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Metrics details Abstract Obesity is an important risk factor for major complications, morbidity and mortality related to intubation procedures and ventilation in the intensive care unit ICU. The fall in functional residual capacity promotes airway closure and atelectasis formation.

INTRODUCTION

This narrative review presents the impact of obesity on the respiratory system and the key points to optimize airway management, noninvasive and invasive mechanical ventilation in ICU patients with obesity. Non-invasive strategies should first optimize body position with reverse Trendelenburg position or sitting position. Noninvasive ventilation NIV is considered as the first-line therapy in patients with obesity having a postoperative acute respiratory failure.

Positive pressure pre-oxygenation before the intubation procedure is the method of reference. The use of videolaryngoscopy has to be considered by adequately trained intensivists, especially in patients with several risk factors.

Prone positioning is a therapeutic choice in severe ARDS patients with obesity. Prophylactic NIV should be considered after extubation to prevent re-intubation.

  • Practical considerations for nutritional management of non-ICU COVID patients in hospital
  • E-mail: moc.
  • Abstract Background The ongoing coronavirus disease COVID pandemic has swept all over the world, posing a great pressure on critical care resources due to large number of patients needing critical care.

FormalPara Take-home message In patients with obesity, using non-invasive ventilation NIV is advised both to prevent and treat acute respiratory failure. When invasive mechanical ventilation is needed, pre-oxygenation with NIV and appropriated choice of intubation devices will decrease complications. During invasive mechanical ventilation, patients with obesity are more prone to lung collapse and require higher PEEP to avoid it; low VT is calculated on predicted body weight.

When acute respiratory distress syndrome occurs, careful recruitment maneuver might be used associated with prone positioning. Obesity has become a global epidemic with prevalences rising both in developed and developing countries.

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The percentage of patients with obesity in the intensive care unit ICU can be expected to increase concomitantly or even more since obesity increases the risk for a more severe disease course with more need for ICU admission and mechanical ventilation [ 3 ] as has been shown in trauma [ 4 ], traumatic brain injury [ 5 ] patients, out-of-hospital cardiac arrest [ 6 ], during the H1N1 pandemic [ 7 ] and recently also in patients affected by coronavirus disease COVID [ 891011 ].

Obesity, especially abdominal obesity android fat distribution and severe obesity [ 12 ], results in altered respiratory anatomy and physiology and, therefore, complicated airway management and adapted ventilator settings during mechanical ventilation. Obesity appears to be associated with an increased risk of acute respiratory distress syndrome ARDS [ 13 ] and infection, mainly pneumonia [ 14 ], probably related to an imbalanced production of adipokines [ 15 ].

In ventilated patients, obesity increases ICU length of stay and the duration of mechanical ventilation [ 16 ].

Dietetic Management

This narrative review will summarize current insights into the impact of obesity on the respiratory system and the measures to be taken to optimize airway management and mechanical ventilation in ICU patients with obesity. Respiratory modifications: pathophysiology The patient with obesity suffers from increased respiratory workload and impaired gas exchange. Both disturbances reduce physical capacity and health margin if exposed to respiratory stress. A basic triggering factor is reduced lung volume, caused by cranial displacement of the diaphragm by increased tissue mass in the abdomen, and by increased chest wall tissue.

The consequence of the increased tissue mass will be greater in the supine than upright position, due to a stronger cranial displacement of the diaphragm.

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In addition, a further decrease in the FRC can be seen during anesthesia with loss of respiratory muscle tone and, most likely, in ICU by the use of sedatives and muscle relaxants. The fall in FRC promotes airway closure and atelectasis formation, as will be discussed later, and an illustration of one representative case with no ventilation in the dorsal part of the lung, likely because of dependent atelectasis formation [ 18 ], is shown in Fig.

Note the ventral shift of ventilation during mechanical ventilation with a positive end-expiratory pressure PEEP of 5 cmH2O bwhich is likely due to atelectasis formation in dependent lung areas. Obviously, the PEEP level was insufficient to keep the lung open Full size image There are several causes of increased work of breathing in the patient with obesity. One is the increased displacement of tissue during the breathing, both in the abdomen and in the lung and chest wall.

Another is increased airway resistance because of smaller airway dimensions, and increased asthma incidence.

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Finally, increased tissue resistance adds to the work of breathing [ 19 ]. The patient with obesity may easily develop respiratory fatigue on physical exercise and, in the most severe cases, already at rest. It is often assumed that chest wall elastance or its inverse, chest wall compliance, is affected by obesity. However, the increased weight of the abdomen and of the chest wall requires work when moving the tissue, but when the move is over, no additional pressure is required [ 19 ].

