Key principles for rehabilitation of critically ill patients with obesity

Intensive Care Medicine: Published: 17 July 2026

Purpose

Patients with obesity who are admitted to an ICU bring specific challenges for rehabilitation during and after critical illness. This narrative review explores impact of differences in body compositions and pathophysiology on outcomes to summarise interprofessional, patient-centred rehabilitation strategies across the trajectory of recovery.

Methods

The interprofessional expert panel reviewed major trials and guidelines, integrating their clinical expertise with the current evidence.

Results

Three distinct phenotypes potentially influence outcomes for survivors. Whilst patients with preserved muscle mass may have a survival advantage, the phenotypes characterised by ectopic visceral fat or sarcopenia are frequently complicated by multimorbidity and polypharmacy, likely increasing the risk of adverse effects such as suboptimal sedation, prolonged ventilation and immobilisation, malnutrition, and impaired recovery. Targeted respiratory interventions, including secretion-clearance techniques and appropriate patient positioning to prevent atelectasis, reduce the work of breathing. Optimisation of communication and swallowing function is an essential component for facilitating safe oral intake and promoting active patient participation in rehabilitation. Concurrently, targeted nutrition strategies combined with early, targeted, progressive mobilisation might mitigate ICU acquired weakness and support functional recovery. The availability of appropriate weight‑based equipment is fundamental to ensuring safe mobilisation for both patients and healthcare professionals.

Conclusion

Interprofessional collaboration is central to optimising outcomes and should extend beyond the ICU to structured post-ICU follow-up to address persistent, worsening, or newly emerging health impairments. Early rehabilitation in critically ill patients with obesity should integrate physiological, logistical, and psychosocial considerations to support equitable and functional recovery.

 

 

 

Airway management in critically ill patients with obesity

Intensive Care Medicine: Published: 13 May 2026

Abstract

Obesity is a global health challenge. An increasing number of patients with obesity are admitted to an intensive care unit. Airway management in these patients represents a unique challenge due to significant anatomical and physiological alterations. Increased adipose tissue in the face, cheeks, pharynx, hypopharynx, and neck narrows the upper airway, renders soft tissues more collapsible, and complicates airway management. In addition, the functional residual capacity is reduced, resulting in markedly shortened safe apnea time, contributing to severe hypoxemia during intubation. Non-invasive ventilation is effective in mitigating this risk and should be applied from pre-induction to laryngoscopy. Peri-intubation physiological optimization should include assessment of preload and cardiac contractility, with careful consideration of right ventricular strain. The transition from negative to positive intrathoracic pressure should be closely monitored, with cautious titration of positive end-expiratory pressure. Recognition of these anatomical and physiological challenges may prompt clinicians to consider awake intubation in selected patients. When rapid sequence induction is performed, both ketamine and etomidate are appropriate options; the choice between them should be guided by the clinical context, patient characteristics, local practice patterns and availability. Videolaryngoscopy increases the incidence of successful intubation on the first attempt and should be adopted routinely in the population with obesity. Several questions remain unanswered, including the safety and efficacy of pre-emptive vasopressor use to prevent post-intubation cardiovascular collapse and the optimal dosing of hypnotic agents to achieve ideal intubation conditions, while minimizing adverse events.

 

Does obesity impact on weaning from invasive ventilation: a secondary analysis of the WEAN SAFE study

Annals of Intensive Care volume 15, Article number: 164 (2025) Published: 21 October 2025

Objective

To understand the impact of obesity on outcomes of weaning from invasive mechanical ventilation (MV).

Methods

The study population consisted of patients enrolled in the WEAN SAFE study. We defined 4 groups based on body mass index (BMI), namely: Normal weight (BMI 18.5–24.9 kg/m²), Overweight (BMI 25–29.9 kg/m²), Obesity Class I (BMI 30–34.9 kg/m²), and obesity classes II and III (BMI ≥ 35 kg/m²). The primary outcome was the rate of successful extubation in patients in each BMI group. Secondary outcomes included the ICU and hospital survival, and PEEP levels at time of weaning eligibility in patients in each BMI group.

