Positive end-expiratory pressure and emergence preoxygenation after bariatric surgery

BACKGROUND Positive end-expiratory pressure (PEEP) is important to increase lung volume and counteract airway closure during anaesthesia, especially in obese patients. However, maintaining PEEP during emergence preoxygenation might increase postoperative atelectasis by allowing susceptible lung areas to be filled with highly absorbable oxygen that gets entrapped when small airways collapse due to the sudden loss of PEEP at extubation. OBJECTIVE This study aimed to test the hypothesis that withdrawing PEEP just before emergence preoxygenation would better maintain postoperative oxygenation. DESIGN Prospective, randomised controlled trial. SETTING Single centre secondary hospital in Sweden between December 2019 and January 2023. PATIENTS A total of 60 patients, with body mass index between 35 and 50 kg m −2 , undergoing laparoscopic bariatric surgery. INTERVENTION Intraoperative ventilation was the same for all patients with a fixed PEEP of 12 or 14 cmH 2 O depending on body mass index. No recruitment manoeuvres were used. After surgery, patients were allocated to maintained PEEP or zero PEEP during emergence preoxygenation. MAIN OUTCOME MEASURES The primary outcome was change in oxygenation from before awakening to 45 min postoperatively as measured by estimated venous admixture calculated from arterial blood gases. RESULTS Both groups had impaired oxygenation postoperatively; in the group with PEEP maintained during awakening, estimated venous admixture increased by mean 9.1%, and for the group with zero PEEP during awakening, estimated venous admixture increased by mean 10.6%, difference −1.5% (95% confidence interval −4.6 to 1.7%), P = 0.354. Throughout anaesthesia, both groups exhibited low driving pressures and superior oxygenation compared with the awake state. CONCLUSIONS Withdrawing PEEP before emergence preoxygenation, did not alter early postoperative oxygenation in obese patients undergoing laparoscopic bariatric surgery. Intraoperative oxygenation was excellent despite using fixed PEEP and no recruitment manoeuvres, but deteriorated after extubation, indicating a need for future studies aimed at improving the emergence procedure. CLINICAL TRIAL NUMBER AND REGISTRY www.clinicaltrials.gov, NCT 04150276. Registration date: 4 November 2019. Principal investigator: Erland Östberg.