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Muñoz J, Cedeño JA, Castañeda GF, Visedo LC. Personalized ventilation adjustment in ARDS: A systematic review and meta-analysis of image, driving pressure, transpulmonary pressure, and mechanical power. Heart Lung 2024; 68:305-315. [PMID: 39214040 DOI: 10.1016/j.hrtlng.2024.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 06/28/2024] [Accepted: 08/16/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Acute Respiratory Distress Syndrome (ARDS) necessitates personalized treatment strategies due to its heterogeneity, aiming to mitigate Ventilator-Induced Lung Injury (VILI). Advanced monitoring techniques, including imaging, driving pressure, transpulmonary pressure, and mechanical power, present potential avenues for tailored interventions. OBJECTIVE To review some of the most important techniques for achieving greater personalization of mechanical ventilation in ARDS patients as evaluated in randomized clinical trials, by analyzing their effect on three clinically relevant aspects: mortality, ventilator-free days, and gas exchange. METHODS Following PRISMA guidelines, we conducted a systematic review and meta-analysis of Randomized Clinical Trials (RCTs) involving adult ARDS patients undergoing personalized ventilation adjustments. Outcomes were mortality (primary end-point), ventilator-free days, and oxygenation improvement. RESULTS Among 493 identified studies, 13 RCTs (n = 1255) met inclusion criteria. No personalized ventilation strategy demonstrated superior outcomes compared to traditional protocols. Meta-analysis revealed no significant reduction in mortality with image-guided (RR 0.88, 95 % CI 0.70-1.11), driving pressure-guided (RR 0.61, 95 % CI 0.29-1.30), or transpulmonary pressure-guided (RR 0.85, 95 % CI 0.58-1.24) strategies. Ventilator-free days and oxygenation outcomes showed no significant differences. CONCLUSION Our study does not support the superiority of personalized ventilation techniques over traditional protocols in ARDS patients. Further research is needed to standardize ventilation strategies and determine their impact on mechanical ventilation outcomes.
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Affiliation(s)
- Javier Muñoz
- ICU, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquedo 46, 28009 Madrid, Spain.
| | - Jamil Antonio Cedeño
- ICU, Hospital General Universitario Gregorio Marañón, C/ Dr. Esquedo 46, 28009 Madrid, Spain
| | | | - Lourdes Carmen Visedo
- C. S. San Juan de la Cruz, Pozuelo de Alarcón, C/ San Juan de la Cruz s/n, 28223 Madrid, Spain
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2
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Boesing C, Rocco PRM, Luecke T, Krebs J. Positive end-expiratory pressure management in patients with severe ARDS: implications of prone positioning and extracorporeal membrane oxygenation. Crit Care 2024; 28:277. [PMID: 39187853 PMCID: PMC11348554 DOI: 10.1186/s13054-024-05059-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 08/06/2024] [Indexed: 08/28/2024] Open
Abstract
The optimal strategy for positive end-expiratory pressure (PEEP) titration in the management of severe acute respiratory distress syndrome (ARDS) patients remains unclear. Current guidelines emphasize the importance of a careful risk-benefit assessment for PEEP titration in terms of cardiopulmonary function in these patients. Over the last few decades, the primary goal of PEEP usage has shifted from merely improving oxygenation to emphasizing lung protection, with a growing focus on the individual pattern of lung injury, lung and chest wall mechanics, and the hemodynamic consequences of PEEP. In moderate-to-severe ARDS patients, prone positioning (PP) is recommended as part of a lung protective ventilation strategy to reduce mortality. However, the physiologic changes in respiratory mechanics and hemodynamics during PP may require careful re-assessment of the ventilation strategy, including PEEP. For the most severe ARDS patients with refractory gas exchange impairment, where lung protective ventilation is not possible, veno-venous extracorporeal membrane oxygenation (V-V ECMO) facilitates gas exchange and allows for a "lung rest" strategy using "ultraprotective" ventilation. Consequently, the importance of lung recruitment to improve oxygenation and homogenize ventilation with adequate PEEP may differ in severe ARDS patients treated with V-V ECMO compared to those managed conservatively. This review discusses PEEP management in severe ARDS patients and the implications of management with PP or V-V ECMO with respect to respiratory mechanics and hemodynamic function.
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Affiliation(s)
- Christoph Boesing
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão, Rio de Janeiro, Brazil
| | - Thomas Luecke
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Joerg Krebs
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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3
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Combes A, Auzinger G, Camporota L, Capellier G, Consales G, Couto AG, Dabrowski W, Davies R, Demirkiran O, Gómez CF, Franz J, Hilty MP, Pestaña D, Rovina N, Tully R, Turani F, Kurz J, Harenski K. Expert perspectives on ECCO 2R for acute hypoxemic respiratory failure: consensus of a 2022 European roundtable meeting. Ann Intensive Care 2024; 14:132. [PMID: 39174831 PMCID: PMC11341504 DOI: 10.1186/s13613-024-01353-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 07/15/2024] [Indexed: 08/24/2024] Open
Abstract
BACKGROUND By controlling hypercapnia, respiratory acidosis, and associated consequences, extracorporeal CO2 removal (ECCO2R) has the potential to facilitate ultra-protective lung ventilation (UPLV) strategies and to decrease injury from mechanical ventilation. We convened a meeting of European intensivists and nephrologists and used a modified Delphi process to provide updated insights into the role of ECCO2R in acute respiratory distress syndrome (ARDS) and to identify recommendations for a future randomized controlled trial. RESULTS The group agreed that lung protective ventilation and UPLV should have distinct definitions, with UPLV primarily defined by a tidal volume (VT) of 4-6 mL/kg predicted body weight with a driving pressure (ΔP) ≤ 14-15 cmH2O. Fourteen (93%) participants agreed that ECCO2R would be needed in the majority of patients to implement UPLV. Furthermore, 10 participants (majority, 63%) would select patients with PaO2:FiO2 > 100 mmHg (> 13.3 kPa) and 14 (consensus, 88%) would select patients with a ventilatory ratio of > 2.5-3. A minimum CO2 removal rate of 80 mL/min delivered by continuous renal support machines was suggested (11/14 participants, 79%) for this objective, using a short, double-lumen catheter inserted into the right internal jugular vein as the preferred vascular access. Of the participants, 14/15 (93%, consensus) stated that a new randomized trial of ECCO2R is needed in patients with ARDS. A ΔP of ≥ 14-15 cmH2O was suggested by 12/14 participants (86%) as the primary inclusion criterion. CONCLUSIONS ECCO2R may facilitate UPLV with lower volume and pressures provided by the ventilator, while controlling respiratory acidosis. Since recent European Society of Intensive Care Medicine guidelines on ARDS recommended against the use of ECCO2R for the treatment of ARDS outside of randomized controlled trials, new trials of ECCO2R are urgently needed, with a ΔP of ≥ 14-15 cmH2O suggested as the primary inclusion criterion.
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Affiliation(s)
- Alain Combes
- Institute of Cardiometabolism and Nutrition, INSERM Unité Mixte de Recherche (UMRS) 1166, Sorbonne Université, 47, Boulevard de l'Hôpital, 75013, Paris, France.
- Service de Médecine Intensive-Réanimation, Sorbonne Université, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 75013, Paris, France.
| | - Georg Auzinger
- Department of Critical Care, King's College Hospital, London, SE5 9RS, UK
- Department of Critical Care, Cleveland Clinic, London, SW1Y 7SW, UK
| | - Luigi Camporota
- Department of Critical Care, Guy's & St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, SE1 1UL, UK
| | - Gilles Capellier
- University of Franche-Comté, 25000, Besançon, France
- Department of Epidemiology and Health, Monash University, Melbourne, VIC, 3004, Australia
| | - Guglielmo Consales
- Anesthesia, Intensive Care and Emergency Department, Prato Hospital, Azienda Toscana Centro, Prato, Italy
| | - Antonio Gomis Couto
- Servicio de Nefrología, Hospital Universitario Ramón y Cajal, 28033, Madrid, Spain
| | - Wojciech Dabrowski
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, 20-954, Lublin, Poland
| | - Roger Davies
- Chelsea and Westminster Hospital NHS Foundation Trust, London, SW10 9NH, UK
- Division of Anaesthetics, Intensive Care and Pain Medicine, Imperial College London, Chelsea and Westminster Hospital Campus, London, SW10 9NH, UK
| | - Oktay Demirkiran
- Department of Anesthesiology and Intensive Care, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, 34098, Turkey
| | - Carolina Ferrer Gómez
- Anesthesiology and Intensive Care Department, Consorcio Hospital General Universitario de Valencia, 46014, Valencia, Spain
| | - Jutta Franz
- Department of Cardiology and Internal Intensive Care, Rems-Murr-Kliniken Winnenden, 71364, Winnenden, Germany
| | - Matthias Peter Hilty
- Institute of Intensive Care Medicine, University Hospital Zurich, 8091, Zurich, Switzerland
| | - David Pestaña
- Servicio de Anestesia-Reanimación, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Km 9, 28034, Madrid, Spain
- Facultad de Medicina, Instituto Ramón y Cajal de Investigación Sanitaria, Universidad de Alcalá, 28034, Madrid, Spain
| | - Nikoletta Rovina
- 1st Respiratory Department, National and Kapodistrian University of Athens Medical School, "Sotiria" Chest Hospital, 152 Mesogion Av, 11527, Athens, Greece
| | - Redmond Tully
- Royal Oldham Hospital, Northern Care Alliance NHS Trust, Oldham, OL1 2JH, UK
| | - Franco Turani
- Department of Intensive Care, Aurelia Hospital, Via Aurelia 860, 00165, Rome, Italy
- Cardiac Anaesthesia European Hospital, Via Portuense, 760, 00416, Rome, Italy
| | - Joerg Kurz
- Baxter Healthcare, Edisonstr 4, 85716, Unterschleißheim, Germany
| | - Kai Harenski
- Baxter Healthcare, Edisonstr 4, 85716, Unterschleißheim, Germany
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Lagier D, Zeng C, Kaczka DW, Zhu M, Grogg K, Gerard SE, Reinhardt JM, Ribeiro GCM, Rashid A, Winkler T, Vidal Melo MF. Mechanical ventilation guided by driving pressure optimizes local pulmonary biomechanics in an ovine model. Sci Transl Med 2024; 16:eado1097. [PMID: 39141699 DOI: 10.1126/scitranslmed.ado1097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 05/13/2024] [Accepted: 07/24/2024] [Indexed: 08/16/2024]
Abstract
Mechanical ventilation exposes the lung to injurious stresses and strains that can negatively affect clinical outcomes in acute respiratory distress syndrome or cause pulmonary complications after general anesthesia. Excess global lung strain, estimated as increased respiratory system driving pressure, is associated with mortality related to mechanical ventilation. The role of small-dimension biomechanical factors underlying this association and their spatial heterogeneity within the lung are currently unknown. Using four-dimensional computed tomography with a voxel resolution of 2.4 cubic millimeters and a multiresolution convolutional neural network for whole-lung image segmentation, we dynamically measured voxel-wise lung inflation and tidal parenchymal strains. Healthy or injured ovine lungs were evaluated as the mechanical ventilation positive end-expiratory pressure (PEEP) was titrated from 20 to 2 centimeters of water. The PEEP of minimal driving pressure (PEEPDP) optimized local lung biomechanics. We observed a greater rate of change in nonaerated lung mass with respect to PEEP below PEEPDP compared with PEEP values above this threshold. PEEPDP similarly characterized a breaking point in the relationships between PEEP and SD of local tidal parenchymal strain, the 95th percentile of local strains, and the magnitude of tidal overdistension. These findings advance the understanding of lung collapse, tidal overdistension, and strain heterogeneity as local triggers of ventilator-induced lung injury in large-animal lungs similar to those of humans and could inform the clinical management of mechanical ventilation to improve local lung biomechanics.
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Affiliation(s)
- David Lagier
- Experimental Interventional Imaging Laboratory (LIIE), European Center for Research in Medical Imaging (CERIMED), Aix Marseille University, Marseille 13005, France
- Department of Anesthesia and Critical Care, University Hospital La Timone, APHM, Marseille 13005, France
| | - Congli Zeng
- Department of Anesthesiology, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY 10032, USA
| | - David W Kaczka
- Departments of Anesthesia and Radiology, University of Iowa, Iowa City, IA 52242, USA
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA 52242, USA
| | - Min Zhu
- Guizhou University South Campus, Guiyang City 550025, China
| | - Kira Grogg
- Yale PET Center, Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT 06520, USA
| | - Sarah E Gerard
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA 52242, USA
| | - Joseph M Reinhardt
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, IA 52242, USA
| | - Gabriel C Motta Ribeiro
- Biomedical Engineering Program, Alberto Luiz Coimbra Institute for Graduate Studies and Research in Engineering, Universidade Federal do Rio de Janeiro, Rio de Janeiro 21941-594, Brazil
| | - Azman Rashid
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Tilo Winkler
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Marcos F Vidal Melo
- Department of Anesthesiology, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY 10032, USA
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5
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Franchi F, Detti E, Fogagnolo A, Spadaro S, Cevenini G, Cataldo G, Addabbo T, Biuzzi C, Marianello D, Volta CA, Taccone FS, Scolletta S. Estimation of the transpulmonary pressure from the central venous pressure in mechanically ventilated patients. J Clin Monit Comput 2024; 38:847-858. [PMID: 38512359 PMCID: PMC11297816 DOI: 10.1007/s10877-024-01150-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/05/2024] [Indexed: 03/23/2024]
Abstract
Transpulmonary pressure (PL) calculation requires esophageal pressure (PES) as a surrogate of pleural pressure (Ppl), but its calibration is a cumbersome technique. Central venous pressure (CVP) swings may reflect tidal variations in Ppl and could be used instead of PES, but the interpretation of CVP waveforms could be difficult due to superposition of heartbeat-induced pressure changes. Thus, we developed a digital filter able to remove the cardiac noise to obtain a filtered CVP (f-CVP). The aim of the study was to evaluate the accuracy of CVP and filtered CVP swings (ΔCVP and Δf-CVP, respectively) in estimating esophageal respiratory swings (ΔPES) and compare PL calculated with CVP, f-CVP and PES; then we tested the diagnostic accuracy of the f-CVP method to identify unsafe high PL levels, defined as PL>10 cmH2O. Twenty patients with acute respiratory failure (defined as PaO2/FiO2 ratio below 200 mmHg) treated with invasive mechanical ventilation and monitored with an esophageal balloon and central venous catheter were enrolled prospectively. For each patient a recording session at baseline was performed, repeated if a modification in ventilatory settings occurred. PES, CVP and airway pressure during an end-inspiratory and -expiratory pause were simultaneously recorded; CVP, f-CVP and PES waveforms were analyzed off-line and used to calculate transpulmonary pressure (PLCVP, PLf-CVP, PLPES, respectively). Δf-CVP correlated better than ΔCVP with ΔPES (r = 0.8, p = 0.001 vs. r = 0.08, p = 0.73), with a lower bias in Bland Altman analysis in favor of PLf-CVP (mean bias - 0.16, Limits of Agreement (LoA) -1.31, 0.98 cmH2O vs. mean bias - 0.79, LoA - 3.14, 1.55 cmH2O). Both PLf-CVP and PLCVP correlated well with PLPES (r = 0.98, p < 0.001 vs. r = 0.94, p < 0.001), again with a lower bias in Bland Altman analysis in favor of PLf-CVP (0.15, LoA - 0.95, 1.26 cmH2O vs. 0.80, LoA - 1.51, 3.12, cmH2O). PLf-CVP discriminated high PL value with an area under the receiver operating characteristic curve 0.99 (standard deviation, SD, 0.02) (AUC difference = 0.01 [-0.024; 0.05], p = 0.48). In mechanically ventilated patients with acute respiratory failure, the digital filtered CVP estimated ΔPES and PL obtained from digital filtered CVP represented a reliable value of standard PL measured with the esophageal method and could identify patients with non-protective ventilation settings.
