VENTILACIÓN EN EL PACIENTE OBESO, ESTADO DEL ARTE
Palabras clave:
Ventilación mecánica, paciente obeso, obesidad, índice de masa corporal (IMC), síndrome de apnea obstructiva del sueño (SAOS), fisiopatología respiratoria, distensibilidad pulmonar, capacidad residual funcional (CRF), trabajo respiratorio, ventilación no invasiva (VNI), presión de soporte (PS), relación PaO2/FiO2, maniobra de reclutamiento, pronóstico, mortalidad
Resumen
La obesidad es una enfermedad creciente, aceptada ya como epidemia con prevalencias de 25% en países desarrollados, es un importante factor de riesgo para complicaciones mayores, morbilidad y mortalidad relacionada con los procedimientos de intubación y ventilación en la unidad de cuidados intensivos (UCI). Esta revisión narrativa presenta el impacto de la obesidad en el sistema respiratorio y da puntos clave para optimizar el manejo de la vía aérea, la ventilación mecánica invasiva y no invasiva en pacientes con obesidad en la UCI. Se debe optimizar primero la posición del cuerpo con la posición de Trendelenburg inversa o la posición sentada.
La ventilación no invasiva (VNI) se considera la terapia de primera línea en pacientes con obesidad que tienen insuficiencia respiratoria aguda postoperatoria. La preoxigenación con presión positiva antes del procedimiento de intubación es el método de referencia. El uso de videolaringoscopia debe ser considerado por intensivistas adecuadamente entrenados, especialmente en pacientes con varios factores de riesgo.
Sobre la ventilación mecánica en pacientes con y sin dificultad respiratoria aguda (SDRA) el uso de bajo volumen tidal (6 ml/kg de peso corporal) y moderado a alto PEEP titulado de ser posible, con cuidadosa maniobra de reclutamiento en pacientes seleccionados. El posicionamiento prono es una terapéutica de elección en pacientes con SDRA grave y obesidad. Se debe considerar la VNI profiláctica después de la extubación para evitar reintubación. Aún queda por definir si la obesidad paradójica son fenotipos de esta población, si la medición seriedad de la presión intra abdominal y transplumonar pudiesen personalizar el manejo.
Citas
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Projected U.S. State-Level Prevalence of Adult Obesity and Severe
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2. Ahima RS, Lazar MA. The health risk of obesity - Better metrics
imperative. Science (80- ). 2013;341(6148):856–8.
3. Kullberg J, Brandberg J, Angelhed JE, Frimmel H, Bergelin E, Strid L,
et al. Whole-body adipose tissue analysis: Comparison of MRI, CT and
dual energy X-ray absorptiometry. Br J Radiol. 2009;82(974):123–30.
4. Bray MS, Loos RJF, McCaffery JM, Ling C, Franks PW, Weinstock
GM, et al. NIH working group report - Using genomic information to
guide weight management: From universal to precision treatment.
Obesity. 2016;24(1):14–22.
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epigenetics and metagenomics unveils the pathophysiology of human
obesity. Clin Sci. 2016;130(12):943–86.
6. Van Der Klaauw AA, Farooqi IS. The hunger genes: Pathways to
obesity. Cell. 2015;161(1):119–32.
7. Tchkonia T, Thomou T, Zhu Y, Karagiannides I, Pothoulakis C, Jensen
MD, et al. Mechanisms and metabolic implications of regional
differences among fat depots. Cell Metab. 2013;17(5):644–56.
8. McCullough AJ. The clinical features, diagnosis and natural history of
nonalcoholic fatty liver disease. Clin Liver Dis. 2004;8(3):521–33.
9. Kaur J. A comprehensive review on metabolic syndrome. Cardiol Res
Pract. 2014;2014.
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JS, et al. Effect of weight loss on upper airway size and facial fat in
men with obstructive sleep apnoea. Thorax. 2011;66(9):797–803.
