451
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Mauri T, Lazzeri M, Bellani G, Zanella A, Grasselli G. Respiratory mechanics to understand ARDS and guide mechanical ventilation. Physiol Meas 2017; 38:R280-H303. [PMID: 28967868 DOI: 10.1088/1361-6579/aa9052] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE As precision medicine is becoming a standard of care in selecting tailored rather than average treatments, physiological measurements might represent the first step in applying personalized therapy in the intensive care unit (ICU). A systematic assessment of respiratory mechanics in patients with the acute respiratory distress syndrome (ARDS) could represent a step in this direction, for two main reasons. Approach and Main results: On the one hand, respiratory mechanics are a powerful physiological method to understand the severity of this syndrome in each single patient. Decreased respiratory system compliance, for example, is associated with low end expiratory lung volume and more severe lung injury. On the other hand, respiratory mechanics might guide protective mechanical ventilation settings. Improved gravitationally dependent regional lung compliance could support the selection of positive end-expiratory pressure and maximize alveolar recruitment. Moreover, the association between driving airway pressure and mortality in ARDS patients potentially underlines the importance of sizing tidal volume on respiratory system compliance rather than on predicted body weight. SIGNIFICANCE The present review article aims to describe the main alterations of respiratory mechanics in ARDS as a potent bedside tool to understand severity and guide mechanical ventilation settings, thus representing a readily available clinical resource for ICU physicians.
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Affiliation(s)
- Tommaso Mauri
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy. Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milan, Italy
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452
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McDermott B, McGinley B, Krukiewicz K, Divilly B, Jones M, Biggs M, O’Halloran M, Porter E. Stable tissue-mimicking materials and an anatomically realistic, adjustable head phantom for electrical impedance tomography. Biomed Phys Eng Express 2017. [DOI: 10.1088/2057-1976/aa922d] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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453
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Shyamsundar M, Bos LDJ, Scala R. Abstracts from the European Respiratory Society Annual Conference 2017 on respiratory critical care. J Thorac Dis 2017; 9:S1537-S1540. [PMID: 29255635 PMCID: PMC5717354 DOI: 10.21037/jtd.2017.11.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 09/09/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Murali Shyamsundar
- School of Medicine, Dentistry and Biomedical Sciences, Centre for Experimental Medicine, Institute for Health Sciences, Belfast, UK
| | - Lieuwe D. J. Bos
- Department of Intensive Care, Emergency Medicine, Infectious Diseases, Respiratory Medicine, University of Amsterdam, Amsterdam, Netherlands
| | - Raffaele Scala
- Respiratory Division with Pulmonary Intensive Care Unit, S. Donato Hospital, AUSL 8 Arr., Arrezzo, Italy
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454
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455
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Radermacher P, Maggiore SM, Mercat A. FiftyYears ofResearch inARDS.Gas Exchange in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017; 196:964-984. [DOI: 10.1164/rccm.201610-2156so] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Peter Radermacher
- Institute of Anaesthesiological Pathophysiology and Process Engineering, University Medical School, Ulm, Germany
| | - Salvatore Maurizio Maggiore
- Section of Anesthesia, Analgesia, Perioperative, and Intensive Care, Department of Medical, Oral, and Biotechnological Sciences, School of Medicine and Health Sciences, “SS. Annunziata” Hospital, “Gabriele d’Annunzio” University of Chieti-Pescara, Chieti, Italy; and
| | - Alain Mercat
- Department of Medical Intensive Care and Hyperbaric Medicine, Angers University Hospital, Angers, France
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456
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Schullcke B, Krueger-Ziolek S, Gong B, Jörres RA, Mueller-Lisse U, Moeller K. Ventilation inhomogeneity in obstructive lung diseases measured by electrical impedance tomography: a simulation study. J Clin Monit Comput 2017; 32:753-761. [PMID: 29019006 DOI: 10.1007/s10877-017-0069-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 09/23/2017] [Indexed: 12/01/2022]
Abstract
Electrical impedance tomography (EIT) has mostly been used in the Intensive Care Unit (ICU) to monitor ventilation distribution but is also promising for the diagnosis in spontaneously breathing patients with obstructive lung diseases. Beside tomographic images, several numerical measures have been proposed to quantitatively assess the lung state. In this study two common measures, the 'Global Inhomogeneity Index' and the 'Coefficient of Variation' were compared regarding their capability to reflect the severity of lung obstruction. A three-dimensional simulation model was used to simulate obstructed lungs, whereby images were reconstructed on a two-dimensional domain. Simulations revealed that minor obstructions are not adequately recognized in the reconstructed images and that obstruction above and below the electrode plane may result in misleading values of inhomogeneity measures. EIT measurements on several electrode planes are necessary to apply these measures in patients with obstructive lung diseases in a promising manner.
