Adaptive support ventilation for gynaecological laparoscopic surgery in Trendelenburg position: bringing ICU modes of mechanical ventilation to the operating room

Abstract

The aim of the present study was to test the efficacy of adaptive support ventilation (ASV) to automatically adapt the ventilatory settings to the changes in the respiratory mechanics that occur during pneumoperitoneum and Trendelenburg position in gynaecological surgeries. We prospectively studied 22 ASA I women scheduled for gynaecological laparoscopic surgery in the Trendelenburg position. After intravenous induction of general anaesthesia, patients were ventilated with ASV, a closed-loop mode of mechanical ventilation based on the Otis formula, designed to automatically adapt the ventilatory settings to changes in the patient's respiratory system mechanics, while maintaining preset minute ventilation. Respiratory mechanics variables, ventilatory setting parameters and analysis of blood gases were recorded at three time points: 5 min after induction (baseline), 15 min after pneumoperitoneum and Trendelenburg positioning (Pneumo-Trend) and 15 min after pneumoperitoneum withdrawal (final). A reduction of 44.4% in respiratory compliance and an increase of 29.1% in airway resistance were observed during the Pneumo-Trend period. Despite these changes in respiratory mechanics, minute ventilation was kept constant. ASV adapted the ventilatory settings by automatically increasing inspiratory pressure by 3.2 +/- 0.9 cmH(2)O (+19%), P < 0.01, respiratory rate by 1.3 +/- 0.5 breaths per minute (+9%) and the inspiratory to total time ratio (T(i)/T(tot)) by 43.3%. At final time, these parameters returned towards their baseline values. Adequate gas exchange was maintained throughout all periods. PaCO(2) increased moderately (+13%) from 4.4 +/- 0.6 (baseline) to 5.0 +/- 0.9 kPa (Pneumo-Trend), P < 0.01; and decreased slightly at final time (4.7 +/- 0.8 kPa), P < 0.05. Clinician's intervention was needed in only one patient who showed a moderate hypercapnia (PaCO(2) 6.9 kPa) during pneumoperitoneum. In healthy women undergoing gynaecologic laparoscopy, ASV automatically adapted the ventilatory settings to the changes in the respiratory mechanics, keeping constant the preset minute ventilation, providing an adequate exchange of respiratory gases and obviating clinician's interventions.