Results

In the study population, 1728 (38.2%) were of normal weight, 1395 (30.8%) were overweight, 590 (13.1%) were class I Obesity, and 431 (9.5%) were obesity classes II and III. Patients with obesity were more likely to be female, to be a medical admission, and to have comorbidities. Patients with grade II-III obesity had lower levels of sedation, later timing of the first separation attempt, longer time to weaning success, they received more noninvasive ventilation post extubation, and they had a longer ICU stay. In contrast, weaning success, and ICU and hospital mortality rates were not different in obese patients. There was no independent relationship between obesity and weaning delay, weaning success, or with overall survival outcomes. Higher PEEP at weaning eligibility was associated with weaning failure in normal and overweight patients but not in patients with obesity.

Conclusions

Patients with obesity had a more complex and longer weaning process, but obesity per se was not independently associated with adverse weaning outcomes.

 

 

 

Comparison of two transpulmonary pressure-based positive end-expiratory pressure titration strategies in acute respiratory distress syndrome: a randomized crossover study

Critical Care volume 29, Article number: 409 (2025) Published: 29 September 2025

Background

Esophageal pressure monitoring, which enables the estimation of transpulmonary pressure, has been proposed to personalize ventilator settings, particularly positive end-expiratory pressure (PEEP), in patients with acute respiratory distress syndrome (ARDS). Two conceptually different transpulmonary pressure-based PEEP titration strategies have thus been described but have never been compared. This study aims to compare the PEEP levels obtained with these two distinct strategies and their physiological effects.

Methods

This was a randomized crossover physiological study. Twenty patients with moderate to severe ARDS (PaO2/FiO2 < 150 mmHg) were included in an academic intensive care unit. The two transpulmonary pressure-based PEEP titration strategies were applied for 45 min each in a randomized order, separated by a 45-minute washout period. In the directly measured expiratory transpulmonary pressure (PL, exp) strategy, PEEP was set to target a PL, exp using a PL, exp/FiO2 table. In the calculated inspiratory transpulmonary pressure (PL, insp) strategy, PEEP was set to maintain PL, insp estimated using the lung/respiratory system elastance ratio between 20 and 22 cmH2O. Gas exchange, hemodynamics and partitioned respiratory mechanics were assessed at the end of each PEEP application period.

Results

Median PEEP levels determined by the two strategies were not different; however, individual values were uncorrelated, with a difference of at least 3 cmH2O in 14 (70%) patients. The PL, insp strategy resulted in higher PEEP levels than the PL, exp strategy in the non-obese patients but not in the obese patients. The effects on gas exchange, hemodynamics, and respiratory mechanics did not differ between the two strategies considering the entire study population or the obese and non-obese patients separately. Recruitment with PEEP (assessed by the recruited lung volume from PEEP 5 cmH2O), PL, insp, transpulmonary driving pressure and lung strain did not differ between the two strategies.

Conclusions

The two transpulmonary pressure-based titration strategies result in different PEEP levels in most patients. Neither strategy is associated with higher recruited lung volume or lower estimated Stress and Strain.

 

 

Short- and long-term outcomes and 15-year time trends of kidney replacement therapy in critically ill patients with obesity: an observational cohort

Intensive Care Medicine, Published: 30 June 2025

Purpose

Obesity is a public health challenge and a risk factor for chronic and acute kidney injury (AKI). The impact of kidney replacement therapy (KRT) on mortality in this specific population remains unclear. The objectives of this study were to evaluate the association between KRT and short- and long-term outcomes in patients with obesity, and to analyze trends over time in mortality as well as AKI and KRT incidence.

Methods

A retrospective analysis was conducted on all consecutive patients with obesity (body mass index ≥ 30 kg/m²) admitted to a medico-surgical intensive care unit from 2009 to 2024. AKI was defined using KDIGO criteria. The primary outcome was 90-day mortality assessed with Kaplan–Meier curves and multivariate Cox analysis. Secondary outcomes included 1-year mortality and time trends assessed on 90-day mortality, AKI, and KRT incidence, as well as SAPS II score.

Results

Among 2,192 patients with obesity included in the study, 295 (13.5%) required KRT. The 90-day mortality was significantly higher in the KRT group compared to the non-KRT group (49.8% (95% CI [44.1–55.5] vs. 18.9% (95% CI [17.2–20.7]), p < 0.0001). Multivariate analysis confirmed that KRT was independently associated with increased mortality. Over the 15-year period, AKI incidence decreased (p < 0.001).

Conclusion

Among critically ill obese patients, KRT was independently associated with increased 90-day mortality. These results highlight the need for prospective studies to better define optimal management strategies in this high-risk population.

