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Ventilation in critically ill obese patients—Why it should be done differently?

  • Cristian Cobilinschi1,2,*,
  • Ana-Maria Cotae1,2
  • Raluca Ungureanu1,2,*,
  • Radu Țincu1,2
  • Ioana Marina Grințescu1,2
  • Liliana Mirea1,2

1Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania

2Clinical Emergency Hospital Bucharest, 014461 Bucharest, Romania

DOI: 10.22514/sv.2022.076

Submitted: 07 July 2022 Accepted: 30 August 2022

Online publish date: 10 November 2022

*Corresponding Author(s): Cristian Cobilinschi E-mail:
*Corresponding Author(s): Raluca Ungureanu E-mail:


Considering the increasing prevalence of obesity among the critically ill patient, mechanical ventilation of this type of patients has almost become a daily practice. However, no consensus regarding mechanical ventilation for obese patients has recently been published. Considering the particular pathophysiological features of respiratory system in obese patients, the risk of ventilator induced lung injury (VILI) is highly elevated. This narrative review aims to present the constrains related to mechanical ventilation in obese patients, as well as the features that predispose them to VILI. Moreover, the effects every determinant incriminated in VILI were described with application on the pathophysiological features of obese patients. Increased emphasis was placed on the newly concept of ergotrauma as one of the main determinants of VILI. This is one of the first reviews dedicated to the effects of mechanical power and ergotrauma on mechanically ventilated patients with obesity. Moreover, increased attention was given to the impact of biotrauma related to VILI, considering that the new concept of “pre-conditioning cloud” related to obesity has recently emerged.


Obesity; Mechanical ventilation; Ventilator induced lung injury; VILI; Biotrauma; Ergotrauma; Volotrauma; Atelectrauma; Barotrauma

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Cristian Cobilinschi,Ana-Maria Cotae,Raluca Ungureanu,Radu Țincu,Ioana Marina Grințescu,Liliana Mirea. Ventilation in critically ill obese patients—Why it should be done differently?. Signa Vitae. 2022.doi:10.22514/sv.2022.076.


[1] WHO. Obesity and overweight. 2021. Available at: (Accessed: 15 September 2020).

[2] Sakr Y, Alhussami I, Nanchal R, Wunderink RG, Pellis T, Wittebole X, et al. Being overweight is associated with greater survival in ICU patients. Critical Care Medicine. 2015; 43: 2623–2632.

[3] Hutagalung R, Marques J, Kobylka K, Zeidan M, Kabisch B, Brunkhorst F, et al. The obesity paradox in surgical intensive care unit patients. Intensive Care Medicine. 2011; 37: 1793–1799.

[4] Pan J, Shaffer R, Sinno Z, Tyler M, Ghosh J. The obesity paradox in ICU patients. 2017 39th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC). 2017; 2017: 3360–3364.

[5] Tocalini P, Vicente A, Amoza RL, García Reid C, Cura AJ, Tozzi WA, et al. Association between obesity and mortality in adult patients receiving invasive mechanical ventilation: a systematic review and meta-analysis. Medicina Intensiva. 2020; 44: 18–26.

[6] M. N. Gong, E. K. Bajwa, B. T. Thompson, D. C. Christiani. Body mass index is associated with the development of acute respiratory distress syndrome. Thorax. 2010; 65: 44–50.

[7] Fernandez-Bustamante A, Hashimoto S, Serpa Neto A, Moine P, Vidal Melo MF, Repine JE. Perioperative lung protective ventilation in obese patients. BMC Anesthesiology. 2015; 15: 56.

[8] Guivarch E, Voiriot G, Rouzé A, Kerbrat S, Tran Van Nhieu J, Montravers P, et al. Pulmonary effects of adjusting tidal volume to actual or ideal body weight in ventilated obese mice. Scientific Reports. 2018; 8: 6439.

[9] Tomescu DR, Popescu M, Dima SO, Bacalbașa N, Bubenek-Turconi Ș. Obesity is associated with decreased lung compliance and hypercapnia during robotic assisted surgery. Journal of Clinical Monitoring and Computing. 2017; 31: 85–92.

[10] J. Porhomayon, P. Papadakos, A. Singh, N. D. Nader. Alteration in respiratory physiology in obesity for anesthesia-critical care physician. HSR Proceedings in Intensive Care & Cardiovascular Anesthesia. 201; 3: 109–118.

[11] Parameswaran K, Todd DC, Soth M. Altered respiratory physiology in obesity. Canadian Respiratory Journal. 2006; 13: 203–210.

[12] U. Peters, A. E. Dixon. Obesity and Lung Compliance. Expert Review of Respiratory Medicine. 2019; 12 755–767.

[13] Lazarus R, Sparrow D, Weiss ST. Effects of obesity and fat distribution on ventilatory function. Chest. 1997; 111: 891–898.

