Technology, Computing, and Simulation

Section Editor: Dwayne Westenskow

Intraoperative Ventilatory Strategies for Prevention of

Pulmonary Atelectasis in Obese Patients Undergoing
Laparoscopic Bariatric Surgery
Hesham F. Talab, MD* BACKGROUND: Atelectasis occurs regularly after induction of general anesthesia,
persists postoperatively, and may contribute to significant postoperative morbidity
Ibrahim Ali Zabani, MBBS, FRCP, and additional health care costs. Laparoscopic surgery has been reported to be
PEMBA, FACPE* associated with an increased incidence of postoperative atelectasis. It has been
shown that during general anesthesia, obese patients have a greater risk of
atelectasis than nonobese patients. Preventing atelectasis is important for all
Hassan Saad Abdelrahman, MD* patients but is especially important when caring for obese patients.
METHODS: We randomly allocated 66 adult obese patients with a body mass index
Waleed L. Bukhari, MD† between 30 and 50 kg/m2 scheduled to undergo laparoscopic bariatric surgery into
3 groups. According to the recruitment maneuver used, the zero end-expiratory
Irfan Mamoun, MD‡ pressure (ZEEP) group (n ⫽ 22) received the vital capacity maneuver (VCM)
maintained for 7– 8 s applied immediately after intubation plus ZEEP; the positive
Majed A. Ashour, MD‡ end-expiratory pressure (PEEP) 5 group (n ⫽ 22) received the VCM maintained for
7– 8 s applied immediately after intubation plus 5 cm H2O of PEEP; and the PEEP
Bakr Bin Sadeq, MD§ 10 group (n ⫽ 22) received the VCM maintained for 7– 8 s applied immediately
after intubation plus 10 cm H2O of PEEP. All other variables (e.g., anesthetic and
surgical techniques) were the same for all patients. Heart rate, noninvasive mean
Sameh Ibrahim El Sayed, MD㛳 arterial blood pressure, arterial oxygen saturation, and alveolar-arterial Pao2
gradient (A-a Pao2) were measured intraoperatively and postoperatively in the
postanesthesia care unit (PACU). Length of stay in the PACU and the use of a
nonrebreathing O2 mask (100% Fio2) or reintubation were also recorded. A
computed tomographic scan of the chest was performed preoperatively and
postoperatively after discharge from the PACU to evaluate lung atelectasis.
RESULTS: Patients in the PEEP 10 group had better oxygenation both intraopera-
tively and postoperatively in the PACU, lower atelectasis score on chest computed
tomographic scan, and less postoperative pulmonary complications than the ZEEP
and PEEP 5 groups. There was no evidence of barotrauma in any patient in the 3
study groups.
CONCLUSIONS: Intraoperative alveolar recruitment with a VCM followed by PEEP 10
cm H2O is effective at preventing lung atelectasis and is associated with better
oxygenation, shorter PACU stay, and fewer pulmonary complications in the
postoperative period in obese patients undergoing laparoscopic bariatric surgery.
(Anesth Analg 2009;109:1511–6)

I n 1964, Nunn1 showed that during routine general

anesthesia, gas exchange was altered by shunt and
animals, with the same location and attenuation as in
anesthetized humans. Microscopy showed that these
uneven ventilation perfusion ratios. In 1985, Brismar densities were atelectatic lung regions.4
et al.2 showed that within 5 min of induction of Postoperative lung atelectasis develops with both
general anesthesia, chest radiographs showed that IV and inhaled anesthesia and whether the patient is
crest-shaped changes of increased density appeared in breathing spontaneously or is paralyzed and venti-
the dependent regions of both lungs. In 1989, Heden- lated mechanically.5 The adverse effects of atelectasis
stierna et al.3 also found densities in anesthetized persist into the postoperative period and can affect
From the Departments of *Anesthesiology, †General Surgery,
patient recovery.6
‡Radiology, §Biostatistics, and 㛳Cardiothoracic Surgery, King Faisal Up to 15% of the entire lung may be atelectatic
Specialist Hospital & Research Centre, Jeddah, Saudi Arabia. during anesthesia, particularly in the basal region,
Accepted for publication July 23, 2009.
resulting in a true pulmonary shunt of approximately
Address correspondence and reprint requests to Sameh Ibrahim
El Sayed, MD, Cardiovascular Surgery Department, KFSH & RC, 5%–10% of cardiac output.7 Laparoscopic surgery is
Jeddah, Saudi Arabia, 21499, PO 40047. Address e-mail to usually performed by intraabdominal insufflation of
[email protected]. carbon dioxide; this insufflation leads to an increase in
Copyright © 2009 International Anesthesia Research Society intraabdominal pressure. The increase in intraabdomi-
DOI: 10.1213/ANE.0b013e3181ba7945
nal pressure could induce shift of the diaphragm

