501
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Zhang Z, Spieth PM, Chiumello D, Goyal H, Torres A, Laffey JG, Hong Y. Declining Mortality in Patients With Acute Respiratory Distress Syndrome: An Analysis of the Acute Respiratory Distress Syndrome Network Trials. Crit Care Med 2019; 47:315-323. [PMID: 30779718 DOI: 10.1097/ccm.0000000000003499] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES There has been multiple advances in the management of acute respiratory distress syndrome, but the temporal trends in acute respiratory distress syndrome-related mortality are not well known. This study aimed to investigate the trends in mortality in acute respiratory distress syndrome patients over time and to explore the roles of daily fluid balance and ventilation variables in those patients. DESIGN Secondary analysis of randomized controlled trials conducted by the Acute Respiratory Distress Syndrome Network from 1996 to 2013. SETTING Multicenter study involving Acute Respiratory Distress Syndrome Network trials. PATIENTS Patients with acute respiratory distress syndrome. INTERVENTIONS None. MEASURES AND MAIN RESULTS Individual patient data from 5,159 acute respiratory distress syndrome patients (excluding the Late Steroid Rescue Study trial) were enrolled in this study. The crude mortality rate decreased from 35.4% (95% CI, 29.9-40.8%) in 1996 to 28.3% (95% CI, 22.0-34.7%) in 2013. By adjusting for the baseline Acute Physiology and Chronic Health Evaluation III, age, ICU type, and admission resource, patients enrolled from 2005 to 2010 (odds ratio, 0.61; 95% CI, 0.50-0.74) and those enrolled after 2010 (odds ratio, 0.73; 95% CI, 0.58-0.92) were associated with lower risk of death as compared to those enrolled before 2000. The effect of year on mortality decline disappeared after adjustment for daily fluid balance, positive end-expiratory pressure, tidal volume, and plateau pressure. There were significant trends of declines in daily fluid balance, tidal volume, and plateau pressure and an increase in positive end-expiratory pressure over the 17 years. CONCLUSIONS Our study shows an improvement in the acute respiratory distress syndrome-related mortality rate in the critically ill patients enrolled in the Acute Respiratory Distress Syndrome Network trials. The effect was probably mediated via decreased tidal volume, plateau pressure, and daily fluid balance and increased positive end-expiratory pressure.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Peter Markus Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital Dresden, Technische Universität Dresden, Germany
| | - Davide Chiumello
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy
- Centro ricerca cordinata di insufficienza respiratoria, Università degli Studi di Milan, Italy
| | - Hemant Goyal
- Department of Internal Medicine, Mercer University School of Medicine, Macon, GA
| | - Antoni Torres
- Department of Pneumology, Institut Clinic del Tórax, Hospital Clinic of Barcelona - Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona - SGR 911- Ciber de Enfermedades Respiratorias (Ciberes) Barcelona, Spain
| | - John G Laffey
- Critical Illness and Injury Research Centre, Keenan Research Centre for Biomedical Science of St Michael's Hospital, Toronto, ON, Canada
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
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502
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Ruppert K, Xin Y, Hamedani H, Amzajerdian F, Loza L, Achekzai T, Duncan IF, Profka H, Siddiqui S, Pourfathi M, Sertic F, Cereda MF, Kadlecek S, Rizi RR. Measurement of Regional 2D Gas Transport Efficiency in Rabbit Lung Using Hyperpolarized 129Xe MRI. Sci Rep 2019; 9:2413. [PMID: 30787357 PMCID: PMC6382756 DOI: 10.1038/s41598-019-38942-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 12/11/2018] [Indexed: 01/25/2023] Open
Abstract
While hyperpolarized xenon-129 (HXe) MRI offers a wide array of tools for assessing functional aspects of the lung, existing techniques provide only limited quantitative information about the impact of an observed pathology on overall lung function. By selectively destroying the alveolar HXe gas phase magnetization in a volume of interest and monitoring the subsequent decrease in the signal from xenon dissolved in the blood inside the left ventricle of the heart, it is possible to directly measure the contribution of that saturated lung volume to the gas transport capacity of the entire lung. In mechanically ventilated rabbits, we found that both xenon gas transport and transport efficiency exhibited a gravitation-induced anterior-to-posterior gradient that disappeared or reversed direction, respectively, when the animal was turned from supine to prone position. Further, posterior ventilation defects secondary to acute lung injury could be re-inflated by applying positive end expiratory pressure, although at the expense of decreased gas transport efficiency in the anterior volumes. These findings suggest that our technique might prove highly valuable for evaluating lung transplants and lung resections, and could improve our understanding of optimal mechanical ventilator settings in acute lung injury.