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Affiliation(s)
- B Schullcke
- Institute of Technical Medicine, Furtwangen University, VS-Schwenningen, Germany. .,Department of Radiology, Ludwig-Maximilians-Universität, Munich, Germany.
| | - S Krueger-Ziolek
- Institute of Technical Medicine, Furtwangen University, VS-Schwenningen, Germany.,Department of Radiology, Ludwig-Maximilians-Universität, Munich, Germany
| | - B Gong
- Institute of Technical Medicine, Furtwangen University, VS-Schwenningen, Germany.,Department of Radiology, Ludwig-Maximilians-Universität, Munich, Germany
| | - R A Jörres
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Ludwig-Maximilians-Universität, Munich, Germany
| | - U Mueller-Lisse
- Department of Radiology, Ludwig-Maximilians-Universität, Munich, Germany
| | - K Moeller
- Institute of Technical Medicine, Furtwangen University, VS-Schwenningen, Germany
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457
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McCall KE, Waldmann AD, Pereira-Fantini P, Oakley R, Miedema M, Perkins EJ, Davis PG, Dargaville PA, Böhm SH, Dellacà R, Sourial M, Zannin E, Rajapaksa AE, Tan A, Adler A, Frerichs I, Tingay DG. Time to lung aeration during a sustained inflation at birth is influenced by gestation in lambs. Pediatr Res 2017; 82:712-720. [PMID: 28604757 DOI: 10.1038/pr.2017.141] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 05/20/2017] [Indexed: 11/10/2022]
Abstract
BackgroundCurrent sustained lung inflation (SI) approaches use uniform pressures and durations. We hypothesized that gestational-age-related mechanical and developmental differences would affect the time required to achieve optimal lung aeration, and resultant lung volumes, during SI delivery at birth in lambs.Methods49 lambs, in five cohorts between 118 and 139 days of gestation (term 142 d), received a standardized 40 cmH2O SI, which was delivered until 10 s after lung volume stability (optimal aeration) was visualized on real-time electrical impedance tomography (EIT), or to a maximum duration of 180 s. Time to stable lung aeration (Tstable) within the whole lung, gravity-dependent, and non-gravity-dependent regions, was determined from EIT recordings.ResultsTstable was inversely related to gestation (P<0.0001, Kruskal-Wallis test), with the median (range) being 229 (85,306) s and 72 (50,162) s in the 118-d and 139-d cohorts, respectively. Lung volume at Tstable increased with gestation from a mean (SD) of 20 (17) ml/kg at 118 d to 56 (13) ml/kg at 139 d (P=0.002, one-way ANOVA). There were no gravity-dependent regional differences in Tstable or aeration.ConclusionsThe trajectory of aeration during an SI at birth is influenced by gestational age in lambs. An understanding of this may assist in developing SI protocols that optimize lung aeration for all infants.
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Affiliation(s)
- Karen E McCall
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | | | - Prue Pereira-Fantini
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Regina Oakley
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Martijn Miedema
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Elizabeth J Perkins
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Peter G Davis
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Neonatal Research, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter A Dargaville
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia.,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | | | - Raffaele Dellacà
- TBM Lab, Dipartimento di Elettronica, Informazione e Ingegneria Biomedica-DEIB, Politecnico di Milano University, Milano, Italy
| | - Magdy Sourial
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Emanuela Zannin
- TBM Lab, Dipartimento di Elettronica, Informazione e Ingegneria Biomedica-DEIB, Politecnico di Milano University, Milano, Italy
| | - Anushi E Rajapaksa
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Andre Tan
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
| | - Andy Adler
- Department of Systems and Computer Engineering, Carleton University, Ottawa, Ontario, Canada
| | - Inéz Frerichs
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - David G Tingay
- Neonatal Research, Murdoch Childrens Research Institute, Parkville, Victoria, Australia.,Neonatal Research, The Royal Women's Hospital, Parkville, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neonatology, The Royal Children's Hospital, Parkville, Victoria, Australia
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458
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Zhao Z, Peng SY, Chang MY, Hsu YL, Frerichs I, Chang HT, Möller K. Spontaneous breathing trials after prolonged mechanical ventilation monitored by electrical impedance tomography: an observational study. Acta Anaesthesiol Scand 2017; 61:1166-1175. [PMID: 28832898 DOI: 10.1111/aas.12959] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 07/12/2017] [Accepted: 07/18/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND The study objective was to examine the correlation between regional ventilation distribution measured with electrical impedance tomography (EIT) and weaning outcomes during spontaneous breathing trial (SBT). METHODS Fifteen patients received 100% automatic tube compensation (ATC) during the first and 70% during the second hour. Another 15 patients received external continuous positive airway pressure (CPAP) of 5 and 7.5 cmH2 O during the first and second hours, respectively. Regional ventilation distributions were monitored with EIT. RESULTS Tidal volume and tidal variation of impedance correlated significantly during assist-control ventilation and ATC in all patients (r2 = 0.80 ± 0.18, P < 0.001). Higher support levels resulted in similar ventilation distribution and tidal volume, but higher end-expiratory lung impedance (EELI) (P < 0.05). Analysis of regional intratidal gas distribution revealed a redistribution of ventilation towards dorsal regions with lower support level in 13 of 30 patients. These patients had a higher weaning success rate (only 1 of 13 patients failed). Eight of 17 other patient failed (P < 0.05). The number of SBT days needed for weaning was significantly lower in the former group of 13 patients (13.1 ± 4.0 vs. 20.9 ± 11.2 days, P < 0.05). CONCLUSIONS Regional ventilation distribution patterns during inspiration were associated with weaning outcomes, and they may be used to predict the success of extubation.
