Recruitable alveolar collapse and overdistension during laparoscopic gynecological surgery and mechanical ventilation : a prospective clinical study

Background: Laparoscopic surgery in the Trendelenburg position may compromise mechanical ventilation due to positioning and high intra-abdominal pressure. We sought to determine the levels of positive end-expiratory pressure (PEEP) required to achieve an equilibrium between hyperdistension and alveolar collapse ("Best-Compromise-PEEP") and to counteract atelectasis ("Open-Lung-PEEP").

Methods: In 30 patients undergoing laparoscopic gynaecological surgery, relative hyperdistension and alveolar collapse were assessed by electrical impedance tomography (EIT) during a decremental PEEP trial (20-4 cmH2O) in the supine position without and in the Trendelenburg position with capnoperitoneum.

Results: In the supine position, median Best-Compromise-PEEP was 8 (6.5-10) cmH2O with 4.2 (2.4-7.2)% hyperdistension and 5.1 (3.9-6.5)% collapse. Meanwhile the Open-Lung-PEEP was 12 (8-14) cmH2O with 8.7 (4.7-15.5)% hyperdistension and 1.7 (0.4-2.2)% collapse. In the Trendelenburg position with capnoperitoneum, Best-Compromise-PEEP was 18 (16-20) cmH2O (p < 0.0001 vs. supine position) with 1.5 (0.7-3.0)% hyperdistension and 0.2 (0-2.7)% collapse and Open-Lung-PEEP was 18 (18-20) cmH2O (p < 0.0001 vs. supine position) with 1.8 (0.5-3.9)% hyperdistension and 0 (0-1. 2)% collapse. Best-Compromise- and Open-Lung-PEEP were positively correlated with body-mass-index during mechanical ventilation in the supine but not in the Trendelenburg position. 

Conclusion: PEEP levels required in Trendelenburg with capnoperitoneum are markedly higher than in supine position, yet without relevant hyperdistension. A positive correlation between body-mass-index and Best-Compromise-PEEP, as well as Open-Lung-PEEP was found in the supine position, but not in the Trendelenburg position with capnoperitoneum.

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