 

Peri-intubation complications in critically ill obese patients: a secondary analysis of the international INTUBE cohort

Critical Care volume 29, Article number: 192 Published: 13 May 2025

Abstract

Background

Airway management in critically ill obese patients is potentially associated with a higher risk of adverse events due to a constellation of physiological and anatomical challenges. Data from international prospective studies on peri-intubation adverse events in obese critically ill patients are lacking.

Methods

INTUBE (International Observational Study to Understand the Impact and Best Practices of Airway Management In Critically Ill Patients) was an international multicentre prospective cohort study enrolling critically ill adult patients undergoing in-hospital tracheal intubation in 197 sites from 29 countries worldwide from October 1, 2018, to July 31, 2019. This secondary analysis compares airway management practices and outcomes between obese (body mass index–BMI ≥ 30 kg/m²) and non-obese patients (BMI < 30 kg/m²).

Results

A total of 2946 patients met inclusion criteria for this secondary analysis, 639 (21.7%) obese and 2307 (78.3%) non-obese. Severe peri-intubation hypoxemia was more frequently reported in obese compared to non-obese patients (12.1% vs 8.6% respectively, p = 0.01). Variables independently associated with a higher risk of peri-intubation hypoxemia were baseline SpO₂/FiO₂ (OR 0.996, 95% CI 0.994–0.997), 30–45° head-up position (OR 1.53, 95% CI 1.04–2.26) and first-pass intubation failure (OR for first-pass success 0.21, 95% CI 0.15–0.29). Obesity (OR 0.71, 95% CI 0.56–0.91) and 20° head-up position (OR 0.67, 95% CI 0.47–0.95) were independently associated with higher likelihood of first-pass intubation failure. In contrast, intubation by staff physician/consultant (OR 1.70, 95% CI 1.30–2.21) or anesthesiologists (OR 1.98, 95% CI 1.55–2.53) were associated with higher first-pass success.

Conclusions

Compared to non-obese patients, obese critically ill exhibit a higher incidence of peri-intubation severe hypoxemia. In this population, worse baseline oxygenation and first-pass intubation failure significantly increase the risk of peri-intubation severe hypoxemia. As obesity is linked to a higher likelihood of first-pass intubation failure, likely driven by more challenging airway features, in this high-risk population first attempt should be performed by an expert operator to minimize peri-intubation complications.

 

A Comparison of High and Usual Protein Dosing in Critically Ill Patients With Obesity: A Post Hoc Analysis of an International, Pragmatic, Single-Blinded, Randomized, Clinical Trial

by Tweel, Lauren E.; Compher, Charlene; Bear, Danielle E.; Gutierrez-Castrellon, Pedro; Leaver, Susannah K.; MacEachern, Kristen; Ortiz-Reyes, Luis; Pooja, Lakhani; León, Angélica; Wedemire, Courtney; Lee, Zheng Yii; Day, Andrew G.; Heyland, Daren K. 

Critical Care Medicine, November 06, 2023. 

Objectives: 

Across guidelines, protein dosing for critically ill patients with obesity varies considerably. The objective of this analysis was to evaluate whether this population would benefit from higher doses of protein.

Design: 

A post hoc subgroup analysis of the effect of higher protein dosing in critically ill patients with high nutritional risk (EFFORT Protein): an international, multicenter, pragmatic, registry-based randomized trial.

Setting: 

Eighty-five adult ICUs across 16 countries.

Patients: 

Patients with obesity defined as a body mass index (BMI) greater than or equal to 30 kg/m2 (n = 425).

Interventions: 

In the primary study, patients were randomized into a high-dose (≥ 2.2 g/kg/d) or usual-dose protein group (≤ 1.2 g/kg/d).

Measurements and Main Results: 

Protein intake was monitored for up to 28 days, and outcomes (time to discharge alive [TTDA], 60-d mortality, days of mechanical ventilation [MV], hospital, and ICU length of stay [LOS]) were recorded until 60 days post-randomization. Of the 1301 patients in the primary study, 425 had a BMI greater than or equal to 30 kg/m2. After adjusting for sites and covariates, we observed a nonsignificant slower rate of TTDA with higher protein that ruled out a clinically important benefit (hazard ratio, 0.78; 95% CI, 0.58–1.05; p = 0.10). We found no evidence of difference in TTDA between protein groups when subgroups with different classes of obesity or patients with and without various nutritional and frailty risk variables were examined, even after the removal of patients with baseline acute kidney injury. Overall, 60-day mortality rates were 31.5% and 28.2% in the high protein and usual protein groups, respectively (risk difference, 3.3%; 95% CI, –5.4 to 12.1; p = 0.46). Duration of MV and LOS in hospital and ICU were not significantly different between groups.

