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How to ventilate the obese ? ff ? patients? It is really different?

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How to ventilate the obese
patients?
? It is really different?
ff
?
Critical Care Canada Forum
October 2525-28 , 2009 Toronto
Dr AndrГ©s Esteban
Dr.
Intensive Care and Burn Service
пѓј No relationships to disclose
Origin
• bariatrics was derived in the 20th
century from the Greek baros
(meaning heavy)
• iatrics ((med-ical treatment)) and
means the science of providing
healthcare for this population
p p
Source International Obesity Task Force 2003
Rising morbid obesity
3,5
Men
3
Women
Lineal (Women)
2,5
Lineal (Men)
2
1,5
1
0,5
0
1993
1994
1995
1996
1997
Source: Health Survey of England
UK Adults 19931993-2002
1998
1999
2000
2001
2002
2003
P. G. Kopelman
Nature 2000;404:635
E.Calle,M.J.Thun,et al.
N Engl J Med 1999;341:1097
E.Calle,M.J.Thun,et al.
N Engl J Med 1999;341:1097
Patients with
Patients with
Patients with
Normal BMI
Overweight
Obese BMI
p
value
644 В± 112
698 В± 128
680 В± 136
NS
Tidal volume
per Kg predict
body w. (ml/Kg)
10.05 В± 1.60
10.56 В± 1.85
10.76 В± 2.22
NS
Static
compliance
p
(ml/cm2)
34.9 В± 13.3
35.5 В± 13.7
34.8 В± 22.0
NS
Pplat
28.9 В± 7.9
30.4 В± 7.4
31.8 В± 8.1
NS
Ppeak
35.5 В± 9.5
36.7 В± 8.6
39.5 В± 9.5
NS
Tidal volume
(ml)
J. M. O’Brien, C. H. Welsh, et al
Ann Intern Med 2004;140:338
Main--Effects Model for Death at 28 Days, Including Indicators
Main
of Excess Body Weight
Variable
Odds Ratio (95% CI)
p value
• Age
1 037 (1
1.037
(1.025
025 – 1.050)
1 050)
<0.001
<0 001
• Apache III score
1.020 (1.013 – 1.027)
<0.001
• PaO2/FiO2 ratio
0.996 (0.993 – 0.999)
0.0044
• Assignment to higher tidal volume
1.688 (1.166 – 2.444)
0.0055
• Peak airway pressure at study enrollment
1.025 (1.003 – 1.048)
0.0237
• Trauma as primary lung injury category
0 322 (0
0.322
(0.120
120 – 0.863)
0 863)
0 0243
0.0243
• Female sex
1.168 (0.802 – 1.700)
>0.2
• Assignment to ketoconazole or lisofyline
0.944 (0.619 – 1.441)
>0.2
Covariates
Excess body weight variables
• BMI category
>0.2
• Overweight BMI versus normal BMI
1 096 (0
1.096
(0.711
711 – 1.690)
1 690)
• Obese BMI versus normal BMI
1.111 (0.693 – 1.782)
A prospective cohort of patients with ALI (1999(1999-2000)
18 hospital with ICUs in King
g County,
y Washington
g
825 patients includedincluded-with BMI recorded
BMI groups:
<18.5
Kg/m2
18 5 – 24.9
18.5
24 9 Kg/m2
25.0 – 34.9 Kg/m2
35 0 – 39.9
35.0
39 9 Kg/m2
>40
Kg/m2
underweight
normal
overweight
obese
severly obese
A.E.Morris,R.D.Stapleton,et al.
Chest 2007;131:342
25
Hospital LOS
20
Mean
15
Difference
10
(Days)
5
All patients
Survivors
0
-5
-10
10
Mean
ICU LOS
5
Difference
(Days)
0
-5
10
Mean
Duration of Mech. Vent.
5
Difference
((Days)
y )
0
-5
Underweight
Overweight
Obese
Severely Obese
A.E.Morris,R.D.Stapleton,et al.
Chest 2007;131:342
2
Mortality
Odds
Ratio
1
0
Underweight
Overweight
Obese
Severely Obese
A.E.Morris,R.D.Stapleton,et al.
Chest 2007;131:342
4698 patients with Mechanical Ventilation > 12 h.
1789 (56 %)
over--weight
over
i ht
(BMI >25 K
Kg/m
/ 2)
797 (16 %)
obese
216 (4 %)
severesevere-obese
(BMI 30
30--Kg/m2)
(BMI >40 Kg/m2)
A. Anzueto, F. Frutos
Frutos--Vivar, A. Esteban,N.Ferguson et al.
(Submitted)
40
35
30
25
20
15
10
5
0
U d
Under
N
Normal
l
O
Over-weight
i ht
Ob
Obese
SevereS
obese
A. Anzueto, F. FrutosFrutos-Vivar, A. EstebanN.Ferguson, et al.
(Submitted)
Demographic characteristics of study patients
Underweight
Normal
Overweight
Obese
Severe
obese
184 (3.7%)
(3 7%)
1995 (40%)
1781(35.8%)
1781(35 8%)
792(15.9%)
792(15 9%)
216(4 34%)
216(4.34%)
Age, years, mean (SD)
55 (19)
57 (19)
61 (17)
61 (14)
55 (14)
<0.001
BMI k
BMI,
kg/m
/ 2, mean (SD)
17 (1)
23 (2)
27 (1)
33 (3)
50 (11)
<0 001
<0.001
Female, n (%)
84 (46)
823 (41)
586 (33)
357 (45)
117 (54)
< 0.001
SAPS II,
II points,
points mean
(SD)
43 (19)
43 (18)
43 (17)
44 (17)
42 (17)
0.60
129 (70)
1189 (60)
997 (56)
472 (60)
134 (62)
N (%)
P
value
Problem, n (%)
п‚· Medical
0.002
п‚· Surgical
55 (30)
800 (40)
778 (44)
319 (40)
82 (38)