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Affiliation(s)
- Federico Franchi
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy.
| | - Emanuele Detti
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy
| | - Alberto Fogagnolo
- Intensive Care Unit, Department of Translational Medicine and for Romagna, Azienda Ospedaliera Universitaria di Ferrara, University of Ferrara, 44121, Ferrara, Italy
| | - Savino Spadaro
- Intensive Care Unit, Department of Translational Medicine and for Romagna, Azienda Ospedaliera Universitaria di Ferrara, University of Ferrara, 44121, Ferrara, Italy
| | - Gabriele Cevenini
- Department of Medical Biotechnologies, University of Siena, 53100, Siena, Italy
| | - Gennaro Cataldo
- Department of Medical Biotechnologies, University of Siena, 53100, Siena, Italy
| | - Tommaso Addabbo
- Department of Information Engineering and Mathematics, University of Siena, 53100, Siena, Italy
| | - Cesare Biuzzi
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy
| | - Daniele Marianello
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy
| | - Carlo Alberto Volta
- Intensive Care Unit, Department of Translational Medicine and for Romagna, Azienda Ospedaliera Universitaria di Ferrara, University of Ferrara, 44121, Ferrara, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, 1070, Belgium
| | - Sabino Scolletta
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy
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6
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Cruces P, Retamal J, Damián A, Lago G, Blasina F, Oviedo V, Medina T, Pérez A, Vaamonde L, Dapueto R, González-Dambrauskas S, Serra A, Monteverde-Fernandez N, Namías M, Martínez J, Hurtado DE. A machine-learning regional clustering approach to understand ventilator-induced lung injury: a proof-of-concept experimental study. Intensive Care Med Exp 2024; 12:60. [PMID: 38954052 PMCID: PMC11220131 DOI: 10.1186/s40635-024-00641-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 06/17/2024] [Indexed: 07/04/2024] Open
Abstract
BACKGROUND The spatiotemporal progression and patterns of tissue deformation in ventilator-induced lung injury (VILI) remain understudied. Our aim was to identify lung clusters based on their regional mechanical behavior over space and time in lungs subjected to VILI using machine-learning techniques. RESULTS Ten anesthetized pigs (27 ± 2 kg) were studied. Eight subjects were analyzed. End-inspiratory and end-expiratory lung computed tomography scans were performed at the beginning and after 12 h of one-hit VILI model. Regional image-based biomechanical analysis was used to determine end-expiratory aeration, tidal recruitment, and volumetric strain for both early and late stages. Clustering analysis was performed using principal component analysis and K-Means algorithms. We identified three different clusters of lung tissue: Stable, Recruitable Unstable, and Non-Recruitable Unstable. End-expiratory aeration, tidal recruitment, and volumetric strain were significantly different between clusters at early stage. At late stage, we found a step loss of end-expiratory aeration among clusters, lowest in Stable, followed by Unstable Recruitable, and highest in the Unstable Non-Recruitable cluster. Volumetric strain remaining unchanged in the Stable cluster, with slight increases in the Recruitable cluster, and strong reduction in the Unstable Non-Recruitable cluster. CONCLUSIONS VILI is a regional and dynamic phenomenon. Using unbiased machine-learning techniques we can identify the coexistence of three functional lung tissue compartments with different spatiotemporal regional biomechanical behavior.
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Affiliation(s)
- Pablo Cruces
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- Unidad de Paciente Crítico Pediátrico, Hospital El Carmen Dr. Luis Valentín Ferrada, Santiago, Chile
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile.
| | - Andrés Damián
- Centro Uruguayo de Imagenología Molecular (CUDIM), Montevideo, Uruguay
- Unidad Académica de Medicina Nuclear e Imagenología Molecular, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Graciela Lago
- Centro Uruguayo de Imagenología Molecular (CUDIM), Montevideo, Uruguay
- Academia Nacional de Medicina, Montevideo, Uruguay
| | - Fernanda Blasina
- Unidad Académica de Neonatología, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Vanessa Oviedo
- Departamento de Medicina Intensiva, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Tania Medina
- Unidad de Paciente Crítico Pediátrico, Hospital El Carmen Dr. Luis Valentín Ferrada, Santiago, Chile
| | - Agustín Pérez
- Department of Structural and Geotechnical Engineering, School of Engineering, Pontificia Universidad Católica de Chile, Santiago, Chile
- Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Lucía Vaamonde
- Departamento de Pediatría y Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Rosina Dapueto
- Centro Uruguayo de Imagenología Molecular (CUDIM), Montevideo, Uruguay
| | - Sebastian González-Dambrauskas
- Departamento de Pediatría y Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell, Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
| | - Alberto Serra
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Centro Asistencial del Sindicato Médico del Uruguay (CASMU), Montevideo, Uruguay
| | - Nicolas Monteverde-Fernandez
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Cuidados Intensivos Pediátricos y Neonatales (CINP), Medica Uruguaya, Montevideo, Uruguay
| | - Mauro Namías
- Fundación Centro Diagnóstico Nuclear, Buenos Aires, Argentina
| | - Javier Martínez
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Hospital Central de las Fuerzas Armadas (HCFFAA), Montevideo, Uruguay
| | - Daniel E Hurtado
- Department of Structural and Geotechnical Engineering, School of Engineering, Pontificia Universidad Católica de Chile, Santiago, Chile
- Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Católica de Chile, Santiago, Chile
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7
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Pellegrini M, Del Sorbo L, Ranieri VM. Finding the optimal tidal volume in acute respiratory distress syndrome. Intensive Care Med 2024; 50:1154-1156. [PMID: 38740616 PMCID: PMC11245429 DOI: 10.1007/s00134-024-07440-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/06/2024] [Indexed: 05/16/2024]
Affiliation(s)
- Mariangela Pellegrini
- Anesthesia, Operation and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden.
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, University of Toronto, Toronto, ON, Canada
| | - V Marco Ranieri
- Dipartimento di Medicina di Precisione e Rigenerativa e Area Jonica (DiMePre-J) Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Bari, Italy
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8
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Carvalho EV, Reboredo MM, Gomes EP, Martins PN, Mota GPS, Costa GB, Colugnati FAB, Pinheiro BV. Driving pressure, as opposed to tidal volume based on predicted body weight, is associated with mortality: results from a prospective cohort of COVID-19 acute respiratory distress syndrome patients. CRITICAL CARE SCIENCE 2024; 36:e20240208en. [PMID: 38747818 PMCID: PMC11098065 DOI: 10.62675/2965-2774.20240208-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 01/06/2024] [Indexed: 05/18/2024]
Abstract
OBJECTIVE To evaluate the association between driving pressure and tidal volume based on predicted body weight and mortality in a cohort of patients with acute respiratory distress syndrome caused by COVID-19. METHODS This was a prospective, observational study that included patients with acute respiratory distress syndrome due to COVID-19 admitted to two intensive care units. We performed multivariable analyses to determine whether driving pressure and tidal volume/kg predicted body weight on the first day of mechanical ventilation, as independent variables, are associated with hospital mortality. RESULTS We included 231 patients. The mean age was 64 (53 - 74) years, and the mean Simplified Acute and Physiology Score 3 score was 45 (39 - 54). The hospital mortality rate was 51.9%. Driving pressure was independently associated with hospital mortality (odds ratio 1.21, 95%CI 1.04 - 1.41 for each cm H2O increase in driving pressure, p = 0.01). Based on a double stratification analysis, we found that for the same level of tidal volume/kg predicted body weight, the risk of hospital death increased with increasing driving pressure. However, changes in tidal volume/kg predicted body weight were not associated with mortality when they did not lead to an increase in driving pressure. CONCLUSION In patients with acute respiratory distress syndrome caused by COVID-19, exposure to higher driving pressure, as opposed to higher tidal volume/kg predicted body weight, is associated with greater mortality. These results suggest that driving pressure might be a primary target for lung-protective mechanical ventilation in these patients.
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Affiliation(s)
- Erich Vidal Carvalho
- Universidade Federal de Juiz de ForaHospital UniversitárioPulmonary and Critical Care DivisionJuiz de ForaMGBrazilPulmonary and Critical Care Division, Hospital Universitário, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil.
| | - Maycon Moura Reboredo
- Universidade Federal de Juiz de ForaHospital UniversitárioPulmonary and Critical Care DivisionJuiz de ForaMGBrazilPulmonary and Critical Care Division, Hospital Universitário, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil.
| | - Edimar Pedrosa Gomes
- Universidade Federal de Juiz de ForaHospital UniversitárioPulmonary and Critical Care DivisionJuiz de ForaMGBrazilPulmonary and Critical Care Division, Hospital Universitário, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil.
| | - Pedro Nascimento Martins
- Universidade Federal de Juiz de ForaHospital UniversitárioPulmonary and Critical Care DivisionJuiz de ForaMGBrazilPulmonary and Critical Care Division, Hospital Universitário, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil.
| | - Gabriel Paz Souza Mota
- Universidade Federal de Juiz de ForaHospital UniversitárioPulmonary and Critical Care DivisionJuiz de ForaMGBrazilPulmonary and Critical Care Division, Hospital Universitário, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil.
| | - Giovani Bernardo Costa
- Universidade Federal de Juiz de ForaHospital UniversitárioPulmonary and Critical Care DivisionJuiz de ForaMGBrazilPulmonary and Critical Care Division, Hospital Universitário, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil.
| | - Fernando Antonio Basile Colugnati
- Universidade Federal de Juiz de ForaHospital UniversitárioPulmonary and Critical Care DivisionJuiz de ForaMGBrazilPulmonary and Critical Care Division, Hospital Universitário, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil.
| | - Bruno Valle Pinheiro
- Universidade Federal de Juiz de ForaHospital UniversitárioPulmonary and Critical Care DivisionJuiz de ForaMGBrazilPulmonary and Critical Care Division, Hospital Universitário, Universidade Federal de Juiz de Fora - Juiz de Fora (MG), Brazil.
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9
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Marini JJ. Detecting end-tidal hyperinflation. Intensive Care Med 2024; 50:752-754. [PMID: 38563895 DOI: 10.1007/s00134-024-07379-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/27/2024] [Indexed: 04/04/2024]
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10
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Pasero D, Pistidda L, Piredda D, Liperi C, Cossu A, Esposito R, Muroni A, Mereu C, Rum C, Branca GP, Mulas F, Puci M, Sotgiu G, Terragni P. Lung (extracorporeal CO 2 removal) and renal (continuous renal replacement therapy) support: the role of ultraprotective strategy in Covid 19 and non-Covid 19 ARDS. A case-control study. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:27. [PMID: 38671540 PMCID: PMC11055375 DOI: 10.1186/s44158-024-00164-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Preliminary studies suggest that moderate ARDS and acute renal failure might benefit from extracorporeal CO2 removal (ECCO2R) coupled with CRRT. However, evidence is limited and potential for this coupled treatment may need to be explored. The aim of the present study was to evaluate whether a protective driving pressure was obtained applying low-flow ECCO2-R plus CRRT in patients affected by moderate ARDS with COVID-19 compared to an historical group without COVID-19. METHODS A case-control study has been conducted comparing a group of consecutive moderate ARDS patients presenting AKI and affected by COVID-19, who needed low-flow ECCO2-R plus CRRT to achieve an ultra-protective ventilatory strategy, with historical group without COVID-19 that matched for clinical presentation and underwent the same ultra-protective treatment. VT was set at 6 mL/kg predicted body weight then ECCO2R was assessed to facilitate ultra-protective low VT ventilation to preserve safe Pplat and low driving pressure. RESULTS ECCO2R+CRRT reduced the driving pressure from 17 (14-18) to 11.5 (10-15) cmH2O (p<0.0004) in the fourteen ARDS patients by decreasing VT from 6.7 ml/kg PBW (6.1-6.9) to 5.1 (4.2-5.6) after 1 hour (p <0.0001). In the ARDS patients with COVID-19, the driving pressure reduction was more effective from baseline 18 (14-24) cmH2O to 11 (10-15) cmH2O (p<0.004), compared to the control group from 15 (13-17) to 12(10-16) cmH2O (p< 0.03), after one hour. ECCO2R+CRRT did not affected 28 days mortality in the two groups, while we observed a shorter duration of mechanical ventilation (19 {7-29} vs 24 {22-38} days; p=0.24) and ICU length of stay (19 {7-29} vs 24 {22-78} days; p=0.25) in moderate ARDS patients with COVID-19 compared to control group. CONCLUSIONS In moderate ARDS patients with or without COVID-19 disease, ECCO2R+CRRT may be and effective supportive treatment to reach protective values of driving pressure unless severe oxygenation defects arise requiring ECMO therapy initiation.
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Affiliation(s)
- Daniela Pasero
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy.
- Department of Medicine, Surgery and Pharmacy, University of Sassari, A.O.U Sassari, Viale San Pietro 43, 07100, Sassari, Italy.
| | - Laura Pistidda
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
- Department of Medicine, Surgery and Pharmacy, University of Sassari, A.O.U Sassari, Viale San Pietro 43, 07100, Sassari, Italy
| | - Davide Piredda
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | - Corrado Liperi
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | - Andrea Cossu
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | | | - Angela Muroni
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | - Cristiano Mereu
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | - Carlino Rum
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | | | - Franco Mulas
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
| | - Mariangela Puci
- Department of Medicine, Surgery and Pharmacy, University of Sassari, A.O.U Sassari, Viale San Pietro 43, 07100, Sassari, Italy
- Clinical Epidemiology and Medical Statistics Unit, University of Sassari, Sassari, Italy
| | - Giovanni Sotgiu
- Department of Medicine, Surgery and Pharmacy, University of Sassari, A.O.U Sassari, Viale San Pietro 43, 07100, Sassari, Italy
- Clinical Epidemiology and Medical Statistics Unit, University of Sassari, Sassari, Italy
| | - Pierpaolo Terragni
- Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy
- Department of Medicine, Surgery and Pharmacy, University of Sassari, A.O.U Sassari, Viale San Pietro 43, 07100, Sassari, Italy
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11
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Pequignot B, Combes A, Lescroart M, Levy B, Koszutski M. Contribution of electrical impedance tomography to personalize positive end-expiratory pressure under ECCO 2R. Crit Care 2024; 28:124. [PMID: 38627745 PMCID: PMC11022412 DOI: 10.1186/s13054-024-04908-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/11/2024] [Indexed: 04/19/2024] Open
Abstract
Extracorporeal Carbon Dioxide Removal (ECCO2R) is used in acute respiratory distress syndrome (ARDS) patients to facilitate lung-protective ventilatory strategies. Electrical Impedance Tomography (EIT) allows individual, non-invasive, real-time, bedside, radiation-free imaging of the lungs, providing global and regional dynamic lung analyses. To provide new insights for future ECCO2R research in ARDS, we propose a potential application of EIT to personalize End-Expiratory Pressure (PEEP) following each reduction in tidal volume (VT), as demonstrated in an illustrative case. A 72-year-old male with COVID-19 was admitted to the ICU for moderate ARDS. Monitoring with EIT was started to determine the optimal PEEP value (PEEPEIT), defined as the intersection of the collapse and overdistention curves, after each reduction in VT during ECCO2R. The identified PEEPEIT values were notably low (< 10 cmH2O). The decrease in VT associated with PEEPEIT levels resulted in improved lung compliance, reduced driving pressure and a more uniform ventilation pattern. Despite current Randomized Controlled Trials showing that ultra-protective ventilation with ECCO2R does not improve survival, the applicability of universal ultra-protective ventilation settings for all patients remains a subject of debate. Inappropriately set PEEP levels can lead to alveolar collapse or overdistension, potentially negating the benefits of VT reduction. EIT facilitates real-time monitoring of derecruitment associated with VT reduction, guiding physicians in determining the optimal PEEP value after each decrease in tidal volume. This original description of using EIT under ECCO2R to adjust PEEP at a level compromising between recruitability and overdistention could be a crucial element for future research on ECCO2R.
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Affiliation(s)
- Benjamin Pequignot
- Service de Médecine Intensive et Réanimation, Université de Lorraine, Hôpital Brabois, CHRU Nancy, 54500, Vandoeuvre Les Nancy, France.
- Faculté de Médecine de Nancy, Université de Lorraine, INSERM UMR_S1116, Vandœuvre-Lès-Nancy, France.
| | - Alain Combes
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, 47, Boulevard de L'Hôpital, 75013, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Hôpital Pitié-Salpêtrière, 75013, Paris, France
| | - Mickael Lescroart
- Service de Médecine Intensive et Réanimation, Université de Lorraine, Hôpital Brabois, CHRU Nancy, 54500, Vandoeuvre Les Nancy, France
- Faculté de Médecine de Nancy, Université de Lorraine, INSERM UMR_S1116, Vandœuvre-Lès-Nancy, France
| | - Bruno Levy
- Service de Médecine Intensive et Réanimation, Université de Lorraine, Hôpital Brabois, CHRU Nancy, 54500, Vandoeuvre Les Nancy, France
- Faculté de Médecine de Nancy, Université de Lorraine, INSERM UMR_S1116, Vandœuvre-Lès-Nancy, France
| | - Matthieu Koszutski
- Service de Médecine Intensive et Réanimation, Université de Lorraine, Hôpital Brabois, CHRU Nancy, 54500, Vandoeuvre Les Nancy, France
- Faculté de Médecine de Nancy, Université de Lorraine, INSERM UMR_S1116, Vandœuvre-Lès-Nancy, France
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12
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Golino G, Forin E, Boni E, Martin M, Perbellini G, Rizzello V, Toniolo A, Danzi V. Secondary pneumomediastinum in COVID-19 patient: A case managed with VV-ECMO. IDCases 2024; 36:e01956. [PMID: 38681081 PMCID: PMC11047182 DOI: 10.1016/j.idcr.2024.e01956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 03/10/2024] [Accepted: 04/14/2024] [Indexed: 05/01/2024] Open
Abstract
Air leak syndrome, including pneumomediastinum (PM), pneumopericardium, pneumothorax, or subcutaneous emphysema, is primarily caused by chest trauma, cardiothoracic surgery, esophageal perforation, and mechanical ventilation. Secondary pneumomediastinum (SP) is a rare complication, with a much lower incidence reported in patients with coronavirus disease 2019 (COVID-19). Our patient was a 44-year-old nonsmoker male with a previous history of obesity (Body Mass Index [BMI] 35 kg/m2), hyperthyroidism, hypokinetic cardiopathy and atrial fibrillation in treatment with flecainide, who presented to the emergency department with 6 days of fever, cough, dyspnea, and respiratory distress. The COVID-19 diagnosis was confirmed based on a polymerase chain reaction (PCR) test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). After initiation of mechanical ventilation, a chest computed tomography (CT) on the first day revealed bilateral multifocal ground-glass opacities, consolidation and an extensive SP and pneumoperitoneum. Our therapeutic strategy was initiation of veno-venous extracorporeal membrane oxygenation (VV-ECMO) as a bridge to recovery after positioning 2 drains (mediastinal and pleural), for both oxygenation and carbon dioxide clearance, to allow protective and ultra-protective ventilation to limit ventilator-induced lung injury (VILI) and the intensity of mechanical power for lung recovery. After another chest CT scan which showed a clear reduction of the PM, 2 pronation and neuromuscular relaxation cycles were also required, with improvement of gas exchange and respiratory mechanics. On the 15th day, lung function recovered and the patient was then weaned from VV-ECMO, and ultimately made a good recovery and was discharged. In conclusion, SP may be a reflection of extensive alveolar damage and should be considered as a potential predictive factor for adverse outcome in critically ill SARS-CoV2 patients.
