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Anesth Analg 2000;91:1520-1525
© 2000 International Anesthesia Research Society

GENERAL ARTICLES

The Effects of the Reverse Trendelenburg Position on Respiratory Mechanics and Blood Gases in Morbidly Obese Patients During Bariatric Surgery

Valter Perilli, MD, Liliana Sollazzi, MD, Patrizia Bozza, MD, Cristina Modesti, MD, Angelo Chierichini, MD, Roberto Maria Tacchino, MD, and Raffaela Ranieri, MD

Departments of *Anesthesiology and {dagger}Surgery, Catholic University of Sacred Heart Rome, Rome, Italy

Address correspondence and reprint requests to V. Perilli, MD, Department of Anesthesiology, Catholic University of Sacred Heart Rome, Largo A. Gemelli, 8, 00168 Roma, Italy.


   Abstract
Top
 Abstract
Introduction
 Methods
 Results
 Discussion
 References
 
Anesthesia adversely affects respiratory function, particularly in morbidly obese patients. Although many studies have been performed to determine the optimal ventilatory settings in these patients, this question has not been answered. The aim of this study was to evaluate the effect of reverse Trendelenburg position (RTP) on gas exchange and respiratory mechanics in 15 obese patients undergoing biliopancreatic diversion. A standardized anesthetic regimen was used and patients were examined at standard times: 1) after tracheal intubation, 2) after laparotomy, 3) after positioning of subcostal retractors, 4) with retractors in RTP. The measurements of respiratory mechanics were repeated for a wide range of tidal volumes by using the technique of rapid occlusion during constant flow inflation. We noted a wide alveolar-arterial oxygen difference [P(A-a)O2] in all patients, particularly during Phase 3. When the patients were placed in RTP, P(A-a)O2 showed a significant improvement and a return toward baseline values. As for mechanics, total respiratory system compliance was significantly higher in RTP than in the other phases. In conclusion, our data suggest that RTP is an appropriate intraoperative posture for obese subjects because it causes minimal arterial blood pressure changes and improves oxygenation.

Implications: The aim of the study was to assess whether the reverse Trendelenburg position could improve pulmonary gas exchange in obese patients undergoing abdominal surgical procedures. Our work may have a clinical value because few studies deal with this issue.


   Introduction
Top
 Abstract
 Introduction
Methods
 Results
 Discussion
 References
 
Amajor problem in anesthesia for morbidly obese patients is the adequacy of pulmonary ventilation (1,2). Anesthesia adversely affects respiratory function, leads to a smaller functional residual capacity (FRC), and promotes airway closure and atelectasis (2–4). In obese patients, FRC markedly decreases with possible hypoxemia in the perioperative period (5–9). Although many studies have been performed to determine the optimal ventilatory settings and posture in these patients, the question has not been resolved (2). In particular, there are few reports that deal with changes in respiratory mechanics and gas exchange in obese patients placed in reverse Trendelenburg position during general anesthesia. Furthermore, Buchwald (10) claimed that the use of a fixed-support retractor system and reverse Trendelenburg position is extremely useful in obese patients undergoing surgery of the upper abdomen.

Therefore, the aim of this study was to evaluate the effects of reverse Trendelenburg posture (RTP) on gas exchange variables and respiratory mechanics in obese patients undergoing abdominal surgery.


   Methods
Top
 Abstract
 Introduction
 Methods
Results
 Discussion
 References
 
After institutional approval, informed consent was obtained. We studied 15 otherwise healthy nonsmoking morbidly obese patients undergoing biliopancreatic diversion.

A standardized anesthetic regimen was used; after 5 min of breathing oxygen, anesthesia was induced with thiopental (3–5 mg/kg) and tracheal intubation was facilitated by succinylcholine (1 mg/kg IV). Anesthesia was maintained with incremental doses of fentanyl (up to 5 µg/kg), isoflurane, and N2O; neuromuscular blockade was induced with atracurium (0.5 mg/kg plus 0.5 mg · kg-1 · h-1).