11. Pelosi P, Croci M, Ravagnan I, Vicardi P, Gattinoni L. Total
Respiratory System, Lung, and Chest Wall Mechanics in Sedated-
Paralyzed Postoperative Morbidly Obese Patients. Chest.
1996;109(1):144–51.
12. Naimark A, Cherniack RM. Compliance of the respiratory system and
its components in health and obesity. J Appl Physiol. 1960;15:377–82.
13. Jones RL, Nzekwu MMU. The effects of body mass index on lung
volumes. Chest. 2006;130(3):827–33.
14. Grieco DL, Anzellotti GM, Russo A, Bongiovanni F, Costantini B,
D’Indinosante M, et al. Airway Closure during Surgical
Pneumoperitoneum in Obese Patients. Anesthesiology.
2019;131(1):58–73.
15. Hedenstierna G, Chen L, Brochard L. Airway closure, more harmful
than atelectasis in intensive care? Intensive Care Med.
2020;46(12):2373–6.
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Effects on gas exchange. Compr Physiol. 2012;2(1):69–96.
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Öhrvik J. Oxygenation Impairment during Anesthesia: Influence of
Age and Body Weight. Anesthesiology. 2019;131(1):46–57.
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distribution of pulmonary ventilation and perfusion in obesity. J Clin
Invest. 1967;46(4):475–81.
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obesity on oxygen cost of breathing (VO(2RESP)) at rest. Am J Respir
Crit Care Med. 1999;160(3):883–6.
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Neural respiratory drive in obesity. Thorax. 2009;64(8):719–25.
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care of the obese patient. Br J Surg. 2020;107(2):e39–55.
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obese patient undergoing surgery. J Thorac Dis. 2015;7(5):943–52.
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patients: From intubation to extubation. Crit Care. 2017;21(1):1–8.
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High Body Mass Index Is a Weak Predictor for Difficult and Failed
Tracheal Intubation. Anesthesiology. 2009;110(2):266–74.
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of obesity in mechanically ventilated patients: A prospective study.
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Respiratory system mechanics in sedated, paralyzed, morbidly obese
patients. J Appl Physiol. 1997;82(3):811–8.
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et al. Difficult tracheal intubation is more common in obese than in
lean patients. Anesth Analg. 2003;97(2):595–600.
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Complications of endotracheal intubation in the critically ill. Intensive
Care Med. 2008;34(10):1835–42.
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Clinical practice and risk factors for immediate complications of
endotracheal intubation in the intensive care unit: A prospective,
multiple-center study. Crit Care Med. 2006;34(9):2355–61.
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association between BMI and plasma cytokine levels in patients with
acute lung injury. Chest. 2010;138(3):568–77.
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et al. Noninvasive ventilation and alveolar recruitment maneuver
improve respiratory function during and after intubation of morbidly
obese patients: A randomized controlled study. En: Anesthesiology.
2011. p. 1354–63.
32. De Jong A, Futier E, Millot A, Coisel Y, Jung B, Chanques G, et al.
How to preoxygenate in operative room: Healthy subjects and
situations “at risk”. Ann Fr Anesth Reanim. 2014;33(7–8):457–61.
33. Futier E, Constantin JM, Petit A, Jung B, Kwiatkowski F, Duclos M,
et al. Positive end-expiratory pressure improves end-expiratory lung
volume but not oxygenation after induction of anaesthesia. Eur J
Anaesthesiol. 2010;27(6):508–13.
34. Gander S, Frascarolo P, Suter M, Spahn DR, Magnusson L. Positive
end-expiratory pressure during induction of general anesthesia
increases duration of nonhypoxic apnea in morbidly obese patients.
Anesth Analg. 2005;100(2):580–4.
35. Delay JM, Sebbane M, Jung B, Nocca D, Verzilli D, Pouzeratte Y, et al.
The effectiveness of noninvasive positive pressure ventilation to
enhance preoxygenation in morbidly obese patients: A randomized
controlled study. Anesth Analg. 2008;107(5):1707–13.