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Affiliation(s)
- Gianlorenzo Golino
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Edoardo Forin
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Elisa Boni
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Marina Martin
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Guido Perbellini
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Veronica Rizzello
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Anna Toniolo
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
| | - Vinicio Danzi
- Ospedale San Bortolo, Vicenza, Italy
- Department of Anesthesia and Intensive Care, Vicenza 36100, Italy
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13
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Szuldrzynski K, Kowalewski M, Swol J. Mechanical ventilation during extracorporeal membrane oxygenation support - New trends and continuing challenges. Perfusion 2024; 39:107S-114S. [PMID: 38651573 DOI: 10.1177/02676591241232270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
BACKGROUND The impact of mechanical ventilation on the survival of patients supported with veno-venous extracorporeal membrane oxygenation (V-V ECMO) due to severe acute respiratory distress syndrome (ARDS) remains still a focus of research. METHODS Recent guidelines, randomized trials, and registry data underscore the importance of lung-protective ventilation during respiratory and cardiac support on ECMO. RESULTS This approach includes decreasing mechanical power delivery by reducing tidal volume and driving pressure as much as possible, using low or very low respiratory rate, and a personalized approach to positive-end expiratory pressure (PEEP) setting. Notably, the use of ECMO in awake and spontaneously breathing patients is increasing, especially as a bridging strategy to lung transplantation. During respiratory support in V-V ECMO, native lung function is of highest importance and adjustments of blood flow on ECMO, or ventilator settings significantly impact the gas exchange. These interactions are more complex in veno-arterial (V-A) ECMO configuration and cardiac support. The fraction on delivered oxygen in the sweep gas and sweep gas flow rate, blood flow per minute, and oxygenator efficiency have an impact on gas exchange on device side. On the patient side, native cardiac output, native lung function, carbon dioxide production (VCO2), and oxygen consumption (VO2) play a role. Avoiding pulmonary oedema includes left ventricle (LV) distension monitoring and prevention, pulse pressure >10 mm Hg and aortic valve opening assessment, higher PEEP adjustment, use of vasodilators, ECMO flow adjustment according to the ejection fraction, moderate use of inotropes, diuretics, or venting strategies as indicated and according to local expertise and resources. CONCLUSION Understanding the physiological principles of gas exchange during cardiac support on femoro-femoral V-A ECMO configuration and the interactions with native gas exchange and haemodynamics are essential for the safe applications of these techniques in clinical practice. Proning during ECMO remains to be discussed until further data is available from prospective, randomized trials implementing individualized PEEP titration during proning.
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Affiliation(s)
- Konstanty Szuldrzynski
- Department of Anaesthesiology and Intensive Care, National Institute of Medicine of the Ministry of Interior and Administration in Warsaw, Warsaw, Poland
| | - Mariusz Kowalewski
- Department of Cardiac Surgery and Transplantology, National Medical Institute of the Ministry of Interior and Administration, Warsaw, Poland
- Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT, Palermo, Italy
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Justyna Swol
- Department of Respiratory Medicine, Paracelsus Medical University, Nuremberg, Germany
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14
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Acosta CM, Poliotto S, Abrego D, Bradley D, de Esteban S, Mir F, Ricci L, Natal M, Wallin M, Hallbäck M, Sipmann FS, Tusman G. Effect of an Individualized Lung Protective Ventilation on Lung Strain and Stress in Children Undergoing Laparoscopy: An Observational Cohort Study. Anesthesiology 2024; 140:430-441. [PMID: 38064715 DOI: 10.1097/aln.0000000000004856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2024]
Abstract
BACKGROUND Exaggerated lung strain and stress could damage lungs in anesthetized children. The authors hypothesized that the association of capnoperitoneum and lung collapse in anesthetized children increases lung strain-stress. Their primary aim was to describe the impact of capnoperitoneum on lung strain-stress and the effects of an individualized protective ventilation during laparoscopic surgery in children. METHODS The authors performed an observational cohort study in healthy children aged 3 to 7 yr scheduled for laparoscopic surgery in a community hospital. All received standard protective ventilation with 5 cm H2O of positive end-expiratory pressure (PEEP). Children were evaluated before capnoperitoneum, during capnoperitoneum before and after lung recruitment and optimized PEEP (PEEP adjusted to get end-expiratory transpulmonary pressure of 0), and after capnoperitoneum with optimized PEEP. The presence of lung collapse was evaluated by lung ultrasound, positive Air-Test (oxygen saturation measured by pulse oximetry 96% or less breathing 21% O2 for 5 min), and negative end-expiratory transpulmonary pressure. Lung strain was calculated as tidal volume/end-expiratory lung volume measured by capnodynamics, and lung stress as the end-inspiratory transpulmonary pressure. RESULTS The authors studied 20 children. Before capnoperitoneum, mean lung strain was 0.20 ± 0.07 (95% CI, 0.17 to 0.23), and stress was 5.68 ± 2.83 (95% CI, 4.44 to 6.92) cm H2O. During capnoperitoneum, 18 patients presented lung collapse and strain (0.29 ± 0.13; 95% CI, 0.23 to 0.35; P < 0.001) and stress (5.92 ± 3.18; 95% CI, 4.53 to 7.31 cm H2O; P = 0.374) increased compared to before capnoperitoneum. During capnoperitoneum and optimized PEEP, children presenting lung collapse were recruited and optimized PEEP was 8.3 ± 2.2 (95% CI, 7.3 to 9.3) cm H2O. Strain returned to values before capnoperitoneum (0.20 ± 0.07; 95% CI, 0.17 to 0.22; P = 0.318), but lung stress increased (7.29 ± 2.67; 95% CI, 6.12 to 8.46 cm H2O; P = 0.020). After capnoperitoneum, strain decreased (0.18 ± 0.04; 95% CI, 0.16 to 0.20; P = 0.090), but stress remained higher (7.25 ± 3.01; 95% CI, 5.92 to 8.57 cm H2O; P = 0.024) compared to before capnoperitoneum. CONCLUSIONS Capnoperitoneum increased lung strain in healthy children undergoing laparoscopy. Lung recruitment and optimized PEEP during capnoperitoneum decreased lung strain but slightly increased lung stress. This little rise in pulmonary stress was maintained within safe, lung-protective, and clinically acceptable limits. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Cecilia M Acosta
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Sergio Poliotto
- Department of Pediatric Surgery, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Diego Abrego
- Department of Pediatric Surgery, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Dolores Bradley
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Santiago de Esteban
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Francisco Mir
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Lila Ricci
- Department of Mathematics, Facultad de Ciencias Exactas, Universidad Nacional de Mar del Plata, Argentina
| | - Marcela Natal
- Department of Mathematics, Facultad de Ciencias Exactas, Universidad Nacional de Mar del Plata, Argentina
| | - Mats Wallin
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden; Getinge Critical Care AB, Solna, Sweden
| | | | - Fernando Suarez Sipmann
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden; CIBERES (Network Biomedical Research Center), Madrid, Spain; Department of Critical Care, Hospital Universitario de La Princesa, Universidad Autonoma de Madrid, Madrid, Spain
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
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15
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Deniel G, Dhelft F, Lancelot S, Orkisz M, Roux E, Mouton W, Benzerdjeb N, Richard JC, Bitker L. Pulmonary inflammation decreases with ultra-protective ventilation in experimental ARDS under VV-ECMO: a positron emission tomography study. Front Med (Lausanne) 2024; 11:1338602. [PMID: 38444415 PMCID: PMC10912585 DOI: 10.3389/fmed.2024.1338602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/24/2024] [Indexed: 03/07/2024] Open
Abstract
Background Experimentally, ultra-protective ventilation (UPV, tidal volumes [VT] < 4 mL.kg-1) strategies in conjunction with veno-venous extracorporeal membrane oxygenation (VV-ECMO) are associated with lesser ventilator-induced lung injuries (VILI) during acute respiratory distress syndrome (ARDS). However, whether these strategies reduce lung inflammation more effectively than protective ventilation (PV) remains unclear. We aimed to demonstrate that a UPV strategy decreases acute lung inflammation in comparison with PV in an experimental swine model of ARDS. Methods ARDS was induced by tracheal instillation of chlorhydric acid in sedated and paralyzed animals under mechanical ventilation. Animals were randomized to receive either UPV (VT 1 mL.kg-1, positive end-expiration pressure [PEEP] set to obtain plateau pressure between 20 and 25 cmH2O and respiratory rate [RR] at 5 min-1 under VV-ECMO) or PV (VT 6 mL.kg-1, PEEP set to obtain plateau pressure between 28 and 30 cmH2O and RR at 25 min-1) during 4 h. After 4 h, a positron emission tomography with [11C](R)-PK11195 (ligand to TSPO-bearing macrophages) injection was realized, coupled with quantitative computerized tomography (CT). Pharmacokinetic multicompartment models were used to quantify regional [11C](R)-PK11195 lung uptake. [11C](R)-PK11195 lung uptake and CT-derived respiratory variables were studied regionally across eight lung regions distributed along the antero-posterior axis. Results Five pigs were randomized to each study group. Arterial O2 partial pressure to inspired O2 fraction were not significantly different between study groups after experimental ARDS induction (75 [68-80] mmHg in a PV group vs. 87 [69-133] mmHg in a UPV group, p = 0.20). Compared to PV animals, UPV animals exhibited a significant decrease in the regional non-aerated compartment in the posterior lung levels, in mechanical power, and in regional dynamic strain and no statistical difference in tidal hyperinflation after 4 h. UPV animals had a significantly lower [11C](R)-PK11195 uptake, compared to PV animals (non-displaceable binding potential 0.35 [IQR, 0.20-0.59] in UPV animals and 1.01 [IQR, 0.75-1.59] in PV animals, p = 0.01). Regional [11C](R)-PK11195 uptake was independently associated with the interaction of regional tidal hyperinflation and regional lung compliance. Conclusion In an experimental model of ARDS, 4 h of UPV strategy significantly decreased lung inflammation, in relation to the control of VT-derived determinants of VILI.
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Affiliation(s)
- Guillaume Deniel
- Service de Médecine Intensive-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Univ Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, Inserm, CREATIS UMR, Villeurbanne, France
| | - François Dhelft
- Service de Médecine Intensive-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Université de Lyon, Université LYON 1, Lyon, France
| | - Sophie Lancelot
- Université de Lyon, Université LYON 1, Lyon, France
- CERMEP – Imagerie du Vivant, Lyon, France
- Hospices Civils de Lyon, Lyon, France
| | - Maciej Orkisz
- Univ Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, Inserm, CREATIS UMR, Villeurbanne, France
| | - Emmanuel Roux
- Univ Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, Inserm, CREATIS UMR, Villeurbanne, France
| | - William Mouton
- Laboratoire Commun de Recherche Hospices Civils de Lyon/bioMérieux, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Nazim Benzerdjeb
- Université de Lyon, Université LYON 1, Lyon, France
- Centre d’Anatomie et Cytologie Pathologique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Jean-Christophe Richard
- Service de Médecine Intensive-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Univ Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, Inserm, CREATIS UMR, Villeurbanne, France
- Université de Lyon, Université LYON 1, Lyon, France
| | - Laurent Bitker
- Service de Médecine Intensive-Réanimation, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
- Univ Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, Inserm, CREATIS UMR, Villeurbanne, France
- Université de Lyon, Université LYON 1, Lyon, France
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16
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Boesing C, Schaefer L, Graf PT, Pelosi P, Rocco PRM, Luecke T, Krebs J. Effects of different positive end-expiratory pressure titration strategies on mechanical power during ultraprotective ventilation in ARDS patients treated with veno-venous extracorporeal membrane oxygenation: A prospective interventional study. J Crit Care 2024; 79:154406. [PMID: 37690365 DOI: 10.1016/j.jcrc.2023.154406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 05/13/2023] [Accepted: 07/09/2023] [Indexed: 09/12/2023]
Abstract
PURPOSE Ultraprotective ventilation in acute respiratory distress syndrome (ARDS) patients with veno-venous extracorporeal membrane oxygenation (VV ECMO) reduces mechanical power (MP) through changes in positive end-expiratory pressure (PEEP); however, the optimal approach to titrate PEEP is unknown. This study assesses the effects of three PEEP titration strategies on MP, hemodynamic parameters, and oxygen delivery in twenty ARDS patients with VV ECMO. MATERIAL AND METHODS PEEP was titrated according to: (A) a PEEP of 10 cmH2O representing the lowest recommendation by the Extracorporeal Life Support Organization (PEEPELSO), (B) the highest static compliance of the respiratory system (PEEPCstat,RS), and (C) a target end-expiratory transpulmonary pressure of 0 cmH2O (PEEPPtpexp). RESULTS PEEPELSO was lower compared to PEEPCstat,RS and PEEPPtpexp (10.0 ± 0.0 vs. 16.2 ± 4.7 cmH2O and 17.3 ± 4.0 cmH2O, p < 0.001 each, respectively). PEEPELSO reduced MP compared to PEEPCstat,RS and PEEPPtpexp (5.3 ± 1.3 vs. 6.8 ± 2.0 and 6.9 ± 2.3 J/min, p < 0.001 each, respectively). PEEPELSO resulted in less lung stress compared to PEEPCstat,RS (p = 0.011) and PEEPPtpexp (p < 0.001) and increased cardiac output and oxygen delivery (p < 0.001 each). CONCLUSIONS An empirical PEEP of 10 cmH2O minimized MP, provided favorable hemodynamics, and increased oxygen delivery in ARDS patients treated with VV ECMO. TRIAL REGISTRATION German Clinical Trials Register (DRKS00013967). Registered 02/09/2018https://drks.de/search/en/trial/DRKS00013967.
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Affiliation(s)
- Christoph Boesing
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Laura Schaefer
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Peter T Graf
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Anesthesiology and Critical Care - San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão, Rio de Janeiro, Brazil.
| | - Thomas Luecke
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
| | - Joerg Krebs
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, Mannheim 68167, Germany.
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17
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Wildi K, Colombo SM, McGuire D, Ainola C, Heinsar S, Sato N, Sato K, Liu K, Bouquet M, Wilson E, Passmore M, Hyslop K, Livingstone S, Di Feliciantonio M, Strugnell W, Palmieri C, Suen J, Li Bassi G, Fraser J. An appraisal of lung computer tomography in very early anti-inflammatory treatment of two different ovine ARDS phenotypes. Sci Rep 2024; 14:2162. [PMID: 38272980 PMCID: PMC10810785 DOI: 10.1038/s41598-024-52698-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Accepted: 01/22/2024] [Indexed: 01/27/2024] Open
Abstract
Mortality and morbidity of Acute Respiratory Distress Syndrome (ARDS) are largely unaltered. A possible new approach to treatment of ARDS is offered by the discovery of inflammatory subphenotypes. In an ovine model of ARDS phenotypes, matching key features of the human subphenotypes, we provide an imaging characterization using computer tomography (CT). Nine animals were randomized into (a) OA (oleic acid, hypoinflammatory; n = 5) and (b) OA-LPS (oleic acid and lipopolysaccharides, hyperinflammatory; n = 4). 48 h after ARDS induction and anti-inflammatory treatment, CT scans were performed at high (H) and then low (L) airway pressure. After CT, the animals were euthanized and lung tissue was collected. OA-LPS showed a higher air fraction and OA a higher tissue fraction, resulting in more normally aerated lungs in OA-LPS in contrast to more non-aerated lung in OA. The change in lung and air volume between H and L was more accentuated in OA-LPS, indicating a higher recruitment potential. Strain was higher in OA, indicating a higher level of lung damage, while the amount of lung edema and histological lung injury were largely comparable. Anti-inflammatory treatment might be beneficial in terms of overall ventilated lung portion and recruitment potential, especially in the OA-LPS group.
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Affiliation(s)
- Karin Wildi
- Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia.
- The University of Queensland, Brisbane, Australia.
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Sebastiano Maria Colombo
- Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia
- The University of Queensland, Brisbane, Australia
- Department of Anaesthesia and Intensive Care Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniel McGuire
- Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia
- The University of Queensland, Brisbane, Australia
- The Prince Charles Hospital, Chermside, QLD, Australia
| | - Carmen Ainola
- Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia
- The University of Queensland, Brisbane, Australia
| | - Silver Heinsar
- Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia
- The University of Queensland, Brisbane, Australia
- Department of Intensive Care, North Estonia Medical Centre, Tallinn, Estonia
| | - Noriko Sato
- Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia
| | - Kei Sato
- Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia
- The University of Queensland, Brisbane, Australia
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia
| | - Mahé Bouquet
- The University of Queensland, Brisbane, Australia
| | - Emily Wilson
- The University of Queensland, Brisbane, Australia
| | - Margaret Passmore
- Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia
- The University of Queensland, Brisbane, Australia
| | - Kieran Hyslop
- Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia
- The University of Queensland, Brisbane, Australia
| | - Samantha Livingstone
- Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia
- The University of Queensland, Brisbane, Australia
| | - Marianna Di Feliciantonio
- Department of Anaesthesia and Intensive Care Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Wendy Strugnell
- The University of Queensland, Brisbane, Australia
- The Prince Charles Hospital, Chermside, QLD, Australia
| | - Chiara Palmieri
- School of Veterinary Science, The University of Queensland, Gatton, Australia
| | - Jacky Suen
- Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia
- The University of Queensland, Brisbane, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia.