Vol. 109, No. 5, November 2009 1511

cranially and compression of basal lung regions. Thus, vein distension, gallop rhythm, hepatomegaly, tibial
the increase in intraabdominal pressure could accen- edema, or rales on auscultation of the chest, or any
tuate the effects of atelectasis already predisposed to abnormalities in the preoperative 12-lead electrocar-
by general anesthesia, and therefore laparoscopic sur- diogram or chest radiograph). If any complications
geries are associated with a frequent incidence of lung occurred that necessitated laparotomy, the patient was
atelectasis.8 excluded from the study.
During general anesthesia, as well as during the Patients were premedicated with metoclopramide
immediate postoperative period, obese patients are 10 mg IV, ranitidine 50 mg IV infusion, and oral
more likely than nonobese patients to develop atelec- lorazepam 1 mg 1 h before induction of anesthesia.
tasis that resolves more slowly.9 This is because of a Induction of anesthesia was achieved by administra-
marked impairment of the respiratory mechanics (de- tion of oxygen by facemask (100% O2) for 3–5 min
creased chest wall and lung compliance and decreased followed by 2–3 mg/kg propofol, 2 ␮g/kg fentanyl,
function residual capacity) promoting airway closure and 0.6 mg/kg rocuronium to facilitate tracheal intuba-
with reduction of the oxygenation index (Pao2/PAo2) tion. Anesthesia was maintained using 2% sevoflurane,
to a greater extent than in healthy-weight subjects.10 1–2 ␮g 䡠 kg⫺1 䡠 h⫺1 fentanyl, and 0.2 mg/kg rocuro-
Also, the weight of the torso and abdomen makes nium boluses every 30 min. In all patients, the lungs
diaphragmatic excursions more difficult, especially
were ventilated with volume-controlled ventilation
when recumbent or supine, which is intensified in the
with a mixture of 50% oxygen in air, and a tidal
setting of diaphragmatic paralysis associated with
volume of 8 –10 mL/kg based on lean body weight.
neuromuscular blockade.11 In obese patients, avoiding
Breathing rate was adjusted to maintain end-tidal
atelectasis formation may be particularly difficult but
carbon dioxide partial pressure between 32 and 36
at the same time particularly important.12
mm Hg. Carbon dioxide was insufflated into the
Over the last several decades, different strategies
were used to reexpand collapsed lungs during general peritoneal cavity until the intraabdominal pressure
anesthesia to “optimize” oxygenation. Atelectatic lung reached 11–15 mm Hg, which was maintained
tissue was fully reexpanded only with a pressure of 40 throughout the procedure.
cm H2O maintained for 15 s. This pressure is equiva- Crystalloid solution at a rate of 20 mL 䡠 kg⫺1 䡠 h⫺1
lent to inflation to vital capacity, and thus this maneu- was administered to all patients starting immediately
ver has been called the vital capacity maneuver before induction of anesthesia until patient position-
(VCM).13 More recently, it has been shown that this ing (modified lithotomy position–anti-Trendelenburg),
maneuver needs to be maintained for only 7– 8 s in followed by 5 mL 䡠 kg⫺1 䡠 h⫺1 until the end of the
order to reexpand all previously collapsed lung tis- surgery. The arms and upper thorax of all patients
sue,14 but in laparoscopic surgery, the recruitment were covered with a warm air-stream blanket to
effect of a single VCM may be lost after pneumoperi- minimize heat loss. Intraoperative hypotension (de-
toneum, which necessitates a further recruitment ma- crease in mean arterial blood pressure [MAP] ⬎25% of
neuver to keep the alveoli opened. Indeed, there have baseline) was treated with a bolus of normal saline
been previous studies on this topic. Our study is 0.9% 250 mL and/or incremental doses of IV vasoac-
focused on preventing atelectasis in obese patients tive drugs (ephedrine 5 mg or phenylephrine 50 ␮g).
undergoing laparoscopic bariatric surgeries. The aim At the conclusion of surgery, sevoflurane was discon-
of this study was to evaluate the safety and efficacy of tinued, and Fio2 was increased to 100%. The muscle
the VCM followed by different levels of positive relaxant was reversed by neostigmine 50 ␮g/kg and
end-expiratory pressure (PEEP) used to prevent post- 0.015 mg/kg atropine sulfate. Tracheal extubation was
operative lung atelectasis in obese patients undergo- performed in a semisitting position after reaching
ing laparoscopic bariatric surgery. satisfactory criteria for extubation. Our extubation
criteria were as follows:

METHODS 1. Intact neurological status; fully awake and alert;

After approval by our local Ethics and Research head lift ⬎5 s
Committee, 66 adult obese patients with a body mass 2. Hemodynamically stable
index (BMI) between 30 and 50 kg/m2, aged between 3. Normothermia; core temperature ⬎36°C
20 and 50 yr, and scheduled to undergo laparoscopic 4. Full reversal of neuromuscular blocking drugs
bariatric surgery, were included in this prospective, 5. Respiratory rate ⬎10 and ⬍30 breaths/min
double-blind, controlled study after obtaining written 6. Baseline peripheral oxygenation Spo2 ⬎95% on
informed consent. Patients were fasted for at least 8 h Fio2 of 0.4
before the induction of anesthesia. Patients were ex- 7. Vital capacity ⬎10 mL/kg ideal body weight;
cluded if they had been hospitalized more than 24 h tidal volume ⬎5 mL/kg ideal body weight
before surgery, had a history of heart or lung diseases, 8. Acceptable pain control in the postanesthesia
had any clinical sign of cardiopulmonary disease care unit (PACU); patients were kept at head-up
during preoperative physical examination (jugular tilt of 30°– 45°

1512 Ventilatory Strategies for Prevention of Pulmonary Atelectasis ANESTHESIA & ANALGESIA
Table 1. Patients Excluded from the Study Groups and Relevant Reasons
ZEEP PEEP 5 PEEP 10
Mesenteric bleeding Splenic bleeding Patient refused postoperative
CT scan
Postoperative bleeding Patient refused the preoperative CT Persistent hypotension required
Scan PEEP discontinuation
Desaturation in PACU required BiPAP & Pawp ⱖ45 cm H2O required PEEP
ICU admission discontinuation
BiPAP ⫽ biphasic positive airway pressure; ICU ⫽ intensive care unit; Pawp ⫽ peak airway pressure; PACU ⫽ postanesthesia care unit; CT ⫽ computed tomography; ZEEP ⫽ zero end-expiratory
pressure; PEEP ⫽ positive end-expiratory pressure.

To prevent development of immediate postextuba- T7: immediately after PACU admission