Conclusions: 

In critically ill patients with obesity, higher protein doses did not improve clinical outcomes, including those with higher nutritional and frailty risk.

Critical Care Bulletin: June 2022

 

The obesity paradox for survivors of critically ill patients

 

by Dawei Zhou, Chao Wang, Qing Lin and Tong Li 

 

Critical Care volume 26, Article number: 198 (2022) Published: 03 July 2022

 

The obesity paradox has been observed in short-term outcomes from critical illness. However, little is known regarding the impact of obesity on long-term outcomes for survivors of critically ill patients. We aimed to evaluate the influence of obesity on long-term mortality outcomes after discharge alive from ICU. The adult patients who were discharged alive from the last ICU admission were extracted. After exclusion, a total of 7619 adult patients discharged alive from ICU were included, with 4-year mortality of 32%. The median body mass index (BMI) was 27.2 (IQR 24–31.4) kg/m2, and 2490 (31.5%) patients were classified as obese or morbidly obese. The morbidly obese patients had the highest ICU and hospital length of stay. However, higher BMI was associated with lower hazard ratio for 4-year mortality. The results showed the obesity paradox may be also suitable for survivors of critically ill patients.

 

Drug dosing in hospitalized obese patients with COVID-19

 

By Jeffrey F. Barletta and Brian L. Erstad 

 

Critical Care volume 26, Article number: 60 (2022) Published: 14 March 2022

 

 

Obesity is highly prevalent in hospitalized patients admitted with COVID-19. Evidence based guidelines are available for COVID-19-related therapies but dosing information specific to patients with obesity is lacking. Failure to account for the pharmacokinetic alterations that exist in this population can lead to underdosing, and treatment failure, or overdosing, resulting in an adverse effect. The objective of this manuscript is to provide clinicians with guidance for making dosing decisions for medications used in the treatment of patients with COVID-19. A detailed literature search was conducted for medications listed in evidence-based guidelines from the National Institutes of Health with an emphasis on pharmacokinetics, dosing and obesity. Retrieved manuscripts were evaluated and the following prioritization strategy was used to form the decision framework for recommendations: clinical outcome data > pharmacokinetic studies > adverse effects > physicochemical properties. Most randomized controlled studies included a substantial number of patients who were obese but few had large numbers of patients more extreme forms of obesity. Pharmacokinetic data have described alterations with volume of distribution and clearance but this variability does not appear to warrant dosing modifications. Future studies should provide more information on size descriptors and stratification of data according to obesity and body habitus.

 

Body Mass Index and Mortality in Coronavirus Disease 2019 and Other Diseases: A Cohort Study in 35,506 ICU Patients

 

by Kooistra, Emma J.; Brinkman, Sylvia; van der Voort, Peter H. J.; de Keizer, Nicolette F.; Dongelmans, Dave A.; Kox, Matthijs; Pickkers, Peter 

 

Critical Care Medicine: January 2022 - Volume 50 - Issue 1 - p e1-e10

 

OBJECTIVES: 

Obesity is a risk factor for severe coronavirus disease 2019 and might play a role in its pathophysiology. It is unknown whether body mass index is related to clinical outcome following ICU admission, as observed in various other categories of critically ill patients. We investigated the relationship between body mass index and inhospital mortality in critically ill coronavirus disease 2019 patients and in cohorts of ICU patients with non-severe acute respiratory syndrome coronavirus 2 viral pneumonia, bacterial pneumonia, and multiple trauma.

DESIGN: 

Multicenter observational cohort study.

SETTING: 

Eighty-two Dutch ICUs participating in the Dutch National Intensive Care Evaluation quality registry.

PATIENTS: 

Thirty-five–thousand five-hundred six critically ill patients.

INTERVENTIONS: 

None.