A. Anzueto, F. FrutosFrutos-Vivar, A. EstebanN.Ferguson, et al.
(Submitted)
C
Comparison
i
off th
the mode
d off ventilation,
til ti
ventilator
til t settings,
tti
use of sedatives weaning outcomes by BMI group
Underweight
Normal
Overweight
Obese
Severe
obese
184
1995
1781
792
216
Non--invasive ventilation (%)
Non
25 (14)
183 (9)
155 (9)
84 (11)
32 (15)
0.01
в—Џ Successful, n (%)
15 (60)
118 (64)
83 (53)
51 (61)
19 (59)
0.40
N
P value
Ventilator settings
Day 1 of mechanical ventilation
в—Џ Tidal volume
ml/kg ABW,
ABW mean (SD)
11 (2
(2.5)
5)
9 (1.8)
(1 8)
7 (1.5)
(1 5)
6 5 (1
6.5
(1.4)
4)
5 (1.5)
(1 5)
<0 001
<0.001
ml/kg PBW, mean (SD)
8.2 (1.8)
8.9(1.9)
9.1 (2.1)
10.1(2.6)
11.1 (3.9)
<0.001
в—Џ PEEP, cm of water, mean (SD)
5 (3)
5 (3)
5.5 (3)
5.5 (3)
6 (4)
<0.001
pressure, cm of water,
в—Џ Peak p
mean (SD)
25 (8)
26 (8)
27 (8)
28 (9)
31 (10)
<0.001
<0 001
в—Џ Plateau pressure, cm of water,
mean (SD)
21 (6)
21 (6)
21 (6)
22 (6)
25 (7)
<0.001
Comparison of the mode of ventilation, ventilator settings,
use of sedatives weaning outcomes by BMI group
Underweight
Normal
Overweight
Obese
Severe
obese
P value
Ventilator settings
Day 3 of mechanical ventilation
в—Џ Tidal volume
ml/kg ABW, mean (SD)
10.5(2.6)
8 (1.8)
7 (1.5)
6 (1.4)
5 (1.2)
<0.001
ml/kg PWB, mean (SD)
8.1 (1.8)
8.7 (1.9)
9 (2.1)
9.8 (2.6)
10.4 (3.8)
<0.001
в—Џ PEEP, cm of water, mean (SD)
6 (4)
6.5 (4)
6.5 (4)
7 (4.6)
7 (5.4)
0.004
в—Џ Peak pressure, cm of water,
mean (SD)
28 (9)
26 (8)
27 (7)
28 (8)
29 (9)
<0.001
в—Џ Plateau pressure, cm of water,
mean (SD)
23 (7)
21 (6)
22 (6)
23 (6)
25 (7)
<0.001
<0 001
ml/kg ABW,
ABW mean (SD)
10.5
10 5 (2
(2.6)
6)
8 5 (1
8.5
(1.9)
9)
7 (1.5)
(1 5)
6 (1.5)
(1 5)
5 (1.3)
(1 3)
<0.001
<0 001
ml/kg PWB, mean (SD)
8.1 (1.8)
8.8 (1.9)
9 (1.9)
10 (2.9)
11 (3.7)
<0.001
в—Џ PEEP, cm of water, mean (SD)
6 (4)
6 (4)
6 (4)
6.5 (4)
7 (5.5)
0.14
в—Џ Peak pressure, cm of water,
mean (SD)
27 (8)
26 (8)
27 (8)
29 (8)
30 (9)
<0.001
в—Џ Plateau pressure, cm of water,
mean (SD)
22 (7)
22 (6)
22 (6)
23 (7)
26 (6)
<0.001
Day 5 of mechanical ventilation
в—Џ Tidal volume
Comparison of the events occurring over the course
of mechanical ventilation in each BMI groups
Underweight
Normal
Overweight
Obese
Severe
obese
184
1995
1781
792
216
Barotrauma, n (%)
8 (4)
63 (3)
54 (3)
27 (3)
5 (2)
0.81
ARDS,, n (%)
ARDS
11 (6)
89 (4.5)
102 (6)
55 (7)
19 (9)
0.02
VAP,, n (%)
VAP
9 (5)
68 (3)
72 (4)
36 (4.5)
12 (6)
0.38
Sepsis,, n (%)
Sepsis
22 (12)
158 (8)
155 (9)
50 (6)
15 (7)
0.08
Cardiovascular failure
failure,, n (%)
60 (33)
620 (31)
587 (33)
224 (28)
63 (29)
0.18
Respiratory failure
failure,, n (%)
15 (8)
143 (7)
140 (8)
66 (8)
23 (11)
0.42
A t renall ffailure,
Acute
failure
il
, n (%)
34 (18
(18.5)
5)
340 (17)
340 (19)
181 (23)
53 (24)
0 002
0.002
Hepatic failure
failure,, n (%)
23 (12.5)
264 (13)
238 (13)
128 (16)
38 (18)
0.12
Coagulopathy,, n (%)
Coagulopathy
42 (23)
348 (17)
361 (20)
135 (17)
42 (19)
0 07
0.07
N
P
value
A. Anzueto, F.Frutos
F.Frutos--Vivar, A. Esteban,N.Ferguson et al.
Submitted
Comparison of the events occurring over the course
of mechanical ventilation in each BMI groups
Underweight
Normal
Overweight
Obese
Severe
obese
184
1995
1781
792
216
Barotrauma, n (%)
8 (4)
63 (3)
54 (3)
27 (3)
5 (2)
0.81
ARDS,, n (%)
ARDS
11 (6)
89 (4.5)
102 (6)
55 (7)
19 (9)
0.02
VAP,, n (%)
VAP
9 (5)
68 (3)
72 (4)
36 (4.5)
12 (6)
0.38
Sepsis,, n (%)
Sepsis
22 (12)
158 (8)
155 (9)
50 (6)
15 (7)
0.08
Cardiovascular failure
failure,, n (%)
60 (33)
620 (31)
587 (33)
224 (28)
63 (29)
0.18
Respiratory failure
failure,, n (%)
15 (8)
143 (7)
140 (8)
66 (8)
23 (11)
0.42
A t renall ffailure,
Acute
failure
il
, n (%)
34 (18
(18.5)
5)
340 (17)
340 (19)
181 (23)
53 (24)
0 002
0.002
Hepatic failure
failure,, n (%)
23 (12.5)
264 (13)
238 (13)
128 (16)
38 (18)
0.12
Coagulopathy,, n (%)
Coagulopathy
42 (23)
348 (17)
361 (20)
135 (17)
42 (19)
0 07
0.07
N
P
value
A. Anzueto, F.Frutos
F.Frutos--Vivar, A. Esteban,N.Ferguson et al.
