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*
Ibrahim Ali Zabani, MBBS, FRCP,
PEMBA, FACPE*
Hassan Saad Abdelrahman, MD*
Waleed L. Bukhari, MD†
Irfan Mamoun, MD‡
Majed A. Ashour, MD‡
Bakr Bin Sadeq, MD§
Sameh Ibrahim El Sayed, MD㛳
BACKGROUND: Atelectasis occurs regularly after induction of general anesthesia,
persists postoperatively, and may contribute to significant postoperative morbidity
and additional health care costs. Laparoscopic surgery has been reported to be
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
patients but is especially important when caring for obese patients.
METHODS: We randomly allocated 66 adult obese patients with a body mass index
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
pressure (ZEEP) group (n ⫽ 22) received the vital capacity maneuver (VCM)
maintained for 7– 8 s applied immediately after intubation plus ZEEP; the positive
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
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
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
uneven ventilation perfusion ratios. In 1985, Brismar
et al.2 showed that within 5 min of induction of
general anesthesia, chest radiographs showed that
crest-shaped changes of increased density appeared in
the dependent regions of both lungs. In 1989, Heden-
stierna et al.3 also found densities in anesthetized
From the Departments of *Anesthesiology, †General Surgery,
‡Radiology, §Biostatistics, and 㛳Cardiothoracic Surgery, King Faisal
Specialist Hospital & Research Centre, Jeddah, Saudi Arabia.
Accepted for publication July 23, 2009.
Address correspondence and reprint requests to Sameh Ibrahim
El Sayed, MD, Cardiovascular Surgery Department, KFSH & RC,
Jeddah, Saudi Arabia, 21499, PO 40047. Address e-mail to
sameh001@yahoo.com.
Copyright © 2009 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e3181ba7945
animals, with the same location and attenuation as in
anesthetized humans. Microscopy showed that these
densities were atelectatic lung regions.4
Postoperative lung atelectasis develops with both
IV and inhaled anesthesia and whether the patient is
breathing spontaneously or is paralyzed and venti-
lated mechanically.5 The adverse effects of atelectasis
persist into the postoperative period and can affect
patient recovery.6
Up to 15% of the entire lung may be atelectatic
during anesthesia, particularly in the basal region,
resulting in a true pulmonary shunt of approximately
5%–10% of cardiac output.7 Laparoscopic surgery is
usually performed by intraabdominal insufflation of
carbon dioxide; this insufflation leads to an increase in
intraabdominal pressure. The increase in intraabdomi-
nal pressure could induce shift of the diaphragm

Vol. 109, No. 5, November 2009 1511

cranially and compression of basal lung regions. Thus,
the increase in intraabdominal pressure could accen-
tuate the effects of atelectasis already predisposed to
by general anesthesia, and therefore laparoscopic sur-
geries are associated with a frequent incidence of lung
atelectasis.8
During general anesthesia, as well as during the
immediate postoperative period, obese patients are
more likely than nonobese patients to develop atelec-
tasis that resolves more slowly.9 This is because of a
marked impairment of the respiratory mechanics (de-
creased chest wall and lung compliance and decreased
function residual capacity) promoting airway closure
with reduction of the oxygenation index (Pao2/PAo2)
to a greater extent than in healthy-weight subjects.10
Also, the weight of the torso and abdomen makes
diaphragmatic excursions more difficult, especially
when recumbent or supine, which is intensified in the
setting of diaphragmatic paralysis associated with
neuromuscular blockade.11 In obese patients, avoiding
atelectasis formation may be particularly difficult but
at the same time particularly important.12
Over the last several decades, different strategies
were used to reexpand collapsed lungs during general
anesthesia to “optimize” oxygenation. Atelectatic lung
tissue was fully reexpanded only with a pressure of 40
cm H2O maintained for 15 s. This pressure is equiva-
lent to inflation to vital capacity, and thus this maneu-
ver has been called the vital capacity maneuver
(VCM).13 More recently, it has been shown that this
maneuver needs to be maintained for only 7– 8 s in
order to reexpand all previously collapsed lung tis-
sue,14 but in laparoscopic surgery, the recruitment
effect of a single VCM may be lost after pneumoperi-
toneum, which necessitates a further recruitment ma-
neuver to keep the alveoli opened. Indeed, there have
been previous studies on this topic. Our study is
focused on preventing atelectasis in obese patients
undergoing laparoscopic bariatric surgeries. The aim
of this study was to evaluate the safety and efficacy of
the VCM followed by different levels of positive
end-expiratory pressure (PEEP) used to prevent post-
operative lung atelectasis in obese patients undergo-
ing laparoscopic bariatric surgery.
