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Esophageal Pressure Versus Gas Exchange to Set PEEP During Intraoperative Ventilation

Gianmaria Cammarota¹, Gianluigi Lauro², Ilaria Sguazzotti²

¹Department of Anesthesiology and Intensive Care, Maggiore della Carità University Hospital, Novara, Italy. gmcamma@gmail.com.

Respiratory Care

|April 30, 2020

Abstract

Background:

Pneumoperitoneum and Trendelenburg position affect respiratory system mechanics and oxygenation during elective pelvic robotic surgery. The primary aim of this randomized pilot study was to compare the effects of a conventional low tidal volume ventilation with PEEP guided by gas exchange (V_Gas-guided) versus low tidal volume ventilation tailoring PEEP according to esophageal pressure (V_Pes-guided) on oxygenation and respiratory mechanics during elective pelvic robotic surgery.

Methods:

This study was conducted in a single-center tertiary hospital between September 2017 and January 2019. Forty-nine adult patients scheduled for elective pelvic robotic surgery were screened; 28 subjects completed the full analysis. Exclusion criteria were American Society of Anesthesiologists physical status ≥ 3, contraindications to nasogastric catheter placement, and pregnancy. After dedicated naso/orogastric catheter insertion, subjects were randomly assigned to V_Gas-guided ([Formula: see text] and PEEP set to achieve [Formula: see text] > 94%) or V_Pes-guided (PEEP tailored to equalize end-expiratory transpulmonary pressure). Oxygenation ([Formula: see text]/[Formula: see text]) was evaluated (1) at randomization, after pneumoperitoneum and Trendelenburg application; (2) at 60 min; (3) at 120 min following randomization; and (4) at end of surgery. Respiratory mechanics were assessed during the duration of the study.

Results:

Compared to V_Gas-guided, oxygenation was higher with V_Pes-guided at 60 min (388 ± 90 vs 308 ± 95 mm Hg, P = .02), at 120 min after randomization (400 ± 90 vs 308 ± 81 mm Hg, P = .008), and at the end of surgery (402 ± 95 vs 312 ± 95 mm Hg, P = .009). Respiratory system elastance was lower with V_Pes-guided compared to V_Gas-guided at 20 min (24.2 ± 7.3 vs 33.4 ± 10.7 cm H₂O/L, P = .001) and 60 min (24.1 ± 5.4 vs 31.9 ± 8.5 cm H₂O/L, P = .006) from randomization.

Conclusions:

Oxygenation and respiratory system mechanics were improved when applying a ventilatory strategy tailoring PEEP to equalize expiratory transpulmonary pressure in subjects undergoing pelvic robotic surgery compared to a V_Gas-guided approach. (ClinicalTrials.gov registration NCT03153592).

Keywords:

laparoscopy pneumoperitoneum positive pressure respiration respiratory mechanics

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