- The University of Queensland, Brisbane, Australia.
- St Andrews War Memorial Hospital, Intensive Care Unit, Spring Hill, QLD, Australia.
- The Wesley Hospital, Intensive Care Unit, Auchenflower, QLD, Australia.
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital, Rode Road, Chermside, Brisbane, QLD, 4032, Australia
- The University of Queensland, Brisbane, Australia
- St Andrews War Memorial Hospital, Intensive Care Unit, Spring Hill, QLD, Australia
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18
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Bickenbach J. [Potential of AI for the Treatment of Acute Respiratory Distress Syndrome (ARDS)]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:34-44. [PMID: 38190824 DOI: 10.1055/a-2043-8644] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
Acute respiratory distress syndrome (ARDS) is still associated with high mortality rates and poses a significant, vital threat to ICU patients because this syndrome is often detected too late (or not at all), and timely therapy and the fastest possible elimination of the underlying causes thus fail to materialize. Artificial Intelligence (AI) solutions can enable clinicians to make every minute in the ICU work for the patient by processing and analyzing all relevant data, thus supporting early diagnosis, adhering to clinical guidelines, and even providing a prognosis for the course of the ICU. This article shows what is already possible and where further challenges lie in this field of digital medicine.
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19
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Thornton LT, Marini JJ. Optimized ventilation power to avoid VILI. J Intensive Care 2023; 11:57. [PMID: 37986109 PMCID: PMC10658809 DOI: 10.1186/s40560-023-00706-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 11/09/2023] [Indexed: 11/22/2023] Open
Abstract
The effort to minimize VILI risk must be multi-pronged. The need to adequately ventilate, a key determinant of hazardous power, is reduced by judicious permissive hypercapnia, reduction of innate oxygen demand, and by prone body positioning that promotes both efficient pulmonary gas exchange and homogenous distributions of local stress. Modifiable ventilator-related determinants of lung protection include reductions of tidal volume, plateau pressure, driving pressure, PEEP, inspiratory flow amplitude and profile (using longer inspiration to expiration ratios), and ventilation frequency. Underappreciated conditional cofactors of importance to modulate the impact of local specific power may include lower vascular pressures and blood flows. Employed together, these measures modulate ventilation power with the intent to avoid VILI while achieving clinically acceptable targets for pulmonary gas exchange.
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Affiliation(s)
- Lauren T Thornton
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis/St Paul, MN, USA
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis/St Paul, MN, USA.
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20
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Marini JJ, Thornton LT, Rocco PRM, Crooke PS. From pressure to tension: a model of damaging inflation stress. Crit Care 2023; 27:441. [PMID: 37968744 PMCID: PMC10652628 DOI: 10.1186/s13054-023-04675-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/04/2023] [Indexed: 11/17/2023] Open
Abstract
Although the stretch that generates ventilator-induced lung injury (VILI) occurs within the peripheral tissue that encloses the alveolar space, airway pressures and volumes monitor the gas within the interior core of the lung unit, not its cellular enclosure. Measured pressures (plateau pressure, positive end-expiratory pressure, and driving pressure) and tidal volumes paint a highly relevant but incomplete picture of forces that act on the lung tissues themselves. Convenient and clinically useful measures of the airspace, such as pressure and volume, neglect the partitioning of tidal elastic energy into the increments of tension and surface area that constitute actual stress and strain at the alveolar margins. More sharply focused determinants of VILI require estimates of absolute alveolar dimension and morphology and the lung's unstressed volume at rest. We present a highly simplified but informative mathematical model that translates the radial energy of pressure and volume of the airspace into its surface energy components. In doing so it elaborates conceptual relationships that highlight the forces tending to cause end-tidal hyperinflation of aerated units within the 'baby lung' of acute respiratory distress syndrome (ARDS).
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Affiliation(s)
- John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, St Paul, MN, USA.
| | - Lauren T Thornton
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, St Paul, MN, USA
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Philip S Crooke
- Department of Mathematics, Vanderbilt University, Nashville, TN, USA
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21
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Richard JC, Terzi N, Yonis H, Chorfa F, Wallet F, Dupuis C, Argaud L, Delannoy B, Thiery G, Pommier C, Abraham P, Muller M, Sigaud F, Rigault G, Joffredo E, Mezidi M, Souweine B, Baboi L, Serrier H, Rabilloud M, Bitker L. Ultra-low tidal volume ventilation for COVID-19-related ARDS in France (VT4COVID): a multicentre, open-label, parallel-group, randomised trial. THE LANCET. RESPIRATORY MEDICINE 2023; 11:991-1002. [PMID: 37453445 DOI: 10.1016/s2213-2600(23)00221-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/28/2023] [Accepted: 05/16/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND COVID-19-related acute respiratory distress syndrome (ARDS) is associated with a high mortality rate and longer mechanical ventilation. We aimed to assess the effectiveness of ventilation with ultra-low tidal volume (ULTV) compared with low tidal volume (LTV) in patients with COVID-19-related ARDS. METHODS This study was a multicentre, open-label, parallel-group, randomised trial conducted in ten intensive care units in France. Eligible participants were aged 18 years or older, received invasive mechanical ventilation for COVID-19 (confirmed by RT-PCR), had ARDS according to the Berlin definition, a partial pressure of arterial oxygen to inspiratory oxygen fraction (PaO2/FiO2) ratio of 150 mm Hg or less, a tidal volume (VT) of 6·0 mL/kg predicted bodyweight or less, and received continuous intravenous sedation. Patients were randomly assigned (1:1) using randomisation blocks to receive ULTV (intervention group) aiming for VT of 4·0 mL/kg predicted bodyweight or LTV (control group) aiming for VT 6·0 mL/kg predicted bodyweight. Participants, investigators, and outcome assessors were not masked to group assignment. The primary outcome was a ranked composite score based on all-cause mortality at day 90 as the first criterion and ventilator-free days among patients alive at day 60 as the second criterion. Effect size was computed with the unmatched win ratio, on the basis of pairwise prioritised comparison of primary outcome components between every patient in the ULTV group and every patient in the LTV group. The unmatched win ratio was calculated as the ratio of the number of pairs with more favourable outcome in the ULTV group over the number of pairs with less favourable outcome in the ULTV group. Primary analysis was done in the modified intention-to-treat population, which included all participants who were randomly assigned and not lost to follow-up. This trial is registered with ClinicalTrials.gov, NCT04349618. FINDINGS Between April 15, 2020, and April 13, 2021, 220 patients were included and five (2%) were excluded. 215 patients were randomly assigned (106 [49%] to the ULTV group and 109 [51%] to the LTV group). 58 (27%) patients were female and 157 (73%) were male. The median age was 68 years (IQR 60-74). 214 patients completed follow-up (one lost to follow-up in the ULTV group) and were included in the modified intention-to-treat analysis. The primary outcome was not significantly different between groups (unmatched win ratio in the ULTV group 0·85 [95% CI 0·60 to 1·19]; p=0·38). 46 (44%) of 105 patients in the ULTV group and 43 (39%) of 109 in the LTV group died by day 90 (absolute difference 4% [-9 to 18]; p=0·52). The rate of severe respiratory acidosis in the first 28 days was higher in the ULTV group than in the LTV group (35 [33%] vs 14 [13%]; absolute difference 20% [95% CI 9 to 31]; p=0·0004). INTERPRETATION In patients with moderate-to-severe COVID-19-related ARDS, there was no significant difference with ULTV compared with LTV in the composite score based on mortality and ventilator-free days among patients alive at day 60. These findings do not support the systematic use of ULTV in patients with COVID-19-related ARDS. FUNDING French Ministry of Solidarity and Health and Hospices Civils de Lyon.
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Affiliation(s)
- Jean-Christophe Richard
- Hospices Civils de Lyon, Croix-Rousse Hospital, Medical Intensive Care Unit, Lyon, France; Université de Lyon, Université Lyon 1, Lyon, France; CREATIS INSERM 1044 CNRS 5220, Lyon, France.
| | - Nicolas Terzi
- CHU Grenoble Alpes, Service de Médecine Intensive Réanimation, Grenoble, France; Université de Grenoble-Alpes, Grenoble, France; INSERM U1042, Grenoble, France
| | - Hodane Yonis
- Hospices Civils de Lyon, Croix-Rousse Hospital, Medical Intensive Care Unit, Lyon, France
| | - Fatima Chorfa
- Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France
| | - Florent Wallet
- Hospices Civils de Lyon, Lyon-Sud Hospital, Medical-Surgical Intensive Care Unit, Lyon, France; International Center of Research in Infectiology, Lyon University, INSERM U1111, CNRS UMR 5308, ENS, UCBL, Lyon, France
| | - Claire Dupuis
- CHU Gabriel Montpied, Medical Intensive Care Unit, Clermont-Ferrand, France
| | - Laurent Argaud
- Hospices Civils de Lyon, Edouard Herriot Hospital, Medical Intensive Care Unit, Lyon, France
| | - Bertrand Delannoy
- Clinique de la Sauvegarde, Medical-Surgical Intensive Care Unit, Lyon, France
| | - Guillaume Thiery
- CHU Saint-Etienne, Hopital Nord, Medical Intensive Care Unit, Saint-Priest-En-Jarez, France; Research on Healthcare Performance RESHAPE, INSERM U1290, Université Lyon 1, Lyon, France
| | - Christian Pommier
- Centre Hospitalier Saint Joseph-Saint Luc, Medical-Surgical Intensive Care Unit, Lyon, France
| | - Paul Abraham
- Hospices Civils de Lyon, Edouard Herriot Hospital, Surgical Intensive Care Unit, Lyon, France
| | - Michel Muller
- Centre Hospitalier Annecy Genevois, Medical-Surgical Intensive Care Unit, Pringy, France
| | - Florian Sigaud
- CHU Grenoble Alpes, Service de Médecine Intensive Réanimation, Grenoble, France
| | - Guillaume Rigault
- CHU Grenoble Alpes, Service de Médecine Intensive Réanimation, Grenoble, France; Université de Grenoble-Alpes, Grenoble, France
| | - Emilie Joffredo
- Hospices Civils de Lyon, Lyon-Sud Hospital, Medical-Surgical Intensive Care Unit, Lyon, France
| | - Mehdi Mezidi
- Hospices Civils de Lyon, Croix-Rousse Hospital, Medical Intensive Care Unit, Lyon, France
| | - Bertrand Souweine
- CHU Gabriel Montpied, Medical Intensive Care Unit, Clermont-Ferrand, France
| | - Loredana Baboi
- Hospices Civils de Lyon, Croix-Rousse Hospital, Medical Intensive Care Unit, Lyon, France
| | - Hassan Serrier
- Hospices Civils de Lyon, Cellule Innovation, Délégation à la Recherche Clinique et à l'Innovation, Lyon, France
| | - Muriel Rabilloud
- Université de Lyon, Université Lyon 1, Lyon, France; Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France; CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Lyon, France
| | - Laurent Bitker
- Hospices Civils de Lyon, Croix-Rousse Hospital, Medical Intensive Care Unit, Lyon, France; Université de Lyon, Université Lyon 1, Lyon, France; CREATIS INSERM 1044 CNRS 5220, Lyon, France
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22
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Thakur A, Bakshi SS, Chakole S. An Elderly Case of Altered Metabolic Profile Presenting With Respiratory Distress: A Radical Display. Cureus 2023; 15:e46818. [PMID: 37954710 PMCID: PMC10636283 DOI: 10.7759/cureus.46818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 10/10/2023] [Indexed: 11/14/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a pulmonary pathology that itself can harm and further lead to many other significant hazardous sequelae. Pulmonary vasculature can be distressed by several diseases, but among all the causes, sepsis is one of the main culprits. Its consequences include significant alveolar injury, refractory hypoxemia, ventilation-perfusion mismatch, and destruction of the alveolar-capillary membrane. Dyspnea with diffuse infiltration on a chest X-ray is the most prevalent clinical symptom. Here, we discuss a case of a 62-year-old male patient who presents with ARDS and metabolic anomalies. The patient was treated medically with drug regimens.
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Affiliation(s)
- Ankita Thakur
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Sanket S Bakshi
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Swaroopa Chakole
- Department of Community Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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23
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Zeng C, Zhu M, Motta-Ribeiro G, Lagier D, Hinoshita T, Zang M, Grogg K, Winkler T, Vidal Melo MF. Dynamic lung aeration and strain with positive end-expiratory pressure individualized to maximal compliance versus ARDSNet low-stretch strategy: a study in a surfactant depletion model of lung injury. Crit Care 2023; 27:307. [PMID: 37537654 PMCID: PMC10401825 DOI: 10.1186/s13054-023-04591-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 07/26/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Positive end-expiratory pressure (PEEP) individualized to a maximal respiratory system compliance directly implies minimal driving pressures with potential outcome benefits, yet, raises concerns on static and dynamic overinflation, strain and cyclic recruitment. Detailed accurate assessment and understanding of these has been hampered by methodological limitations. We aimed to investigate the effects of a maximal compliance-guided PEEP strategy on dynamic lung aeration, strain and tidal recruitment using current four-dimensional computed tomography (CT) techniques and analytical methods of tissue deformation in a surfactant depletion experimental model of acute respiratory distress syndrome (ARDS). METHODS ARDS was induced by saline lung lavage in anesthetized and mechanically ventilated healthy sheep (n = 6). Animals were ventilated in a random sequence with: (1) ARDSNet low-stretch protocol; (2) maximal compliance PEEP strategy. Lung aeration, strain and tidal recruitment were acquired with whole-lung respiratory-gated high-resolution CT and quantified using registration-based techniques. RESULTS Relative to the ARDSNet low-stretch protocol, the maximal compliance PEEP strategy resulted in: (1) improved dynamic whole-lung aeration at end-expiration (0.456 ± 0.064 vs. 0.377 ± 0.101, P = 0.019) and end-inspiration (0.514 ± 0.079 vs. 0.446 ± 0.083, P = 0.012) with reduced non-aerated and increased normally-aerated lung mass without associated hyperinflation; (2) decreased aeration heterogeneity at end-expiration (coefficient of variation: 0.498 ± 0.078 vs. 0.711 ± 0.207, P = 0.025) and end-inspiration (0.419 ± 0.135 vs. 0.580 ± 0.108, P = 0.014) with higher aeration in dorsal regions; (3) tidal aeration with larger inspiratory increases in normally-aerated and decreases in poorly-aerated areas, and negligible in hyperinflated lung (Aeration × Strategy: P = 0.026); (4) reduced tidal strains in lung regions with normal-aeration (Aeration × Strategy: P = 0.047) and improved regional distributions with lower tidal strains in middle and ventral lung (Region-of-interest [ROI] × Strategy: P < 0.001); and (5) less tidal recruitment in middle and dorsal lung (ROI × Strategy: P = 0.044) directly related to whole-lung tidal strain (r = 0.751, P = 0.007). CONCLUSIONS In well-recruitable ARDS models, a maximal compliance PEEP strategy improved end-expiratory/inspiratory whole-lung aeration and its homogeneity without overinflation. It further reduced dynamic strain in middle-ventral regions and tidal recruitment in middle-dorsal areas. These findings suggest the maximal compliance strategy minimizing whole-lung dynamically quantified mechanisms of ventilator-induced lung injury with less cyclic recruitment and no additional overinflation in large heterogeneously expanded and recruitable lungs.
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Affiliation(s)
- Congli Zeng
- Department of Anesthesiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA.
| | - Min Zhu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gabriel Motta-Ribeiro
- Biomedical Engineering Program, Alberto Luiz Coimbra Institute for Graduate Studies and Research in Engineering, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - David Lagier
- Department of Cardiovascular Anesthesiology and Critical Care Medicine, University Hospital Timone, Marseille, France
| | | | - Mingyang Zang
- Department of Biomedical Engineering, Columbia University, New York, NY, USA
| | - Kira Grogg
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Tilo Winkler
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcos F Vidal Melo
- Department of Anesthesiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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24
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Carvalho EV, Pinto SPS, Gomes EP, Peñuelas Ó, Stohler CG, Arantes GC, Carvalho LL, Oliveira RMF, Martins PN, Reboredo MM, Pinheiro BV. Adherence to protective mechanical ventilation in COVID-19 versus non-COVID-19-associated acute respiratory distress syndrome: Comparison between two prospective cohorts. Med Intensiva 2023; 47:445-453. [PMID: 36813658 DOI: 10.1016/j.medine.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 01/02/2023] [Accepted: 01/08/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To compare adherence to protective mechanical ventilation (MV) parameters in patients with acute respiratory distress syndrome (ARDS) caused by COVID-19 with patients with ARDS from other etiologies. DESIGN Multiple prospective cohort study. SETTING Two Brazilian cohorts of ARDS patients were evaluated. One with COVID-19 patients admitted to two Brazilian intensive care units (ICUs) in 2020 and 2021 (C-ARDS, n=282), the other with ARDS-patients from other etiologies admitted to 37 Brazilian ICUs in 2016 (NC-ARDS, n=120). PATIENTS ARDS patients under MV. INTERVENTIONS None. MAIN VARIABLES OF INTEREST Adherence to protective MV (tidal volume ≤8mL/kg PBW; plateau pressure ≤30cmH2O; and driving pressure ≤15cmH2O), adherence to each individual component of the protective MV, and the association between protective MV and mortality. RESULTS Adherence to protective MV was higher in C-ARDS than in NC-ARDS patients (65.8% vs. 50.0%, p=0.005), mainly due to a higher adherence to driving pressure ≤15cmH2O (75.0% vs. 62.4%, p=0.02). Multivariable logistic regression showed that the C-ARDS cohort was independently associated with adherence to protective MV. Among the components of the protective MV, only limiting driving pressure was independently associated with lower ICU mortality. CONCLUSIONS Higher adherence to protective MV in patients with C-ARDS was secondary to higher adherence to limiting driving pressure. Additionally, lower driving pressure was independently associated with lower ICU mortality, which suggests that limiting exposure to driving pressure may improve survival in these patients.