Patients’ lungs were mechanically ventilated (Servo C; Siemens Elema AB, Berlin Germany) with constant inspiratory flow, aiming at an ETCO2 of 30 mm Hg; respiratory rate was 12 ± 2 breaths/min, tidal volume (TV) ranged from 6 to 8 mL per kg of body weight and was kept essentially constant throughout the surgical procedure with the fraction of inspired oxygen (FIO2) of 50%. No positive end-expiratory pressure was used and airway plateau pressure was maintained at a level of <=35 cm H2O.

In addition to the usual multiparametric monitoring, direct arterial pressure monitoring (radial artery catheter inserted after the induction) was used. The average time of the surgical procedure was 131 ± 36 min, and fluid administration consisted of 2–3 L lactated Ringer’s solution (8–10 mL · kg-1 · h-1).

Respiratory mechanics and blood gases were examined at the following standard times: 1) after tracheal intubation, 2) after laparotomy, 3) after positioning of subcostal retractors, and 4) with retractors in RTP (head up 30°). The time interval between each phase was never <20 min.

In these sets of measurements, end-expiratory and end-inspiratory airway occlusions have been obtained by using end-expiratory and end-inspiratory hold buttons of the Servo C for end-expiratory and end-inspiratory occlusion, respectively. The occlusion at the end of expiration provides measurement of intrinsic positive end-expiratory pressure. Specifically developed software provided online time-related trends of airway pressures during inspiratory and expiratory block. This system was based on a personal computer equipped with a 12-bit analog-to-digital converter (20 samples/s per channel) and connected with a Servo C37 pin analogic plug by using a short shielded cable. The use of this software allows elaboration of data in real time.

The measurement of respiratory mechanics was repeated for a wide range of TVs (6–8 different TVs for each patient) to obtain a volume/pressure curve for each patient in all phases. The different TVs were assessed by changing respiratory frequency on the ventilator, and after each measurement baseline ventilation was resumed. TVs ranged from 150 mL to 1200 mL and respiratory rates ranged from 6 to 30 breaths/min. During these maneuvers, SpO2 never decreased to <91%, and no muscular twitch was elicitable (Microstim Wellcome). No patient showed evidence of barotrauma on radiographs taken after surgery, and there were no pulmonary complications before hospital discharge.

The total respiratory system compliance (Ctot) was conventionally obtained by dividing the deflation volume by the difference between the plateau pressure measured during end-inspiratory airway occlusion (breath holding for 2–4 s) and end-expiratory pressure. In each phase before respiratory mechanics measurements, arterial blood samples were taken to evaluate pulmonary gas exchange. Alveolar-arterial oxygen difference [P(A-a)O2] was obtained from the following equation: Go


where PB is the actual barometric pressure, PH2O is the water vapor tension at 37°C, and RQ the respiratory quotient assumed to be 0.8.

A commercial software package (Statgraphics; SGS, Rockville, MD) was used for analysis of the data. Values were expressed as mean and SD unless otherwise stated; ranges are shown in Table 1. Statistical analysis was performed as analysis of variance followed by post hoc comparisons of means (Tukey) when the F values indicated significant differences among groups. Regression analysis was used to determine relationships (Pearson’s correlation coefficients) between variables. P < 0.05 was accepted as statistically significant.


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  		Table 1. Respiratory Data
 

   Results
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 Abstract
 Introduction
 Methods
 Results
Discussion
 References
 
Anthropometric and spirometric data are in Table 2; respiratory data are summarized in Table 1.


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  		Table 2. Anthropometric and Spirometric Data
 
A wide P(A-a)O2 occurred in all patients throughout the operation; the higher values coincided with the application of subcostal retractors. At this time (Phase 3), P(A-a)O2 showed a significant increase and PaO2 decreased. When the patients were placed in RTP, oxygenation improved with a return toward baseline values; P(A-a)O2 was ameliorated in 80% of the patients (12/15). As for respiratory mechanics, with the same ventilatory setting, average Ctot was higher and airway pressures were significantly lower in Phase 4 than in the other phases. Volume-pressure relationships were obtained in all phases for each patient; individual lines of regression and pooled data (with fitted lines) are shown in Figures 1 and 2. Correlations between airway pressures and TVs were found highly significant for both pooled and individual patients (Table 3). The slopes of Phases 1, 2, and 3 are significantly lower than that of Phase 4 (P < 0.01). Gas exchange variables showed a weak correlation with compliance [P(A-a)O2 vs Ctot r = -0.32, P < 0.03], whereas changes of P(A-a)O2 were more closely correlated with variations of Ctot (r = -0.45, P < 0.05). Stepwise regression analysis showed that FIO2 and Ctot accounted for 44% of change in PaO2. Other than diastolic blood pressure, cardiovascular variables did not change significantly (Table 4).