METHODS
After approval by our local Ethics and Research
Committee, 66 adult obese patients with a body mass
index (BMI) between 30 and 50 kg/m2, aged between
20 and 50 yr, and scheduled to undergo laparoscopic
bariatric surgery, were included in this prospective,
double-blind, controlled study after obtaining written
informed consent. Patients were fasted for at least 8 h
before the induction of anesthesia. Patients were ex-
cluded if they had been hospitalized more than 24 h
before surgery, had a history of heart or lung diseases,
had any clinical sign of cardiopulmonary disease
during preoperative physical examination (jugular
1512 Ventilatory Strategies for Prevention of Pulmonary Atelectasis
vein distension, gallop rhythm, hepatomegaly, tibial
edema, or rales on auscultation of the chest, or any
abnormalities in the preoperative 12-lead electrocar-
diogram or chest radiograph). If any complications
occurred that necessitated laparotomy, the patient was
excluded from the study.
Patients were premedicated with metoclopramide
10 mg IV, ranitidine 50 mg IV infusion, and oral
lorazepam 1 mg 1 h before induction of anesthesia.
Induction of anesthesia was achieved by administra-
tion of oxygen by facemask (100% O2) for 3–5 min
followed by 2–3 mg/kg propofol, 2 ␮g/kg fentanyl,
and 0.6 mg/kg rocuronium to facilitate tracheal intuba-
tion. Anesthesia was maintained using 2% sevoflurane,
1–2 ␮g 䡠 kg⫺1 䡠 h⫺1 fentanyl, and 0.2 mg/kg rocuro-
nium boluses every 30 min. In all patients, the lungs
were ventilated with volume-controlled ventilation
with a mixture of 50% oxygen in air, and a tidal
volume of 8 –10 mL/kg based on lean body weight.
Breathing rate was adjusted to maintain end-tidal
carbon dioxide partial pressure between 32 and 36
mm Hg. Carbon dioxide was insufflated into the
peritoneal cavity until the intraabdominal pressure
reached 11–15 mm Hg, which was maintained
throughout the procedure.
Crystalloid solution at a rate of 20 mL 䡠 kg⫺1 䡠 h⫺1
was administered to all patients starting immediately
before induction of anesthesia until patient position-
ing (modified lithotomy position–anti-Trendelenburg),
followed by 5 mL 䡠 kg⫺1 䡠 h⫺1 until the end of the
surgery. The arms and upper thorax of all patients
were covered with a warm air-stream blanket to
minimize heat loss. Intraoperative hypotension (de-
crease in mean arterial blood pressure [MAP] ⬎25% of
baseline) was treated with a bolus of normal saline
0.9% 250 mL and/or incremental doses of IV vasoac-
tive drugs (ephedrine 5 mg or phenylephrine 50 ␮g).
At the conclusion of surgery, sevoflurane was discon-
tinued, and Fio2 was increased to 100%. The muscle
relaxant was reversed by neostigmine 50 ␮g/kg and
0.015 mg/kg atropine sulfate. Tracheal extubation was
performed in a semisitting position after reaching
satisfactory criteria for extubation. Our extubation
criteria were as follows:
1. Intact neurological status; fully awake and alert;
head lift ⬎5 s
2. Hemodynamically stable
3. Normothermia; core temperature ⬎36°C
4. Full reversal of neuromuscular blocking drugs
5. Respiratory rate ⬎10 and ⬍30 breaths/min
6. Baseline peripheral oxygenation Spo2 ⬎95% on
Fio2 of 0.4
7. Vital capacity ⬎10 mL/kg ideal body weight;
tidal volume ⬎5 mL/kg ideal body weight
8. Acceptable pain control in the postanesthesia
care unit (PACU); patients were kept at head-up
tilt of 30°– 45°
ANESTHESIA & ANALGESIA
Table 1. Patients Excluded from the Study Groups and Relevant Reasons
ZEEP
Mesenteric bleeding
Postoperative bleeding
Desaturation in PACU required BiPAP &
ICU admission
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-
tion hypoxia, uninterrupted administration of oxygen
was continued until patients were transferred to the
PACU.