[14] A. H. Gifford, J. C. Leiter, and H. L. Manning. Respiratory function in an obese patient with sleep-disordered breathing. Chest. 2010; 138: 704–715.

[15] Mafort TT, Rufino R, Costa CH, Lopes AJ. Obesity: systemic and pulmonary complications, biochemical abnormalities, and impairment of lung function. Multidisciplinary Respiratory Medicine. 2016; 11: 28.

[16] Pelosi P, Croci M, Ravagnan I, Cerisara M, Vicardi P, Lissoni A, et al. Respiratory system mechanics in sedated, paralyzed, morbidly obese patients. Journal of Applied Physiology. 1997; 82: 811–818.

[17] A. Banerjee, E. Heiden. Obesity and the effects on the respiratory system. Practical Guide to Obesity Medicine. 2018; 109–121.

[18] C. K. Lin, C. C. Lin. Work of breathing and respiratory drive in obesity. Respirology. 2012; 17: 402–411.

[19] Fischer AJ, Kaese S, Lebiedz P. Management of obese patients with respiratory failure—a practical approach to a health care issue of increasing significance. Respiratory Medicine. 2016; 117: 174–178.

[20] J. L. Pépin, J. F. Timsit, R. Tamisier, J. C. Borel, P. Lévy, S. Jaber. Prevention and care of respiratory failure in obese patients. The Lancet. Respiratory Medicine. 2016; 4: 407–418.

[21] Tonetti T, Vasques F, Rapetti F, Maiolo G, Collino F, Romitti F, et al. A driving pressure and mechanical power: new targets for VILI prevention. Annals of Translational Medicine. 2017; 5: 1–10.

[22] D. Dreyfuss, G. Saumon. State of the Art Ventilator-induced Lung Injury. American Journal of Respiratory and Critical Care Medicine. 1998: 157: 294–323.

[23] de Prost N, Ricard J, Saumon G, Dreyfuss D. Ventilator-induced lung injury: historical perspectives and clinical implications. Annals of Intensive Care. 2011; 1: 28.

[24] F. S. L. Vianna, F. J. Do Amaral Pfeilsticker, A. S. Neto. Driving pressure in obese patients with acute respiratory distress syndrome: One size fits all? Journal of Thoracic Disease. 2018; 10: S3957–S3960.

[25] Gattinoni L, Marini JJ, Collino F, Maiolo G, Rapetti F, Tonetti T, et al. The future of mechanical ventilation: Lessons from the present and the past. Critical Care. 2017; 21: 1–11.

[26] Marini JJ, Rocco PRM, Gattinoni L. Static, Dynamic contributors to ventilator-induced lung injury in clinical practice. Pressure, Energy, and Power. American Journal of Respiratory and Critical Care Medicine. 2020; 201: 767–774.

[27] R. G. Brower, M. A. Matthay, A. Morris, D. Schoenfeld, B. T. Thompson, A. Wheeler. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The New England Journal of Medicine. 2000; 342: 1301–1308.

[28] Futier E, Constantin J, Paugam-Burtz C, Pascal J, Eurin M, Neuschwan-der A, et al. A Trial of intraoperative low-tidal-volume ventilation in abdominal surgery. New England Journal of Medicine. 2013; 369: 428–437.

[29] Ball L, Hemmes SNT, Serpa Neto A, Bluth T, Canet J, Hiesmayr M, et al. Intraoperative ventilation settings and their associations with postoperative pulmonary complications in obese patients. British Journal of Anaesthesia. 2018; 121: 899–908.

[30] Jaber S, Coisel Y, Chanques G, Futier E, Constantin J-, Michelet P, et al. A multicentre observational study of intra-operative ventilatory management during general anaesthesia: tidal volumes and relation to body weight. Anaesthesia. 2012; 67: 999–1008.

[31] Z. L. Chen, Y. L. Song, Z. Y. Hu, S. Zhang, Y. Z. Chen. An estimation of mechanical stress on alveolar walls during repetitive alveolar reopening and closure. Journal of applied physiology. 2015; 119: 190–201.

[32] Gattinoni L, Quintel M, Marini JJ. Volutrauma and atelectrauma: which is worse? Critical Care. 2018; 22: 264.

[33] Grieco DL, Russo A, Romanò B, Anzellotti GM, Ciocchetti P, Torrini F, et al. Lung volumes, respiratory mechanics and dynamic strain during general anaesthesia. British Journal of Anaesthesia. 2018; 121: 1156–1165.

[34] Leong R, Marks JA, Cereda M. How does mechanical ventilation damage lungs? what can be done to prevent it? Evidence-Based Practice of Critical Care. 2020; 68–73.e1.

[35] Reinius H, Jonsson L, Gustafsson S, Sundbom M, Duvernoy O, Pelosi P, et al. Prevention of atelectasis in morbidly obese patients during general anesthesia and paralysis. Anesthesiology. 2009; 111: 979–987.