Submitted
O. Gajic, F. FrutosFrutos-Vivar, A. Esteban et al.
Intensive Care Med 2005;31:9222005;31:922-926
O. Gajic, F. FrutosFrutos-Vivar, A. Esteban et al.
Intensive Care Med 2005;31:9222005;31:922-926
Comparison of outcomes in each BMI groups
Underweight
Normal
Overweight
Obese
Severe
obese
184
1995
1781
792
216
D
Days
off mechanical
h i l
ventilation, median
(interquartile range)
4 (2, 8)
4 (2, 8)
4 (2, 8)
4 (2, 8)
4 (2, 8)
0.28
Days
y of weaning,
g, median
(interquartile range)
1 (1
(1, 3)
1 (1
(1, 2)
1 (1
(1, 2)
1 (1
(1, 2)
2 (1
(1, 3)
0 99
0.99
Length of stay in the ICU,
median
(interquartile range)
8 (4, 16)
8 (4, 15)
8 (4, 14)
8 (5, 15)
8 (5, 15)
0.27
18 (10, 36)
17 (9, 31)
17 (9, 31)
17 (10, 31)
17 (9, 28)
0.47
Mortality in the ICU, n (%)
60 (32.6)
630(31.6)
558 (31.3)
227 (28.7)
58 (26.9)
0.36
Mortality in the Hospital,
n (%)
71 (40
(40.8)
8)
708 (37
(37.2)
2)
655 (38
(38.3)
3)
263 (34
(34.4)
4)
63 (30
(30.7)
7)
0 09
0.09
N
Length of stay in the
Hospital, median
(interquartile range)
P
value
A. Anzueto, F.Frutos
F.Frutos--Vivar, A. Esteban,N.Ferguson et al.
Submitted
AJRCCM 2008
H1N1 2008
MV > 12 h
h.
MV > 12 h
h.
n = 4968
n = 150
BMI >30 = 20 %
BMI >30 = 39 %
1008 patients BMI>30
Matched 1:1 BMI< 30
Age ,gender,severity of illness
(SAPSII) and reason for
mechanical ventilation
Marched cohort analysis to estimate morbidity and mortality of obesity
Age, years, mean (SD)
BMI, kg/m2, mean (SD)
SAPS II, points, mean (SD)
Female %
Female,
Problem, %
в—Џ Medical
в—Џ Surgical
Reason to mechanical ventilation
ventilation, %
в—Џ COPD
в—Џ Asthma
в—Џ Chronic pulmonary disease
в—Џ Acute respiratory failure
ARDS
Postoperative
CHF
Aspiration
Pneumonia
Sepsis
Trauma
C di arrestt
Cardiac
Other ARF
в—Џ Coma
в—Џ Neuromuscular disease
Patients with obesity
Cases
N = 1008
60 (15)
37 (9)
43 (17)
47%
Patients without obesity
Controls
N = 1008
60 (15)
24 (3)
43 (16)
45%
60%
40%
58%
42%
0.32
7%
2%
3%
7%
2%
3%
1.0
1.0
1.0
3%
23%
7%
2%
8%
3%
23%
7%
2%
8%
1.0
1.0
1.0
10
1.0
1.0
10%
6%
5%
9%
15%
1%
10%
6%
5%
9%
15%
1%
1.0
1.0
10
1.0
1.0
1.0
1.0
P value
0.93
< 0.001
0.94
0 37
0.37
Marched cohort analysis to estimate morbidity and mortality of obesity
Age, years, mean (SD)
BMI, kg/m2, mean (SD)
SAPS II, points, mean (SD)
Female %
Female,
Problem, %
в—Џ Medical
в—Џ Surgical
R
Reason
tto mechanical
h i l ventilation,
til ti
%
в—Џ COPD
в—Џ Asthma
в—Џ Chronic pulmonary disease
в—Џ Acute
A t respiratory
i t
ffailure
il
ARDS
Postoperative
CHF
Aspiration
Pneumonia
Sepsis
Trauma
Cardiac arrest
Other ARF
в—Џ Coma
в—Џ Neuromuscular disease
Patients with obesity
Cases
N = 1008
60 (15)
37 (9)
43 (17)
47%
Patients without obesity
Controls
N = 1008
60 (15)
24 (3)
43 (16)
45%
60%
40%
58%
42%
0.32
7%
2%
3%
7%
2%
3%
1.0
1.0
1.0
3%
23%
7%
2%
8%
3%
23%
7%
2%
8%
1.0
1.0
1.0
1.0
1.0
10%
6%
5%
9%
15%
1%
10%
6%
5%
9%
15%
1%
1.0
1.0
1.0
1.0
1.0
1.0
P value
0.93
< 0.001
0.94
0 37
0.37
Marched cohort analysis to estimate morbidity and mortality of obesity
Patients with obesity
Cases
N = 1008
Patients without obesity
Controls
N = 1008
P value
E
Events
t during
d i the
th course off mechanical
h i l ventilation
til ti
Barotrauma, n (%)
32 (3%)
37 (4%)
0.54
ARDS,, n (%)
ARDS
74 (7%)
47 (5%)
0.01
VAP,, n (%)
VAP
48 (5%)
34 (3%)
0.11
Sepsis,, n (%)
Sepsis
65 (6%)
71 (7%)
0.59
287 (28.5%)
313 (31%)
0.20
Respiratory failure
failure,, n (%)
89 (9%)
73 (7%)
0.19
Acute renal failure
failure,, n (%)
234 (23%)
184 (18%)
0.006
Hepatic failure
failure,, n (%)
166 (16.5%)
145 (14.4%)
0.19
Coagulopathy,, n (%)
Coagulopathy
177 (18%)
208 (21%)
0.08
Cardiovascular failure
failure,, n (%)
A. Anzueto, F. Frutos
Frutos--Vivar, A. Esteban,N.Ferguson et al.