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Affiliation(s)
- E V Carvalho
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil; School of Medicine, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - S P S Pinto
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - E P Gomes
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil; School of Medicine, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - Ó Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, Madrid, Spain; CIBER de Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | - C G Stohler
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - G C Arantes
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - L L Carvalho
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - R M F Oliveira
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - P N Martins
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - M M Reboredo
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil; School of Medicine, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil
| | - B V Pinheiro
- Pulmonary and Critical Care Division, University Hospital of Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil; School of Medicine, Federal University of Juiz de Fora, Juiz de Fora, Minas Gerais, Brazil.
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Öner Ö, Ergan B, Kizil AS, Gurkok MC, Dugral E, Gökmen N. Investigation of high flow nasal cannule efficiency with electric impedance tomography based parameters in COVID-19 adults patients: a retrospective study. PeerJ 2023; 11:e15555. [PMID: 37465153 PMCID: PMC10351510 DOI: 10.7717/peerj.15555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 05/23/2023] [Indexed: 07/20/2023] Open
Abstract
Background/Aim This study aimed to investigate the effects of oxygen therapy using a high flow nasal cannula (HFNC) on patients diagnosed with COVID-19 Acute Respiratory Distress Syndrome (C-ARDS) by utilizing electrical impedance tomography (EIT)-based parameters. Materials and Methods Oxygen therapy was administered to the patients at two different flow rates and two different positions: T0-baseline measurements were taken in the supine position before any therapy was initiated. T1-HFNC was administered in the supine position with a flow rate of 30 L/min. T2-HFNC was administered in the supine position with a flow rate of 50 L/min. T3-HFNC was administered in the prone position with a flow rate of 30 L/min. T4-HFNC was administered in the prone position with a flow rate of 50 L/min. EIT-based parameters (global inhomogeneity index (GI index), center of ventilation (CoV), regional ventilation delay index (RVD index), region of interest ratio (ROI ratio)), as well as respiratory and hemodynamic parameters of the patients, were recorded from the database. Results A total of twenty patients were included in this retrospective observational study. The mean age of the included patients was 64.3 ± 10.6 years. Statistically significant differences were observed in the measurements of GI index, CoV, RVD index, ROI ratio, PaO2/FiO2 ratio, respiratory rate, and mean arterial pressure parameters across different time intervals (p < 0.005). Pairwise comparisons of EIT parameters and measurements of respiratory and hemodynamic parameters at five different time points revealed statistically significant differences. For the GI index, significant differences were observed between the mean measurements taken at T0-T1, T0-T2, T0-T3, T0-T4, T1-T3, T1-T4, T2-T3, T2-T4, and T3-T4 time intervals (p < 0.05). Regarding CoV, significant differences were found between the mean measurements taken at T0-T3, T1-T3, T2-T3, and T3-T4 time intervals (p < 0.05). Additionally, for the ROI ratio, significant differences were observed between the measurement averages taken at each time interval (p < 0.05). Conclusion Our findings suggest that prone positioning during the management of C-ARDS patients leads to improved lung homogeneity, as indicated by EIT parameters. However, further research is required to enhance the visualization of ventilation using EIT.
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Affiliation(s)
- Özlem Öner
- Faculty of Medicine Department of Anesthesiology and Reanimation, Subdivision of Critical Care Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Begum Ergan
- University Faculty of Medicine Department of Pulmonary, Subdivision of Critical Care, Dokuz Eylül University, İzmir, Turkey
| | - Ayse Sezin Kizil
- Faculty of Medicine Department of Anesthesiology and Reanimation, Subdivision of Critical Care Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Mehmet Cagatay Gurkok
- Faculty of Medicine Department of General Surgery, Subdivision of Critical Care Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Esra Dugral
- Pulmonologist and Physiology Specialist, İzmir Katip Çelebi Research and Training Hospital, İzmir, Turkey
| | - Necati Gökmen
- Faculty of Medicine Department of Anesthesiology and Reanimation, Subdivision of Critical Care Medicine, Dokuz Eylül University, İzmir, Turkey
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26
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Jonkman AH, Alcala GC, Pavlovsky B, Roca O, Spadaro S, Scaramuzzo G, Chen L, Dianti J, Sousa MLDA, Sklar MC, Piraino T, Ge H, Chen GQ, Zhou JX, Li J, Goligher EC, Costa E, Mancebo J, Mauri T, Amato M, Brochard LJ. Lung Recruitment Assessed by Electrical Impedance Tomography (RECRUIT): A Multicenter Study of COVID-19 Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2023; 208:25-38. [PMID: 37097986 PMCID: PMC10870845 DOI: 10.1164/rccm.202212-2300oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/24/2023] [Indexed: 04/26/2023] Open
Abstract
Rationale: Defining lung recruitability is needed for safe positive end-expiratory pressure (PEEP) selection in mechanically ventilated patients. However, there is no simple bedside method including both assessment of recruitability and risks of overdistension as well as personalized PEEP titration. Objectives: To describe the range of recruitability using electrical impedance tomography (EIT), effects of PEEP on recruitability, respiratory mechanics and gas exchange, and a method to select optimal EIT-based PEEP. Methods: This is the analysis of patients with coronavirus disease (COVID-19) from an ongoing multicenter prospective physiological study including patients with moderate-severe acute respiratory distress syndrome of different causes. EIT, ventilator data, hemodynamics, and arterial blood gases were obtained during PEEP titration maneuvers. EIT-based optimal PEEP was defined as the crossing point of the overdistension and collapse curves during a decremental PEEP trial. Recruitability was defined as the amount of modifiable collapse when increasing PEEP from 6 to 24 cm H2O (ΔCollapse24-6). Patients were classified as low, medium, or high recruiters on the basis of tertiles of ΔCollapse24-6. Measurements and Main Results: In 108 patients with COVID-19, recruitability varied from 0.3% to 66.9% and was unrelated to acute respiratory distress syndrome severity. Median EIT-based PEEP differed between groups: 10 versus 13.5 versus 15.5 cm H2O for low versus medium versus high recruitability (P < 0.05). This approach assigned a different PEEP level from the highest compliance approach in 81% of patients. The protocol was well tolerated; in four patients, the PEEP level did not reach 24 cm H2O because of hemodynamic instability. Conclusions: Recruitability varies widely among patients with COVID-19. EIT allows personalizing PEEP setting as a compromise between recruitability and overdistension. Clinical trial registered with www.clinicaltrials.gov (NCT04460859).
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Affiliation(s)
- Annemijn H. Jonkman
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Glasiele C. Alcala
- Pulmonology Division, Cardiopulmonary Department, Heart Institute, University of Sao Paulo, Sao Paulo, Brazil
| | - Bertrand Pavlovsky
- Department of Anesthesia, Critical Care and Emergency, Institute for Treatment and Research, Ca’ Granda Maggiore Policlinico Hospital Foundation, Milan, Italy
- University Hospital of Angers, Angers, France
| | - Oriol Roca
- Parc Taulí Hospital Universitari, Institut de Investigació i Innovació Parc Taulí, Sabadell, Spain
- Ciber Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Savino Spadaro
- Anesthesia and Intensive Care Medicine, University Hospital of Ferrara, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Gaetano Scaramuzzo
- Anesthesia and Intensive Care Medicine, University Hospital of Ferrara, Ferrara, Italy
- Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Lu Chen
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Mayson L. de A. Sousa
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Pulmonology Division, Cardiopulmonary Department, Heart Institute, University of Sao Paulo, Sao Paulo, Brazil
| | - Michael C. Sklar
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Thomas Piraino
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Huiqing Ge
- Department of Respiratory and Critical Care Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Guang-Qiang Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University, Chicago, Illinois
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Ontario, Canada
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Eduardo Costa
- Pulmonology Division, Cardiopulmonary Department, Heart Institute, University of Sao Paulo, Sao Paulo, Brazil
| | - Jordi Mancebo
- Servei de Medicina Intensiva Hospital de Sant Pau, Barcelona, Spain; and
| | - Tommaso Mauri
- Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca’ Granda General Hospital, Milan, Italy
| | - Marcelo Amato
- Pulmonology Division, Cardiopulmonary Department, Heart Institute, University of Sao Paulo, Sao Paulo, Brazil
| | - Laurent J. Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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27
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Cutuli SL, Grieco DL, Michi T, Cesarano M, Rosà T, Pintaudi G, Menga LS, Ruggiero E, Giammatteo V, Bello G, De Pascale G, Antonelli M. Personalized Respiratory Support in ARDS: A Physiology-to-Bedside Review. J Clin Med 2023; 12:4176. [PMID: 37445211 DOI: 10.3390/jcm12134176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/19/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a leading cause of disability and mortality worldwide, and while no specific etiologic interventions have been shown to improve outcomes, noninvasive and invasive respiratory support strategies are life-saving interventions that allow time for lung recovery. However, the inappropriate management of these strategies, which neglects the unique features of respiratory, lung, and chest wall mechanics may result in disease progression, such as patient self-inflicted lung injury during spontaneous breathing or by ventilator-induced lung injury during invasive mechanical ventilation. ARDS characteristics are highly heterogeneous; therefore, a physiology-based approach is strongly advocated to titrate the delivery and management of respiratory support strategies to match patient characteristics and needs to limit ARDS progression. Several tools have been implemented in clinical practice to aid the clinician in identifying the ARDS sub-phenotypes based on physiological peculiarities (inspiratory effort, respiratory mechanics, and recruitability), thus allowing for the appropriate application of personalized supportive care. In this narrative review, we provide an overview of noninvasive and invasive respiratory support strategies, as well as discuss how identifying ARDS sub-phenotypes in daily practice can help clinicians to deliver personalized respiratory support and potentially improve patient outcomes.
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Affiliation(s)
- Salvatore Lucio Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Melania Cesarano
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Gabriele Pintaudi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Luca Salvatore Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Ersilia Ruggiero
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Valentina Giammatteo
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Giuseppe Bello
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
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Dianti J, McNamee JJ, Slutsky AS, Fan E, Ferguson ND, McAuley DF, Goligher EC. Determinants of Effect of Extracorporeal CO 2 Removal in Hypoxemic Respiratory Failure. NEJM EVIDENCE 2023; 2:EVIDoa2200295. [PMID: 38320056 DOI: 10.1056/evidoa2200295] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Dead space and respiratory system elastance (Ers) may influence the clinical benefit of a ventilation strategy combining very low tidal volume (VT) with extracorporeal carbon dioxide removal (ECCO2R) in patients with acute hypoxemic respiratory failure. We sought to evaluate whether the effect of ECCO2R on mortality varies according to ventilatory ratio (VR; a composite variable reflective of dead space and shunt) and Ers. METHODS: Secondary analysis of a trial of a strategy combining very low VT and low-flow ECCO2R planned before the availability of trial results. Bayesian logistic regression was used to estimate the posterior probability of effect moderation by VR, Ers, and severity of hypoxemia (ratio of arterial partial pressure of oxygen to fraction of inspired oxygen [PaO2:FiO2]) on 90-day mortality. Credibility of effect moderation was appraised according to the Instrument for Assessing the Credibility of Effect Modification Analyses criteria. RESULTS: A total of 405 patients were available for analysis. The effect of the intervention on mortality varied substantially with VR (posterior probability of interaction, 94%; high credibility). Benefit was more probable than harm in patients with VR 3 or higher. In patients with VR less than 3, the probability of increased mortality with intervention was high (>90%). The effect of the intervention also varied with PaO2:FiO2 (posterior probability of interaction, >99%; low credibility). Benefit was more probable than harm in patients with PaO2:FiO2 110 mm Hg or higher. The effect of the intervention did not vary substantially with Ers (posterior probability of interaction, 68%; low credibility). CONCLUSIONS: VR has a highly credible influence on the effect of a strategy combining very low VT and low-flow ECCO2R on mortality. This intervention may reduce mortality in patients with high VR. (Funded by an Early Career Investigator Award from the Canadian Institutes of Health Research to Dr. Goligher.)
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Affiliation(s)
- Jose Dianti
- Department of Medicine, Division of Respirology, University Health Network, University of Toronto, Toronto, ON
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
| | - James J McNamee
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - Eddy Fan
- Department of Medicine, Division of Respirology, University Health Network, University of Toronto, Toronto, ON
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
- Toronto General Hospital Research Institute, Toronto, ON
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Niall D Ferguson
- Department of Medicine, Division of Respirology, University Health Network, University of Toronto, Toronto, ON
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
- Toronto General Hospital Research Institute, Toronto, ON
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
- Department of Physiology, University of Toronto, Toronto, ON
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen's University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Ewan C Goligher
- Department of Medicine, Division of Respirology, University Health Network, University of Toronto, Toronto, ON
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON
- Toronto General Hospital Research Institute, Toronto, ON
- Department of Physiology, University of Toronto, Toronto, ON
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29
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Marini JJ, Thornton LT, Rocco PRM, Gattinoni L, Crooke PS. Practical assessment of risk of VILI from ventilating power: a conceptual model. Crit Care 2023; 27:157. [PMID: 37081517 PMCID: PMC10120146 DOI: 10.1186/s13054-023-04406-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/16/2023] [Indexed: 04/22/2023] Open
Abstract
At the bedside, assessing the risk of ventilator-induced lung injury (VILI) requires parameters readily measured by the clinician. For this purpose, driving pressure (DP) and end-inspiratory static 'plateau' pressure ([Formula: see text]) of the tidal cycle are unquestionably useful but lack key information relating to associated volume changes and cumulative strain. 'Mechanical power', a clinical term which incorporates all dissipated ('non-elastic') and conserved ('elastic') energy components of inflation, has drawn considerable interest as a comprehensive 'umbrella' variable that accounts for the influence of ventilating frequency per minute as well as the energy cost per tidal cycle. Yet, like the raw values of DP and [Formula: see text], the absolute levels of energy and power by themselves may not carry sufficiently precise information to guide safe ventilatory practice. In previous work we introduced the concept of 'damaging energy per cycle'. Here we describe how-if only in concept-the bedside clinician might gauge the theoretical hazard of delivered energy using easily observed static circuit pressures ([Formula: see text] and positive end expiratory pressure) and an estimate of the maximally tolerated (threshold) non-dissipated ('elastic') airway pressure that reflects the pressure component applied to the alveolar tissues. Because its core inputs are already in use and familiar in daily practice, the simplified mathematical model we propose here for damaging energy and power may promote deeper comprehension of the key factors in play to improve lung protective ventilation.
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Affiliation(s)
- John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis/St Paul, MN, USA.
| | - Lauren T Thornton
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis/St Paul, MN, USA
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Luciano Gattinoni
- Department of Anesthesiology, University of Göttingen, Göttingen, Germany
| | - Philip S Crooke
- Department of Mathematics, Vanderbilt University, Nashville, TN, USA
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30
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Costamagna A, Steinberg I, Pivetta E, Arina P, Veglia S, Brazzi L, Fanelli V. Clinical performance of lung ultrasound in predicting time-dependent changes in lung aeration in ARDS patients. J Clin Monit Comput 2023; 37:473-480. [PMID: 35939164 PMCID: PMC9358118 DOI: 10.1007/s10877-022-00902-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 07/25/2022] [Indexed: 11/17/2022]
Abstract
To evaluate whether lung ultrasound is reliable bedside tool to monitor changes of lung aeration at the early and late stages of ARDS. LUS was performed in ARDS patients that underwent at least two consecutive CT scan at ICU admission and at least 1 week after admission. Twelve fields were evaluated and graded from 0 (normal) to 3 (consolidation). Changes of LUS score in twelve fields (ΔLUStot) and in four ventral (ΔLUSV), intermediate (ΔLUSI) and dorsal (ΔLUSD) zones were calculated at each time points. Three categories were described: Improve (ΔLUS < 0), Equal (ΔLUS = 0) or Worse (ΔLUS > 0). LUS scores were correlated with total changes in lung CT aeration (ΔCTair) and with normally, poorly and not aerated regions (ΔCTnorm, ΔCTpoor and ΔCTnot, respectively). Eleven patients were enrolled. ΔLUStot had significant correlation with ΔCTair (r = - 0.74, p < 0.01). ΔLUSV, ΔLUSI and ΔLUSD showed significant correlations with ΔCTair (r = - 0.66, r = - 0.69, r = - 0.63, respectively; p < 0.05). Compared to Equal, Improve and Worse categories had significantly higher (p < 0.01) and lower (p < 0.05) ΔCTair values, respectively. Compared to Equal, Improve and Worse categories had lower (p < 0.01) and higher (p < 0.01) ΔCTnot values, respectively. LUS score had a good correlation with lung CT in detecting changes of lung aeration.