MEASUREMENTS AND MAIN RESULTS: 

Patient characteristics and clinical outcomes were compared between four cohorts (coronavirus disease 2019, nonsevere acute respiratory syndrome coronavirus 2 viral pneumonia, bacterial pneumonia, and multiple trauma patients) and between body mass index categories within cohorts. Adjusted analyses of the relationship between body mass index and inhospital mortality within each cohort were performed using multivariable logistic regression. Coronavirus disease 2019 patients were more likely male, had a higher body mass index, lower Pao2/Fio2 ratio, and were more likely mechanically ventilated during the first 24 hours in the ICU compared with the other cohorts. Coronavirus disease 2019 patients had longer ICU and hospital length of stay, and higher inhospital mortality. Odds ratios for inhospital mortality for patients with body mass index greater than or equal to 35 kg/m2 compared with normal weight in the coronavirus disease 2019, nonsevere acute respiratory syndrome coronavirus 2 viral pneumonia, bacterial pneumonia, and trauma cohorts were 1.15 (0.79–1.67), 0.64 (0.43–0.95), 0.73 (0.61–0.87), and 0.81 (0.57–1.15), respectively.

CONCLUSIONS: 

The obesity paradox, which is the inverse association between body mass index and mortality in critically ill patients, is not present in ICU patients with coronavirus disease 2019–related respiratory failure, in contrast to nonsevere acute respiratory syndrome coronavirus 2 viral and bacterial respiratory infections.

Noninvasive ventilation vs. high-flow nasal cannula oxygen for preoxygenation before intubation in patients with obesity: a post hoc analysis of a randomized controlled trial

Noninvasive ventilation vs. high-flow nasal cannula oxygen for preoxygenation before intubation in patients with obesity: a post hoc analysis of a randomized controlled trial

 

by Maeva Rodriguez, Stéphanie Ragot, Rémi Coudroy, Jean-Pierre Quenot, Philippe Vignon, Jean-Marie Forel, Alexandre Demoule, Jean-Paul Mira, Jean-Damien Ricard, Saad Nseir, Gwenhael Colin, Bertrand Pons, Pierre-Eric Danin, Jérome Devaquet, Gwenael Prat, Hamid Merdji…

 

Annals of Intensive Care volume 11, Article number: 114, Published: 22 July 2021

 

Background

Critically ill patients with obesity may have an increased risk of difficult intubation and subsequent severe hypoxemia. We hypothesized that pre-oxygenation with noninvasive ventilation before intubation as compared with high-flow nasal cannula oxygen may decrease the risk of severe hypoxemia in patients with obesity.

Methods

Post hoc subgroup analysis of critically ill patients with obesity (body mass index ≥ 30 kg·m−2) from a multicenter randomized controlled trial comparing preoxygenation with noninvasive ventilation and high-flow nasal oxygen before intubation of patients with acute hypoxemic respiratory failure (PaO2/FiO2 < 300 mm Hg). The primary outcome was the occurrence of severe hypoxemia (pulse oximetry < 80%) during the intubation procedure.

Results

Among the 313 patients included in the original trial, 91 (29%) had obesity with a mean body mass index of 35 ± 5 kg·m−2. Patients with obesity were more likely to experience an episode of severe hypoxemia during intubation procedure than patients without obesity: 34% (31/91) vs. 22% (49/222); difference, 12%; 95% CI 1 to 23%; P = 0.03. Among patients with obesity, 40 received preoxygenation with noninvasive ventilation and 51 with high-flow nasal oxygen. Severe hypoxemia occurred in 15 patients (37%) with noninvasive ventilation and 16 patients (31%) with high-flow nasal oxygen (difference, 6%; 95% CI − 13 to 25%; P = 0.54). The lowest pulse oximetry values during intubation procedure were 87% [interquartile range, 77–93] with noninvasive ventilation and 86% [78–92] with high-flow nasal oxygen (P = 0.98). After multivariable analysis, factors independently associated with severe hypoxemia in patients with obesity were intubation difficulty scale > 5 points and respiratory primary failure as reason for admission.

Conclusions

Patients with obesity and acute hypoxemic respiratory failure had an increased risk of severe hypoxemia during intubation procedure as compared to patients without obesity. However, preoxygenation with noninvasive ventilation may not reduce this risk compared with high-flow nasal oxygen.

Trial registration Clinical trial number: NCT02668458 (http://www.clinicaltrials.gov)

 

 

Transpulmonary pressures in obese and non-obese COVID-19 ARDS

 

Transpulmonary pressures in obese and non-obese COVID-19 ARDS

by Mehdi Mezidi, Florence Daviet, Paul Chabert, Sami Hraiech, Laurent Bitker, Jean-Marie Forel, Hodane Yonis, Ines Gragueb, Francois Dhelft, Laurent Papazian, Jean-Christophe Richard and Christophe Guervilly

Annals of Intensive Care volume 10, Article number: 129 (2020) Published: 01 October 2020

Background

Data on respiratory mechanics of COVID-19 ARDS patients are scarce. Respiratory mechanics and response to positive expiratory pressure (PEEP) may be different in obese and non-obese patients.