Submitted
Marched cohort analysis to estimate morbidity and mortality of obesity
Patients with obesity
Cases
N = 1008
Patients without obesity
Controls
N = 1008
P value
Events during the course of mechanical ventilation
Barotrauma, n (%)
32 (3%)
37 (4%)
0.54
ARDS,, n (%)
ARDS
74 (7%)
47 (5%)
0.01
VAP,, n (%)
VAP
48 (5%)
34 (3%)
0.11
Sepsis,, n (%)
Sepsis
65 (6%)
71 (7%)
0.59
287 (28.5%)
313 (31%)
0.20
Respiratory failure
failure,, n (%)
89 (9%)
73 (7%)
0.19
Acute renal failure
failure,, n (%)
234 (23%)
184 (18%)
0.006
Hepatic failure
failure,, n (%)
166 (16.5%)
145 (14.4%)
0.19
Coagulopathy,, n (%)
Coagulopathy
177 (18%)
208 (21%)
0.08
Cardiovascular failure
failure,, n (%)
A. Anzueto, F. Frutos
Frutos--Vivar, A. Esteban, N.Ferguson et al.
Submitted
Marched cohort analysis to estimate morbidity and mortality of obesity
Patients with obesity
Cases
N = 1008
Patients without obesity
Controls
N = 1008
P value
4 (2, 8)
4 (2, 7)
0.10
560 (56%)
549 (54%)
0.62
1 (1, 3)
1 (1, 2)
0.31
Reintubation, n (%)
73 (12%)
69 (12%)
0.82
Tracheostomy, n (%)
147 (15%)
130 (13%)
0.24
8 (5, 15)
7 (4, 14)
0.12
Length of stay in the Hospital,
Hospital median
(interquartile range)
17 (10, 30)
17 (9, 31)
0.84
Mortality in the ICU, n (%)
285 (28.3%)
309 (30.7%)
0.24
M t lit in
Mortality
i the
th Hospital,
H
it l n (%)
326 (33.6%)
(33 6%)
350 (36.2%)
(36 2%)
0 24
0.24
Outcomes
Days of mechanical ventilation, median
(interquartile range)
Weaning, n (%)
D
Days
off weaning,
i
median
di
(interquartile range)
Length of stay in the ICU, median
(interquartile range)
A. Anzueto, F. Frutos
Frutos--Vivar, A. Esteban, et al.
Submitted
Colesterol
( endotoxin)
Adipocites
Adipocites
p
Adipoquines
C l t
Colesterol
l
Inhibit the
productiГіn
TNF
IL--6
IL
IL--8
IL
Leptina
Conclusions
п‚—
A significant number of patients that received
mechanical ventilation have increased body
weight.
п‚—
Up
p to 20 % of patients
p
are obese or severely
y obese.
п‚—
Obese patients are ventilated with hight tidal
volume based on actual body
y weight.
g
п‚—
Have significant complications during the course
of ventilatory support.
п‚—
These are no association with increased duration
of mechanical ventilation,
ventilation leinght of stay,
stay or
mortality.
Risk--Adjusted
Risk
Adjusted--Hospital Mortality
Body Mass Index (Kg/m2)
Adjusted OR (95 CI)
p
1.94 (1.05 – 3.60)
.035
Underweight
< 18.5
Normal
N
l
18 5 - 24.9
18.5
24 9
Overweight
25 - 29.9
0.72 (0.51 – 1.02)
.067
Obese
30 - 39.9
0.67 (0.46 – 0.97)
.033
0.78 (0.44 – 1.38)
.385
Severe obesity п‚і 40
R f
Reference
J. M. O’Brien, G. S. Phillips et al.
Crit Care Med 2006;34:
Demographyc characteristics
Underweight
Normal
Overweight
Obese
Severe
obese
184
(3.7
(
%))
1995
(40%)
(
)
1781
(35.8%)
(
)
792
(15.9
(
%))
216
(4.3
(
%))
Age, years, mean (SD)
55 (19)
57 (19)
61 (17)
61 (14)
55 (14)
<0.001
Body mass index, Kg/m2, mean (SD)
17 (1)
23 (2)
27 (1)
33 (3)
50 (11)
<0.001
Female, n (%)
84 (46)
823 (41)
586 (33)
357 (45)
117 (54)
<0.001
SAPS II
II, points,
points mean (SD)
43 (19)
43 (18)
43 (17)
44 (17)
42 (17)
0 60
0.60
в—Џ Chronic obstruct. pulm. disease
14 (8)
101 (5)
80 (4.5)
56 (7)
16 (7)
0.002
в—Џ Asthma
2 (1)
23 (1)
20 (1)
13 (2)
5 (2))
0.50
в—Џ Chronic pulmonary disease
8 (4)
26 (1)
20 (1)
13 (2)
18 (8)
<0.001
п‚Ё Acute respir. distress syndrome
12 (6.5)
63 (3)
44 (2.5)
28 (3.5)
1 (0.5)
0.004
п‚Ё Postoperative
31 (17)
408 (20
(20.5)
5)
384 (22)
183 (23)
47 (22)
0 34
0.34
п‚Ё Congestive heart failure
5 (3)
112 (6)
95 (5)
59 (7)
14 (6.5)
0.08
п‚Ё Aspiration
9 (5)
64 (3)
47 (3)
17 (2)
2 (1)
0.08
23 (12.5)
168 (8)
125 (7)
47 (6)
13 (6)
0.01
п‚Ё Hospital Pneumonia
14 (8)
63 (3)
56 (3)
16 (2)
3 (1)
0.001
п‚Ё Sepsis
11 (6)
177 (9)
161 (9)
70 (9)
30 (14)
0.08
п‚Ё Trauma
9 (5)
111 (6)
103 (6)
47 (6)
14 (6.5)
0.96
п‚Ё Cardiac arrest
11 ((6))
91 ((5))
89 ((5))
39 ((5))
9 ((4))
0.88