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Affiliation(s)
- Andrea Costamagna
- Department of Anaesthesia and Critical Care, AOU Città Della Salute E Della Scienza Di Torino, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Irene Steinberg
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Emanuele Pivetta
- Division of Emergency Medicine and High Dependency Unit, Department of Medical Sciences, AOU Città Della Salute E Della Scienza Di Torino, Turin, Italy
| | - Pietro Arina
- Division of Medicine, UCL, Bloomsbury Institute for Intensive Care Medicine, Gower street, London, UK
| | - Simona Veglia
- Department of Diagnostic Imaging and Radiotherapy, AOU Città Della Salute E Della Scienza Di Torino, University of Turin, Turin, Italy
| | - Luca Brazzi
- Department of Anaesthesia and Critical Care, AOU Città Della Salute E Della Scienza Di Torino, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Vito Fanelli
- Department of Anaesthesia and Critical Care, AOU Città Della Salute E Della Scienza Di Torino, University of Turin, Corso Dogliotti 14, 10126, Turin, Italy.
- Department of Surgical Sciences, University of Turin, Turin, Italy.
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Penarrubia L, Verstraete A, Orkisz M, Davila E, Boussel L, Yonis H, Mezidi M, Dhelft F, Danjou W, Bazzani A, Sigaud F, Bayat S, Terzi N, Girard M, Bitker L, Roux E, Richard JC. Precision of CT-derived alveolar recruitment assessed by human observers and a machine learning algorithm in moderate and severe ARDS. Intensive Care Med Exp 2023; 11:8. [PMID: 36797424 PMCID: PMC9934943 DOI: 10.1186/s40635-023-00495-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 01/24/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND Assessing measurement error in alveolar recruitment on computed tomography (CT) is of paramount importance to select a reliable threshold identifying patients with high potential for alveolar recruitment and to rationalize positive end-expiratory pressure (PEEP) setting in acute respiratory distress syndrome (ARDS). The aim of this study was to assess both intra- and inter-observer smallest real difference (SRD) exceeding measurement error of recruitment using both human and machine learning-made lung segmentation (i.e., delineation) on CT. This single-center observational study was performed on adult ARDS patients. CT were acquired at end-expiration and end-inspiration at the PEEP level selected by clinicians, and at end-expiration at PEEP 5 and 15 cmH2O. Two human observers and a machine learning algorithm performed lung segmentation. Recruitment was computed as the weight change of the non-aerated compartment on CT between PEEP 5 and 15 cmH2O. RESULTS Thirteen patients were included, of whom 11 (85%) presented a severe ARDS. Intra- and inter-observer measurements of recruitment were virtually unbiased, with 95% confidence intervals (CI95%) encompassing zero. The intra-observer SRD of recruitment amounted to 3.5 [CI95% 2.4-5.2]% of lung weight. The human-human inter-observer SRD of recruitment was slightly higher amounting to 5.7 [CI95% 4.0-8.0]% of lung weight, as was the human-machine SRD (5.9 [CI95% 4.3-7.8]% of lung weight). Regarding other CT measurements, both intra-observer and inter-observer SRD were close to zero for the CT-measurements focusing on aerated lung (end-expiratory lung volume, hyperinflation), and higher for the CT-measurements relying on accurate segmentation of the non-aerated lung (lung weight, tidal recruitment…). The average symmetric surface distance between lung segmentation masks was significatively lower in intra-observer comparisons (0.8 mm [interquartile range (IQR) 0.6-0.9]) as compared to human-human (1.0 mm [IQR 0.8-1.3] and human-machine inter-observer comparisons (1.1 mm [IQR 0.9-1.3]). CONCLUSIONS The SRD exceeding intra-observer experimental error in the measurement of alveolar recruitment may be conservatively set to 5% (i.e., the upper value of the CI95%). Human-machine and human-human inter-observer measurement errors with CT are of similar magnitude, suggesting that machine learning segmentation algorithms are credible alternative to humans for quantifying alveolar recruitment on CT.
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Affiliation(s)
- Ludmilla Penarrubia
- grid.7849.20000 0001 2150 7757Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, INSERM, CREATIS UMR 5220, U1294, Université de Lyon, Villeurbanne, France
| | - Aude Verstraete
- grid.413852.90000 0001 2163 3825Service de Médecine Intensive Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de La Croix Rousse, 69004 Lyon, France
| | - Maciej Orkisz
- grid.7849.20000 0001 2150 7757Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, INSERM, CREATIS UMR 5220, U1294, Université de Lyon, Villeurbanne, France
| | - Eduardo Davila
- grid.7849.20000 0001 2150 7757Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, INSERM, CREATIS UMR 5220, U1294, Université de Lyon, Villeurbanne, France
| | - Loic Boussel
- grid.7849.20000 0001 2150 7757Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, INSERM, CREATIS UMR 5220, U1294, Université de Lyon, Villeurbanne, France ,grid.413852.90000 0001 2163 3825Service de Radiologie, Hôpital De La Croix Rousse, Hospices Civils de Lyon, Lyon, France
| | - Hodane Yonis
- grid.413852.90000 0001 2163 3825Service de Médecine Intensive Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de La Croix Rousse, 69004 Lyon, France
| | - Mehdi Mezidi
- grid.413852.90000 0001 2163 3825Service de Médecine Intensive Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de La Croix Rousse, 69004 Lyon, France
| | - Francois Dhelft
- grid.413852.90000 0001 2163 3825Service de Médecine Intensive Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de La Croix Rousse, 69004 Lyon, France ,grid.7849.20000 0001 2150 7757Université de Lyon, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - William Danjou
- grid.413852.90000 0001 2163 3825Service de Médecine Intensive Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de La Croix Rousse, 69004 Lyon, France
| | - Alwin Bazzani
- grid.413852.90000 0001 2163 3825Service de Médecine Intensive Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de La Croix Rousse, 69004 Lyon, France
| | - Florian Sigaud
- grid.410529.b0000 0001 0792 4829Service de Médecine-Intensive Réanimation, CHU Grenoble-Alpes, Grenoble, France
| | - Sam Bayat
- grid.450307.50000 0001 0944 2786Synchrotron Radiation for Biomedicine Laboratory (STROBE), INSERM UA07, Univ. Grenoble Alpes, Grenoble, France ,grid.410529.b0000 0001 0792 4829Department of Pulmonology and Physiology, Grenoble University Hospital, Grenoble, France
| | - Nicolas Terzi
- grid.411154.40000 0001 2175 0984Maladies Infectieuses et Réanimation Médicale, CHU Rennes, Rennes, France ,grid.410368.80000 0001 2191 9284Faculté de Médecine, Biosit, Université Rennes1, Rennes, France ,grid.410368.80000 0001 2191 9284INSERM-CIC-1414, Faculté de Médecine, IFR 140, Université Rennes I, Rennes, France
| | - Mehdi Girard
- grid.413852.90000 0001 2163 3825Service de Médecine Intensive Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de La Croix Rousse, 69004 Lyon, France
| | - Laurent Bitker
- grid.7849.20000 0001 2150 7757Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, INSERM, CREATIS UMR 5220, U1294, Université de Lyon, Villeurbanne, France ,grid.413852.90000 0001 2163 3825Service de Médecine Intensive Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de La Croix Rousse, 69004 Lyon, France
| | - Emmanuel Roux
- grid.7849.20000 0001 2150 7757Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, INSERM, CREATIS UMR 5220, U1294, Université de Lyon, Villeurbanne, France
| | - Jean-Christophe Richard
- Université Claude Bernard Lyon 1, INSA-Lyon, CNRS, INSERM, CREATIS UMR 5220, U1294, Université de Lyon, Villeurbanne, France. .,Service de Médecine Intensive Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de La Croix Rousse, 69004, Lyon, France.
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Wang L, Jiang Z. Tidal Volume Level Estimation Using Respiratory Sounds. JOURNAL OF HEALTHCARE ENGINEERING 2023; 2023:4994668. [PMID: 36844947 PMCID: PMC9949945 DOI: 10.1155/2023/4994668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/19/2022] [Accepted: 11/24/2022] [Indexed: 02/18/2023]
Abstract
Respiratory sounds have been used as a noninvasive and convenient method to estimate respiratory flow and tidal volume. However, current methods need calibration, making them difficult to use in a home environment. A respiratory sound analysis method is proposed to estimate tidal volume levels during sleep qualitatively. Respiratory sounds are filtered and segmented into one-minute clips, all clips are clustered into three categories: normal breathing/snoring/uncertain with agglomerative hierarchical clustering (AHC). Formant parameters are extracted to classify snoring clips into simple snoring and obstructive snoring with the K-means algorithm. For simple snoring clips, the tidal volume level is calculated based on snoring last time. For obstructive snoring clips, the tidal volume level is calculated by the maximum breathing pause interval. The performance of the proposed method is evaluated on an open dataset, PSG-Audio, in which full-night polysomnography (PSG) and tracheal sound were recorded simultaneously. The calculated tidal volume levels are compared with the corresponding lowest nocturnal oxygen saturation (LoO2) data. Experiments show that the proposed method calculates tidal volume levels with high accuracy and robustness.
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Affiliation(s)
- Lurui Wang
- Graduate School of Science and Engineering, Yamaguchi University, Yamaguchi, Japan
| | - Zhongwei Jiang
- Graduate School of Science and Engineering, Yamaguchi University, Yamaguchi, Japan
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33
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Dhelft F, Lancelot S, Mouton W, Le Bars D, Costes N, Roux E, Orkisz M, Benzerdjeb N, Richard JC, Bitker L. Prone position decreases acute lung inflammation measured by [ 11C](R)-PK11195 positron emission tomography in experimental acute respiratory distress syndrome. J Appl Physiol (1985) 2023; 134:467-481. [PMID: 36633865 DOI: 10.1152/japplphysiol.00234.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Whether prone positioning (PP) modulates acute lung inflammation by the modulation of biomechanical forces of ventilator-induced lung injuries (VILIs) remains unclear. We aimed to demonstrate that PP decreases acute lung inflammation in animals with experimental acute respiratory distress syndrome (ARDS). Animals were under general anesthesia and protective ventilation (tidal volume 6 mL·kg-1, PEEP 5 cmH2O). ARDS was induced by intratracheal instillation of chlorohydric acid. Animals were then randomized to PP, or to supine position (SP). After 4 h, a positron emission tomography (PET) acquisition with [11C](R)-PK11195 was performed coupled with computerized tomography (CT) acquisitions, allowing the CT quantification of VILI-associated parameters. [11C](R)-PK11195 lung uptake was quantified using pharmacokinetic multicompartment models. Analyses were performed on eight lung sections distributed along the antero-posterior dimension. Six animals were randomized to PP, five to SP (median [Formula: see text]/[Formula: see text] [interquartile range]: 164 [102-269] mmHg). The normally aerated compartment was significantly redistributed to the posterior lung regions of animals in PP, compared with SP. Dynamic strain was significantly increased in posterior regions of SP animals, compared with PP. After 4 h, animals in PP had a significantly lower uptake of [11C](R)-PK11195, compared with SP. [11C](R)-PK11195 regional uptake was independently associated with the study group, dynamic strain, tidal hyperinflation, and regional respiratory system compliance in multivariate analysis. In an experimental model of ARDS, 4 h of PP significantly decreased acute lung inflammation assessed with PET. The beneficial impact of PP on acute lung inflammation was consecutive to the combination of decreased biomechanical forces and changes in the respiratory system mechanics.NEW & NOTEWORTHY Prone position decreases acute lung macrophage inflammation quantified in vivo with [11C](R)-PK11195 positron emission tomography in an experimental acute respiratory distress syndrome. Regional macrophage inflammation is maximal in the most anterior and posterior lung section of supine animals, in relation with increased regional tidal strain and hyperinflation, and reduced regional lung compliance.
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Affiliation(s)
- François Dhelft
- Service de Médecine Intensive - Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, CNRS, Inserm, CREATIS UMR 5220, U1294, Villeurbanne, France.,Claude Bernard University Lyon 1, Lyon, France
| | - Sophie Lancelot
- Claude Bernard University Lyon 1, Lyon, France.,CERMEP - Imagerie du Vivant, Lyon, France.,Hospices Civils de Lyon, Lyon, France
| | - William Mouton
- Laboratoire Commun de Recherche Hospices Civils de Lyon/bioMérieux, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Didier Le Bars
- Claude Bernard University Lyon 1, Lyon, France.,CERMEP - Imagerie du Vivant, Lyon, France.,Hospices Civils de Lyon, Lyon, France
| | - Nicolas Costes
- Claude Bernard University Lyon 1, Lyon, France.,CERMEP - Imagerie du Vivant, Lyon, France
| | - Emmanuel Roux
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, CNRS, Inserm, CREATIS UMR 5220, U1294, Villeurbanne, France
| | - Maciej Orkisz
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, CNRS, Inserm, CREATIS UMR 5220, U1294, Villeurbanne, France
| | - Nazim Benzerdjeb
- Centre d'Anatomie et Cytologie Pathologique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Jean-Christophe Richard
- Service de Médecine Intensive - Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, CNRS, Inserm, CREATIS UMR 5220, U1294, Villeurbanne, France.,Claude Bernard University Lyon 1, Lyon, France
| | - Laurent Bitker
- Service de Médecine Intensive - Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, CNRS, Inserm, CREATIS UMR 5220, U1294, Villeurbanne, France.,Claude Bernard University Lyon 1, Lyon, France
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34
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Constantino K, Gottlieb M, Long B. Interstitial Lung Disease: A Focused Review for the Emergency Clinician. J Emerg Med 2023; 64:156-166. [PMID: 36707347 DOI: 10.1016/j.jemermed.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 10/05/2022] [Accepted: 10/21/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Interstitial lung disease (ILD) is a group of restrictive pulmonary diseases associated with diffuse interstitial and parenchymal inflammation. Patients can present to the emergency department with severe exacerbation. OBJECTIVE This narrative review provides emergency clinicians with the most recent evidence concerning acute exacerbation of ILD (AE-ILD). DISCUSSION AE-ILD can present as acute respiratory distress in a patient with a pre-existing ILD diagnosis or as a de novo presentation of ILD, and is associated with significant morbidity and mortality. A variety of underlying triggers may result in AE-ILD. Emergency clinicians must first assess for extraneous causes of respiratory decompensation prior to diagnosing AE-ILD. For a de novo presentation of ILD, emergency physicians should also assess for possible reversible causes. AE-ILD is managed with systemic steroids, immunosuppressants, intravenous antibiotics, supplemental oxygen, and extracorporeal membrane oxygenation in severe cases. Given the high mortality rates in the absence of lung transplantation, early referral to transplant centers is essential to increase chances of survival. CONCLUSIONS Emergency clinician knowledge of AE-ILD can improve the evaluation and management of these patients.
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Affiliation(s)
- Krishna Constantino
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
| | - Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, Illinois
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas
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35
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Extracorporeal Carbon Dioxide Removal: From Pathophysiology to Clinical Applications; Focus on Combined Continuous Renal Replacement Therapy. Biomedicines 2023; 11:biomedicines11010142. [PMID: 36672649 PMCID: PMC9855411 DOI: 10.3390/biomedicines11010142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/29/2022] [Accepted: 12/31/2022] [Indexed: 01/08/2023] Open
Abstract
Lung-protective ventilation (LPV) with low tidal volumes can significantly increase the survival of patients with acute respiratory distress syndrome (ARDS) by limiting ventilator-induced lung injuries. However, one of the main concerns regarding the use of LPV is the risk of developing hypercapnia and respiratory acidosis, which may limit the clinical application of this strategy. This is the reason why different extracorporeal CO2 removal (ECCO2R) techniques and devices have been developed. They include low-flow or high-flow systems that may be performed with dedicated platforms or, alternatively, combined with continuous renal replacement therapy (CRRT). ECCO2R has demonstrated effectiveness in controlling PaCO2 levels, thus allowing LPV in patients with ARDS from different causes, including those affected by Coronavirus disease 2019 (COVID-19). Similarly, the suitability and safety of combined ECCO2R and CRRT (ECCO2R-CRRT), which provides CO2 removal and kidney support simultaneously, have been reported in both retrospective and prospective studies. However, due to the complexity of ARDS patients and the limitations of current evidence, the actual impact of ECCO2R on patient outcome still remains to be defined. In this review, we discuss the main principles of ECCO2R and its clinical application in ARDS patients, in particular looking at clinical experiences of combined ECCO2R-CRRT treatments.
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36
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Extracorporeal CO 2 Removal During Renal Replacement Therapy to Allow Lung-Protective Ventilation in Patients With COVID-19-Associated Acute Respiratory Distress Syndrome. ASAIO J 2023; 69:36-42. [PMID: 35998214 PMCID: PMC9797119 DOI: 10.1097/mat.0000000000001803] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The aim of this retrospective multicenter observational study is to test the feasibility and safety of a combined extracorporeal CO 2 removal (ECCO 2 R) plus renal replacement therapy (RRT) system to use an ultraprotective ventilator setting while maintaining (1) an effective support of renal function and (2) values of pH within the physiologic limits in a cohort of coronavirus infectious disease 2019 (COVID-19) patients. Among COVID-19 patients admitted to the intensive care unit of 9 participating hospitals, 27 patients with acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI) requiring invasive mechanical ventilation undergoing ECCO 2 R-plus-RRT treatment were included in the analysis. The treatment allowed to reduce V T from 6.0 ± 0.6 mL/kg at baseline to 4.8 ± 0.8, 4.6 ± 1.0, and 4.3 ± 0.3 mL/kg, driving pressure (ΔP) from 19.8 ± 2.5 cm H 2 O to 14.8 ± 3.6, 14.38 ± 4.1 and 10.2 ± 1.6 cm H 2 O after 24 hours, 48 hours, and at discontinuation of ECCO 2 R-plus-RRT (T3), respectively ( p < 0.001). PaCO 2 and pH remained stable. Plasma creatinine decreased over the study period from 3.30 ± 1.27 to 1.90 ± 1.30 and 1.27 ± 0.90 mg/dL after 24 and 48 hours of treatment, respectively ( p < 0.01). No patient-related events associated with the extracorporeal system were reported. These data show that in patients with COVID-19-induced ARDS and AKI, ECCO 2 R-plus-RRT is effective in allowing ultraprotective ventilator settings while maintaining an effective support of renal function and values of pH within physiologic limits.