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Affiliation(s)
- Z. Zhao
- Institute of Technical Medicine; Furtwangen University; Villingen-Schwenningen Germany
- Department of Biomedical Engineering; Fourth Military Medical University; Xi'an China
| | - S.-Y. Peng
- Division of Pulmonary Medicine; Department of Internal Medicine; Far Eastern Memorial Hospital; New Taipei City Taiwan
| | - M.-Y. Chang
- Division of Pulmonary Medicine; Department of Internal Medicine; Far Eastern Memorial Hospital; New Taipei City Taiwan
| | - Y.-L. Hsu
- Division of Pulmonary Medicine; Department of Internal Medicine; Far Eastern Memorial Hospital; New Taipei City Taiwan
| | - I. Frerichs
- Department of Anesthesiology and Intensive Care Medicine; University Medical Center of Schleswig-Holstein Campus Kiel; Kiel Germany
| | - H.-T. Chang
- Medical Intensive Care Unit; Department of Critical Care Medicine; Far Eastern Memorial Hospital; New Taipei City Taiwan
| | - K. Möller
- Institute of Technical Medicine; Furtwangen University; Villingen-Schwenningen Germany
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459
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Franchineau G, Bréchot N, Lebreton G, Hekimian G, Nieszkowska A, Trouillet JL, Leprince P, Chastre J, Luyt CE, Combes A, Schmidt M. Bedside Contribution of Electrical Impedance Tomography to Setting Positive End-Expiratory Pressure for Extracorporeal Membrane Oxygenation–treated Patients with Severe Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017; 196:447-457. [DOI: 10.1164/rccm.201605-1055oc] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Guillaume Franchineau
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
| | - Nicolas Bréchot
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
| | - Guillaume Lebreton
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Cardiac Surgery Department, Assistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière Hospital, Paris, France
| | - Guillaume Hekimian
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
| | - Ania Nieszkowska
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
| | - Jean-Louis Trouillet
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
| | - Pascal Leprince
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Cardiac Surgery Department, Assistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière Hospital, Paris, France
| | - Jean Chastre
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
| | - Charles-Edouard Luyt
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
| | - Alain Combes
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
| | - Matthieu Schmidt
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
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460
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Bhatia R, Davis PG, Tingay DG. Regional Volume Characteristics of the Preterm Infant Receiving First Intention Continuous Positive Airway Pressure. J Pediatr 2017; 187:80-88.e2. [PMID: 28545875 DOI: 10.1016/j.jpeds.2017.04.046] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 03/27/2017] [Accepted: 04/21/2017] [Indexed: 01/19/2023]
Abstract
OBJECTIVE To determine whether applying nasal continuous positive airway pressure (CPAP) using systematic changes in continuous distending pressure (CDP) results in a quasi-static pressure-volume relationship in very preterm infants receiving first intention CPAP in the first 12-18 hours of life. STUDY DESIGN Twenty infants at <32 weeks' gestation with mild respiratory distress syndrome (RDS) managed exclusively with nasal CPAP had CDP increased from 5 to 8 to 10 cmH2O, and then decreased to 8 cmH2O and returned to baseline CDP. Each CDP was maintained for 20 min. At each CDP, relative impedance change in end-expiratory thoracic volume (ΔZEEV) and tidal volume (ΔZVT) were measured using electrical impedance tomography. Esophageal pressure (Poes) was measured as a proxy for intrapleural pressure to determine transpulmonary pressure (Ptp). RESULTS Overall, there was a relationship between Ptp and global ΔZEEV representing the pressure-volume relationship in the lungs. There were regional variations in ΔZEEV, with 13 infants exhibiting hysteresis with the greatest gains in EEV and tidal volume in the dependent lung with no hemodynamic compromise. Seven infants did not demonstrate hysteresis during decremental CDP changes. CONCLUSION It was possible to define a pressure-volume relationship of the lung and demonstrate reversal of atelectasis by systematically manipulating CDP in most very preterm infants with mild RDS. This suggests that CDP manipulation can be used to optimize the volume state of the preterm lung.