Methods

We investigated esophageal pressure allowing determination of transpulmonary pressures (PL ) and elastances (EL) during a decremental PEEP trial from 20 to 6 cm H2O in a cohort of COVID-19 ARDS patients.

Results

Fifteen patients were investigated, 8 obese and 7 non-obese patients. PEEP ≥ 16 cm H2O for obese patients and PEEP ≥10 cm H2O for non-obese patients were necessary to obtain positive expiratory PL. Change of PEEP did not alter significantly ΔPL or elastances in obese patients. However, in non-obese patients lung EL  and ΔPL increased significantly with PEEP increase. Chest wall EL was not affected by PEEP variations in both groups.

A lung rescue team improves survival in obesity with acute respiratory distress syndrome

A lung rescue team improves survival in obesity with acute respiratory distress syndrome

by Gaetano Florio, Matteo Ferrari, Edward A. Bittner, Roberta De Santis Santiago, Massimiliano Pirrone, Jacopo Fumagalli, Maddalena Teggia Droghi, Cristina Mietto, Riccardo Pinciroli, Sheri Berg, Aranya Bagchi, Kenneth Shelton, Alexander Kuo, Yvonne Lai, Abraham Sonny, Peggy Lai…

Critical Care volume 24, Article number: 4 (2020) Published: 15 January 2020

Background

Limited data exist regarding ventilation in patients with class III obesity [body mass index (BMI) > 40 kg/m2] and acute respiratory distress syndrome (ARDS). The aim of the present study was to determine whether an individualized titration of mechanical ventilation according to cardiopulmonary physiology reduces the mortality in patients with class III obesity and ARDS.

Methods

In this retrospective study, we enrolled adults admitted to the ICU from 2012 to 2017 who had class III obesity and ARDS and received mechanical ventilation for > 48 h. Enrolled patients were divided in two cohorts: one cohort (2012–2014) had ventilator settings determined by the ARDSnet table for lower positive end-expiratory pressure/higher inspiratory fraction of oxygen (standard protocol-based cohort); the other cohort (2015–2017) had ventilator settings determined by an individualized protocol established by a lung rescue team (lung rescue team cohort). The lung rescue team used lung recruitment maneuvers, esophageal manometry, and hemodynamic monitoring.

Results

The standard protocol-based cohort included 70 patients (BMI = 49 ± 9 kg/m2), and the lung rescue team cohort included 50 patients (BMI = 54 ± 13 kg/m2). Patients in the standard protocol-based cohort compared to lung rescue team cohort had almost double the risk of dying at 28 days [31% versus 16%, P = 0.012; hazard ratio (HR) 0.32; 95% confidence interval (CI95%) 0.13–0.78] and 3 months (41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16–0.74), and this effect persisted at 6 months and 1 year (incidence of death unchanged 41% versus 22%, P = 0.006; HR 0.35; CI95% 0.16–0.74).

Conclusion

Individualized titration of mechanical ventilation by a lung rescue team was associated with decreased mortality compared to use of an ARDSnet table.

Does Obesity Protect Against Death in Sepsis? A Retrospective Cohort Study of 55,038 Adult Patients*

Does Obesity Protect Against Death in Sepsis? A Retrospective Cohort Study of 55,038 Adult Patients*

by Pepper, Dominique J.; Demirkale, Cumhur Y.; Sun, Junfeng; Rhee, Chanu; Fram, David; Eichacker, Peter; Klompas, Michael; Suffredini, Anthony F.; Kadri, Sameer S.

Critical Care Medicine: May 2019 - Volume 47 - Issue 5 - p 643–650

Objectives: Observational studies suggest obesity is associated with sepsis survival, but these studies are small, fail to adjust for key confounders, measure body mass index at inconsistent time points, and/or use administrative data to define sepsis. To estimate the relationship between body mass index and sepsis mortality using detailed clinical data for case detection and risk adjustment. Design: Retrospective cohort analysis of a large clinical data repository.

Setting: One-hundred thirty-nine hospitals in the United States.

Patients: Adult inpatients with sepsis meeting Sepsis-3 criteria. Exposure: Body mass index in six categories: underweight (body mass index < 18.5 kg/m2), normal weight (body mass index = 18.5–24.9 kg/m2), overweight (body mass index = 25.0–29.9 kg/m2), obese class I (body mass index = 30.0–34.9 kg/m2), obese class II (body mass index = 35.0–39.9 kg/m2), and obese class III (body mass index ≥ 40 kg/m2).