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  		Figure 1. Top, correlation between airways pressure (press) and tidal volume (vol) in Phase 1. Top left, all data points are shown (n = 143), r = 0.89 P < 0.001; top right, individual lines of correlation are shown. Bottom, correlation between airway pressure and tidal volume in Phase 2. Bottom left, all data points are shown (n = 150), r = 0.88 P < 0.001; bottom right, individual lines of correlation are shown.

 

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  		Table 3. Lines of Regression
 

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  		Table 4. Hemodynamic Data
 


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  		Figure 2. Top, correlation between airways pressure (press) and tidal volume (vol) in Phase 3. Top left, all data points are shown (n = 141), r = 0.90 P < 0.001; top right, individual lines of correlation are shown. Bottom, correlation between airway pressure and tidal volume in Phase 4. Bottom left, all data points are shown (n = 150), r = 0.91 P < 0.001; bottom right, individual lines of correlation are shown.

 

   Discussion
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
References
 
Measurement of respiratory mechanics can be useful for examining patients whose lungs are mechanically ventilated, and some techniques are suitable to evaluate anesthetized patients; we used one of these techniques, i.e., the rapid occlusion during constant flow inflation.

As previously mentioned, the maintenance of an adequate pulmonary ventilation and oxygenation may still be a major problem in anesthetized obese patients, because anesthesia significantly affects respiratory function. The decrease of FRC is one of the main side effects of anesthesia on respiratory function, and this change is particularly marked in morbidly obese patients (2,8,9,11–13). Pelosi et al. (14) demonstrated that the reduction of FRC is closely related to body mass index.

A cranial shift of the diaphragm has been identified as an important factor causing decrease of FRC in obese patients undergoing general anesthesia (8,14); the loss of tone of this muscle may determine the reduction in lung volume because of unopposed intra-abdominal pressure (8,14). However, also atelectasis seems related to a number of interacting factors that include the shape of chest wall structures, volume, and distribution of blood (14). In clinical practice, some morbidly obese patients do not tolerate the supine posture, and it may even be fatal to them (2,7,15).

Large TVs (15–20 mL/ideal body weight) are often recommended for these patients to move tidal ventilation higher than the closing volume and consequently increase arterial oxygen tension (2,5,7,16). This traditional approach to mechanical ventilation intends to aggressively recruit and ventilate atelectatic lung units, but may risk overdistention of the normal lung units. Thus, large TVs may cause a decrease in PaCO2, respiratory alkalosis, cardiovascular impairment, and excessive stretch of nondependent lung regions (2,16,17). Furthermore Bardoczky et al. (16) demonstrated that very large TVs do not improve oxygenation in obese patients.

However, even the use of positive end-expiratory pressure to increase FRC and improve oxygenation in obese patients is questionable (2,5). Although the use of positive end-expiratory pressure is of proven value for improving oxygenation in many situations involving respiratory failure, its role in anesthetized patients is controversial. In normal subjects, positive end-expiratory pressure can reduce the atelectasis but not necessarily the shunt (18); however, recently Pelosi et al. (19) claimed that positive end-expiratory pressure can improve oxygenation and respiratory mechanics in obese patients. Nevertheless, a possible detrimental effect of positive end-expiratory pressure on the oxygenation of obese patients has been described by Salem (20).

In this study performed during upper abdomen surgery, we used the RTP to counteract the weight of the abdominal contents and the effects of the retractors on the diaphragm. A wide P(A-a)O2 was observed in all of our patients in every phase, with a further significant increase during Phase 3; this worsening seems related to the application of subcostal retractors, which may cause a further decrease of FRC and a more limited movement of the diaphragm during mechanical ventilation. In Phase 4, with the patients placed in RTP without removing the retractors, oxygenation indexes improved, and P(A-a)O2 returned toward the baseline values.