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Affiliation(s)
- Risha Bhatia
- Newborn Research, The Royal Women's Hospital, Melbourne, Australia; Neonatal Research, Murdoch Childrens Research Institute, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; Monash Newborn, Monash Children's Hospital, Melbourne, Australia.
| | - Peter G Davis
- Newborn Research, The Royal Women's Hospital, Melbourne, Australia; Neonatal Research, Murdoch Childrens Research Institute, Melbourne, Australia; The University of Melbourne, Melbourne, Australia
| | - David G Tingay
- Newborn Research, The Royal Women's Hospital, Melbourne, Australia; Neonatal Research, Murdoch Childrens Research Institute, Melbourne, Australia; The University of Melbourne, Melbourne, Australia; Department of Neonatology, The Royal Children's Hospital, Melbourne, Australia
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461
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Santos SA, Wembers CC, Horst K, Pfeifer R, Simon TP, Pape HC, Hildebrand F, Czaplik M, Leonhardt S, Teichmann D. Monitoring lung contusion in a porcine polytrauma model using EIT: an application study. Physiol Meas 2017. [DOI: 10.1088/1361-6579/aa7985] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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462
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Eronia N, Mauri T, Maffezzini E, Gatti S, Bronco A, Alban L, Binda F, Sasso T, Marenghi C, Grasselli G, Foti G, Pesenti A, Bellani G. Bedside selection of positive end-expiratory pressure by electrical impedance tomography in hypoxemic patients: a feasibility study. Ann Intensive Care 2017; 7:76. [PMID: 28730554 PMCID: PMC5519511 DOI: 10.1186/s13613-017-0299-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/06/2017] [Indexed: 01/28/2023] Open
Abstract
Background Positive end-expiratory pressure (PEEP) is a key element of mechanical ventilation. It should optimize recruitment, without causing excessive overdistension, but controversy exists on the best method to set it. The purpose of the study was to test the feasibility of setting PEEP with electrical impedance tomography in order to prevent lung de-recruitment following a recruitment maneuver. We enrolled 16 patients undergoing mechanical ventilation with PaO2/FiO2 <300 mmHg. In all patients, under constant tidal volume (6–8 ml/kg) PEEP was set based on the PEEP/FiO2 table proposed by the ARDS network (PEEPARDSnet). We performed a recruitment maneuver and monitored the end-expiratory lung impedance (EELI) over 10 min. If the EELI signal decreased during this period, the recruitment maneuver was repeated and PEEP increased by 2 cmH2O. This procedure was repeated until the EELI maintained a stability over time (PEEPEIT). Results The procedure was feasible in 87% patients. PEEPEIT was higher than PEEPARDSnet (13 ± 3 vs. 9 ± 2 cmH2O, p < 0.001). PaO2/FiO2 improved during PEEPEIT and driving pressure decreased. Recruited volume correlated with the decrease in driving pressure but not with oxygenation improvement. Finally, regional alveolar hyperdistention and collapse was reduced in dependent lung layers and increased in non-dependent lung layers. Conclusions In hypoxemic patients, a PEEP selection strategy aimed at stabilizing alveolar recruitment guided by EIT at the bedside was feasible and safe. This strategy led, in comparison with the ARDSnet table, to higher PEEP, improved oxygenation and reduced driving pressure, allowing to estimate the relative weight of overdistension and recruitment. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0299-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nilde Eronia
- Department of Emergency and Intensive Care, San Gerardo Hospital, Via Pergolesi 33, Monza, Italy
| | - Tommaso Mauri
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 7, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 28, Milan, Italy
| | - Elisabetta Maffezzini
- Department of Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, Italy
| | - Stefano Gatti
- Department of Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, Italy
| | - Alfio Bronco
- Department of Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, Italy
| | - Laura Alban
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 7, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 28, Milan, Italy
| | - Filippo Binda
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 28, Milan, Italy
| | - Tommaso Sasso
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 7, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 28, Milan, Italy
| | - Cristina Marenghi
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 28, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 28, Milan, Italy
| | - Giuseppe Foti
- Department of Emergency and Intensive Care, San Gerardo Hospital, Via Pergolesi 33, Monza, Italy.,Department of Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, Italy
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 7, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Francesco Sforza 28, Milan, Italy
| | - Giacomo Bellani
- Department of Emergency and Intensive Care, San Gerardo Hospital, Via Pergolesi 33, Monza, Italy. .,Department of Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, Italy.