 Measurements: Multivariate logistic regression with generalized estimating equations to estimate the effect of body mass index category on short-term mortality (in-hospital death or discharge to hospice) adjusting for patient, infection, and hospital-level factors. Sensitivity analyses were conducted in subgroups of age, gender, Elixhauser comorbidity index, Sequential Organ Failure Assessment quartiles, bacteremic sepsis, and ICU admission.

 Main Results: From 2009 to 2015, we identified 55,038 adults with sepsis and assessable body mass index measurements: 6% underweight, 33% normal weight, 28% overweight, and 33% obese. Crude mortality was inversely proportional to body mass index category: underweight (31%), normal weight (24%), overweight (19%), obese class I (16%), obese class II (16%), and obese class III (14%). Compared with normal weight, the adjusted odds ratio (95% CI) of mortality was 1.62 (1.50–1.74) for underweight, 0.73 (0.70–0.77) for overweight, 0.61 (0.57–0.66) for obese class I, 0.61 (0.55–0.67) for obese class II, and 0.65 (0.59–0.71) for obese class III. Results were consistent in sensitivity analyses. 

Conclusions: In adults with clinically defined sepsis, we demonstrate lower short-term mortality in patients with higher body mass indices compared with those with normal body mass indices (both unadjusted and adjusted analyses) and higher short-term mortality in those with low body mass indices. Understanding how obesity improves survival in sepsis would inform prognostic and therapeutic strategies.

Recruitment Maneuvers and Positive End-Expiratory Pressure Titration in Morbidly Obese ICU Patients

Recruitment Maneuvers and Positive End-Expiratory Pressure Titration in Morbidly Obese ICU Patients
Critical Care Medicine: February 2016 - Volume 44 - Issue 2 - p 300–307
Pirrone, M et al

Objective: The approach to applying positive end-expiratory pressure in morbidly obese patients is not well defined. These patients frequently require prolonged mechanical ventilation, increasing the risk for failed liberation from ventilatory support. We hypothesized that lung recruitment maneuvers and titration of positive end-expiratory pressure were both necessary to improve lung volumes and the elastic properties of the lungs, leading to improved gas exchange. Design: Prospective, crossover, nonrandomized interventional study. Setting: Medical and surgical ICUs at Massachusetts General Hospital. Patients: Critically ill, mechanically ventilated morbidly obese (body mass index > 35 kg/m2) patients (n = 14). Interventions: This study evaluated two methods of titrating positive end-expiratory pressure; both trials were done utilizing positive end-expiratory pressure titration and recruitment maneuvers while measuring hemodynamics and respiratory mechanics. Measurements were obtained at the baseline positive end-expiratory pressure set by the clinicians, at zero positive end-expiratory pressure, at best positive end-expiratory pressure identified through esophageal pressure measurement before and after a recruitment maneuver, and at best positive end-expiratory pressure identified through a best decremental positive end-expiratory pressure trial. Measurements and Main Results: The average body mass index was 50.7 ± 16.0 kg/m2. The two methods of evaluating positive end-expiratory pressure identified similar optimal positive end-expiratory pressure levels (20.7 ± 4.0 vs 21.3 ± 3.8 cm H2O; p = 0.40). End-expiratory pressure titration increased end-expiratory lung volumes (Δ11 ± 7 mL/kg; p < 0.01) and oxygenation (Δ86 ± 50 torr; p < 0.01) and decreased lung elastance (Δ5 ± 5 cm H2O/L; p < 0.01). Recruitment maneuvers followed by titrated positive end-expiratory pressure were effective at increasing end-expiratory lung volumes while decreasing end-inspiratory transpulmonary pressure, suggesting an improved distribution of lung aeration and reduction of overdistension. The positive end-expiratory pressure levels set by the clinicians (11.6 ± 2.9 cm H2O) were associated with lower lung volumes, worse elastic properties of the lung, and lower oxygenation. Conclusions: Commonly used positive end-expiratory pressure by clinicians is inadequate for optimal mechanical ventilation of morbidly obese patients. A recruitment maneuver followed by end-expiratory pressure titration was found to significantly improve lung volumes, respiratory system elastance, and oxygenation.

