilation in obese patient : 10 Tips 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
32 Positioning at 30-45º promotes better respiratory function (avoid 0º or 90º) 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 - 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: 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:
33 Obese position Beach chair position improves Respiratory fonction
34 Feasibility 2.Safety 3.Efficiency +54 % + 88 % Supine Position Prone Position Supine Position Prone Position Prone Position more efficient in obese patient than in non-obese patient
35 Steps of switch from supine to prone position in an obese patient
36 OBJECTIVES. Ventilation in obese patient : 10 Tips 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
37 No specificities about obese patient Avril 2005 Budapest (Hongrie) 37
38 How to perform Spontaneous Breathing Trial in obese patients?
39 Experimental bench Esophageal tube Ventilator Pneumotachograph
40 Inspiratory effort PSV+7 PEEP+7 PSV+0 PEEP+7 PSV+7 PEEP+0 PSV+0 AI PEEP+0 0 PEEP 0 T-Tube Post Extubation VE (L/s) Poes (cmh2o) Paw (cmh2o) Pga (cmh2o) Pdi (cmh2o)
41 Swing Pes (cmh2o) A 40 Esophageal pressure Swing p < NS * * * _ mean = = PSV 7 PEEP 7 PSV 0 PEEP 7 PSV 7 PEEP 0 PSV 0 PEEP 0 T PIECE AFTER Post EXTUBATION Extubation SBT
42 Obese SBT-extubation?
43 Alveolar collapse during airways aspiration Courtesy Dr. Strang EXTUBATION PROCEDURE (tube remove) at the end of a maximal inspiration (auto-recruitment)
44
45 % * * 15% Intubation difficile 3% 15% Stridor postextubation Non-Obese (n=124) Obese (n=82)
46 OBJECTIVES. Ventilation in obese patient : 10 Tips 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
47 Preventive High flow nasal cannula (HFNC) oxygen therapy, noninvasive ventilation (NIV) and obesity? - Prevention acute respiratory failure following thoracic surgery - No difference NIV vs HFNC Stephan et al. Respiratory Care 2017
48 Perioperative noninvasive ventilation (NIV) in obese pts: a qualitative review and meta-analysis. Carron M et al. Surg Obes Relat Dis Dec patients included
49
50 airway obstruction in SAOS obese patients Impact of CPAP? Impact of PEEP on : 1. Lung 2. Upper Airway
51 NIV in Upright position
52 NIV Curative P= 0,03 P= 0,14 P < 0, Standard (n=62) VNI préventive (n=62) 5 0 Détresse respiratoire (%) Réintubation (%) Durée séjour réa (j)
53
54 COMPRESSION PNEUMATIQUE INTERMITTENTE
55 Il n y a pas «une obésité» mais «des obésités» = possible explication des résultats controversés d études sur les patients obèses = médecine «personnalisée» Gynoïde (hanches, cuisses, Fesses) Androïde (tronc)
56 OBJECTIVES. Ventilation in obese patient : 10 Tips 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
57 Take Home Messages 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++
58 Thanks for the attention
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