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463
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Dmytrowich J, Holt T, Schmid K, Hansen G. Mechanical ventilation guided by electrical impedance tomography in pediatric acute respiratory distress syndrome. J Clin Monit Comput 2017; 32:503-507. [DOI: 10.1007/s10877-017-0048-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 07/18/2017] [Indexed: 11/24/2022]
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464
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Bickenbach J, Czaplik M, Polier M, Marx G, Marx N, Dreher M. Electrical impedance tomography for predicting failure of spontaneous breathing trials in patients with prolonged weaning. Crit Care 2017; 21:177. [PMID: 28697778 PMCID: PMC5506613 DOI: 10.1186/s13054-017-1758-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 06/19/2017] [Indexed: 11/23/2022] Open
Abstract
Background Spontaneous breathing trials (SBTs) on a T-piece can be difficult in patients with prolonged weaning because of remaining de-recruitment phenomena and/or insufficient ventilation. There is no clinically established method existent other than experience for estimating whether an SBT is most probably beneficial. Electrical impedance tomography (EIT) is a clinical useful online monitoring technique during mechanical ventilation, particularly because it enables analysis of effects of regional ventilation distribution. The aim of our observational study was to examine if EIT can predict whether patients with prolonged weaning will benefit from a planned SBT. Methods Thirty-one patients were examined. Blood gas analysis, vital parameter measurements, and EIT recordings were performed at three time points: (1) baseline with pressure support ventilation (PSV) (t0), (2) during a T-piece trial (t1), and (3) after resumption of PSV (t2). Calculation of EIT parameters was performed, including the impedance ratio (IR), the tidal variation of impedance (TIV), the changes in end-expiratory lung impedance (ΔEELI), the global inhomogeneity index (GI), and the regional ventilation delay (RVD) index with use of different thresholds of the percentage inspiration time (RVD40, RVD60, RVD80). The predictive power of the baseline GI with regard to clinical impairment of an SBT was analyzed by means of ROC curves. Clinical deterioration was assumed when tidal volume was decreased by at least 20 ml after the T-piece trial, measured at t2. Results Partial pressure of arterial oxygen significantly decreased at t1 (71 ± 15 mmHg) compared with t0 (85 ± 17 mmHg, p < 0.05) and t2 (82 ± 18 mmHg, p < 0.05). The IR trended toward higher values during t1. At t1, TIV and ΔEELI significantly decreased. The GI was significantly increased at t1 (t0 59.3 ± 46.1 vs t1 81.5 ± 62.5, p = 0.001), as were all RVD indexes. Assuming a GI cutoff value of >40, sensitivity of 85% and specificity of 50% were reached for predicting an increased future tidal volume. Conclusions EIT enables monitoring of regional ventilation distribution during SBTs and is suitable to estimate whether an SBT probably will be beneficial for an individual patient. Therefore, the application of EIT can support clinical decisions regarding patients in the phase of prolonged weaning.
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Affiliation(s)
- Johannes Bickenbach
- Department of Intensive Care Medicine, University Hospital of the RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Michael Czaplik
- Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Mareike Polier
- Department of Intensive Care Medicine, University Hospital of the RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Gernot Marx
- Department of Intensive Care Medicine, University Hospital of the RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Nikolaus Marx
- Department of Cardiology, Pneumology, Angiology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Dreher
- Department of Cardiology, Pneumology, Angiology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
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465
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Regional ventilation distribution and dead space in anaesthetized horses treated with and without continuous positive airway pressure: novel insights by electrical impedance tomography and volumetric capnography. Vet Anaesth Analg 2017; 45:31-40. [PMID: 29222030 DOI: 10.1016/j.vaa.2017.06.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/11/2017] [Accepted: 06/15/2017] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the effect of continuous positive airway pressure (CPAP) on regional distribution of ventilation and dead space in anaesthetized horses. STUDY DESIGN Randomized, experimental, crossover study. ANIMALS A total of eight healthy adult horses. METHODS Horses were anaesthetized twice with isoflurane in 50% oxygen and medetomidine as continuous infusion in dorsal recumbency, and administered in random order either CPAP (8 cmH2O) or NO CPAP for 3 hours. Electrical impedance tomography (and volumetric capnography (VCap) measurements were performed every 30 minutes. Lung regions with little ventilation [dependent silent spaces (DSSs) and nondependent silent spaces (NSSs)], centre of ventilation (CoV) and dead space variables, as well as venous admixture were calculated. Statistical analysis was performed using multivariate analysis of variance and Pearson correlation. RESULTS Data from six horses were statistically analysed. In CPAP, the CoV shifted to dependent parts of the lungs (p < 0.001) and DSSs were significantly smaller (p < 0.001), while no difference was seen in NSSs. Venous admixture was significantly correlated with DSS with the treatment time taken as covariate (p < 0.0001; r = 0.65). No differences were found for any VCap parameters. CONCLUSIONS AND CLINICAL RELEVANCE In dorsally recumbent anaesthetized horses, CPAP of 8 cmH2O results in redistribution of ventilation towards the dependent lung regions, thereby improving ventilation-perfusion matching. This improvement was not associated with an increase in dead space indicative for a lack in distension of the airways or impairment of alveolar perfusion.
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466
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Mosing M, Sacks M, Tahas SA, Ranninger E, Böhm SH, Campagnia I, Waldmann AD. Ventilatory incidents monitored by electrical impedance tomography in an anaesthetized orangutan ( Pongo abelii ). Vet Anaesth Analg 2017; 44:973-976. [DOI: 10.1016/j.vaa.2016.12.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Revised: 12/13/2016] [Accepted: 12/15/2016] [Indexed: 11/17/2022]
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467
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Larsson A, Guerin C. Monitoring of lung function in acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:284. [PMID: 28828359 DOI: 10.21037/atm.2017.06.56] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Monitoring of lung function is essential to assess changes in the lung condition, and to correct and improve ventilator and adjuvant therapies in acute respiratory distress syndrome (ARDS). In this review we discuss the use of monitoring of gas exchange, lung mechanics and shortly on lung imaging in this condition.
