Résumé
La prévalence des patients obèses admis en réanimation augmente. Ceux-ci présentent, de par leur pression abdominale augmentée par rapport à celle des patients non obèses, une capacité résiduelle fonctionnelle réduite, responsable d’une augmentation de la formation d’atélectasies lors de l’anesthésie. Les patients obèses sont donc à risque de complications respiratoires liées à la ventilation, telles que le syndrome de détresse respiratoire aigu en réanimation doit tenir compte de ces particularités physiopathologiques. Ainsi, avant l’intubation, une préoxygénation en aide inspiratoire avec application d’une pression expiratoire positive (PEP) (entre 5 et 10 cmH2O) est recommandée, suivie d’une ventilation à bas volumes courants, calculés à partir du poids idéal (6 ml/kg), avec de hautes PEP (10 cmH2O), sous réserve d’une bonne tolérance hémodynamique. Les manoeuvres de recrutement sont importantes chez ces patients prédisposés aux atélectasies et doivent être réalisées régulièrement, par exemple en appliquant une pression de 40 cmH2O pendant 40 secondes. La ventilation peut être indifféremment réalisée en volume ou en pression contrôlés, selon les habitudes de l’équipe. En cas de SDRA, le décubitus ventral est efficace chez les patients obèses, permettant une amélioration du rapport PaO2/FiO2 supérieure à celle des patients non obèses. Enfin, l’impact pronostique de l’obésité reste discuté en ventilation mécanique.
Abstract
There is an increasing trend in the prevalence of obesity in intensive care units (ICU). Obesity is associated with an increase in abdominal pressure that markedly affects respiratory mechanics and is associated with a reduction in functional residual capacity, the leading cause of atelectasis formation during anesthesia. Obese patients are prone to respiratory complications related to ventilation, especially acute respiratory distress syndrome (ARDS). Ventilation of obese patients in the ICU has to take into account these pathophysiological characteristics. Preoxygenation using pressure support ventilation with a positive end-expiratory pressure (PEEP) between 5 and 10 cmH2O is recommended, followed by lung protective mechanical ventilation using low tidal volume, calculated on ideal rather than actual body weight (6 ml/kg), and high PEEP (10 cmH2O), provided the absence of severe hemodynamic alteration. The use of recruitment maneuvers (like applying a pressure of 40 cmH2O during 40 seconds) should be considered in these patients prone to atelectasis formation. Mechanical ventilation can be performed using either volume-or pressurecontrolled mode, according to the each center specific expertise. Prone position should be considered in obese patients with ARDS, allowing significant improvement in the PaO2/ FiO2 ratio. Finally, despite high resource utilization, the prognosis of obese patients receiving mechanical ventilation seems to be similar to that of non-obese patients.
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De Jong, A., Futier, E., Jung, B. et al. Particularités de la ventilation chez le patient obèse. Réanimation 23, 48–53 (2014). https://doi.org/10.1007/s13546-013-0832-2
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DOI: https://doi.org/10.1007/s13546-013-0832-2