As for respiratory mechanics, RTP determined a significant increase in the compliance that reached a level higher than baseline; the slopes of volume-pressure relationships in supine postures were less than that in RTP (Table 3). The increased compliance obtained by RTP and steeper volume/pressure regression lines suggest a recruitment of alveolar units and therefore an increase of FRC; thus the operating compliance could be improved by increasing end expiratory volume toward the more compliant range.

A limitation of our study might be the lack of the direct measure of FRC. However, because the reduction in FRC is most likely responsible for the decreased Ctot during general anesthesia, it is reasonable to argue that the increase of Ctot obtained with RTP can be related to an increased FRC (13,18). However, despite this significant increase in compliance, well above baseline values, P(A-a)O2 did not decrease much.

A weak correlation was found between compliance and P(A-a)O2 (r = -0.32; P <0.05; r = -0.45; P <0.05), meaning that other factors play a significant role in determining gas exchange efficiency.

As for hemodynamic factors, it is possible that RTP may compromise cardiovascular function by reducing venous return. Therefore, the beneficial effects of RTP on PaO2 could be offset by a decreased cardiac output. However, obese subjects show a reduced venous compliance and a smaller decrease of the central blood volume and of the cardiac stroke volume during orthostatic stress (21). Moreover, even if extensive hemodynamic monitoring has not been performed, no clinically relevant cardiovascular change was noted in our study.

Another reasonable explanation for this weak relationship between compliance and P(A-a)O2 could be the redistribution of pulmonary blood flow toward less-ventilated dependent zones along a gravitational gradient (22); so reversing the decrease in lung volume with RTP meets with limited success. In this regard, Heneghan et al. (23) showed that there was no improvement in oxygenation when lung volumes were increased significantly by RTP (head up 30°) in normal anesthetized subjects.

However, in our series, other than P(A-a)O2 values significantly wider than those found by Heneghan et al. (23) in normal subjects (P < 0.01), we found a correlation between P(A-a)O2 values of Phase 3 and the improvement in oxygenation obtained with RTP (r = -0.64; P < 0.001) (Figure 3); so the improvement in oxygenation obtained with RTP is greater when P(A-a)O2 is wider. This relationship, as well as the different type of patients, could explain the difference with Heneghan et al’s (23) study.



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  		Figure 3. Correlation between alveolar-arterial oxygen difference in Phase 3 and changes of alveolar-arterial oxygen difference [Delta P(A-a)O2] in Phase 4 is shown (y = ax b; intercept = loga a = 14.25 (SE 1.8) slope= -9.52 (SE = 0.32); r = -0.64; P < 0.001).

 
Moreover, in upper abdomen surgery of obese subjects, the exposure of the operative field creates major problems, and the use of a fixed-support retractor system greatly facilitates the surgeon (10). Like any procedure that increases the subdiaphragmatic pressure, it may make a further decrease in FRC and pulmonary compliance leading to hypoxemia (2). In this regard, the RTP offers potential advantages; it ameliorates the oxygenation indexes, exposes at best the subdiaphragmatic region, and allows mechanical ventilation with safe levels of airway pressures.

In conclusion, our data suggest that RTP is a simple and safe intraoperative posture for obese patients and offers some cardiorespiratory advantages during upper abdominal surgery.


   Acknowledgments
 
We express our thanks to Dr. A. Ceccarelli for his statistical analysis of original data presented in this article.