tion hypoxia, uninterrupted administration of oxygen T8: before discharge from PACU
was continued until patients were transferred to the Arterial blood gas samples were taken preopera-
PACU. tively (T0) and postoperatively (T8) to measure partial
During the PACU stay, all patients were in a pressure of oxygen (Pao2) and to calculate alveolar-
semisitting position with supplemental oxygen by arterial Pao2 gradient (A-a Pao2).
Venturi facemask (Oximask; Tyco-Healthcare, Ken- Alveolar Po2 was calculated from the alveolar gas
dall) (Fio2 35%). A nonrebreathing oxygen mask was equation16:
applied when oxygen saturation decreased to ⬍94%.
Postoperative analgesia was started in the PACU by Pio2 ⴝ FiO2(PB ⴚ PH2O)
patient-controlled analgesia, 1-mg bolus of morphine
on demand with a lockout time of 6 min without where PAo2 is partial pressure of alveolar O2, Pio2 is
background infusion. The patients were discharged to partial pressure of inspired O2, PB is barometric atmo-
the ward after fulfilling the recovery criteria.15 spheric pressure (760 mm Hg), and PH2O is partial
pressure of water vapor (47 mm Hg at normal body
Study Design temperature).
Patients were randomly allocated into 3 groups Length of PACU stay and the need for nonrebreath-
according to the recruitment maneuver used: the zero ing O2 mask (100% Fio2) or reintubation were recorded.
end-expiratory pressure (ZEEP) group (n ⫽ 22) re-
ceived the VCM maintained for 7– 8 s applied imme- Computed Tomographic Imaging
diately after intubation plus ZEEP, the PEEP 5 group The chest computed tomographic (CT) imaging
(n ⫽ 22) received the VCM maintained for 7– 8 s was performed on hospital admission and after dis-
applied immediately after intubation plus 5 cm H2O of charge from the PACU. CT scans were interpreted by
PEEP, and the PEEP 10 group (n ⫽ 22) received the VCM radiologists who were aware of the experimental
maintained for 7– 8 s applied immediately after intuba- protocol but unaware of patient group assignment.
tion plus 10 cm H2O of PEEP. All other variables were Atelectasis was evaluated using a Siemens Volume
maintained constant throughout the procedure. Zoom CT Scanner (Siemens Volume Zoom CT Scan-
The study protocol was designed to 1) discontinue ner, Erlangen, Germany). A tomogram film of the
PEEP or VCM and start inotropic drugs in case of chest was done with the patient in supine position and
persistent hypotension (decrease MAP ⬎25% of base- his or her hand up. Four slices of 5-mm thickness were
line) after giving vasoactive drugs; and 2) discontinue obtained above the diaphragm. The CT images were
PEEP or VCM and change the ventilatory mode to specifically evaluated for atelectasis, which was classi-
pressure-controlled ventilation. Patients with high air- fied into 4 types depending on thickness: lamellar atel-
way pressure ⬎45 cm H2O were excluded from the ectasis (⬍3 mm), plate atelectasis (3–10 mm), segmental
study (Table 1). atelectasis (⬎10 mm but less than a lobe), and lobar
atelectasis (atelectasis involving the entire lower lobe).17
Measurements
Statistical Analysis
Heart rate, noninvasive MAP, and arterial oxygen
The sample size for this study was based on the
saturation were measured at the following times:
assumption that a reduction of atelectasis of 35% or
T0: before induction of anesthesia breathing room air more would be of clinical importance. Using the SPSS
T1: immediately after induction of anesthesia program (version 14), analysis of variance (ANOVA)
T2: immediately after VCM test for numerical parametric data and ␹2 test for
T3: immediately after establishing pneumoperitoneum ordinal and categorical data were applied, and a P
T4: immediately after patient positioning (modified value of 0.05 or less was considered significant. One-
lithotomy position with anti-Trendelenburg) way ANOVA was used to compare the age, BMI, and
T5: 30 min after establishing positioning surgery time among the 3 study groups. Mixed between-
T6: 60 min after establishing positioning/end of within subjects ANOVA (a combination of between-
procedure groups ANOVA and repeated-measures ANOVA) was
Vol. 109, No. 5, November 2009 © 2009 International Anesthesia Research Society 1513
Table 2. Patient Characteristics and Duration of Surgery
Statistical test PEEP 10 group PEEP5 group ZEEP group
F (2,63) ⫽ 2.4, P ⫽ 0.1 29.3 ⫾ 9.2 34.2 ⫾ 9.3 28.9 ⫾ 8.5
␹2, df 2 ⫽ 1.48, P ⫽ 0.93 7/15 6/16 6/16
F (2,63) ⫽ 4, P ⫽ 0.022 38.30 ⫾ 6.85 44.53 ⫾ 6.99* 41.8 ⫾ 7.9
␹2, df 2 ⫽ 0.85, P ⫽ 0.65 13/9 10/12 11/11
F (2,63) ⫽ 1.56, P ⫽ 0.217 104.3 ⫾ 49.5 131.4 ⫾ 72 105.7 ⫾ 43.4
Values are numbers, mean ⫾ SD, number or ratio.
ZEEP ⫽ zero end-expiratory pressure; PEEP ⫽ positive end-expiratory pressure; BMI ⫽ body mass index.
* P ⬍ 0.05 in comparison with PEEP 10 groups.

