How to ventilate obese patients in the ICU
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NARRATIVE REVIEW
How to ventilate obese patients in the ICU Audrey De Jong1, Hermann Wrigge2,3,4, Goran Hedenstierna5, Luciano Gattinoni6, Davide Chiumello6,7,8, Jean‑Pierre Frat9,10, Lorenzo Ball11,12, Miet Schetz13, Peter Pickkers14 and Samir Jaber1* © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
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. 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 refer‑ ence. The use of videolaryngoscopy has to be considered by adequately trained intensivists, especially in patients with several risk factors. Regarding mechanical ventilation in patients with and without acute respiratory distress syndrome (ARDS), low tidal volume (6 ml/kg of predicted body weight) and moderate to high positive end-expiratory pressure (PEEP), with careful recruitment maneuver in selected patients, are advised. Prone positioning is a therapeu‑ tic choice in severe ARDS patients with obesity. Prophylactic NIV should be considered after extubation to prevent re-intubation. If obesity increases mortality and risk of ICU admission in the overall population, the impact of obesity on ICU mortality is less clear and several confounding factors have to be taken into account regarding the “obesity ICU paradox”. Keywords: Obesity, Obese, HFNC, Mechanical ventilation, NIV, Prone position, Prone positioning, ARDS, COVID-19 Introduction Obesity (defined by a body mass index (BMI) ≥ 30 kg/ m2) is a disease caused by excess or abnormal distribution of fat tissue and resulting in chronic diseases related to chronic inflammation and metabolic dysfunction [1]. Obesity has become a global epidemic with prevalences rising both in developed and developing countries. Front runners in 2020 are the United States of America (USA, 36%) and Australasia (30%), with a prevalence expected to increase in the USA until 50% by 2030 [2], whereas
*Correspondence: s‑jaber@chu‑montpellier.fr 1 Research Unit: PhyMedExp, INSERM U‑1046, CNRS, Anesthesia and Critical Care Department (DAR‑B), Saint Eloi, University of Montpellier, 34295 Montpellier, cedex 5, France Full author information is available at the end of the article
European countries have prevalences between 20 and 30%. The percentage of patients with obesity in the intensive care unit (ICU) can be expected to increase concomitantly or even more since
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