   References
Top
 Abstract
 Introduction
 Methods
 Results
 Discussion
 References
 

  1. Winer J, Brodsky JB, Merrell RC. Massive obesity and arterial oxygenation. Anesth Analg 1981; 60: 691–3.[Free Full Text]
  2. Øberg B, Poulsen TD. Obesity: an anesthetic challenge. Acta Anaesthesiol Scand 1996; 40: 191–200.[Web of Science][Medline]
  3. Hickey RF, Visick WD, Fairley HB, Fourcade HE. Effects of halothane on functional residual capacity and alveolar-arterial oxygen tension difference. Anesthesiology 1973; 38: 20–4.[Web of Science][Medline]
  4. Rehder K, Marsh M. Respiratory mechanics during anesthesia and mechanical ventilation. In: Macklem PT, Head J, eds. Handbook of physiology section 3, volume III: Mechanics of breathing part 2. Bethesda MD: American Physiological Society, 1986: 737–52.
  5. Shenkman Z, Shir Y, Brodsky JB. Perioperative management of the obese patient. Br J Anaesth 1993; 70: 349–59.[Free Full Text]
  6. Buckley FD. Anaesthesia for the morbidly obese patient. Can J Anaesthesiol 1994; 41: R94–100.
  7. Dumont L, Mattis M, Mardirosoff C, et al. Changes in pulmonary mechanics during laparoscopic gastroplasty in morbidly obese patients. Acta Anaesthesiol Scand 1997; 41: 408–13.[Web of Science][Medline]
  8. Pelosi P, Croci M, Ravagnan I, et al. Respiratory system mechanics in sedated, paralyzed, morbidly obese patients. J Appl Physiol 1997; 82: 811–8.[Abstract/Free Full Text]
  9. Damia G, Mascheroni D, Croci M, Tarenzi L. Perioperative changes in functional residual capacity in morbidly obese patients. Br J Anaesth 1988; 60: 574–8.[Abstract/Free Full Text]
  10. Buchwald H. Three helpful techniques for facilitating abdominal procedures, in particular for surgery in the obese. Am J Surg 1998; 175: 63–4.[Web of Science][Medline]
  11. Roothen HU, Sporre B, Engberg G, et al. Atelectasis and pulmonary shunting during induction of general anaesthesia: can they be avoided? Acta Anaesthesiol Scand 1996; 40: 191–200.
  12. Nunn JF. Effects of anaesthesia on respiration. Br J Anaesth 1990; 65: 54–62.[Free Full Text]
  13. Nunn JF. Respiratory aspects of anaesthesia. In: Nunn JF, eds. Applied physiology. 4th ed. Oxford: Butterworth-Heinemann, 1993: 384–417.
  14. Pelosi P, Croci M, Ravagnan I, et al. The effects of body mass index on lung volumes, respiratory mechanics, and gas exchange during general anesthesia. Anesth Analg 1998; 87: 654–60.[Abstract/Free Full Text]
  15. Tsueda K, Debrand M, Zeok SS, et al. Obesity supine death syndrome: reports of two morbidly obese patients. Anesth Analg 1978; 58: 345–7.[Free Full Text]
  16. Bardoczky GI, Yernault JC, Houben JJ, d’Hollander AA. Large tidal volume ventilation does not improve oxygenation in morbidly obese patients during anaesthesia. Anesth Analg 1995; 81: 385–8.[Abstract]
  17. MacIntyre NR. Minimizing alveolar stretch injury during mechanical ventilation.
  18. Tockics L, Hedenstierna G, Strandberg Å, et al. Lung collapse and gas exchange during general anesthesia: effects of spontaneous breathing, muscle paralysis, and positive end-expiratory pressure. Anesthesiology 1987; 66: 157–67.[Web of Science][Medline]
  19. Pelosi P, Ravagnan I, Giurati G, et al. Positive end-expiratory pressure improves respiratory function in obese but not in normal subjects during anesthesia and paralysis. Anesthesiol 1999; 91: 1221–31.[Web of Science][Medline]
  20. Salem MR. Does PEEP improve intraoperative arterial oxygenation in grossly obese patients? Anesthesiology 1978; 48: 280–2.[Web of Science][Medline]
  21. Stepniakowsky K, Egan BM. Additive effects of obesity and hypertension to limit venous volume. Am J Physiol 1995; 268: R562–8.[Abstract/Free Full Text]
  22. Pelosi P, Croci M, Calappi E., et al. Prone positioning improves pulmonary function in obese patients during general anesthesia. Anesth Analg 1996; 83: 578–83.[Abstract]
  23. Heneghan CPH, Bergman NA, Jones JG. Changes in lung volume and (PAO2-PaO2) during anaesthesia. Br J Anaesth 1984; 56: 437–45.[Abstract/Free Full Text]
Accepted for publication August 2, 2000.




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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press