Table 3. HR and MAP in the 3 Groups During the Study Period

MAP (mm Hg) HR (bpm)

PEEP 10 PEEP 5 ZEEP PEEP 10 PEEP 5 ZEEP

T0 93.57 ⫾ 9.37 93.90 ⫾ 8.55 93.68 ⫾ 10.75 82.67 ⫾ 10.19 84.45 ⫾ 12.91 86.82 ⫾ 13.14
T1 84.71 ⫾ 10.95 91.45 ⫾ 12.74 87.00 ⫾ 13.56 77.48 ⫾ 12.65 86.80 ⫾ 15.23 84.55 ⫾ 12.18
T2 80.24 ⫾ 15.68 90.80 ⫾ 13.12 82.73 ⫾ 9.90 82.10 ⫾ 12.77 84.85 ⫾ 13.27 84.05 ⫾ 9.21
T3 80.86 ⫾ 13.94 87.40 ⫾ 14.64 83.41 ⫾ 15.18 76.76 ⫾ 10.90 80.85 ⫾ 12.12 85.09 ⫾ 16.86
T4 72.43 ⫾ 14.49 77.25 ⫾ 14.18 81.45 ⫾ 14.85 82.43 ⫾ 13.23 85.30 ⫾ 11.82 87.55 ⫾ 16.16
T5 80.52 ⫾ 1273 78.65 ⫾ 12.52 83.50 ⫾ 11.44 83.29 ⫾ 10.37 82.35 ⫾ 11.20 86.50 ⫾ 13.98
T6 85.00 ⫾ 10.73 82.80 ⫾ 12.31 88.86 ⫾ 9.63 81.24 ⫾ 10.55 83.30 ⫾ 11.22 84.64 ⫾ 11.43
T7 91.29 ⫾ 10.07 92.55 ⫾ 11.09 92.00 ⫾ 6.10 79.48 ⫾ 10.85 86.70 ⫾ 12.55 85.64 ⫾ 11.64
T8 92.05 ⫾ 9.20 92.00 ⫾ 10.58 88.64 ⫾ 9.19 77.14 ⫾ 8.30 84.50 ⫾ 9.32 80.95 ⫾ 10.85
T0 ⫽ before induction of anesthesia breathing room air; T1 ⫽ immediately after induction of anesthesia; T2 ⫽ immediately after vital capacity maneuver (VCM); T3 ⫽ immediately after
establishing pneumoperitonium; T4 ⫽ immediately after patient positioning (modified lithotomy position with anti-Trendelenberg); T5 ⫽ 30 min after establishing positioning; T6 ⫽ 60 min after
establishing positioning/end of procedure; T7 ⫽ immediately after postanesthesia care unit (PACU) admission; T8 ⫽ before discharge from PACU; MAP ⫽ mean arterial blood pressure;
HR ⫽ heart rate; PEEP ⫽ positive end-expiratory pressure; ZEEP ⫽ zero end-expiratory pressure.

