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      Effect of Different Levels of Positive End-Expiratory Pressure (PEEP) on Respiratory Status during Gynecologic Laparoscopy

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          Abstract

          Background

          During gynecologic laparoscopy, pneumoperitoneum, and the position of the patient's head can lead to pathophysiologic changes in cardiovascular and respiratory systems, complicating the management of anesthesia in these patients. One of the strategies for improving the respiratory status of patients undergoing laparoscopy is the use of Positive End-Expiratory Pressure (PEEP).

          Objectives

          This study aimed to evaluate the effect of different levels of PEEP on the respiratory status of patients undergoing gynecologic laparoscopy.

          Methods

          In this clinical trial, 60 patients with ASA I were randomly assigned to three groups to control anesthesia: ZEEP (PEEP 0 cmH 2O; 20 cases), PEEP 5 (PEEP 5 cmH 2O; 20 cases), and PEEP 10 (PEEP 10 cmH 2O; 20 cases). Respiratory and hemodynamic variables of patients were compared before general anesthetic induction and immediately after CO 2 insufflation at intervals of 5, 10, 20, 30, and 60 min and the end of the operation in the three study groups.

          Results

          The PEEP application improved pH, PaCO 2, and PaO 2 levels at the end of pneumoperitoneum compared to baseline when compared with the non-use of PEEP (ZEEP group). Also, the frequency of dysrhythmia in the use of PEEP in controlled ventilation was significantly lower in patients with PEEP 10 (P < 0.05). The application of PEEP 5 resulted in similar effects to PEEP 10 in the levels of respiratory variables.

          Conclusions

          The PEEP application is associated with improved arterial blood gas in patients with gynecologic laparoscopy. The use of PEEP 10 has a greater effect on the improvement of respiratory parameters and complications of pneumoperitoneum.

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          Most cited references21

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          Circulatory and Respiratory Complications of Carbon Dioxide Insufflation

          C.N. Gutt, T Oniu, A Mehrabi … (2004)
          Background: Although providing excellent outcome results, laparoscopy also induces particular pathophysiological changes in response to pneumoperitoneum. Knowledge of the pathophysiology of a CO 2 pneumoperitoneum can help minimize complications while profiting from the benefits of laparoscopic surgery without concerns about its safety. Methods: A review of articles on the pathophysiological changes and complications of carbon dioxide pneumoperitoneum as well as prevention and treatment of these complications was performed using the Medline database. Results: The main pathophysiological changes during CO 2 pneumoperitoneum refer to the cardiovascular system and are mainly correlated with the amount of intra-abdominal pressure in combination with the patient’s position on the operating table. These changes are well tolerated even in older and more debilitated patients, and except for a slight increase in the incidence of cardiac arrhythmias, no other significant cardiovascular complications occur. Although there are important pulmonary pathophysiological changes, hypercarbia, hypoxemia and barotraumas, they would develop rarely since effective ventilation monitoring and techniques are applied. The alteration in splanchnic perfusion is proportional with the increase in intra-abdominal pressure and duration of pneumoperitoneum. Conclusion: A moderate-to-low intra-abdominal pressure (<12 mm Hg) can help limit the extent of the pathophysiological changes since consecutive organ dysfunctions are minimal, transient and do not influence the outcome.
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            Intraoperative recruitment maneuver reverses detrimental pneumoperitoneum-induced respiratory effects in healthy weight and obese patients undergoing laparoscopy.

            Samir Jaber, Fabrice Kwiatkoskwi, Emmanuel Futier … (2010)
            Pulmonary function is impaired during pneumoperitoneum mainly as a result of atelectasis formation. We studied the effects of 10 cm H2O of positive end-expiratory pressure (PEEP) and PEEP followed by a recruitment maneuver (PEEP+RM) on end-expiratory lung volume (EELV), oxygenation and respiratory mechanics in patients undergoing laparoscopic surgery. Sixty consecutive adult patients (30 obese, 30 healthy weight) in reverse Trendelenburg position were prospectively studied. EELV, static elastance of the respiratory system, dead space, and gas exchange were measured before and after pneumoperitoneum insufflation with zero end-expiratory pressure, with PEEP alone, and with PEEP+RM. Results are presented as mean ± SD. Pneumoperitoneum reduced EELV (healthy weight, 1195 ± 405 vs. 1724 ± 774 ml; obese, 751 ± 258 vs. 886 ± 284 ml) and worsened static elastance and dead space in both groups (in all P < 0.01 vs. zero-end expiratory pressure before pneumoperitoneum) whereas oxygenation was unaffected. PEEP increased EELV (healthy weight, 570 ml, P < 0.01; obese, 364 ml, P < 0.01) with no effect on oxygenation. Compared with PEEP alone, EELV and static elastance were further improved after RM in both groups (P < 0.05), as was oxygenation (P < 0.01). In all patients, RM-induced change in EELV was 16% (P = 0.04). These improvements were maintained 30 min after RM. RM-induced changes in EELV correlated with change in oxygenation (r = 0.42, P < 0.01). RM combined with 10 cm H2O of PEEP improved EELV, respiratory mechanics, and oxygenation during pneumoperitoneum whereas PEEP alone did not.
            Article 0 comments Cited 49 times – based on 0 reviews     Review now
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              Impairment of lung and chest wall mechanics in patients with acute respiratory distress syndrome: role of abdominal distension.