п‚Ё Other
17 (9)
173 (9)
152 (8.5)
73 (9)
17 (8)
0.96
п‚· Coma
14 (8)
386 (19)
389 (22)
126 (16)
23 (11)
<0.001
п‚· Neuromuscular disease
4 (2)
29 (1.5)
16 (1)
5 (1)
4 (2)
0.14
N (%)
P value
Reason to mechan. ventilation, n (%)
в—Џ Acute respiratory failure
п‚Ё Community Pneumonia
C
Comparison
i
off th
the mode
d off ventilation,
til ti
ventilator
til t settings,
tti
use of sedatives weaning outcomes by BMI group
Underweight
Normal
Overweight
Obese
Severe
obese
184
1995
1781
792
216
Non--invasive ventilation (%)
Non
25 (14)
183 (9)
155 (9)
84 (11)
32 (15)
0.01
в—Џ Successful, n (%)
15 (60)
118 (64)
83 (53)
51 (61)
19 (59)
0.40
N
P value
Ventilator settings
Day 1 of mechanical ventilation
в—Џ Tidal volume
ml/kg ABW,
ABW mean (SD)
11 (2
(2.5)
5)
9 (1.8)
(1 8)
7 (1.5)
(1 5)
6 5 (1
6.5
(1.4)
4)
5 (1.5)
(1 5)
<0.001
<0 001
ml/kg PBW, mean (SD)
8.2 (1.8)
8.9(1.9)
9.1 (2.1)
10.1(2.6)
11.1 (3.9)
<0.001
в—Џ PEEP, cm of water, mean (SD)
5 (3)
5 (3)
5.5 (3)
5.5 (3)
6 (4)
<0.001
pressure, cm of water,
в—Џ Peak p
mean (SD)
25 (8)
26 (8)
27 (8)
28 (9)
31 (10)
<0.001
<0 001
в—Џ Plateau pressure, cm of water,
mean (SD)
21 (6)
21 (6)
21 (6)
22 (6)
25 (7)
<0.001
Comparison of the mode of ventilation, ventilator settings,
use of sedatives weaning outcomes by BMI group
Underweight
Normal
Overweight
Obese
Severe
obese
b
184
1995
1781
792
216
Non--invasive ventilation (%)
Non
25 (14)
183 (9)
155 (9)
84 (11)
32 (15)
0.01
( )
в—Џ Successful,, n (%)
15 ((60))
118 ((64))
83 ((53))
51 ((61))
19 ((59))
0.40
N
P value
Ventilator settings
Day 1 of mechanical ventilation
в—Џ Tidal volume
ml/kg ABW, mean (SD)
11 (2.5)
9 (1.8)
7 (1.5)
6.5 (1.4)
5 (1.5)
<0.001
ml/kg PBW, mean (SD)
8.2 (1.8)
8.9(1.9)
9.1 (2.1)
10.1(2.6)
11.1 (3.9)
<0.001
5 (3)
5 (3)
5.5 (3)
5.5 (3)
6 (4)
<0.001
ml/kg ABW, mean (SD)
10.5(2.6)
8 (1.8)
7 (1.5)
6 (1.4)
5 (1.2)
<0.001
g PWB, mean (SD)
( )
ml/kg
8.1 ((1.8))
8.7 ((1.9))
9 ((2.1))
9.8 ((2.6))
10.4 ((3.8))
<0.001
в—Џ PEEP, cm of water, mean (SD)
6 (4)
6.5 (4)
6.5 (4)
7 (4.6)
7 (5.4)
0.004
ml/kg ABW, mean (SD)
10.5 (2.6)
8.5 (1.9)
7 (1.5)
6 (1.5)
5 (1.3)
<0.001
ml/kg PWB, mean (SD)
8.1 (1.8)
8.8 (1.9)
9 (1.9)
10 (2.9)
11 (3.7)
<0.001
6 (4)
6 (4)
6 (4)
6.5 (4)
7 (5.5)
0.14
в—Џ PEEP, cm of water, mean (SD)
Day 3 of mechanical ventilation
в—Џ Tidal volume
Day 5 of mechanical ventilation
в—Џ Tidal volume
в—Џ PEEP, cm of water, mean (SD)
Demographic characteristics of study patients
Underweight
Normal
Overweight
Obese
Severe obese
P value
п‚· COPD
14 (8)
101 (5)
80 (4.5)
(4 5)
56 (7)
16 (7)
0 02
0.02
п‚· Asthma
2 (1)
23 (1)
20 (1)
13 (2)
5 (2)
0.50
п‚· Chronic pulmonary disease
8 (4)
26 (1)
20 (1)
13 (2)
18 (8)
< 0.001
- ARDS
12 (6.5)
63 (3)
44 (2.5)
28 (3.5)
1 (0.5)
- Postoperative
31 (17)
408 (20.5)
384 (22)
183 (23)
47 (22)
0.34
- CHF
5 (3)
112 (6)
95 (5)
59 (7)
14 (6.5)
0.08
- Aspiration
9 (5)
64 (3)
47 (3)
17 (2)
2 (1)
0.08
23 (12.5)
168 (8)
125 (7)
47 (6)
13 (6)
0.01
- Hospital Pneumonia
14 (8)
63 (3)
56 (3)
16 (2)
3 (1)
0.001
- Sepsis
11 (6)
177 (9)
161 (9)
70 (9)
30 (14)
0.08
- Trauma
9 ((5))
111 ((6))
103 ((6))
47 ((6))
14 ((6.5))
0.96
- Cardiac arrest
11(6)
91 (5)
89 (5)
39 (5)
9 (4)
0.88
- Other ARF
17 (9)
173 (9)
152 (8.5)
73 (9)
17 (8)
0.96
- Metabolic
4 (2)
42 (2)
58 (3)
20 (2.5)
5 (2)
0.27
- Intoxication/overdose
2 (1)
69 (3.5)
57 (3)
16 (2)
4 (2)
0.10
1 (0.5)
111 (6)
128 (7)
62 (8)
8 (4)
<0.001
2 (1)
51 (3)
48 (3)
16 (2)
2 (1)
0 32
0.32
5 (3)
112 (6)
95 (5)
12 (1.5)
4 (2)
< 0.001
-
1 (0.1)
3 (0.2)
-
-
0.57
4 (2)
29 (1.5)
16 (1)
5 (1)
4 (2)
0.14
Reason to mech. vent., n (%)
п‚· Acute respiratory failure
- Community Pneumonia
п‚· Coma
- Stroke
Hemorrhagic
Ischemic
- Brain trauma
- Other cause of coma
п‚· Neuromuscular disease
Diagnosis of infection
Mean 0.25 d.
(range 0 to 7 d.)
Sepsis
Mean 1
1.05
05 e
e.
(range 00-30 d.)
Severe epsis
M
Mean
0 90 d
0.90
d.