During the PACU stay, all patients were in a
semisitting position with supplemental oxygen by
Venturi facemask (Oximask; Tyco-Healthcare, Ken-
dall) (Fio2 35%). A nonrebreathing oxygen mask was
applied when oxygen saturation decreased to ⬍94%.
Postoperative analgesia was started in the PACU by
patient-controlled analgesia, 1-mg bolus of morphine
on demand with a lockout time of 6 min without
background infusion. The patients were discharged to
the ward after fulfilling the recovery criteria.15
Study Design
Patients were randomly allocated into 3 groups
according to the recruitment maneuver used: the zero
end-expiratory pressure (ZEEP) group (n ⫽ 22) re-
ceived the VCM maintained for 7– 8 s applied imme-
diately after intubation plus ZEEP, the 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 10 group (n ⫽ 22) received the VCM
maintained for 7– 8 s applied immediately after intuba-
tion plus 10 cm H2O of PEEP. All other variables were
maintained constant throughout the procedure.
The study protocol was designed to 1) discontinue
PEEP or VCM and start inotropic drugs in case of
persistent hypotension (decrease MAP ⬎25% of base-
line) after giving vasoactive drugs; and 2) discontinue
PEEP or VCM and change the ventilatory mode to
pressure-controlled ventilation. Patients with high air-
way pressure ⬎45 cm H2O were excluded from the
study (Table 1).
Measurements
Heart rate, noninvasive MAP, and arterial oxygen
saturation were measured at the following times:
T0: before induction of anesthesia breathing room air
T1: immediately after induction of anesthesia
T2: immediately after VCM
T3: immediately after establishing pneumoperitoneum
T4: immediately after patient positioning (modified
lithotomy position with anti-Trendelenburg)
T5: 30 min after establishing positioning
T6: 60 min after establishing positioning/end of
procedure
Vol. 109, No. 5, November 2009
PEEP 5 PEEP 10
Splenic bleeding Patient refused postoperative
CT scan
Patient refused the preoperative CT Persistent hypotension required
Scan PEEP discontinuation
Pawp ⱖ45 cm H2O required PEEP
discontinuation
T7: immediately after PACU admission
T8: before discharge from PACU
Arterial blood gas samples were taken preopera-
tively (T0) and postoperatively (T8) to measure partial
pressure of oxygen (Pao2) and to calculate alveolar-
arterial Pao2 gradient (A-a Pao2).
Alveolar Po2 was calculated from the alveolar gas
equation16:
Pio2 ⴝ FiO2(PB ⴚ PH2O)
where PAo2 is partial pressure of alveolar O2, Pio2 is
partial pressure of inspired O2, PB is barometric atmo-
spheric pressure (760 mm Hg), and PH2O is partial
pressure of water vapor (47 mm Hg at normal body
temperature).
Length of PACU stay and the need for nonrebreath-
ing O2 mask (100% Fio2) or reintubation were recorded.
Computed Tomographic Imaging
The chest computed tomographic (CT) imaging
was performed on hospital admission and after dis-
charge from the PACU. CT scans were interpreted by
radiologists who were aware of the experimental
protocol but unaware of patient group assignment.
Atelectasis was evaluated using a Siemens Volume
Zoom CT Scanner (Siemens Volume Zoom CT Scan-
ner, Erlangen, Germany). A tomogram film of the
chest was done with the patient in supine position and
his or her hand up. Four slices of 5-mm thickness were
obtained above the diaphragm. The CT images were
specifically evaluated for atelectasis, which was classi-
fied into 4 types depending on thickness: lamellar atel-
ectasis (⬍3 mm), plate atelectasis (3–10 mm), segmental
atelectasis (⬎10 mm but less than a lobe), and lobar
atelectasis (atelectasis involving the entire lower lobe).17
Statistical Analysis
The sample size for this study was based on the
assumption that a reduction of atelectasis of 35% or
more would be of clinical importance. Using the SPSS
program (version 14), analysis of variance (ANOVA)
test for numerical parametric data and ␹2 test for
ordinal and categorical data were applied, and a P
value of 0.05 or less was considered significant. One-
way ANOVA was used to compare the age, BMI, and
surgery time among the 3 study groups. Mixed between-
within subjects ANOVA (a combination of between-
groups ANOVA and repeated-measures ANOVA) was
© 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
Pressure Gradient
ZEEP PEEP 5
Preoperative 12.54 ⫾ 9.2 15.06 ⫾ 2.87 9.87 ⫾ 4.7
A-a gradient
Postoperative 63.23 ⫾ 35.12 53.05 ⫾ 30.42 29.85 ⫾ 18.83*
A-a gradient
PEEP ⫽ positive end-expiratory pressure; ZEEP ⫽ zero end-expiratory pressure.