36. Langeron O, Masso E, Huraux C, Guggiari M. Prediction of Difficult
Mask Ventilation. Surv Anesthesiol. 2001;45(4):233–4.
37. De Jong A, Molinari N, Terzi N, Mongardon N, Arnal JM, Guitton C,
et al. Early identification of patients at risk for difficult intubation in
the intensive care unit: Development and validation of the MACOCHA
score in a multicenter cohort study. Am J Respir Crit Care Med.
2013;187(8):832–9.
38. Andersen LH, Rovsing L, Olsen KS. GlideScope videolaryngoscope vs.
Macintosh direct laryngoscope for intubation of morbidly obese
patients: A randomized trial. Acta Anaesthesiol Scand.
2011;55(9):1090–7.
39. Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, et al.
Official ERS/ATS clinical practice guidelines: Noninvasive ventilation
for acute respiratory failure. Vol. 50, European Respiratory Journal.
2017.
40. Jaber S, Delay JM, Chanques G, Sebbane M, Jacquet E, Souche B,
et al. Outcomes of patients with acute respiratory failure after
abdominal surgery treated with noninvasive positive pressure
ventilation. Chest. 2005;128(4):2688–95.
41. Stéphan F, Bérard L, Rézaiguia-Delclaux S, Amaru P. High-flow nasal
cannula therapy versus intermittent noninvasive ventilation in obese
subjects after cardiothoracic surgery. Respir Care. 2017;62(9):1193–
202.
42. Frat J-P, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al.
High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic
Respiratory Failure. N Engl J Med. 2015;372(23):2185–96.
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Vangrunderbeeck N, et al. Determinants of noninvasive ventilation
success or failure in morbidly obese patients in acute respiratory
failure. PLoS One. 2014;9(5):5–11.
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Binnekade JM, et al. Protective versus Conventional Ventilation for
Surgery: A Systematic Review and Individual Patient Data Meta- analysis. Anesthesiology. 2015;123(1):66–78.
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Obesity. N Engl J Med. 2019;381(25):2440–50.
2. Ahima RS, Lazar MA. The health risk of obesity - Better metrics
imperative. Science (80- ). 2013;341(6148):856–8.
3. Kullberg J, Brandberg J, Angelhed JE, Frimmel H, Bergelin E, Strid L,
et al. Whole-body adipose tissue analysis: Comparison of MRI, CT and
dual energy X-ray absorptiometry. Br J Radiol. 2009;82(974):123–30.
4. Bray MS, Loos RJF, McCaffery JM, Ling C, Franks PW, Weinstock
GM, et al. NIH working group report - Using genomic information to
guide weight management: From universal to precision treatment.
Obesity. 2016;24(1):14–22.
5. Pigeyre M, Yazdi FT, Kaur Y, Meyre D. Recent progress in genetics,
epigenetics and metagenomics unveils the pathophysiology of human
obesity. Clin Sci. 2016;130(12):943–86.
6. Van Der Klaauw AA, Farooqi IS. The hunger genes: Pathways to
obesity. Cell. 2015;161(1):119–32.
7. Tchkonia T, Thomou T, Zhu Y, Karagiannides I, Pothoulakis C, Jensen
MD, et al. Mechanisms and metabolic implications of regional
differences among fat depots. Cell Metab. 2013;17(5):644–56.
8. McCullough AJ. The clinical features, diagnosis and natural history of
nonalcoholic fatty liver disease. Clin Liver Dis. 2004;8(3):521–33.
9. Kaur J. A comprehensive review on metabolic syndrome. Cardiol Res
Pract. 2014;2014.
10. Sutherland K, Lee RWW, Phillips CL, Dungan G, Yee BJ, Magnussen
JS, et al. Effect of weight loss on upper airway size and facial fat in
men with obstructive sleep apnoea. Thorax. 2011;66(9):797–803.
11. Pelosi P, Croci M, Ravagnan I, Vicardi P, Gattinoni L. Total
Respiratory System, Lung, and Chest Wall Mechanics in Sedated-
Paralyzed Postoperative Morbidly Obese Patients. Chest.