Table 4. Preoperative and Postoperative Alveolar⫺Arterial physical status classification, duration of surgery, or
Pressure Gradient BMI (Table 2).
ZEEP PEEP 5 PEEP 10 Sixty-six patients were included in this double-
blind, prospective, randomized study. During the
Preoperative 12.54 ⫾ 9.2 15.06 ⫾ 2.87 9.87 ⫾ 4.7
A-a gradient study, 3 patients in the ZEEP group, 3 patients in the
Postoperative 63.23 ⫾ 35.12 53.05 ⫾ 30.42 29.85 ⫾ 18.83* PEEP 5 group, and 2 patients in the PEEP 10 group
A-a gradient were excluded (Table 1). There were no significant
PEEP ⫽ positive end-expiratory pressure; ZEEP ⫽ zero end-expiratory pressure. differences in MAP and heart rate among the 3 study
* P ⬍ 0.05 in comparison with ZEEP and PEEP 5 groups. groups (Table 3), and there was a significant decrease
of postoperative A-a gradient in the PEEP 10 com-
pared with the ZEEP and PEEP 5 groups (Table 4 and
Fig. 1). Time spent in the PACU was significantly
shorter in the PEEP 10 group compared with both the
ZEEP and PEEP 5 groups. During PACU stay, only 1
patient in the PEEP 10 group needed oxygen from a
nonrebreathing O2 mask (Fio2 100%) compared with 5
patients in the ZEEP group (1 of them transferred to
Figure 1. Alveolar-to-arterial oxygen gradient (mm Hg) in the intensive care unit because of persistent hypox-
each study group preoperatively and postoperatively. All emia) and 3 patients in the PEEP 5 group (Table 5).
groups showed a larger postoperative gradient compared During the first 48 h postoperatively, no significant
with the preoperative value. The positive end-expiratory
pressure (PEEP) 10 group has the smallest postoperative desaturation, chest infection, or bronchospasm was
gradient. noted in the PEEP 10 group, compared with 4 and 3
patients in the ZEEP and PEEP 5 groups, respectively
(Table 6). All of the preoperative CT scans were
used to compare the repeated measures and between normal in all 3 study groups. Postoperatively, patients
groups. Nonparametric data, e.g., atelectasis or high Fio2 in the PEEP 10 group had significantly less segmental
requirement were analyzed using the ␹2 test. and lobar atelectasis (4 patients) compared with the
ZEEP and PEEP 5 groups (14 and 9 patients, respec-
RESULTS tively) (Table 7). The postoperative atelectasis score
There were no statistically significant differences was comparable without significant differences be-
among the 3 groups with regard to age, sex, ASA tween the ZEEP and PEEP 5 groups. No barotraumas
1514 Ventilatory Strategies for Prevention of Pulmonary Atelectasis ANESTHESIA & ANALGESIA
Table 5. Length of Stay in Postanesthesia Care Unit (PACU) and Need for 100% FIO2
ZEEP group PEEP 5 group PEEP 10 group
Length of stay in PACU (min) 87.95 ⫾ 35.31 77.50 ⫾ 20.35 66.90⫾18.60*ANOVA
Need for 100% Fio2 in PACU, n (%) 5 (26.3%) 3 (16.7%) 1 (4.5%)* ␹
Values are mean (SD) and n (%).
PEEP ⫽ positive end-expiratory pressure; ZEEP ⫽ zero end-expiratory pressure; ANOVA ⫽ analysis of variance.
* P ⬍ 0.05 in comparison with ZEEP and PEEP groups.