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Affiliation(s)
- Anders Larsson
- Hedenstierna laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Claude Guerin
- Réanimation Médicale, Hôpital de la Croix Rousse, Lyon, France
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468
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Hochhausen N, Dohmeier H, Rossaint R, Czaplik M. Monitoring of cardiac output and lung ventilation by Electrical Impedance Tomography in a porcine model of acute lung injury. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2017:352-355. [PMID: 29059883 DOI: 10.1109/embc.2017.8036835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Adequate medical treatment of the Acute Respiratory Distress Syndrome is still challenging since patient-individual aspects have to be taken into account. Lung protective ventilation and hemodynamic stability have always been two of the most crucial aims of intensive care therapy. For both aspects, a continuous - preferably non-invasive - monitoring is desirable that is available at the bedside. Unfortunately, there is no technique clinically established yet, that provides both measurement of cardiac stroke volume and ventilation dynamics in real-time. Electrical Impedance Tomography (EIT) is a promising technique to close this gap. The aim of the study was to investigate if stroke volume can be estimated by a self-developed software using EIT-based image analysis. In addition, two EIT-derived parameters, namely Global Inhomogeneity Index (GII) and Impedance Ratio (IR), were calculated to evaluate homogeneity of air distribution. Experimental acute lung injury (ALI) was provoked in seven female pigs (German Landrace) by lipopolysaccharide (LPS). All animals suffered from experimental ALI 3 to 4 hours after LPS infusion. At defined time points, respiratory and hemodynamic parameters, blood gas analyses and EIT-recordings were performed. Eight hours after ALI, animals were euthanized. Stroke volume, derived from pulmonary artery catheter (PAC), decreased continuously up to four hours after ALI. Then, stroke volume increased slightly. Stroke volume, derived from the self-developed tool, showed the same characteristics (p=0.047, r = 0.365). In addition to the GII and IR individually, both classified scores showed a high correlation with the Horowitz Index, defined as paO2/FiO2. To conclude, EIT-derived measures enabled a reliable estimation of cardiac stroke volume and regional distribution of ventilation.
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469
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Hsu YL, Tien AJ, Chang MY, Chang HT, Möller K, Frerichs I, Zhao Z. Regional ventilation redistribution measured by electrical impedance tomography during spontaneous breathing trial with automatic tube compensation. Physiol Meas 2017; 38:1193-1203. [DOI: 10.1088/1361-6579/aa66fd] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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470
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Prone Positioning Improves Ventilation Homogeneity in Children With Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2017; 18:e229-e234. [PMID: 28328787 DOI: 10.1097/pcc.0000000000001145] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To determine the effect of prone positioning on ventilation distribution in children with acute respiratory distress syndrome. DESIGN Prospective observational study. SETTING Paediatric Intensive Care at Red Cross War Memorial Children's Hospital, Cape Town, South Africa. PATIENTS Mechanically ventilated children with acute respiratory distress syndrome. INTERVENTIONS Electrical impedance tomography measures were taken in the supine position, after which the child was turned into the prone position, and subsequent electrical impedance tomography measurements were taken. MEASUREMENTS AND MAIN RESULTS Thoracic electrical impedance tomography measures were taken at baseline and after 5, 20, and 60 minutes in the prone position. The proportion of ventilation, regional filling characteristics, and global inhomogeneity index were calculated for the ventral and dorsal lung regions. Arterial blood gas measurements were taken before and after the intervention. A responder was defined as having an improvement of more than 10% in the oxygenation index after 60 minutes in prone position. Twelve children (nine male, 65%) were studied. Four children were responders, three were nonresponders, and five showed no change to prone positioning. Ventilation in ventral and dorsal lung regions was no different in the supine or prone positions between response groups. The proportion of ventilation in the dorsal lung increased from 49% to 57% in responders, while it became more equal between ventral and dorsal lung regions in the prone position in nonresponders. Responders showed greater improvements in ventilation homogeneity with R improving from 0.86 ± 0.24 to 0.98 ± 0.02 in the ventral lung and 0.91 ± 0.15 to 0.99 ± 0.01 in the dorsal lung region with time in the prone position. CONCLUSIONS The response to prone position was variable in children with acute respiratory distress syndrome. Prone positioning improves homogeneity of ventilation and may result in recruitment of the dorsal lung regions.
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471
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Ventilation distribution and lung recruitment with speaking valve use in tracheostomised patient weaning from mechanical ventilation in intensive care. J Crit Care 2017; 40:164-170. [PMID: 28411422 DOI: 10.1016/j.jcrc.2017.04.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/21/2017] [Accepted: 04/05/2017] [Indexed: 11/20/2022]
Abstract
PURPOSE Speaking valves (SV) are used infrequently in tracheostomised ICU patients due to concerns regarding their putative effect on lung recruitment. A recent study in cardio-thoracic population demonstrated increased end-expiratory lung volumes during and post SV use without examining if the increase in end-expiratory lung impedance (EELI) resulted in alveolar recruitment or potential hyperinflation in discrete loci. MATERIALS AND METHODS A secondary analysis of Electrical Impedance Tomography (EIT) data from a previous study was conducted. EELI distribution and tidal variation (TV) were assessed with a previously validated tool. A new tool was used to investigate ventilated surface area (VSA) and regional ventilation delay (RVD) as indicators of alveolar recruitment. RESULTS The increase in EELI was found to be uniform with significant increase across all lung sections (p<0.001). TV showed an initial non-significant decrease (p=0.94) with subsequent increase significantly above baseline (p<0.001). VSA and RVD showed non-significant changes during and post SV use. CONCLUSIONS These findings indicate that hyperinflation did not occur with SV use, which is supported by previously published data on respiratory parameters. These data along with obvious psychological benefits to patients are encouraging towards safe use of SVs in this critically ill cardio-thoracic patient population. TRIAL REGISTRATION Anna-Liisa Sutt, Australian New Zealand Clinical Trials Registry (ANZCTR). ACTRN ACTRN12615000589583. 4/6/2015.