1996;109(1):144–51.
12. Naimark A, Cherniack RM. Compliance of the respiratory system and
its components in health and obesity. J Appl Physiol. 1960;15:377–82.
13. Jones RL, Nzekwu MMU. The effects of body mass index on lung
volumes. Chest. 2006;130(3):827–33.
14. Grieco DL, Anzellotti GM, Russo A, Bongiovanni F, Costantini B,
D’Indinosante M, et al. Airway Closure during Surgical
Pneumoperitoneum in Obese Patients. Anesthesiology.
2019;131(1):58–73.
15. Hedenstierna G, Chen L, Brochard L. Airway closure, more harmful
than atelectasis in intensive care? Intensive Care Med.
2020;46(12):2373–6.
16. Hedenstierna G, Rothen HU. Respiratory function during anesthesia:
Effects on gas exchange. Compr Physiol. 2012;2(1):69–96.
17. Hedenstierna G, Tokics L, Scaramuzzo G, Rothen HU, Edmark L,
Öhrvik J. Oxygenation Impairment during Anesthesia: Influence of
Age and Body Weight. Anesthesiology. 2019;131(1):46–57.
18. Holley HS, Milic-Emili J, Becklake MR, Bates D V. Regional
distribution of pulmonary ventilation and perfusion in obesity. J Clin
Invest. 1967;46(4):475–81.
19. Kress JP, Pohlman AS, Alverdy J, Hall JB. The impact of morbid
obesity on oxygen cost of breathing (VO(2RESP)) at rest. Am J Respir
Crit Care Med. 1999;160(3):883–6.
20. Steier J, Jolley CJ, Seymour J, Roughton M, Polkey MI, Moxham J.
Neural respiratory drive in obesity. Thorax. 2009;64(8):719–25.
21. Carron M, Safaee Fakhr B, Ieppariello G, Foletto M. Perioperative
care of the obese patient. Br J Surg. 2020;107(2):e39–55.
22. Hodgson LE, Murphy PB, Hart N. Respiratory management of the
obese patient undergoing surgery. J Thorac Dis. 2015;7(5):943–52.
23. De Jong A, Chanques G, Jaber S. Mechanical ventilation in obese ICU
patients: From intubation to extubation. Crit Care. 2017;21(1):1–8.
24. Lundstrøm LH, Møller AM, Rosenstock C, Astrup G, Wetterslev J.
High Body Mass Index Is a Weak Predictor for Difficult and Failed
Tracheal Intubation. Anesthesiology. 2009;110(2):266–74.
25. Frat JP, Gissot V, Ragot S, Desachy A, Runge I, Lebert C, et al. Impact
of obesity in mechanically ventilated patients: A prospective study.
Intensive Care Med. 2008;34(11):1991–8.
26. Pelosi P, Croci M, Ravagnan I, Cerisara M, Vicardi P, Lissoni A, et al.
Respiratory system mechanics in sedated, paralyzed, morbidly obese
patients. J Appl Physiol. 1997;82(3):811–8.
27. Juvin P, Lavaut E, Dupont H, Lefevre P, Demetriou M, Dumoulin JL,
et al. Difficult tracheal intubation is more common in obese than in
lean patients. Anesth Analg. 2003;97(2):595–600.
28. Griesdale DEG, Bosma TL, Kurth T, Isac G, Chittock DR.
Complications of endotracheal intubation in the critically ill. Intensive
Care Med. 2008;34(10):1835–42.
29. Jaber S, Amraoui J, Lefrant JY, Arich C, Cohendy R, Landreau L, et al.
Clinical practice and risk factors for immediate complications of
endotracheal intubation in the intensive care unit: A prospective,
multiple-center study. Crit Care Med. 2006;34(9):2355–61.
30. Stapleton RD, Dixon AE, Parsons PE, Ware LB, Suratt BT. The
association between BMI and plasma cytokine levels in patients with
acute lung injury. Chest. 2010;138(3):568–77.