Table 6. Postoperative Pulmonary Complications ZEEP group. Also, there was no significant difference
in the atelectasis score between the 2 groups, i.e.,
PEEP PEEP
application of 5 cm H2O PEEP did not improve
ZEEP group 5 group 10 group
oxygenation and did not decrease atelectasis forma-
Desaturation 2 2 0
tion. This is in contrast to Azab et al.8 who concluded
Chest infection 1 1 0
Bronchospasm 1 0 0 that PEEP (5 cm H2O) prevents deoxygenation during
PEEP ⫽ positive end-expiratory pressure; ZEEP ⫽ zero end-expiratory pressure.
pneumoperitoneum and leads to a lower atelectasis
score on CT scan examination up to 2 h postopera-
Table 7. Number and Percentage of Patients in the 3 Groups tively. However, their study used nonobese patients,
According to Their Atelectasis Score whereas our study was conducted on obese patients
with a BMI ⬎30 kg/m2 who had lower functional
ZEEP PEEP 5 PEEP 10 residual capacity in whom PEEP 5 cm H2O may not be
group group group enough to reopen collapsed alveoli after induction of
Normal 0 (0%) 0 (0%) 2 (10%) anesthesia.
Lamellar atelectasis 2 (10.5%) 4 (21%) 11 (55%)*
In this study, a VCM followed by 10 cm H2O of
Plate atelectasis 3 (15.78%) 6 (31.57%) 3 (15%)
Segmental 13 (68.42%) 9 (47.3%) 4 (20%)* PEEP was accompanied by better intraoperative and
Lobar 1 (5.26%) 0 (0%) 0 (0%) postoperative oxygenation in addition to a lower
Values are n (%). atelectasis score in chest CT scan done approximately
PEEP ⫽ positive end-expiratory pressure; ZEEP ⫽ zero end-expiratory pressure. 2 h postoperatively in comparison with the VCM
* P ⬍ 0.05 in comparison with ZEEP and PEEP groups. alone. Coussa et al.19 had similar results and con-
cluded that application of PEEP (10 cm H2O) in mor-
(pneumothorax, air in mediastinum, or subcutaneous bidly obese patients was very effective for preventing
emphysema) were detected in chest CT scans in any atelectasis during induction of general anesthesia.
patient in the 3 study groups. This is in contrast to Rothen et al.13 who found that the
VCM alone could completely abolish atelectasis that
DISCUSSION developed after induction of general anesthesia. This
Even though this study indicated positive benefits can be explained by the difference in patient popula-
from the VCM and PEEP, there are potential disad- tions because they applied the VCM to nonobese
vantages as well. Increased intrathoracic pressure as a patients undergoing nonlaparoscopic surgery com-
result of PEEP or VCM may reduce the pressure pared with obese patients undergoing laparoscopic
gradient along which blood returns to the heart. This surgery in our study.
reduces right ventricular preload, right ventricular In animal experiments, the VCM had no deleterious
output, and ultimately cardiac output. This may lead pulmonary effects as measured by extra vascular lung
to a reduction in MAP and pooling of blood in the water, pulmonary clearance of 99mTc-diethylene tri-
abdomen and peripheries, especially in patients who are amine pentaacetic acid (DTPA) (which is a marker of
hypovolemic and in those whose adaptive cardiac re- the functional integrity of the alveolocapillary barrier),
serves are blunted by intrinsic disease or medication.18 and light microscopy in pigs that received repeated
In this study, application of PEEP and VCM was VCM hourly for 6 h.20 Similarly, in this study, no
not accompanied by a significant reduction in MAP, pneumothorax, air in the mediastinum, or subcutane-
even after pneumoperitoneum and positioning (modi- ous emphysema was detected in chest CT scan done
fied lithotomy position and anti-Trendelenburg). This postoperatively in any patient in the 3 study groups.
can be explained by sufficient preoperative preload Many previous studies have investigated postop-
with crystalloid solution (20 mL 䡠 kg⫺1 䡠 h⫺1) for all erative hypoxemia in the PACU. Mathes et al.21 found
patients. Similarly, Azab et al.8 found in their study that, on arrival to the PACU, 20% of patients may have
that application of 5 cm H2O PEEP was not accompa- an oxygen saturation ⬍92% and in 10% the saturation
nied by any reduction in MAP in patients undergoing may be ⬍90%. Xue et al.22 reported that, in the PACU
laparoscopic cholecystectomy. In our study, there was within 3 h of surgery, 7% of patients will have at least
no significant change in intraoperative or postopera- 1 episode of desaturation ⬍90% and 3% will desatu-
tive oxygen saturation and A-a gradient in patients rate to ⬍85%. This incidence is increased for thoraco-
who received 5 cm H2O PEEP compared with the abdominal procedures, in which more than half of the
Vol. 109, No. 5, November 2009 © 2009 International Anesthesia Research Society 1515
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Brismar B, Frostell C. Pulmonary densities during anaesthesia.
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1516 Ventilatory Strategies for Prevention of Pulmonary Atelectasis ANESTHESIA & ANALGESIA