Tracheal intubation in the ICU: Life saving or life threatening?

End-inspiratory and end-expiratory pauses should be long enough when measuring chest wall compliance. Lung compliance, on the other hand, is reduced [ 20 ].

The decreased lung volume may require pressure during inspiration to open closed units, and that may be recorded as a decrease in compliance.

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Airways may close in dependent lung regions during an expiration, a normal age-dependent phenomenon. While this has been known for many years, a more extensive, indeed complete airway closure has been shown during the last few years in anesthetised patients with obesity [ 21 ] or ICU patients with obesity on mechanical ventilation. This means that a certain airway pressure is needed to start inflation of the lungs and it is not caused by a time-dependent intrinsic positive end-expiratory pressure PEEP.

Where the complete closure occurs is not clear but may be in the most central airways and not in the periphery. The latter would require simultaneous closure of thousands of airways, as recently discussed [ 22 ].

Coronavirus: How to Redeploy Anesthesiology Resources to the ICU Setting | HealthLeaders Media

Hopefully, the morphology behind complete closure can be demonstrated in the near future. A consequence of the classic airway closure is impeded ventilation where the closure occurs and the decrease in ventilation will be larger the longer the closure lasts during the respiratory cycle.

If airways are continuously closed, as can be seen during anesthesia and most likely in ICU, the alveoli distal to the closure will collapse because of gas absorption [ 23 ].

The higher the oxygen concentration is in the inspired gas, the faster is the collapse. With pure oxygen, it can take a few minutes and with air, a couple of hours. The complete closure, on the other hand, will delay onset of inspiration without affecting the distribution per se. Uneven ventilation distribution caused by airway closure will occur primarily in dependent lung regions. Perfusion of the lung, on the other hand, increases down the lung independent of anatomy. Regions that are poorly but still ventilated will cause ventilation—perfusion mismatch and regions that collapse because of continuous airway closure will cause shunt [ 23 ].

Both impede oxygenation [ 24 ] and a large shunt may even impair carbon dioxide CO2 elimination.

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With an extreme shunt, oxygenation is poorly or not at all improved by increasing oxygen in the inspired gas. Finally, in patient with obesity, there is significant heterogeneity in both how to trade in icyu option and compliance, Therefore, inhomogeneous inflation or deflation of the lungs can cause dynamic pressure differences between regions and lead to interregional airflows known as pendelluft effect.

However, the patients with obesity are not a homogeneous group regarding the physiological modifications, the level of obesity and the fat distribution gynoid versus android being confounding factors that should be taken into account. Management of the acute respiratory failure patient Although hypoxemic acute respiratory failure ARF is not the first cause of ARF in the patient with obesity [ 2526 ], hypoxemia is frequent as it is favored by increased oxygen consumption or work of breathing and atelectasis formation, especially in cases of patients with morbid obesity and during ARF [ 27 ].

COVID With the coronavirus pandemic creating shortages of critical care staff and ventilators, anesthesiology resources can fill the gaps. Operating room anesthesiologists and their equipment are well-suited to help treat coronavirus disease COVID patients, an anesthesiology expert says. In COVID hotspots such as New York City, there are shortages of critical care personnel and ventilators to treat severely ill coronavirus patients, and these shortages are expected to spread nationwide. To help address these shortages, OR anesthesiologists and their anesthesia gas machines, which include a ventilator function, are being shifted to ICU settings. All anesthesiologists get a minimum of four months of concentrated work in intensive care units during a residency, and many other anesthesiologists also complete a fellowship year in critical care medicine and become board-certified in critical care medicine, Peterson says.

In patients having postoperative hypoxemia or ARF, non-invasive ventilation NIV is recommended with moderate certainty of evidence, justified by a decreased need of intubation, mortality and morbidity as compared to standard oxygen [ 3031 ]. However, according to physiological abnormalities in patients with obesity, NIV could play a role, especially in patients with morbid obesity, through PEEP that may improve oxygenation and lung volume or alveolar recruitment [ 39 ].

Hypercapnic ARF in patients with obesity can not only be part of the clinical course of cardiogenic pulmonary edema, pneumonia, asthma, and exacerbation of chronic lung diseases, but also may be due to exacerbation of obesity hypoventilation syndrome OHS [ 40 ].

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Positive airway pressure, i. Similarly, NIV is the usual treatment applied in OHS exacerbation, but no trial has evaluated its benefit as compared to other oxygen strategies.