31. Futier E, Constantin JM, Pelosi P, Chanques G, Massone A, Petit A,
et al. Noninvasive ventilation and alveolar recruitment maneuver
improve respiratory function during and after intubation of morbidly
obese patients: A randomized controlled study. En: Anesthesiology.
2011. p. 1354–63.
32. De Jong A, Futier E, Millot A, Coisel Y, Jung B, Chanques G, et al.
How to preoxygenate in operative room: Healthy subjects and
situations “at risk”. Ann Fr Anesth Reanim. 2014;33(7–8):457–61.
33. Futier E, Constantin JM, Petit A, Jung B, Kwiatkowski F, Duclos M,
et al. Positive end-expiratory pressure improves end-expiratory lung
volume but not oxygenation after induction of anaesthesia. Eur J
Anaesthesiol. 2010;27(6):508–13.
34. Gander S, Frascarolo P, Suter M, Spahn DR, Magnusson L. Positive
end-expiratory pressure during induction of general anesthesia
increases duration of nonhypoxic apnea in morbidly obese patients.
Anesth Analg. 2005;100(2):580–4.
35. Delay JM, Sebbane M, Jung B, Nocca D, Verzilli D, Pouzeratte Y, et al.
The effectiveness of noninvasive positive pressure ventilation to
enhance preoxygenation in morbidly obese patients: A randomized
controlled study. Anesth Analg. 2008;107(5):1707–13.
36. Langeron O, Masso E, Huraux C, Guggiari M. Prediction of Difficult
Mask Ventilation. Surv Anesthesiol. 2001;45(4):233–4.
37. De Jong A, Molinari N, Terzi N, Mongardon N, Arnal JM, Guitton C,
et al. Early identification of patients at risk for difficult intubation in
the intensive care unit: Development and validation of the MACOCHA
score in a multicenter cohort study. Am J Respir Crit Care Med.
2013;187(8):832–9.
38. Andersen LH, Rovsing L, Olsen KS. GlideScope videolaryngoscope vs.
Macintosh direct laryngoscope for intubation of morbidly obese
patients: A randomized trial. Acta Anaesthesiol Scand.
2011;55(9):1090–7.
39. Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, et al.
Official ERS/ATS clinical practice guidelines: Noninvasive ventilation
for acute respiratory failure. Vol. 50, European Respiratory Journal.
2017.
40. Jaber S, Delay JM, Chanques G, Sebbane M, Jacquet E, Souche B,
et al. Outcomes of patients with acute respiratory failure after
abdominal surgery treated with noninvasive positive pressure
ventilation. Chest. 2005;128(4):2688–95.
41. Stéphan F, Bérard L, Rézaiguia-Delclaux S, Amaru P. High-flow nasal
cannula therapy versus intermittent noninvasive ventilation in obese
subjects after cardiothoracic surgery. Respir Care. 2017;62(9):1193–
202.
42. Frat J-P, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al.
High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic
Respiratory Failure. N Engl J Med. 2015;372(23):2185–96.
43. Lemyze M, Taufour P, Duhamel A, Temime J, Nigeon O,
Vangrunderbeeck N, et al. Determinants of noninvasive ventilation
success or failure in morbidly obese patients in acute respiratory
failure. PLoS One. 2014;9(5):5–11.
44. Serpa Neto A, Hemmes SNT, Barbas CSV, Beiderlinden M, Biehl M,
Binnekade JM, et al. Protective versus Conventional Ventilation for
Surgery: A Systematic Review and Individual Patient Data Meta- analysis. Anesthesiology. 2015;123(1):66–78.
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Publicado
2024-08-01
Cómo citar
Velarde, G., Godoy, A., & Godoy, M. (2024). VENTILACIÓN EN EL PACIENTE OBESO, ESTADO DEL ARTE. REFLEXIONES. Revista científica Del Hospital Eugenio Espejo, 21(2). https://doi.org/10.16921/reflexiones.v21i2.117
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