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37
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Chen R, Krueger-Ziolek S, Lovas A, Benyó B, Rupitsch SJ, Moeller K. Structural priors represented by discrete cosine transform improve EIT functional imaging. PLoS One 2023; 18:e0285619. [PMID: 37167237 PMCID: PMC10174522 DOI: 10.1371/journal.pone.0285619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 04/26/2023] [Indexed: 05/13/2023] Open
Abstract
Structural prior information can improve electrical impedance tomography (EIT) reconstruction. In this contribution, we introduce a discrete cosine transformation-based (DCT-based) EIT reconstruction algorithm to demonstrate a way to incorporate the structural prior with the EIT reconstruction process. Structural prior information is obtained from other available imaging methods, e.g., thorax-CT. The DCT-based approach creates a functional EIT image of regional lung ventilation while preserving the introduced structural information. This leads to an easier interpretation in clinical settings while maintaining the advantages of EIT in terms of bedside monitoring during mechanical ventilation. Structural priors introduced in the DCT-based approach are of two categories in terms of different levels of information included: a contour prior only differentiates lung and non-lung region, while a detail prior includes information, such as atelectasis, within the lung area. To demonstrate the increased interpretability of the EIT image through structural prior in the DCT-based approach, the DCT-based reconstructions were compared with reconstructions from a widely applied one-step Gauss-Newton solver with background prior and from the advanced GREIT algorithm. The comparisons were conducted both on simulation data and retrospective patient data. In the simulation, we used two sets of forward models to simulate different lung conditions. A contour prior and a detail prior were derived from simulation ground truth. With these two structural priors, the reconstructions from the DCT-based approach were compared with the reconstructions from both the one-step Gauss-Newton solver and the GREIT. The difference between the reconstructions and the simulation ground truth is calculated by the ℓ2-norm image difference. In retrospective patient data analysis, datasets from six lung disease patients were included. For each patient, a detail prior was derived from the patient's CT, respectively. The detail prior was used for the reconstructions using the DCT-based approach, which was compared with the reconstructions from the GREIT. The reconstructions from the DCT-based approach are more comprehensive and interpretable in terms of preserving the structure specified by the priors, both in simulation and retrospective patient data analysis. In simulation analysis, the ℓ2-norm image difference of the DCT-based approach with a contour prior decreased on average by 34% from GREIT and 49% from the Gauss-Newton solver with background prior; for reconstructions of the DCT-based approach with detail prior, on average the ℓ2-norm image difference is 53% less than GREIT and 63% less than the reconstruction with background prior. In retrospective patient data analysis, the reconstructions from both the DCT-based approach and GREIT can indicate the current patient status, but the DCT-based approach yields more interpretable results. However, it is worth noting that the preserved structure in the DCT-based approach is derived from another imaging method, not from the EIT measurement. If the structural prior is outdated or wrong, the result might be misleadingly interpreted, which induces false clinical conclusions. Further research in terms of evaluating the validity of the structural prior and detecting the outdated prior is necessary.
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Affiliation(s)
- Rongqing Chen
- Institute of Technical Medicine (ITeM), Furtwangen University, Villingen-Schwenningen, Germany
- Faculty of Engineering, University of Freiburg, Freiburg, Germany
| | - Sabine Krueger-Ziolek
- Institute of Technical Medicine (ITeM), Furtwangen University, Villingen-Schwenningen, Germany
| | - András Lovas
- Department of Anaesthesiology and Intensive Therapy, Kiskunhalas Semmelweis Hospital, Kiskunhalas, Hungary
| | - Balázs Benyó
- Department of Control Engineering and Information Technology, Faculty of Electrical Engineering and Informatics, Budapest University of Technology and Economics, Budapest, Hungary
| | | | - Knut Moeller
- Institute of Technical Medicine (ITeM), Furtwangen University, Villingen-Schwenningen, Germany
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38
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Guervilly C, Fournier T, Chommeloux J, Arnaud L, Pinglis C, Baumstarck K, Boucekine M, Valera S, Sanz C, Adda M, Bobot M, Daviet F, Gragueb-Chatti I, Forel JM, Roch A, Hraiech S, Dignat-George F, Schmidt M, Lacroix R, Papazian L. Ultra-lung-protective ventilation and biotrauma in severe ARDS patients on veno-venous extracorporeal membrane oxygenation: a randomized controlled study. Crit Care 2022; 26:383. [PMID: 36510324 PMCID: PMC9744058 DOI: 10.1186/s13054-022-04272-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Ultra-lung-protective ventilation may be useful during veno-venous extracorporeal membrane oxygenation (vv-ECMO) for severe acute respiratory distress syndrome (ARDS) to minimize ventilator-induced lung injury and to facilitate lung recovery. The objective was to compare pulmonary and systemic biotrauma evaluated by numerous biomarkers of inflammation, epithelial, endothelial injuries, and lung repair according to two ventilator strategies on vv-ECMO. METHODS This is a prospective randomized controlled study. Patients were randomized to receive during 48 h either ultra-lung-protective ventilation combining very low tidal volume (1-2 mL/kg of predicted body weight), low respiratory rate (5-10 cycles per minute), positive expiratory transpulmonary pressure, and 16 h of prone position or lung-protective-ventilation which followed the ECMO arm of the EOLIA trial (control group). RESULTS The primary outcome was the alveolar concentrations of interleukin-1-beta, interleukin-6, interleukin-8, surfactant protein D, and blood concentrations of serum advanced glycation end products and angiopoietin-2 48 h after randomization. Enrollment was stopped for futility after the inclusion of 39 patients. Tidal volume, respiratory rate, minute ventilation, plateau pressure, and mechanical power were significantly lower in the ultra-lung-protective group. None of the concentrations of the pre-specified biomarkers differed between the two groups 48 h after randomization. However, a trend to higher 60-day mortality was observed in the ultra-lung-protective group compared to the control group (45 vs 17%, p = 0.06). CONCLUSIONS Despite a significant reduction in the mechanical power, ultra-lung-protective ventilation during 48 h did not reduce biotrauma in patients with vv-ECMO-supported ARDS. The impact of this ventilation strategy on clinical outcomes warrants further investigation. Trial registration Clinical trial registered with www. CLINICALTRIALS gov ( NCT03918603 ). Registered 17 April 2019.
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Affiliation(s)
- Christophe Guervilly
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Théotime Fournier
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France
| | - Juliette Chommeloux
- grid.411439.a0000 0001 2150 9058Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP, Sorbonne, Université Hôpital Pitié- Salpêtrière, Paris, France ,grid.462844.80000 0001 2308 1657INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Laurent Arnaud
- grid.414336.70000 0001 0407 1584Laboratoire d’Hématologie et de Biologie Vasculaire, Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | - Camille Pinglis
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Karine Baumstarck
- grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Mohamed Boucekine
- grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Sabine Valera
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Celine Sanz
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Mélanie Adda
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Mickaël Bobot
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817INSERM 1263, Institut National de Recherche Pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Centre de Recherche en CardioVasculaire et Nutrition (C2VN), Université Aix-Marseille, Marseille, France ,grid.411535.70000 0004 0638 9491Centre de Néphrologie et Transplantation Rénale, AP-HM, Hôpital de la Conception, CHU de la Conception, 13005 Marseille, France
| | - Florence Daviet
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Ines Gragueb-Chatti
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Jean-Marie Forel
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Antoine Roch
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Sami Hraiech
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France
| | - Françoise Dignat-George
- grid.414336.70000 0001 0407 1584Laboratoire d’Hématologie et de Biologie Vasculaire, Assistance Publique-Hôpitaux de Marseille, Marseille, France ,grid.5399.60000 0001 2176 4817INSERM 1263, Institut National de Recherche Pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Centre de Recherche en CardioVasculaire et Nutrition (C2VN), Université Aix-Marseille, Marseille, France
| | - Matthieu Schmidt
- grid.411439.a0000 0001 2150 9058Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP, Sorbonne, Université Hôpital Pitié- Salpêtrière, Paris, France ,grid.462844.80000 0001 2308 1657INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - Romaric Lacroix
- grid.414336.70000 0001 0407 1584Laboratoire d’Hématologie et de Biologie Vasculaire, Assistance Publique-Hôpitaux de Marseille, Marseille, France ,grid.5399.60000 0001 2176 4817INSERM 1263, Institut National de Recherche Pour l’Agriculture, l’Alimentation et l’Environnement (INRAE), Centre de Recherche en CardioVasculaire et Nutrition (C2VN), Université Aix-Marseille, Marseille, France
| | - Laurent Papazian
- grid.414244.30000 0004 1773 6284Service de Médecine Intensive Réanimation, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Chemin des Bourrely, 13915 Marseille Cedex 20, France ,grid.5399.60000 0001 2176 4817Centre d’Etudes et de Recherches sur les Services de Santé et qualite de vie EA 3279, Aix-Marseille Université, 13005 Marseille, France ,Centre Hospitalier de Bastia, Service de Réanimation, 604 Chemin de Falconaja, 20600 Bastia, France
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Rezaiguia-Delclaux S, Ren L, Gruner A, Roman C, Genty T, Stéphan F. Oxygenation versus driving pressure for determining the best positive end-expiratory pressure in acute respiratory distress syndrome. Crit Care 2022; 26:214. [PMID: 35831827 PMCID: PMC9281138 DOI: 10.1186/s13054-022-04084-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 06/29/2022] [Indexed: 12/16/2022] Open
Abstract
Objective The aim of this prospective longitudinal study was to compare driving pressure and absolute PaO2/FiO2 ratio in determining the best positive end-expiratory pressure (PEEP) level. Patients and methods In 122 patients with acute respiratory distress syndrome, PEEP was increased until plateau pressure reached 30 cmH2O at constant tidal volume, then decreased at 15-min intervals, to 15, 10, and 5 cmH2O. The best PEEP by PaO2/FiO2 ratio (PEEPO2) was defined as the highest PaO2/FiO2 ratio obtained, and the best PEEP by driving pressure (PEEPDP) as the lowest driving pressure. The difference between the best PEEP levels was compared to a non-inferiority margin of 1.5 cmH2O. Main results The best mean PEEPO2 value was 11.9 ± 4.7 cmH2O compared to 10.6 ± 4.1 cmH2O for the best PEEPDP: mean difference = 1.3 cmH2O (95% confidence interval [95% CI], 0.4–2.3; one-tailed P value, 0.36). Only 46 PEEP levels were the same with the two methods (37.7%; 95% CI 29.6–46.5). PEEP level was ≥ 15 cmH2O in 61 (50%) patients with PEEPO2 and 39 (32%) patients with PEEPDP (P = 0.001). Conclusion Depending on the method chosen, the best PEEP level varies. The best PEEPDP level is lower than the best PEEPO2 level. Computing driving pressure is simple, faster and less invasive than measuring PaO2. However, our results do not demonstrate that one method deserves preference over the other in terms of patient outcome. Clinical trial number: #ACTRN12618000554268. Registered 13 April 2018.
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Selickman J, Tawfik P, Crooke PS, Dries DJ, Shelver J, Gattinoni L, Marini JJ. Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP. Crit Care 2022; 26:201. [PMID: 35791021 PMCID: PMC9255488 DOI: 10.1186/s13054-022-04073-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/24/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Chest wall loading has been shown to paradoxically improve respiratory system compliance (CRS) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The most likely, albeit unconfirmed, mechanism is relief of end-tidal overdistension in ‘baby lungs’ of low-capacity. The purpose of this study was to define how small changes of tidal volume (VT) and positive end-expiratory pressure (PEEP) affect CRS (and its associated airway pressures) in patients with ARDS who demonstrate a paradoxical response to chest wall loading. We hypothesized that small reductions of VT or PEEP would alleviate overdistension and favorably affect CRS and conversely, that small increases of VT or PEEP would worsen CRS.
Methods
Prospective, multi-center physiologic study of seventeen patients with moderate to severe ARDS who demonstrated paradoxical responses to chest wall loading. All patients received mechanical ventilation in volume control mode and were passively ventilated. Airway pressures were measured before and after decreasing/increasing VT by 1 ml/kg predicted body weight and decreasing/increasing PEEP by 2.5 cmH2O.
Results
Decreasing either VT or PEEP improved CRS in all patients. Driving pressure (DP) decreased by a mean of 4.9 cmH2O (supine) and by 4.3 cmH2O (prone) after decreasing VT, and by a mean of 2.9 cmH2O (supine) and 2.2 cmH2O (prone) after decreasing PEEP. CRS increased by a mean of 3.1 ml/cmH2O (supine) and by 2.5 ml/cmH2O (prone) after decreasing VT. CRS increased by a mean of 5.2 ml/cmH2O (supine) and 3.6 ml/cmH2O (prone) after decreasing PEEP (P < 0.01 for all). Small increments of either VT or PEEP worsened CRS in the majority of patients.
Conclusion
Patients with a paradoxical response to chest wall loading demonstrate uniform improvement in both DP and CRS following a reduction in either VT or PEEP, findings in keeping with prior evidence suggesting its presence is a sign of end-tidal overdistension. The presence of ‘paradox’ should prompt re-evaluation of modifiable determinants of end-tidal overdistension, including VT, PEEP, and body position.
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Pavlovsky B, Pesenti A, Spinelli E, Scaramuzzo G, Marongiu I, Tagliabue P, Spadaro S, Grasselli G, Mercat A, Mauri T. Effects of PEEP on regional ventilation-perfusion mismatch in the acute respiratory distress syndrome. Crit Care 2022; 26:211. [PMID: 35818077 PMCID: PMC9272883 DOI: 10.1186/s13054-022-04085-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 07/05/2022] [Indexed: 11/10/2022] Open
Abstract
Purpose In the acute respiratory distress syndrome (ARDS), decreasing Ventilation-Perfusion \documentclass[12pt]{minimal}
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\begin{document}$$\left( {{{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}} \right)$$\end{document}V˙/Q˙ mismatch might enhance lung protection. We investigated the regional effects of higher Positive End Expiratory Pressure (PEEP) on \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ mismatch and their correlation with recruitability. We aimed to verify whether PEEP improves regional \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ mismatch, and to study the underlying mechanisms. Methods In fifteen patients with moderate and severe ARDS, two PEEP levels (5 and 15 cmH2O) were applied in random order. \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ mismatch was assessed by Electrical Impedance Tomography at each PEEP. Percentage of ventilation and perfusion reaching different ranges of \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ ratios were analyzed in 3 gravitational lung regions, leading to precise assessment of their distribution throughout different \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ mismatch compartments. Recruitability between the two PEEP levels was measured by the recruitment-to-inflation ratio method. Results In the non-dependent region, at higher PEEP, ventilation reaching the normal \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ compartment (p = 0.018) increased, while it decreased in the high \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ one (p = 0.023). In the middle region, at PEEP 15 cmH2O, ventilation and perfusion to the low \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ compartment decreased (p = 0.006 and p = 0.011) and perfusion to normal \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ increased (p = 0.003). In the dependent lung, the percentage of blood flowing through the non-ventilated compartment decreased (p = 0.041). Regional \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ mismatch improvement was correlated to lung recruitability and changes in regional tidal volume. Conclusions In patients with ARDS, higher PEEP optimizes the distribution of both ventilation (in the non-dependent areas) and perfusion (in the middle and dependent lung). Bedside measure of recruitability is associated with improved \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ mismatch. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04085-y.
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Richard JC, Sigaud F, Gaillet M, Orkisz M, Bayat S, Roux E, Ahaouari T, Davila E, Boussel L, Ferretti G, Yonis H, Mezidi M, Danjou W, Bazzani A, Dhelft F, Folliet L, Girard M, Pozzi M, Terzi N, Bitker L. Response to PEEP in COVID-19 ARDS patients with and without extracorporeal membrane oxygenation. A multicenter case–control computed tomography study. Crit Care 2022; 26:195. [PMID: 35780154 PMCID: PMC9250720 DOI: 10.1186/s13054-022-04076-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 06/27/2022] [Indexed: 11/23/2022] Open
Abstract
Background PEEP selection in severe COVID-19 patients under extracorporeal membrane oxygenation (ECMO) is challenging as no study has assessed the alveolar recruitability in this setting. The aim of the study was to compare lung recruitability and the impact of PEEP on lung aeration in moderate and severe ARDS patients with or without ECMO, using computed tomography (CT). Methods We conducted a two-center prospective observational case–control study in adult COVID-19-related patients who had an indication for CT within 72 h of ARDS onset in non-ECMO patients or within 72 h after ECMO onset. Ninety-nine patients were included, of whom 24 had severe ARDS under ECMO, 59 severe ARDS without ECMO and 16 moderate ARDS. Results Non-inflated lung at PEEP 5 cmH2O was significantly greater in ECMO than in non-ECMO patients. Recruitment induced by increasing PEEP from 5 to 15 cmH2O was not significantly different between ECMO and non-ECMO patients, while PEEP-induced hyperinflation was significantly lower in the ECMO group and virtually nonexistent. The median [IQR] fraction of recruitable lung mass between PEEP 5 and 15 cmH2O was 6 [4–10]%. Total superimposed pressure at PEEP 5 cmH2O was significantly higher in ECMO patients and amounted to 12 [11–13] cmH2O. The hyperinflation-to-recruitment ratio (i.e., a trade-off index of the adverse effects and benefits of PEEP) was significantly lower in ECMO patients and was lower than one in 23 (96%) ECMO patients, 41 (69%) severe non-ECMO patients and 8 (50%) moderate ARDS patients. Compliance of the aerated lung at PEEP 5 cmH2O corrected for PEEP-induced recruitment (CBABY LUNG) was significantly lower in ECMO patients than in non-ECMO patients and was linearly related to the logarithm of the hyperinflation-to-recruitment ratio. Conclusions Lung recruitability of COVID-19 pneumonia is not significantly different between ECMO and non-ECMO patients, with substantial interindividual variations. The balance between hyperinflation and recruitment induced by PEEP increase from 5 to 15 cmH2O appears favorable in virtually all ECMO patients, while this PEEP level is required to counteract compressive forces leading to lung collapse. CBABY LUNG is significantly lower in ECMO patients, independently of lung recruitability. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04076-z.