Body mass index is associated with hospital mortality in critically ill patients

Body mass index is associated with hospital mortality in critically ill patients: An observational cohort study. Critical care medicine, Aug 2013, Vol. 41(8), p.1878-83.

Pickkers, P., et al.

http://journals.lww.com/ccmjournal/Abstract/2013/08000/Body_Mass_Index_Is_Associated_With_Hospital.7.aspx

Obesity is associated with a variety of diseases, which results in a decreased overall life expectancy. Nevertheless, some studies suggest that being overweight may reduce hospital mortality of certain patient groups, referred to as obesity paradox. Conflicting results for critically ill patients are reported. Therefore, we wished to investigate the association of body mass index and hospital mortality in critically ill patients.

The obesity paradox in the ICU

The obesity paradox in the ICU: real or not? Critical care, June 2013, 17: 154.

Dickerson, R.N.

[no link available]

The obesity paradox has been used to describe the observed phenomenon described by several studies that indicated improved survival for critically ill patients with mild to moderate obesity when compared with their lean counterparts. The study by Arabi and coworkers challenges the obesity paradox concept for critically ill obese patients with septic shock. Their data indicate that obesity, per se, does not significantly improve mortality when outcomes are adjusted for differences in baseline characteristics and sepsis interventions. Further studies are needed to assess the influence of body weight, lean weight, and fat mass for optimizing fluid resuscitation, pharmacotherapy, and nutritional therapy for critically ill patients with sepsis.

Clinical review: Ventilatory strategies for obstetric, brain-injured and obese patients

Critical Care Feb-March 2009

Review
Clinical review: Ventilatory strategies for obstetric, brain-injured and obese patients Lapinsky SE, Posadas-Calleja J, McCullagh I Critical Care 2008, 13:206 (4 March 2009)[Abstract] [Full text] [PDF]

Intensive Care Medicine articles: VOL 34; NUMBER 11; 2008

INTENSIVE CARE MEDICINE
VOL 34; NUMBER 11; 2008
ISSN 0342-4642

pp. 1980-1990
Immunonutrition in critically ill patients: a systematic review and analysis of the literature.
Marik, P. E.; Zaloga, G. P.
http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN238986988&field=zid

pp. 1961-1963
ICU patients: fatter is better?.
Druml, W.
http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN238987013&field=zid

pp. 1991-1998
Impact of obesity in mechanically ventilated patients: a prospective study.
Frat, J. P.; Gissot, V. r.; Ragot, S. p.; Desachy, A.; Runge, I.; Lebert, C.; Robert, R.; for, t. A.
http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN238987026&field=zid


pp. 1964-1965
Impact of body weight on critically ill patients: a heavy load!!.
Esteban, A.; Frutos-Vivar, F.; Anzueto, A.
http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN238987038&field=zid

pp. 1999-2009
Obesity is associated with increased morbidity but not mortality in critically ill patients.
Sakr, Y.; Madl, C.; Filipescu, D.; Moreno, R.; Groeneveld, J.; Artigas, A.; Reinhart, K.; Vincent, J. L.
http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN238987049&field=zid

pp. 1950-1954
Science, medicine and industry: are we getting out of the black hole in sepsis research?.
Suter, P. M.; Takala, J.
http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN238987052&field=zid

pp. 1955-1960
Once is not enough: clinical trials in sepsis.
Sweeney, D. A.; Danner, R. L.; Eichacker, P. Q.; Natanson, C.
http://zetoc.mimas.ac.uk/wzgw?db=etoc&terms=RN238987074&field=zid

Impact of obesity in mechanically ventilated patients : a prospective study

Bibliographic export Print Select
Jean - Pierre Frat ; Valérie Gissot ; Stéphanie Ragot ; Arnaud Desachy ; Isabelle Runge ; Christine Lebert ; René Robert
Proquest NHS (01/2002 - 10/2007)
Page: 1991 - 1998 Vol/Issue: 2008 ; VOL 34 ; PART 11 Date: 2008/10
ISSN Print: 0342-4642 E-ISSN: 1432-1238
Search Google: Article Author(s)


Bibliographic export Print Select
Obesity is associated with increased morbidity but not mortality in critically ill patients
Yasser Sakr ; Christian Madl ; Daniela Filipescu ; et al
Proquest NHS (01/2002 - 10/2007)
Page: 1999 - 2009 Vol/Issue: 2008 ; VOL 34 ; PART 11 Date: 2008/10
ISSN Print: 0342-4642 E-ISSN: 1432-1238
Search Google: Article Author(s)