[36] Kubiak BD, Gatto LA, Jimenez EJ, Silva-Parra H, Snyder KP, Vieau CJ, et al. Plateau and transpulmonary pressure with elevated intra-abdominal pressure or atelectasis. The Journal of Surgical Research. 2010; 159: e17–e24.

[37] J. R. Beitler, A. Malhotra, B. T. Thompson. Ventilator-induced lung injury. Clinics in Chest Medicine. 2016; 37: 633–646.

[38] Bluth T, Serpa Neto A, Schultz MJ, Pelosi P, Gama de Abreu M. Effect of intraoperative high positive end-expiratory pressure (PEEP) with recruitment maneuvers vs. low PEEP on postoperative pulmonary complications in obese patients. JAMA. 2019; 321: 2292.

[39] Nestler C, Simon P, Petroff D, Hammermüller S, Kamrath D, Wolf S, et al. Individualized positive end-expiratory pressure in obese patients during general anaesthesia: a randomized controlled clinical trial using electrical impedance tomography. British Journal of Anaesthesia. 2017; 119: 1194–1205.

[40] L. Ball, P. Pelosi. How I ventilate an obese patient. Critical Care. 2019; 23: 1–3.

[41] Cruz FF, Ball L, Rocco PRM, Pelosi P. Ventilator-induced lung injury during controlled ventilation in patients with acute respiratory distress syndrome: less is probably better. Expert Review of Respiratory Medicine. 2018; 12: 403–414.

[42] Gattinoni L, Tonetti T, Cressoni M, Cadringher P, Herrmann P, Moerer O, et al. Ventilator-related causes of lung injury: the mechanical power. Intensive Care Medicine. 2016; 42: 1567–1575.

[43] Marini JJ. Dissipation of energy during the respiratory cycle. Current Opinion in Critical Care. 2018; 24: 16–22.

[44] J. J. Marini, P. R. M. Rocco. Which component of mechanical power is most important in causing VILI? Critical Care. 2020; 24: 1–3.

[45] A. De Jong, D. Verzilli, S. Jaber. ARDS in obese patients: specificities and management. Critical Care. 2019; 23; 1–9.

[46] G. F. Curley, J. G. Laffey, H. Zhang, A. S. Slutsky. Biotrauma and ventilator-induced lung injury: clinical implications. Chest. 2016; 150: 1109–1117.

[47] Ricard J, Dreyfuss D, Saumon G. Production of inflammatory cytokines in ventilator-induced lung injury: a reappraisal. American Journal of Respiratory and Critical Care Medicine. 2001; 163: 1176–1180.

[48] P. M. Spieth, T. Bluth, M. G. De Abreu, A. Bacelis, A. E. Goetz, R. Kiefmann. Mechanotransduction in the lungs. Minerva Anestesiol. 2014; 80: 933–941.

[49] Chen L, Xia H, Shang Y, Yao S. Molecular mechanisms of ventilator-induced lung injury. Chinese Medical Journal. 2018; 131: 1225–1231.

[50] Takahashi K, Saha D, Shattino I, Pavlov VI, Stahl GL, Finnegan P, et al. Complement 3 is involved with ventilator-induced lung injury. International Immunopharmacology. 2011; 12: 2138–2143.

[51] Matthay MA, Bhattacharya S, Gaver D, Ware LB, Lim LHK, Syrkina O, et al. Ventilator-induced lung injury: in vivo and in vitro mechanisms. American Journal of Physiology-Lung Cellular and Molecular Physiology. 2002; 283: L678–L682.

[52] Wang C. Obesity, inflammation, and lung injury (OILI): the good. Mediators of Inflammation. 2014; 2014: 1–15.

[53] Bustamante AF. Adipose-lung cell crosstalk in the obesity-ARDS paradox. Journal of Pulmonary & Respiratory Medicine. 2013; 3: 144.

[54] Calabrese EJ. Preconditioning is hormesis part II: how the conditioning dose mediates protection: dose optimization within temporal and mechanistic frameworks. Pharmacological Research. 2016; 110: 265–275.

[55] ARDSnet. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The New England journal of medicine. 2000; 342: 1301–1308.

[56] Samary CS, Santos RS, Santos CL, Felix NS, Bentes M, Barboza T, et al. Biological impact of transpulmonary driving pressure in experimental acute respiratory distress syndrome. Anesthesiology. 2015; 123: 423–433.

[57] A. De Jong, G. Chanques, S. Jaber. Mechanical ventilation in obese ICU patients: from intubation to extubation. Critical Care. 2017; 21: 1–8.

[58] K. Erlandsson, H. Odenstedt, S. Lundin, O. Stenqvist. Positive end-expiratory pressure optimization using electric impedance tomography in morbidly obese patients during laparoscopic gastric bypass surgery. Acta Anaesthesiologica Scandinavica. 2006; 50: 833–839.

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