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Selickman J, Marini JJ. Chest wall loading in the ICU: pushes, weights, and positions. Ann Intensive Care 2022; 12:103. [PMID: 36346532 PMCID: PMC9640797 DOI: 10.1186/s13613-022-01076-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
Clinicians monitor mechanical ventilatory support using airway pressures—primarily the plateau and driving pressure, which are considered by many to determine the safety of the applied tidal volume. These airway pressures are influenced not only by the ventilator prescription, but also by the mechanical properties of the respiratory system, which consists of the series-coupled lung and chest wall. Actively limiting chest wall expansion through external compression of the rib cage or abdomen is seldom performed in the ICU. Recent literature describing the respiratory mechanics of patients with late-stage, unresolving, ARDS, however, has raised awareness of the potential diagnostic (and perhaps therapeutic) value of this unfamiliar and somewhat counterintuitive practice. In these patients, interventions that reduce resting lung volume, such as loading the chest wall through application of external weights or manual pressure, or placing the torso in a more horizontal position, have unexpectedly improved tidal compliance of the lung and integrated respiratory system by reducing previously undetected end-tidal hyperinflation. In this interpretive review, we first describe underappreciated lung and chest wall interactions that are clinically relevant to both normal individuals and to the acutely ill who receive ventilatory support. We then apply these physiologic principles, in addition to published clinical observation, to illustrate the utility of chest wall modification for the purposes of detecting end-tidal hyperinflation in everyday practice.
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Affiliation(s)
- John Selickman
- grid.17635.360000000419368657Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN USA ,grid.415858.50000 0001 0087 6510Department of Critical Care Medicine, Regions Hospital, MS 11203B, 640 Jackson St., St. Paul, MN 55101-2595 USA
| | - John J. Marini
- grid.17635.360000000419368657Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN USA ,grid.415858.50000 0001 0087 6510Department of Critical Care Medicine, Regions Hospital, MS 11203B, 640 Jackson St., St. Paul, MN 55101-2595 USA
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Ramcharran H, Bates JHT, Satalin J, Blair S, Andrews PL, Gaver DP, Gatto LA, Wang G, Ghosh AJ, Robedee B, Vossler J, Habashi NM, Daphtary N, Kollisch-Singule M, Nieman GF. Protective ventilation in a pig model of acute lung injury: timing is as important as pressure. J Appl Physiol (1985) 2022; 133:1093-1105. [PMID: 36135956 PMCID: PMC9621707 DOI: 10.1152/japplphysiol.00312.2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/26/2022] [Accepted: 09/19/2022] [Indexed: 11/22/2022] Open
Abstract
Ventilator-induced lung injury (VILI) is a significant risk for patients with acute respiratory distress syndrome (ARDS). Management of the patient with ARDS is currently dominated by the use of low tidal volume mechanical ventilation, the presumption being that this mitigates overdistension (OD) injury to the remaining normal lung tissue. Evidence exists, however, that it may be more important to avoid cyclic recruitment and derecruitment (RD) of lung units, although the relative roles of OD and RD in VILI remain unclear. Forty pigs had a heterogeneous lung injury induced by Tween instillation and were randomized into four groups (n = 10 each) with higher (↑) or lower (↓) levels of OD and/or RD imposed using airway pressure release ventilation (APRV). OD was increased by setting inspiratory airway pressure to 40 cmH2O and lessened with 28 cmH2O. RD was attenuated using a short duration of expiration (∼0.45 s) and increased with a longer duration (∼1.0 s). All groups developed mild ARDS following injury. RD ↑ OD↑ caused the greatest degree of lung injury as determined by [Formula: see text]/[Formula: see text] ratio (226.1 ± 41.4 mmHg). RD ↑ OD↓ ([Formula: see text]/[Formula: see text]= 333.9 ± 33.1 mmHg) and RD ↓ OD↑ ([Formula: see text]/[Formula: see text] = 377.4 ± 43.2 mmHg) were both moderately injurious, whereas RD ↓ OD↓ ([Formula: see text]/[Formula: see text] = 472.3 ± 22.2 mmHg; P < 0.05) was least injurious. Both tidal volume and driving pressure were essentially identical in the RD ↑ OD↓ and RD ↓ OD↑ groups. We, therefore, conclude that considerations of expiratory time may be at least as important as pressure for safely ventilating the injured lung.NEW & NOTEWORTHY In a large animal model of ARDS, recruitment/derecruitment caused greater VILI than overdistension, whereas both mechanisms together caused severe lung damage. These findings suggest that eliminating cyclic recruitment and derecruitment during mechanical ventilation should be a preeminent management goal for the patient with ARDS. The airway pressure release ventilation (APRV) mode of mechanical ventilation can achieve this if delivered with an expiratory duration (TLow) that is brief enough to prevent derecruitment at end expiration.
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Affiliation(s)
| | | | | | - Sarah Blair
- SUNY Upstate Medical University, Syracuse, New York
| | | | | | | | - Guirong Wang
- SUNY Upstate Medical University, Syracuse, New York
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Bedside Detection of End-Tidal Hyperinflation in Acute Respiratory Distress Syndrome. Ann Am Thorac Soc 2022; 19:1791-1795. [PMID: 35849421 DOI: 10.1513/annalsats.202205-460ps] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Munshi L, Brodie D, Fan E. Extracorporeal Support for Acute Respiratory Distress Syndrome in Adults. NEJM EVIDENCE 2022; 1:EVIDra2200128. [PMID: 38319864 DOI: 10.1056/evidra2200128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Extracorporeal Support for ARDS in AdultsThere is a subset of patients who develop severe ARDS for whom supportive care with mechanical ventilation is insufficient or possibly injurious. The use of ECMO as an adjunct to treat these patients is reviewed.
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Affiliation(s)
- Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto
- Institute of Health Policy, Management and Evaluation, University of Toronto
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York
- Center for Acute Respiratory Failure, NewYork-Presbyterian Hospital, New York
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto
- Institute of Health Policy, Management and Evaluation, University of Toronto
- Toronto General Hospital Research Institute
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Smith LD, Alne T, Briere H, Hernandez A, Freeman R, Gabel K, Berube J, Carreon CJ, Grimshaw KS, Indar-Maraj M, Ledford L, Rosier P, Tyner T, Walker J, Hope AA. What the American Journal of Critical Care Junior Peer Reviewers Were Reading During Year 2 of the Program. Am J Crit Care 2022; 31:425-430. [PMID: 36045036 DOI: 10.4037/ajcc2022628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
The American Journal of Critical Care's Junior Peer Reviewer program aims to mentor novice reviewers in the peer review process. To grow their critical appraisal skills, the participants take part in discussion sessions in which they review articles published in other journals. Here we summarize the articles reviewed during the second year of the program, which again focused on the care of critically ill patients with COVID-19. This article aims to share these reviews and the reviewers' thoughts regarding the relevance, design, and applicability of the findings from the selected studies. High rates of delirium associated with COVID-19 may be impacted by optimizing sedation strategies and allowing safe family visitation. Current methodology in crisis standards of care may result in inequity and further research is needed. The use of extracorporeal carbon dioxide removal to facilitate super low tidal volume ventilation does not improve 90-day mortality outcomes. Continued research to better understand the natural history of COVID-19 and interventions useful for improving outcomes is imperative.
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Affiliation(s)
- L Douglas Smith
- L. Douglas Smith Jr is a critical care nurse practitioner with ICC Healthcare at HCA TriStar Centennial Medical Center and an instructor of nursing at Vanderbilt University School of Nursing, Nashville, Tennessee
| | - Thomas Alne
- Thomas Alne is a nurse practitioner with the Mechanical Circulatory Support Program at the Hospital of the University of Pennsylvania, Philadelphia
| | - Heather Briere
- Heather Briere is a nurse practitioner and nurse educator at the Tan Chingfen Graduate School of Nursing at the UMass Chan Medical School, Worcester, Massachusetts
| | - Angelica Hernandez
- Angelica Hernandez is an assistant professor at Advent Health University, Orlando, Florida
| | - Regi Freeman
- Regi Freeman is a cardiovascular intensive care unit clinical nurse specialist at University of Michigan Health and a clinical adjunct faculty member at the University of Michigan School of Nursing, Ann Arbor
| | - Katie Gabel
- Katie Gabel is a virtual lecturer at the Fort Hays State University Department of Nursing, Hays, Kansas, and a nurse educator at Ascension St John Medical Center, Tulsa, Oklahoma
| | - Jennifer Berube
- Jennifer Berube is an assistant professor at the College of Health Professions, Trine University, Fort Wayne, Indiana
| | - Christian Justin Carreon
- Christian Justin Carreon is a staff nurse in the intensive care unit/critical care unit and cardiovascular intensive care unit, Kaiser Permanente, San Francisco, California
| | - Kelly S Grimshaw
- Kelly S. Grimshaw is a value analysis nurse at Yale New Haven Health, New Haven, Connecticut
| | - Mintie Indar-Maraj
- Mintie Indar-Maraj is a staff nurse in the intensive care unit/critical care unit and telemetry unit, Montefiore Health System, Bronx, New York
| | - Lori Ledford
- Lori Ledford is a flight nurse with Air EMS and adjunct nursing faculty at Estrella Mountain Community College in Phoenix, Arizona
| | - Patricia Rosier
- Patricia Rosier is a surgical clinical nurse specialist at Berkshire Medical Center, Pittsfield, Massachusetts
| | - Tracy Tyner
- Tracy Tyner is a surgical/trauma critical care nurse practitioner, Parkland Health, Dallas, Texas
| | - Janeane Walker
- Janeane Walker is director of educational outcomes, Graduate Medical Education, Northeast Georgia Medical Center, Gainesville
| | - Aluko A Hope
- Aluko A. Hope is an associate professor in the Department of Medicine, Division of Pulmonary, Allergy and Critical Care Medicine, Oregon Health & Science University, Portland
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48
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Imaging the acute respiratory distress syndrome: past, present and future. Intensive Care Med 2022; 48:995-1008. [PMID: 35833958 PMCID: PMC9281340 DOI: 10.1007/s00134-022-06809-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/27/2022] [Indexed: 12/13/2022]
Abstract
In patients with the acute respiratory distress syndrome (ARDS), lung imaging is a fundamental tool in the study of the morphological and mechanistic features of the lungs. Chest computed tomography studies led to major advances in the understanding of ARDS physiology. They allowed the in vivo study of the syndrome's lung features in relation with its impact on respiratory physiology and physiology, but also explored the lungs' response to mechanical ventilation, be it alveolar recruitment or ventilator-induced lung injuries. Coupled with positron emission tomography, morphological findings were put in relation with ventilation, perfusion or acute lung inflammation. Lung imaging has always been central in the care of patients with ARDS, with modern point-of-care tools such as electrical impedance tomography or lung ultrasounds guiding clinical reasoning beyond macro-respiratory mechanics. Finally, artificial intelligence and machine learning now assist imaging post-processing software, which allows real-time analysis of quantitative parameters that describe the syndrome's complexity. This narrative review aims to draw a didactic and comprehensive picture of how modern imaging techniques improved our understanding of the syndrome, and have the potential to help the clinician guide ventilatory treatment and refine patient prognostication.
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Cheng J, Yang J, Ma A, Dong M, Yang J, Wang P, Xue Y, Zhou Y, Kang Y. The Effects of Airway Pressure Release Ventilation on Pulmonary Permeability in Severe Acute Respiratory Distress Syndrome Pig Models. Front Physiol 2022; 13:927507. [PMID: 35936889 PMCID: PMC9354663 DOI: 10.3389/fphys.2022.927507] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: The aim of the study was to compare the effects of APRV and LTV ventilation on pulmonary permeability in severe ARDS.Methods: Mini Bama adult pigs were randomized into the APRV group (n = 5) and LTV group (n = 5). A severe ARDS animal model was induced by the whole lung saline lavage. Pigs were ventilated and monitored continuously for 48 h.Results: Compared with the LTV group, CStat was significantly better (p < 0.05), and the PaO2/FiO2 ratio showed a trend to be higher throughout the period of the experiment in the APRV group. The extravascular lung water index and pulmonary vascular permeability index showed a trend to be lower in the APRV group. APRV also significantly mitigates lung histopathologic injury determined by the lung histopathological injury score (p < 0.05) and gross pathological changes of lung tissues. The protein contents of occludin (p < 0.05), claudin-5 (p < 0.05), E-cadherin (p < 0.05), and VE-cadherin (p < 0.05) in the middle lobe of the right lung were higher in the APRV group than in the LTV group; among them, the contents of occludin (p < 0.05) and E-cadherin (p < 0.05) of the whole lung were higher in the APRV group. Transmission electron microscopy showed that alveolar–capillary barrier damage was more severe in the middle lobe of lungs in the LTV group.Conclusion: In comparison with LTV, APRV could preserve the alveolar–capillary barrier architecture, mitigate lung histopathologic injury, increase the expression of cell junction protein, improve respiratory system compliance, and showed a trend to reduce extravascular lung water and improve oxygenation. These findings indicated that APRV might lead to more profound beneficial effects on the integrity of the alveolar–capillary barrier architecture and on the expression of biomarkers related to pulmonary permeability.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Yan Kang
- *Correspondence: Yongfang Zhou, ; Yan Kang,
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50
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Selickman J, Tawfik P, Crooke PS, Dries DJ, Shelver J, Gattinoni L, Marini JJ. Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP. Crit Care 2022. [PMID: 35791021 DOI: 10.1186/s13054-022-04073-] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND Chest wall loading has been shown to paradoxically improve respiratory system compliance (CRS) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The most likely, albeit unconfirmed, mechanism is relief of end-tidal overdistension in 'baby lungs' of low-capacity. The purpose of this study was to define how small changes of tidal volume (VT) and positive end-expiratory pressure (PEEP) affect CRS (and its associated airway pressures) in patients with ARDS who demonstrate a paradoxical response to chest wall loading. We hypothesized that small reductions of VT or PEEP would alleviate overdistension and favorably affect CRS and conversely, that small increases of VT or PEEP would worsen CRS. METHODS Prospective, multi-center physiologic study of seventeen patients with moderate to severe ARDS who demonstrated paradoxical responses to chest wall loading. All patients received mechanical ventilation in volume control mode and were passively ventilated. Airway pressures were measured before and after decreasing/increasing VT by 1 ml/kg predicted body weight and decreasing/increasing PEEP by 2.5 cmH2O. RESULTS Decreasing either VT or PEEP improved CRS in all patients. Driving pressure (DP) decreased by a mean of 4.9 cmH2O (supine) and by 4.3 cmH2O (prone) after decreasing VT, and by a mean of 2.9 cmH2O (supine) and 2.2 cmH2O (prone) after decreasing PEEP. CRS increased by a mean of 3.1 ml/cmH2O (supine) and by 2.5 ml/cmH2O (prone) after decreasing VT. CRS increased by a mean of 5.2 ml/cmH2O (supine) and 3.6 ml/cmH2O (prone) after decreasing PEEP (P < 0.01 for all). Small increments of either VT or PEEP worsened CRS in the majority of patients. CONCLUSION Patients with a paradoxical response to chest wall loading demonstrate uniform improvement in both DP and CRS following a reduction in either VT or PEEP, findings in keeping with prior evidence suggesting its presence is a sign of end-tidal overdistension. The presence of 'paradox' should prompt re-evaluation of modifiable determinants of end-tidal overdistension, including VT, PEEP, and body position.
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Affiliation(s)
- John Selickman
- Department of Pulmonary and Critical Care Medicine, University of Minnesota School of Medicine, 640 Jackson Street, Mail Stop 11203B, MinneapolisSt. Paul, MN, 55101, USA.
| | - Pierre Tawfik
- Department of Pulmonary and Critical Care Medicine, University of Minnesota School of Medicine, 640 Jackson Street, Mail Stop 11203B, MinneapolisSt. Paul, MN, 55101, USA
| | - Philip S Crooke
- Department of Mathematics, Vanderbilt University, Nashville, TN, USA
| | - David J Dries
- Department of Surgery, Regions Hospital, St Paul, MN, USA
- Department of Surgery, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Jonathan Shelver
- Department of Pulmonary and Critical Care Medicine, Methodist Hospital, St. Louis Park, MN, USA
| | - Luciano Gattinoni
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Göttingen, Germany
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota School of Medicine, 640 Jackson Street, Mail Stop 11203B, MinneapolisSt. Paul, MN, 55101, USA
- Department of Critical Care Medicine, Regions Hospital, St. Paul, MN, USA
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