(range 00-6 d.)
Septic shock
Mechanical
Ventilation
Brussels
March 2121-24
2006
Is
s itt
different
i obese
in
b
patients?
A. Esteban,
t b
Hospital Universitario de Getafe. Madrid. Spain
BMI category, Kg/m2(n=1.488)
Alive
Dead
40 (43%)
48 (8
(8.7
7 %)
Underweight
U d
i ht
< 18.5
18 5
Normal
18.5 - 24.9
321 ((34.2 %))
223 ((40.6 %))
Overweight
25 - 29.9
257 (27.4 %)
142 (25.8 %)
Obese
30 - 39.9
227 (24.2 %)
99 (18.0 %)
93 (9
(9.9
9 %)
38 (6
(6.8
8 %)
Severely obese п‚і 40
J. M. O’Brien, G. S. Phillips et al.
Crit Care Med 2006;34:
Mortality. Multivariaty analysis
OR
95 % CI
p
Age
1.01
0.97 – 1.02
0.09
LOS in ICU
1.02
0.99 – 1.04
0.11
SAPS II (for point)
1.08
1.07 – 1.04
0.0001
BMI > 27
1.83
1.10 – 2.86
0.017
C. Gulenok, M. Monchi, et al
Chest 2004;125:14412004;125:1441-1445
Predictors of Mortality. Logistic Regression
BMI
OR (95 % CI)
< 18.5
1.63
18.5 – 24.9
1.00
25 – 29.9
29 9
p
(1.11 – 2.39)
0.01
0 75
0.75
(0 56 – 1.004)
(0.56
1 004)
0 53
0.53
> 30
0.60
(0.40 – 0.88)
0.01
Admis--diagnostic COPD
Admis
At least one underlying
disease (%)
0 51
0.51
(0 32 – 0.82)
(0.32
0 82)
0 005
0.005
1.65
(1.25 – 2.15)
0.04
Transfer from a ward
SAPS at admission (per
point)
1.30
(1.01 – 1.66)
0.039
1.036 ((1.027 – 1.046))
0.0001
M. GarrousteGarrouste-Orgeas, et al.
Int Care Med 2004;30:4372004;30:437-443
Patients with
Patients with
Patients with
Normal BMI
Overweight
Obese BMI
644 В± 112
698 В± 128
680 В± 136
Tidal volume
per Kg predict
body w. (ml(Kg)
10.05 В± 1.60
10.56 В± 1.85
10.76 В± 2.22
Static
compliance
p
(ml/cm2)
34.9 В± 13.3
35.5 В± 13.7
34.8 В± 22.0
Pplat
28.9 В± 7.9
30.4 В± 7.4
31.8 В± 8.1
Ppeak
35.5 В± 9.5
36.7 В± 8.6
39.5 В± 9.5
Tidal volume
(ml)
p
value
J. M. O’Brien, C. H. Welsh, et al
Ann Intern Med 2004;140:338
Unadjusted Differences in Clinical Outcomes across Body Mass Index
Categories, Stratified by Treatment Assignment
Patients
with
Normal
BMI
Patients
with
Overweight
BMI
Patients
with
Obese
BMI
28-day mortality rate, n (%)
286-mL/Kg tidal volume group
12--mL/kg tidal volume group
12
30 (20.7)
58 (36.3)
34 (25.8)
43 (35.2)
30 (25.4)
29 (28.7)
>0.2
>0.2
Unassisted ventilation by
day 28, n (%)
6-mL/Kg tidal volume group
12--mL/kg tidal volume group
12
136 (78.2)
101 (63
(63.1)
1)
96 (72.7)
79 (64
(64.8)
8)
86 (72.9)
69 (68
(68.3)
3)
>0.2
>0.2
>0 2
180-day mortality rate, n (%)
1806-mL/Kg tidal volume group
12--mL/kg tidal volume group
12
51 (29.4)
65 (40
(40.6)
6)
39 (29.6)
48 (39
(39.4)
4)
34 (28.8)
35 (34
(34.7)
7)
>0.2
>0.2
>0 2
13 5 (12
13.5
(12.0
(12.00-15.1)
15 1)
11.6
11 6 (9
(9.8
(9.88-13.4)
13 4)
12 7 (10
12.7
(10.8
(10.88-14.6)
14 6)
10.3 (8.6
(8.6--12.0)
10.2 (8.4
(8.4--12.1)
11.8 (9.6
(9.6--13.9)
>0.2
>0 2
>0.2
Mean ventilatorventilator-free days
(95 % CI)
6-mL/Kg tidal volume group
12--mL/kg tidal volume group
12
p
value
Main--Effects Model for Death at 28 Days, Including Indicators
Main
of Excess Body Weight
Variable
Odds Ratio (95% CI)
p value
• Age
1 037 (1
1.037
(1.025
025 – 1.050)
1 050)
<0.001
<0 001
• Apache III score
1.020 (1.013 – 1.027)
<0.001
• PaO2/FiO2 ratio
0.996 (0.993 – 0.999)
0.0044
• Assignment to higher tidal volume
1.688 (1.166 – 2.444)
0.0055
• Peak airway pressure at study enrollment
1.025 (1.003 – 1.048)
0.0237
• Trauma as primary lung injury category
0 322 (0
0.322
(0.120
120 – 0.863)
0 863)
0 0243
0.0243
• Female sex
1.168 (0.802 – 1.700)
>0.2
• Assignment to ketoconazole or lisofyline
0.944 (0.619 – 1.441)
>0.2
Covariates
Excess body weight variables
• BMI category
>0.2
• Overweight BMI versus normal BMI
1 096 (0
1.096
(0.711
711 – 1.690)
1 690)
• Obese BMI versus normal BMI
1.111 (0.693 – 1.782)
Obese
Non Obese
p value
ARDS
7%
5%
0 02
0.02
ARF
23%
18%
0 006
0.006
NMB
12%
9%
0.04
Obese
Non Obese
M V d.
4 (4,8)
4 (4,7)
Weaning d.
1 (1,3)
1 (1,2)
LOS ICU d.
