Effects of Different PEEP Levels on Work of Breathing in Morbidly Obese Patients Prior to and After Extubation
| Status: | Recruiting |
|---|---|
| Conditions: | Obesity Weight Loss |
| Therapuetic Areas: | Endocrinology |
| Healthy: | No |
| Age Range: | 18 - Any |
| Updated: | 3/13/2019 |
| Start Date: | November 2015 |
| End Date: | June 30, 2020 |
| Contact: | Lorenzo Berra, MD |
| Email: | lberra@partners.org |
| Phone: | 6176437733 |
The main purpose of this study is to define at the bedside the "Titrated-PEEP" level for
obese patients that increases the likelihood of extubation and ventilator liberation.
The investigators hypothesized that a titrated level of PEEP ("Titrated-PEEP") during SBT
will keep the lung recruited, maintain oxygenation, and decrease the work of breathing
resulting in successful ventilator liberation. In addition, post-extubation the investigators
hypothesize that these patients will require noninvasive ventilatory support in the form of
CPAP at the level of "titrated-PEEP" used during the SBT.
obese patients that increases the likelihood of extubation and ventilator liberation.
The investigators hypothesized that a titrated level of PEEP ("Titrated-PEEP") during SBT
will keep the lung recruited, maintain oxygenation, and decrease the work of breathing
resulting in successful ventilator liberation. In addition, post-extubation the investigators
hypothesize that these patients will require noninvasive ventilatory support in the form of
CPAP at the level of "titrated-PEEP" used during the SBT.
The high WOB of morbidly obese patients is associated with respiratory muscle fatigue and
failure in extubation. The investigators hypothesized that the use of a titrated PEEP level
prior to and after extubation might improve successful extubation rates and avoid
re-intubation.
In this study, patients will be awake and ventilated in the pressure support ventilation
(PSV) mode. The investigators will apply different PEEP levels to measure WOB, transpulmonary
pressure and characterize the response of the respiratory system to increasing or decreasing
PEEP. The "Titrated-PEEP" will be identified as the PEEP level associated with the lowest
value of respiratory system elastance and an end expiratory transpulmonary pressure of 2
cmH2O. Then the participants will have two spontaneous breathing trials; one at PEEP 0-5
cmH2O, and the other at the "Titrated-PEEP" level, with PSV=0 and FiO2 unchanged. After
extubation, the participants will first receive CPAP set at "Titrated-PEEP", then spontaneous
breathing. Electrical impedance tomography (EIT), respiratory system mechanics and gas
exchange will be recorded during the study.
The investigators believe that the real-time determination of "Titrated-PEEP" can guide the
treatment of mechanical ventilation and give us a better understanding of the physiology and
pathophysiology of morbidly obese patients. As a result, this study will improve patient
safety; reduce the duration of mechanical ventilation, complications and healthcare costs.
failure in extubation. The investigators hypothesized that the use of a titrated PEEP level
prior to and after extubation might improve successful extubation rates and avoid
re-intubation.
In this study, patients will be awake and ventilated in the pressure support ventilation
(PSV) mode. The investigators will apply different PEEP levels to measure WOB, transpulmonary
pressure and characterize the response of the respiratory system to increasing or decreasing
PEEP. The "Titrated-PEEP" will be identified as the PEEP level associated with the lowest
value of respiratory system elastance and an end expiratory transpulmonary pressure of 2
cmH2O. Then the participants will have two spontaneous breathing trials; one at PEEP 0-5
cmH2O, and the other at the "Titrated-PEEP" level, with PSV=0 and FiO2 unchanged. After
extubation, the participants will first receive CPAP set at "Titrated-PEEP", then spontaneous
breathing. Electrical impedance tomography (EIT), respiratory system mechanics and gas
exchange will be recorded during the study.
The investigators believe that the real-time determination of "Titrated-PEEP" can guide the
treatment of mechanical ventilation and give us a better understanding of the physiology and
pathophysiology of morbidly obese patients. As a result, this study will improve patient
safety; reduce the duration of mechanical ventilation, complications and healthcare costs.
Inclusion Criteria:
- Intubated and mechanically ventilated;
- Weaning from mechanical ventilation;
- BMI ≥ 35 kg/m2 with waist circumference > 88 cm for women; waist circumference > 102
cm for men.
- A well functioning arterial line.
Exclusion Criteria:
- Known presence of esophageal varices
- Recent esophageal trauma or surgery
- Severe thrombocytopenia (PTL ≤ 5,000/mm3)
- Severe coagulopathy (INR ≥ 4)
- Presence of pneumothorax
- Pregnancy
- Pacemaker and/or internal cardiac defibrillator
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