Gaetano Florio1, Roberta Ribeiro De Santis Santiago1, Jacopo Fumagalli1, David A Imber1, Francesco Marrazzo1, Abraham Sonny1, Aranya Bagchi1, Angela K Fitch2, Chika V Anekwe2, Marcelo Britto Passos Amato3, Pankaj Arora4, Robert M Kacmarek5, Lorenzo Berra6. 1. Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA. 2. Weight Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA. 3. Pulmonary Division, Cardio-Pulmonary Department, Heart Institute (Incor), Hospital Das Clinicas da FMUSP, University of São Paulo, São Paulo, Brazil. 4. Division of Cardiovascular Disease, University of Alabama at Birmingham, Birmingham, AL. 5. Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Department of Respiratory Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA. 6. Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Department of Respiratory Care, Massachusetts General Hospital and Harvard Medical School, Boston, MA. Electronic address: lberra@mgh.harvard.edu.
Abstract
BACKGROUND: Increased pleural pressure affects the mechanics of breathing of people with class III obesity (BMI > 40 kg/m2). RESEARCH QUESTION: What are the acute effects of CPAP titrated to match pleural pressure on cardiopulmonary function in spontaneously breathing patients with class III obesity? STUDY DESIGN AND METHODS: We enrolled six participants with BMI within normal range (control participants, group I) and 12 patients with class III obesity (group II) divided into subgroups: IIa, BMI of 40 to 50 kg/m2; and IIb, BMI of ≥ 50 kg/m2. The study was performed in two phases: in phase 1, participants were supine and breathing spontaneously at atmospheric pressure, and in phase 2, participants were supine and breathing with CPAP titrated to match their end-expiratory esophageal pressure in the absence of CPAP. Respiratory mechanics, esophageal pressure, and hemodynamic data were collected, and right heart function was evaluated by transthoracic echocardiography. RESULTS: The levels of CPAP titrated to match pleural pressure in group I, subgroup IIa, and subgroup IIb were 6 ± 2 cmH2O, 12 ± 3 cmH2O, and 18 ± 4 cmH2O, respectively. In both subgroups IIa and IIb, CPAP titrated to match pleural pressure decreased minute ventilation (IIa, P = .03; IIb, P = .03), improved peripheral oxygen saturation (IIa, P = .04; IIb, P = .02), improved homogeneity of tidal volume distribution between ventral and dorsal lung regions (IIa, P = .22; IIb, P = .03), and decreased work of breathing (IIa, P < .001; IIb, P = .003) with a reduction in both the work spent to initiate inspiratory flow as well as tidal ventilation. In five hypertensive participants with obesity, BP decreased to normal range, without impairment of right heart function. INTERPRETATION: In ambulatory patients with class III obesity, CPAP titrated to match pleural pressure decreased work of breathing and improved respiratory mechanics while maintaining hemodynamic stability, without impairing right heart function. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT02523352; URL: www.clinicaltrials.gov.
BACKGROUND: Increased pleural pressure affects the mechanics of breathing of people with class III obesity (BMI > 40 kg/m2). RESEARCH QUESTION: What are the acute effects of CPAP titrated to match pleural pressure on cardiopulmonary function in spontaneously breathing patients with class III obesity? STUDY DESIGN AND METHODS: We enrolled six participants with BMI within normal range (control participants, group I) and 12 patients with class III obesity (group II) divided into subgroups: IIa, BMI of 40 to 50 kg/m2; and IIb, BMI of ≥ 50 kg/m2. The study was performed in two phases: in phase 1, participants were supine and breathing spontaneously at atmospheric pressure, and in phase 2, participants were supine and breathing with CPAP titrated to match their end-expiratory esophageal pressure in the absence of CPAP. Respiratory mechanics, esophageal pressure, and hemodynamic data were collected, and right heart function was evaluated by transthoracic echocardiography. RESULTS: The levels of CPAP titrated to match pleural pressure in group I, subgroup IIa, and subgroup IIb were 6 ± 2 cmH2O, 12 ± 3 cmH2O, and 18 ± 4 cmH2O, respectively. In both subgroups IIa and IIb, CPAP titrated to match pleural pressure decreased minute ventilation (IIa, P = .03; IIb, P = .03), improved peripheral oxygen saturation (IIa, P = .04; IIb, P = .02), improved homogeneity of tidal volume distribution between ventral and dorsal lung regions (IIa, P = .22; IIb, P = .03), and decreased work of breathing (IIa, P < .001; IIb, P = .003) with a reduction in both the work spent to initiate inspiratory flow as well as tidal ventilation. In five hypertensive participants with obesity, BP decreased to normal range, without impairment of right heart function. INTERPRETATION: In ambulatory patients with class III obesity, CPAP titrated to match pleural pressure decreased work of breathing and improved respiratory mechanics while maintaining hemodynamic stability, without impairing right heart function. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT02523352; URL: www.clinicaltrials.gov.
Authors: Jacopo Fumagalli; Lorenzo Berra; Changsheng Zhang; Massimiliano Pirrone; Roberta R De Santis Santiago; Susimeire Gomes; Federico Magni; Glaucia A B Dos Santos; Desmond Bennett; Vinicius Torsani; Daniel Fisher; Caio Morais; Marcelo B P Amato; Robert M Kacmarek Journal: Crit Care Med Date: 2017-08 Impact factor: 7.598
Authors: Jacopo Fumagalli; Roberta R S Santiago; Maddalena Teggia Droghi; Changsheng Zhang; Florian J Fintelmann; Fabian M Troschel; Caio C A Morais; Marcelo B P Amato; Robert M Kacmarek; Lorenzo Berra Journal: Anesthesiology Date: 2019-05 Impact factor: 7.892
Authors: Miguel-Angel Martínez-García; Francisco Capote; Francisco Campos-Rodríguez; Patricia Lloberes; María Josefa Díaz de Atauri; María Somoza; Juan F Masa; Mónica González; Lirios Sacristán; Ferrán Barbé; Joaquín Durán-Cantolla; Felipe Aizpuru; Eva Mañas; Bienvenido Barreiro; Mar Mosteiro; Juan J Cebrián; Mónica de la Peña; Francisco García-Río; Andrés Maimó; Jordi Zapater; Concepción Hernández; Nuria Grau SanMarti; Josep María Montserrat Journal: JAMA Date: 2013-12-11 Impact factor: 56.272
Authors: Massimiliano Pirrone; Daniel Fisher; Daniel Chipman; David A E Imber; Javier Corona; Cristina Mietto; Robert M Kacmarek; Lorenzo Berra Journal: Crit Care Med Date: 2016-02 Impact factor: 7.598
Authors: Paul K Whelton; Robert M Carey; Wilbert S Aronow; Donald E Casey; Karen J Collins; Cheryl Dennison Himmelfarb; Sondra M DePalma; Samuel Gidding; Kenneth A Jamerson; Daniel W Jones; Eric J MacLaughlin; Paul Muntner; Bruce Ovbiagele; Sidney C Smith; Crystal C Spencer; Randall S Stafford; Sandra J Taler; Randal J Thomas; Kim A Williams; Jeff D Williamson; Jackson T Wright Journal: Hypertension Date: 2017-11-13 Impact factor: 9.897