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472
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Roth CJ, Becher T, Frerichs I, Weiler N, Wall WA. Coupling of EIT with computational lung modeling for predicting patient-specific ventilatory responses. J Appl Physiol (1985) 2017; 122:855-867. [DOI: 10.1152/japplphysiol.00236.2016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 12/06/2016] [Accepted: 12/06/2016] [Indexed: 12/19/2022] Open
Abstract
Providing optimal personalized mechanical ventilation for patients with acute or chronic respiratory failure is still a challenge within a clinical setting for each case anew. In this article, we integrate electrical impedance tomography (EIT) monitoring into a powerful patient-specific computational lung model to create an approach for personalizing protective ventilatory treatment. The underlying computational lung model is based on a single computed tomography scan and able to predict global airflow quantities, as well as local tissue aeration and strains for any ventilation maneuver. For validation, a novel “virtual EIT” module is added to our computational lung model, allowing to simulate EIT images based on the patient's thorax geometry and the results of our numerically predicted tissue aeration. Clinically measured EIT images are not used to calibrate the computational model. Thus they provide an independent method to validate the computational predictions at high temporal resolution. The performance of this coupling approach has been tested in an example patient with acute respiratory distress syndrome. The method shows good agreement between computationally predicted and clinically measured airflow data and EIT images. These results imply that the proposed framework can be used for numerical prediction of patient-specific responses to certain therapeutic measures before applying them to an actual patient. In the long run, definition of patient-specific optimal ventilation protocols might be assisted by computational modeling. NEW & NOTEWORTHY In this work, we present a patient-specific computational lung model that is able to predict global and local ventilatory quantities for a given patient and any selected ventilation protocol. For the first time, such a predictive lung model is equipped with a virtual electrical impedance tomography module allowing real-time validation of the computed results with the patient measurements. First promising results obtained in an acute respiratory distress syndrome patient show the potential of this approach for personalized computationally guided optimization of mechanical ventilation in future.
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Affiliation(s)
- Christian J. Roth
- Institute for Computational Mechanics, Technical University of Munich, Munich, Germany; and
| | - Tobias Becher
- Department of Anesthesiology and Intensive Care Medicine, Christian Albrechts University, Kiel, Germany
| | - Inéz Frerichs
- Department of Anesthesiology and Intensive Care Medicine, Christian Albrechts University, Kiel, Germany
| | - Norbert Weiler
- Department of Anesthesiology and Intensive Care Medicine, Christian Albrechts University, Kiel, Germany
| | - Wolfgang A. Wall
- Institute for Computational Mechanics, Technical University of Munich, Munich, Germany; and
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473
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Becher T, Rostalski P, Kott M, Adler A, Schädler D, Weiler N, Frerichs I. Global and regional assessment of sustained inflation pressure-volume curves in patients with acute respiratory distress syndrome. Physiol Meas 2017; 38:1132-1144. [PMID: 28339394 DOI: 10.1088/1361-6579/aa6923] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE Static or quasi-static pressure-volume (P-V ) curves can be used to determine the lung mechanical properties of patients suffering from acute respiratory distress syndrome (ARDS). According to the traditional interpretation, lung recruitment occurs mainly below the lower point of maximum curvature (LPMC) of the inflation P-V curve. Although some studies have questioned this assumption, setting of positive end-expiratory pressure 2 cmH2O above the LPMC was part of a 'lung-protective' ventilation strategy successfully applied in several clinical trials. The aim of our study was to quantify the amount of unrecruited lung at different clinically relevant points of the P-V curve. APPROACH P-V curves and electrical impedance tomography (EIT) data from 30 ARDS patients were analysed. We determined the regional opening pressures for every EIT image pixel and fitted the global P-V curves to five sigmoid model equations to determine the LPMC, inflection point (IP) and upper point of maximal curvature (UPMC). Points of maximal curvature and IP were compared between the models by one-way analysis of variance (ANOVA). The percentages of lung pixels remaining closed ('unrecruited lung') at LPMC, IP and UPMC were calculated from the number of lung pixels exhibiting regional opening pressures higher than LPMC, IP and UPMC and were also compared by one-way ANOVA. MAIN RESULTS As results, we found a high variability of LPMC values among the models, a smaller variability of IP and UPMC values. We found a high percentage of unrecruited lung at LPMC, a small percentage of unrecruited lung at IP and no unrecruited lung at UPMC. SIGNIFICANCE Our results confirm the notion of ongoing lung recruitment at pressure levels above LPMC for all investigated model equations and highlight the importance of a regional assessment of lung recruitment in patients with ARDS.