8 (5,15)
7 (4,12)
28%
31%
Mortality
P value
0.24
Physicians should not assume
th t intubated
that
i t b t d obese
b
patients
ti t
fare worse are of normal
weight.Whether excess body
weight
g puts
p
patients
p
at risk for
poor outcomes in other types of
critical illness is a subject for
future study
Relationship Between Observed and APACHE II –
Predicted Mortality in the Morbidly Obese Group
Predicted
Mortality, %
Patients, No.
Observed
Mortality, No. (%)
0 – 10
11 – 20
21 – 30
31 – 40
41 – 50
51 – 60
61 – 70
71 – 80
81 – 90
91 – 100
21
29
27
15
11
5
6
2
0
1
4 (19)
8 (28)
8 (30)
3 (20)
5 ((45))
2 (40)
2 (33)
2 (100)
0 (0)
1 (100)
A. El
El--Solh, et al
Chest 2001;20:1989
BMI category, Kg/m2(n=1.488)
Alive
Dead
40 (43%)
48 (8
(8.7
7 %)
Underweight
U d
i ht
< 18.5
18 5
Normal
18.5 - 24.9
321 ((34.2 %))
223 ((40.6 %))
Overweight
25 - 29.9
257 (27.4 %)
142 (25.8 %)
Obese
30 - 39.9
227 (24.2 %)
99 (18.0 %)
93 (9
(9.9
9 %)
38 (6
(6.8
8 %)
Severely obese п‚і 40
J. M. O’Brien, G. S. Phillips et al.
Crit Care Med 2006;34:
Mortality. Multivariaty analysis
OR
95 % CI
p
Age
1.01
0.97 – 1.02
0.09
LOS in ICU
1.02
0.99 – 1.04
0.11
SAPS II (for point)
1.08
1.07 – 1.04
0.0001
BMI > 27
1.83
1.10 – 2.86
0.017
C. Goulenok, M. Monchi, et al
Chest 2004;125:14412004;125:1441-1445
Multivariate analysis*
Variables
OR
p Value
95 % CI
Age
1.01
0.098
0.99 – 1.02
LOS in ICU
1 02
1.02
0 11
0.11
0 99 – 1.04
0.99
1 04
SAPS II (for each
additional point)
1.08
<0.0001
1.07 – 1.10
BMI >27
1.83
0.017
1.10 – 2.86
* OR= odds ratio; CI = confidence interval
C. Goulenok, et al.
Chest 2004;125:1441
Total complications
BMI
Groups
1 to 3
BMI
Groups
4 and 5
Total
Any complication
218 (13.64)
73 (13.27)
291
No complication
1 380
1,380
477
1 857
1,857
Total
1,598
550
2,148
Variables
D. E. Ray, et al
Chest 2005;127:2125
Logistic regression on MICU and Hospital Mortality
Variables
ICU
APACHE II score
BMI
Hospital
APACHE II score
BMI
Wald
St ti ti
Statistic
Significance
293.49
2.82
< 0.001
0.588
320.56
320
56
3.56
< 0.001
0 001
0.469
D. E. Ray, et al
Chest 2005;127:2125
Distribution of Organ Failure in the Study Population
Morbidly
Obese
Nonobese
Pulmonary
71 (61)
61 (46)
Cardiovascular
43 (37)
29 (22)
Renal
28 (24)
17 (13)
GI
14 (12)
21 (16)
Liver
6 (5)
12 (9)
Hematologic
3 (3)
6 (5)
CNS
2 (2)
4 (3)
Organ Failure
A. El
El--Solh, et al
Chest 2001;20:1989
Differences in unadjusted analysis between patients
surviving
su
g to hospital
osp ta discharge
d sc a ge a
and
d tthose
ose dy
dying
g
BMI (n=1,488)
BMI category,
g y, kg/m
g 2
(n=1,488)
Underweight: <18.5
Normal: 18.518.5-24.9
Overweight:25--29.9
Overweight:25
Obese: 30
30--39.9
39 9
Severely obese ≥40
Alive
Dead
p Value
28.8 (9.39)
26.8 (8.57)
<0.001
<0.001
40 (4.3 %)
48 (8.7 %)
321 (34.2 %) 223 (40.6 %)
257 (27.4 %) 142 (25.8 %)
227 (24.2
(24 2 %) 99 (18.0
(18 0 %)
93 (9.9 %)
38 (6.9 %)
J.M. O’Brien et al
Crit Care Med 2006;34
Source International Obesity Task Force 2003
45--54
BMI>
BMI
>40 in adults age 45
4,5
Men
4
Women
Lineal (Women)
Lineal (Men)
3,5
3
2,5
2
1,5
1
0,5
0
1993
1994
1995
1996
1997
Source: Health Survey of England
UK Adults 1993-2002
1998
1999
2000
2001
2002
2003
Cuidados Intensivos en el Paciente Obeso
VI Congreso Colombiano de Medicina
Critica y Cuidado Intensivo.
Medellin 1717-21 Abril 2007
Dr AndrГ©s Esteban
Dr.
Servicio de Cuidados Intensivos y Grandes Quemados
VENTILACION MECANICA EN EL PACIENTE OBESO
VIII Congreso Panamericano IbГ©rico de
Medicina Intensiva Punta del Este Nov 2007
Dr AndrГ©s Esteban
Dr.
Servicio de Cuidados Intensivos y Grandes Quemados
How to ventilate the Obese Patients?.It is
really different!
9th Pulmonary Medicine Update Course
Cairo 44-5 February
y 2009
Dr AndrГ©s Esteban
Dr.
Intensive Care and Burn Service
Hospital Mortality
SAPS II Group
MPMMPM-O Group
BMI
OR
9 % CI
95
OR
9 % CI
95
Underweight
1.19
1.08 – 1.32
1.26
1.14 – 1.39
Overweight
0.92
0.85 – 1.01
0.89
0.82 – 0.97
Obese
0.96
0.87 – 1.06
0.93
0.85 – 1.03
Severely obese
1.09
1 09
0 93 – 1.27
0.93
1 27
1 03
1.03
0 88 – 1.21
0.88
1 21
A. Tremblay, V. Bandi.
Chest 2003;123:12022003;123:1202-1207
VentilaciГіn MecГЎnica en el Obeso
XXXVI ReuniГіn Anual de la Sociedad
Mexicana de Medicina CrГ­tica y
Terapia Intensiva. Acapulco . 2009
Dr AndrГ©s Esteban
Dr.