* P ⬍ 0.05 in comparison with ZEEP and PEEP 5 groups.
Figure 1. Alveolar-to-arterial oxygen gradient (mm Hg) in
each study group preoperatively and postoperatively. All
groups showed a larger postoperative gradient compared
with the preoperative value. The positive end-expiratory
pressure (PEEP) 10 group has the smallest postoperative
gradient.
used to compare the repeated measures and between
groups. Nonparametric data, e.g., atelectasis or high Fio2
requirement were analyzed using the ␹2 test.
RESULTS
There were no statistically significant differences
among the 3 groups with regard to age, sex, ASA
1514 Ventilatory Strategies for Prevention of Pulmonary Atelectasis
physical status classification, duration of surgery, or
BMI (Table 2).
PEEP 10 Sixty-six patients were included in this double-
blind, prospective, randomized study. During the
study, 3 patients in the ZEEP group, 3 patients in the
PEEP 5 group, and 2 patients in the PEEP 10 group
were excluded (Table 1). There were no significant
differences in MAP and heart rate among the 3 study
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
the intensive care unit because of persistent hypox-
emia) and 3 patients in the PEEP 5 group (Table 5).
During the first 48 h postoperatively, no significant
desaturation, chest infection, or bronchospasm was
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
normal in all 3 study groups. Postoperatively, patients
in the PEEP 10 group had significantly less segmental
and lobar atelectasis (4 patients) compared with the
ZEEP and PEEP 5 groups (14 and 9 patients, respec-
tively) (Table 7). The postoperative atelectasis score
was comparable without significant differences be-
tween the ZEEP and PEEP 5 groups. No barotraumas
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
patients will have oxygen saturation ⬍90% and 20% of
patients will have severe hypoxemia (⬍85%). Russell
and Graybeal23 reported that, despite the use of 40%
oxygen given by facemask, 15% of patients in the
PACU will have oxygen saturation ⬍92% lasting ⬎30 s.
This event seems to prolong the PACU stay and cause
more intensive care admissions. In all previous stud-
ies, all patients were anesthetized for different types of
surgeries with volume-controlled ventilation without
any recruitment maneuver.
Postoperative pulmonary complications occurred
only in the ZEEP and PEEP 5 groups, which can be
explained by the increased frequency of atelectasis in
those groups. The same finding was reached by Mich-
elle et al.6 who reported that development of atelecta-
sis is associated with decreased lung compliance,
impairment of oxygenation, increased pulmonary vas-
cular resistance, and development of lung injury. The
adverse effects of atelectasis persist into the postop-
erative period and can affect patient recovery. The
absence of pulmonary complications in group PEEP
10 patients can be attributed to less atelectasis in those
patients.
The severity and effect of atelectasis are expected to
be increased in super morbidly obese patients with a
BMI ⬎50 kg/m2 compared with obese patients with a
BMI between 30 and 50 kg/m2, but the standard CT
table cannot support a patient weighing ⬎170 kg,
which is why we did not include patients with BMI
⬎50 kg/m2. We needed to be able to evaluate postop-
erative atelectasis by CT scan.
CONCLUSIONS
Intraoperative alveolar recruitment with the VCM
followed by PEEP of 10 cm H2O is more effective than
ZEEP or PEEP of 5 cm H2O for prevention of postop-
erative lung atelectasis and is associated with better
oxygenation, shorter PACU stay, and fewer pulmo-
nary complications in the immediate postoperative
period in obese patients undergoing laparoscopic bari-
atric surgery.
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