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NIV brings together potentially beneficial physiological effects, including PEEP preserving upper airway patency and pressure support to control central hypoventilation. Airway management In addition to the pathophysiological modification of the respiratory system discussed above, patients with obesity have peculiar morphological alterations potentially associated with difficulties during mask ventilation and airway management: reduced neck mobility, limited mouth opening, increased size of pharyngeal and glossal soft tissues, unfavorable conformation and positioning of the larynx, increased neck circumference and decreased thyromental distance [ 41 ].

Moreover, patients with obesity have a high incidence of obstructive sleep apnea [ 42 ], which is directly related to many of the complications occurring during airway management of this sub-population of critically ill patients [ 43 ]. Obesity contributes to airway compression through increased airway fat deposits [ 44 ], and placing the patient with obesity recumbent may lead to sudden death [ 36 ].

It is very important to encourage upright positioning and avoid supine positioning. Most of the literature existing on how to trade in icyu option airway management of patients with obesity is related to the operating room setting [ 46 ]. However, compared to the elective surgical patient with obesity, the intubation of the critically ill patient has profound differences in indications, timing and co-existing conditions; therefore, caution should be applied when translating in the ICU the recommendations based on evidence in the operating room.

In the ICU, the incidence of difficult intubation how to trade in icyu option double compared to the OR and the occurrence of severe complications is dramatically higher [ 46 ].

How to ventilate obese patients in the ICU | SpringerLink

Pre-procedural patient preparation is key to successful intubation. An ideal preparation aims at prolonging time-to-desaturation, which in patients with obesity is mainly related to the rapid loss of FRC after sedation. Concerning positioning, a randomized controlled trial questioned the usefulness of the ramped position applied in critically ill patients [ 48 ]; however, the study included a large proportion of patients without obesity.

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Conventional bag-mask ventilation can result in rapid desaturation in patients with morbid obesity. Several studies confirmed that pre-oxygenation with CPAP or NIV improves oxygenation allowing a longer time window for intubation [ 3949 ]. For these reasons, positive pressure pre-oxygenation should be considered the reference in critically ill patients with obesity, considering that obesity carries an intrinsic increased risk for difficult mask ventilation.

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HFNC might also have a role [ 50 ], especially in rapid sequence intubation in non-severely hypoxemic patients, where avoidance of bag ventilation might be desirable but is associated with higher incidence of severe desaturation [ 51 ].

However, the value of HFNC value in patients with obesity how to make money quickly in mrr be clarified, and cannot replace a preoxygenation using positive pressure [ 52 ]. The intubation maneuver should be always considered as potentially difficult in patients with obesity [ 46 ], with older age, higher BMI, high Mallampati and MACOCHA scores and reduced neck mobility being independent risk factors for both difficult mask ventilation and intubation.

Offer high energy, high protein menu, snacks and drinks e. Check biochemistry and follow local policy Nutrition support may need to be escalated to enteral tube feeding if dependence on oxygen therapy reduces capacity for oral intake, these patients should be referred to Dietetics Enteral tube feeding should be implemented when nutritional needs cannot be met by the oral route e. Many patients with COVID have pre-existing co-morbidities including cardiovascular disease and diabetes. Poorly controlled blood glucose has an adverse impact on outcome.

A meta-analysis in surgical patients with obesity suggested an advantage of videolaryngoscopes over direct laryngoscopy [ 47 ]. In ICU patients with obesity, it seems reasonable to consider the use of videolaryngoscopes by adequately trained intensivists, especially in patients with several risk factors. Mechanical ventilation in non-ARDS patients Translated concepts from anesthesia to ICU Obesity is associated with abdominal and thoracic tissue mass, which transmit additional hydrostatic pressure via the chest wall and diaphragm to the pleural space and, thus, the alveoli.

If pleural pressure is higher than intra-alveolar pressure, the alveoli will collapse, and compression atelectasis will occur predominantly how to trade in icyu option dependent lung areas, where hydrostatic pressure is highest. The main mechanism of gas exchange impairment is, therefore, shunt atelectasis in patients with obesity [ 24 ].

Recruitment maneuver Because the opening pressure of alveoli is higher than the pressure needed to keep them open, application of an initial recruitment maneuver RM followed by adequate PEEP after intubation or disconnection of the patient from the ventilatory circuit seems intuitive.

Due to the high pleural pressure in patients with obesity, opening pressures up to 50 cmH2O applied during a RM in patients with obesity without lung injury may not result in full lung recruitment [ 53 ]. Potential side effects of applying such high airway pressures include a decrease in venous return and, thus, cardiac preload with a drop in cardiac output and systemic blood pressure. In addition, barotrauma such as pneumothorax or pneumomediastinum especially in patients with pre-existing structural lung damage such as emphysema, and a mechanically triggered boost of pre-existing lung inflammation may occur.

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