Intensive Care and Burn Service
Mortalidad %
41
33
37
32
38
32
24
29
31
27
IMC
Mortalidad %
33
32
32
29
27
IMC
Cut-off points proposed by a WHO expert
Cutcommittee for the classification of everweight
g
BMI
(Kg/m2)
WHO
classification
Popular
description
< 18.5
Underweight
Thin
-----
Healthy, normal,
acceptable
25 – 29.9
Grade 1 overweight
Overweight
30.0 – 39.9
Grade 2 overweight
Obesity
п‚і 40
Grade 3 overweight
Morbid obesity
18.5 – 24.9
P. G. Kopelman
Nature 2000;404:6362000;404:636-643
Global Prevalence of obesity BMI >30 in Female
Global obesity rates
Global prevalence Obesity BMI > 30 in males
BMI groups
Multiple
organ failure
and shock
Acute
respiratory
failure
Exacerbation
of COPD
Acute renal
failure
Coma
Trauma
Monitoring
< 18.5
18.5 - 24.9
25 - 29.9
> 30
n = 189
n = 806
n = 476
n = 227
39 (20.6)
126 (15.6)
102 (21.4)
61 (26.8)
0.001
61 (32)
249 (31)
155 (32.6)
59 (26)
0.4
20 (10.5)
61 (7.6)
39 (8.2)
25 (11)
0.3
66 (34)
41 (5)
29 (6)
17 (7.5)
0.23
31 (16)
121(15)
63 (13)
25 (11)
0.4
2 (1)
16 (2)
7 (1.5)
2 (0.8)
0.7
18 (9.5)
81 (10)
37 (7.7)
14 (6.2)
0.5
p value
M. GarrousteGarrouste-Orgeas et al.
Int Care Med 2004;30:437
Predictors of Mortality. Logistic Regression
BMI
OR (95 % CI)
< 18.5
1.63
18.5 – 24.9
1.00
25 – 29.9
29 9
p
(1.11 – 2.39)
0.01
0 75
0.75
(0 56 – 1.004)
(0.56
1 004)
0 53
0.53
> 30
0.60
(0.40 – 0.88)
0.01
Admis--diagnostic COPD
Admis
At least one underlying
disease (%)
0 51
0.51
(0 32 – 0.82)
(0.32
0 82)
0 005
0.005
1.65
(1.25 – 2.15)
0.04
Transfer from a ward
SAPS at admission (per
point)
1.30
(1.01 – 1.66)
0.039
1.036 ((1.027 – 1.046))
0.0001
M. GarrousteGarrouste-Orgeas, et al.
Int Care Med 2004;30:4372004;30:437-443
Unadjusted Differences in Clinical Outcomes across Body Mass Index
Categories, Stratified by Treatment Assignment
Patients
with
Normal
BMI
Patients
with
Overweight
BMI
Patients
with
Obese
BMI
28-day mortality rate, n (%)
286-mL/Kg tidal volume group
12--mL/kg tidal volume group
12
30 (20.7)
58 (36.3)
34 (25.8)
43 (35.2)
30 (25.4)
29 (28.7)
>0.2
>0.2
U
Unassisted
i d ventilation
il i
by
b
day 28, n (%)
6-mL/Kg tidal volume group
12--mL/kg tidal volume group
12
136 (78.2)
101 (63
(63.1)
1)
96 (72.7)
79 (64
(64.8)
8)
86 (72.9)
69 (68
(68.3)
3)
>0.2
>0.2
>0 2
180-day mortality rate, n (%)
1806-mL/Kg tidal volume group
12--mL/kg tidal volume group
12
51 (29.4)
65 (40
(40.6)
6)
39 (29.6)
48 (39
(39.4)
4)
34 (28.8)
35 (34
(34.7)
7)
>0.2
>0.2
>0 2
13 5 (12
13.5
(12.0
(12.00-15.1)
15 1)
11.6
11 6 (9
(9.8
(9.88-13.4)
13 4)
12 7 (10
12.7
(10.8
(10.88-14.6)
14 6)
10.3 (8.6
(8.6--12.0)
10.2 (8.4
(8.4--12.1)
11.8 (9.6
(9.6--13.9)
>0.2
>0 2
>0.2
Mean ventilatorventilator-free days
(95 % CI)
6-mL/Kg tidal volume group
12--mL/kg tidal volume group
12
p
value
OВґBrien J et al Ann Intern Med 2004;140:345
Comparison of the mode of ventilation, ventilator settings,
use of sedatives weaning outcomes by BMI group
Underweight
U d
i ht
Normal
N
l
O
Overweight
i ht
Ob
Obese
Severe
obese
P value
l
Pharmacology
Use of neuromuscular
blockers,
blockers n (%)
22 (12)
197 (10)
184 (10)
97 (12)
24 (11)
0.41
Use of sedatives, n (%)
127 (69)
1382 (69)
1263 (71)
562 (71)
152 (70)
0.81
Weaning
Simple
p weaning,
g, n (%)
( )
53 ((59))
555 ((57.5))
515 ((57.5))
229 ((58))
55 ((49))
0.46
Difficult weaning, n (%)
33 (37)
352 (36)
332 (37)
139 (35)
47 (42)
0.79
Prolonged weaning, n (%)
4 (4)
59 (6)
49 (5.5)
28 (7)
11 (10)
0.37
Accidental extubation, n (%)
4 (2)
58 (3)
45 (2.5)
23 (3)
5 (2)
0.87
Scheduled extubation, n (%)
98 (53)
1070 (54)
996 (56)
438 (55)
122 (56)
0.64
в—Џ Accidental extubation, n (%)
1 (25)
15 (26)
8 (18)
14 (61)
3 (60)
0.003
в—Џ Scheduled extubation, n (%)
11 (11)
121 (11)
91 (9)
45 (10)
11 (9)
0.57
Tracheostomy, n (%)
26 (15)
257 (13)
234 (13)
119 (15)
28 (13)
0.64
10 (5, 14)
9 (6, 14)
10 (6, 16)
8 (6, 13)
11 (4, 16)
0.21
Reintubation, n (%)
в—Џ Timing, median
(interquartile range)
A. Anzueto, F. FrutosFrutos-Vivar, A.Esteban, et al.
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