Effect of Recruitment Maneuvers and PEEP on Respiratory Failure After Cardiothoracic Surgery in Obese Subjects: A Randomized Controlled Trial

Priscilla Amaru; Bertrand Delannoy; Thibaut Genty; Olivier Desebbe; Florent Laverdure; Saida Rezaiguia-Delclaux; François Stéphan

doi:10.4187/respcare.08607

Effect of Recruitment Maneuvers and PEEP on Respiratory Failure After Cardiothoracic Surgery in Obese Subjects: A Randomized Controlled Trial

Respir Care. 2021 Aug;66(8):1306-1314. doi: 10.4187/respcare.08607. Epub 2021 May 11.

Authors

Priscilla Amaru¹, Bertrand Delannoy², Thibaut Genty¹, Olivier Desebbe², Florent Laverdure³, Saida Rezaiguia-Delclaux², François Stéphan⁴

Affiliations

¹ Cardiothoracic ICU, Department of Anesthesiology and ICU, Hôpital Marie Lannelongue, Le Plessis Robinson, France.
² Anesthesiology, Clinique de la Sauvegarde, Lyon, France.
³ Anesthesiology, Department of Anesthesiology and ICU, Hôpital Marie Lannelongue, Le Plessis Robinson, France.
⁴ Cardiothoracic ICU, Department of Anesthesiology and ICU, Hôpital Marie Lannelongue, Le Plessis Robinson, France. f.stephan@ghpsj.fr.

PMID: 33975901
DOI: 10.4187/respcare.08607

Abstract

Background: Obesity may increase the risk of respiratory failure after cardiothoracic surgery. A recruitment maneuver followed by PEEP might decrease the risk of respiratory failure in obese subjects. We hypothesized that the routine use after heart surgery of a recruitment maneuver followed by high or low PEEP level would decrease the frequency of respiratory failure in obese subjects.

Methods: In a pragmatic, randomized controlled trial, we assigned obese subjects (ie, with body mass index [BMI] ≥ 30 kg/m²) in the immediate postoperative period of cardiothoracic surgery to either volume control ventilation with 5 cm H₂O of PEEP (control group) or a recruitment maneuver followed by 5 or 10 cm H₂O of PEEP in the intervention arms (RM5 and RM10 groups, respectively). The primary outcome was the proportion of subjects with postextubation respiratory failure, defined as the need for re-intubation, bi-level positive airway pressure, or high-flow nasal cannula within the first 48 h.

Results: The study included 192 subjects: 65 in the control group (BMI 33.5 ± 3.2 kg/m²), 66 in the RM5 group (BMI 34.5 ± 3.2 kg/m², and 61 in RM10 group (BMI 33.8 ± 4.8 kg/m²). Postextubation respiratory failure occurred in 14 subjects in the control group (21.5% [95% CI 13.3-35.3]), 21 subjects in the RM5 group (31.8% [95% CI 21.2-44.6]), and 9 subjects in the RM10 group (14.7% [95% CI 7.4-26.7]) (P = .07). The recruitment maneuver was stopped prematurely due to severe hypotension in 8 (12.1%) RM5 subjects and in 4 (6.6%) RM10 subjects (P = .28). There were no significant differences between the 3 groups for the frequencies of atelectasis, pneumonia, and death in the ICU.

Conclusions: The routine use after heart surgery of a recruitment maneuver followed by 5 or 10 cm H₂O of PEEP did not decrease the frequency of respiratory failure in obese subjects. A recruitment maneuver followed by 5 cm H₂O of PEEP is inappropriate.

Keywords: cardiac surgery; obesity; positive end-expiratory pressure; randomized controlled trial; recruitment maneuver; respiratory failure.

Publication types

Randomized Controlled Trial

MeSH terms

Body Mass Index
Humans
Obesity / complications
Positive-Pressure Respiration
Pulmonary Atelectasis*
Respiratory Insufficiency* / etiology
Respiratory Insufficiency* / therapy