              V Memeo, Arthur Slutsky, John Bruno … (1997)
              Recent data have suggested that the elastic properties of the chest wall (CW) may be compromised in patients with ARDS because of abdominal distension (4). We partitioned CW and lung (L) mechanics, assessed the role of abdominal distension, and verified whether the underlying disease responsible for ARDS affects the impairment of respiratory mechanics. Volume-pressure (V-P) curves (interrupter technique) were assessed in nine patients with surgical ARDS and nine patients with medical ARDS. Relative to nine patients undergoing heart surgery, V-P curves of the respiratory system (rs) and L of patients with surgical or medical ARDS showed a rightward displacement. V-P curves of the CW and the L showed an upward concavity in patients with medical ARDS and a downward concavity in patients with surgical ARDS. Although the CW and the abdomen (abd) V-P curves in patients with medical ARDS were similar to those obtained in patients undergoing heart surgery, they showed a rightward shift and a downward flattening in patients with surgical ARDS. In five of these patients, a reduction in static end-inspiratory pressure of the abd (69+/-4%), rs (30+/-3%), CW (41+/-2%), and L (27+/-3%) was observed after abdominal decompression for acute bleeding. Abdominal decompression therefore caused an upward and leftward shift of the V-P curves of the respiratory system, chest wall, lung, and abdomen. In conclusion we showed that impairment of the elastic properties of the respiratory system may vary with the underlying disease responsible for ARDS. The flattening of the V-P curve at high pressures observed in some patients with ARDS may be due to an increase in chest wall elastance related to abdominal distension. These observations have implications for the assessment and ventilatory management of patients with ARDS.
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                Author and article information

                Contributors
                Simin Atashkhoei
                Negin Yavari:
                ORCID: https://orcid.org/0000-0002-9914-2935
                Mahsa Zarrintan
                Eisa Bilejani
                Sina Zarrintan
                Journal
                Journal ID (nlm-ta): Anesth Pain Med
                Journal ID (iso-abbrev): Anesth Pain Med
                Journal ID (doi): 10.5812/aapm
                Journal ID (publisher-id): Kowsar
                Title: Anesthesiology and Pain Medicine
                Publisher: Kowsar
                ISSN (Print): 2228-7523
                ISSN (Electronic): 2228-7531
                Publication date (Electronic): 18 April 2020
                Publication date Collection: April 2020
                Volume: 10
                Issue: 2
                Electronic Location Identifier: e100075
                Affiliations
                [1 ]Department of Anesthesia, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
                [2 ]Research Department, Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
                [3 ]Division of Vascular and Endovascular Surgery, Department of General & Vascular Surgery, Shohada-Tajrish Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
                Author notes
                [* ]Corresponding Author: Department of Anesthesia, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran. Email: mahsa_zarrintan@ 123456yahoo.com
                Author information
                https://orcid.org/0000-0002-9914-2935
                Article
                DOI: 10.5812/aapm.100075
                PMC ID: 7322673
                PubMed ID: 32637348
                SO-VID: 07d82042-9021-4268-9afc-dbf307d5f389
                Copyright © Copyright © 2020, Author(s)
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.

                History
                Date received : 10 December 2019
                Date accepted : 13 February 2020
                Date revision received : 05 February 2020
                Categories
                Subject: Research Article

                Keywords: laparoscopy,pneumoperitoneum,positive end-expiratory pressure,respiratory status
                Data availability:
                Keywords: laparoscopy, pneumoperitoneum, positive end-expiratory pressure, respiratory status

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