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Affiliation(s)
- T Becher
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Campus Kiel, Kiel, Germany
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474
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Braun F, Proenca M, Sola J, Thiran JP, Adler A. A Versatile Noise Performance Metric for Electrical Impedance Tomography Algorithms. IEEE Trans Biomed Eng 2017; 64:2321-2330. [PMID: 28141516 DOI: 10.1109/tbme.2017.2659540] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Electrical impedance tomography (EIT) is an emerging technology for real-time monitoring of patients under mechanical ventilation. EIT has the potential to offer continuous medical monitoring while being noninvasive, radiation free, and low cost. Due to their ill-posedness, image reconstruction typically uses regularization, which implies a hyperparameter controlling the tradeoff between noise rejection and resolution or other accuracies. In order to compare reconstruction algorithms, it is common to choose hyperparameter values such that the reconstructed images have equal noise performance (NP), i.e., the amount of measurement noise reflected in the images. For EIT many methods have been suggested, but none work well when the data originate from different measurement setups, such as for different electrode positions or measurement patterns. To address this issue, we propose a new NP metric based on the average signal-to-noise ratio in the image domain. The approach is validated for EIT using simulation experiments on a human thorax model and measurements on a resistor phantom. Results show that the approach is robust to the measurement configuration (i.e., number and position of electrodes, skip pattern) and the reconstruction algorithm used. We propose this novel approach as a way to select optimized measurement configurations and algorithms.
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475
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Tingay DG, Rajapaksa A, Zannin E, Pereira-Fantini PM, Dellaca RL, Perkins EJ, Zonneveld CEE, Adler A, Black D, Frerichs I, Lavizzari A, Sourial M, Grychtol B, Mosca F, Davis PG. Effectiveness of individualized lung recruitment strategies at birth: an experimental study in preterm lambs. Am J Physiol Lung Cell Mol Physiol 2016; 312:L32-L41. [PMID: 27881405 DOI: 10.1152/ajplung.00416.2016] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 11/20/2016] [Indexed: 02/02/2023] Open
Abstract
Respiratory transition at birth involves rapidly clearing fetal lung liquid and preventing efflux back into the lung while aeration is established. We have developed a sustained inflation (SIOPT) individualized to volume response and a dynamic tidal positive end-expiratory pressure (PEEP) (open lung volume, OLV) strategy that both enhance this process. We aimed to compare the effect of each with a group managed with PEEP of 8 cmH2O and no recruitment maneuver (No-RM), on gas exchange, lung mechanics, spatiotemporal aeration, and lung injury in 127 ± 1 day preterm lambs. Forty-eight fetal-instrumented lambs exposed to antenatal steroids were ventilated for 60 min after application of the allocated strategy. Spatiotemporal aeration and lung mechanics were measured with electrical impedance tomography and forced-oscillation, respectively. At study completion, molecular and histological markers of lung injury were analyzed. Mean (SD) aeration at the end of the SIOPT and OLV groups was 32 (22) and 38 (15) ml/kg, compared with 17 (10) ml/kg (180 s) in the No-RM (P = 0.024, 1-way ANOVA). This translated into better oxygenation at 60 min (P = 0.047; 2-way ANOVA) resulting from better distal lung tissue aeration in SIOPT and OLV. There was no difference in lung injury. Neither SIOPT nor OLV achieved homogeneous aeration. Histological injury and mRNA biomarker upregulation were more likely in the regions with better initial aeration, suggesting volutrauma. Tidal ventilation or an SI achieves similar aeration if optimized, suggesting that preventing fluid efflux after lung liquid clearance is at least as important as fluid clearance during the initial inflation at birth.
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Affiliation(s)
- David G Tingay
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia; .,Neonatology, The Royal Children's Hospital, Parkville, Australia.,Neonatal Research, The Royal Women's Hospital, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Anushi Rajapaksa
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Emanuela Zannin
- TBM Laboratory, Dipartimento di Elettronica, Informazione e Ingegneria Biomedica-DEIB, Politecnico di Milano University, Milano, Italy
| | - Prue M Pereira-Fantini
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Raffaele L Dellaca
- TBM Laboratory, Dipartimento di Elettronica, Informazione e Ingegneria Biomedica-DEIB, Politecnico di Milano University, Milano, Italy
| | - Elizabeth J Perkins
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia.,Neonatology, The Royal Children's Hospital, Parkville, Australia
| | | | - Andy Adler
- Systems and Computer Engineering, Carleton University, Ottawa, Canada
| | - Don Black
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia
| | - Inéz Frerichs
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Anna Lavizzari
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia.,NICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico-Università degli Studi di Milano, Milano, Italy
| | - Magdy Sourial
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia
| | - Bartłomiej Grychtol
- Fraunhofer Project Group for Automation in Medicine and Biotechnology, Mannheim, Germany; and
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico-Università degli Studi di Milano, Milano, Italy
| | - Peter G Davis
- Neonatal Research, Murdoch Children's Research Institute, Parkville, Australia.,Neonatal Research, The Royal Women's Hospital, Parkville, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
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