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Affiliation(s)
- Kai Ruppert
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, 19104, USA.,Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Hooman Hamedani
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, 19104, USA.,Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Faraz Amzajerdian
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, 19104, USA.,Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Luis Loza
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Tahmina Achekzai
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Ian F Duncan
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Harrilla Profka
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Sarmad Siddiqui
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, 19104, USA.,Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Mehrdad Pourfathi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, 19104, USA.,Department of Electrical and Systems Engineering, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Federico Sertic
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Maurizio F Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Stephen Kadlecek
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Rahim R Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, 19104, USA.
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503
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Frisvold SK, Robba C, Guérin C. What respiratory targets should be recommended in patients with brain injury and respiratory failure? Intensive Care Med 2019; 45:683-686. [PMID: 30778650 DOI: 10.1007/s00134-019-05556-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 02/02/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Shirin K Frisvold
- Department of Intensive Care Medicine, University Hospital of North Norway, Tromsö, Norway
| | - Chiara Robba
- Anaesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology, Genoa, Italy
| | - Claude Guérin
- Service de Médecine Intensive-Réanimation, Hospices Civils de Lyon, Lyon, France.
- Université de Lyon, Lyon, France.
- INSERM 955, Créteil, France.
- Service de Médecine Intensive Réanimation, Grenoble, France.
- INSERM 1042, Grenoble, France.
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504
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Das A, Camporota L, Hardman JG, Bates DG. What links ventilator driving pressure with survival in the acute respiratory distress syndrome? A computational study. Respir Res 2019; 20:29. [PMID: 30744629 PMCID: PMC6371576 DOI: 10.1186/s12931-019-0990-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 01/23/2019] [Indexed: 01/07/2023] Open
Abstract
Background Recent analyses of patient data in acute respiratory distress syndrome (ARDS) showed that a lower ventilator driving pressure was associated with reduced relative risk of mortality. These findings await full validation in prospective clinical trials. Methods To investigate the association between driving pressures and ventilator induced lung injury (VILI), we calibrated a high fidelity computational simulator of cardiopulmonary pathophysiology against a clinical dataset, capturing the responses to changes in mechanical ventilation of 25 adult ARDS patients. Each of these in silico patients was subjected to the same range of values of driving pressure and positive end expiratory pressure (PEEP) used in the previous analyses of clinical trial data. The resulting effects on several physiological variables and proposed indices of VILI were computed and compared with data relating ventilator settings with relative risk of death. Results Three VILI indices: dynamic strain, mechanical power and tidal recruitment, showed a strong correlation with the reported relative risk of death across all ranges of driving pressures and PEEP. Other variables, such as alveolar pressure, oxygen delivery and lung compliance, correlated poorly with the data on relative risk of death. Conclusions Our results suggest a credible mechanistic explanation for the proposed association between driving pressure and relative risk of death. While dynamic strain and tidal recruitment are difficult to measure routinely in patients, the easily computed VILI indicator known as mechanical power also showed a strong correlation with mortality risk, highlighting its potential usefulness in designing more protective ventilation strategies for this patient group. Electronic supplementary material The online version of this article (10.1186/s12931-019-0990-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anup Das
- School of Engineering, University of Warwick, Coventry, UK
| | - Luigi Camporota
- Intensive Care Medicine, Guy's and St Thomas' NHS Foundation Trust and Division of Asthma Allergy and Lung Biology, King's College London, London, UK
| | - Jonathan G Hardman
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust and School of Medicine, University of Nottingham, Nottingham, UK
| | - Declan G Bates
- School of Engineering, University of Warwick, Coventry, UK.
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505
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Kung SC, Hung YL, Chen WL, Wang CM, Chang HC, Liu WL. Effects of Stepwise Lung Recruitment Maneuvers in Patients with Early Acute Respiratory Distress Syndrome: A Prospective, Randomized, Controlled Trial. J Clin Med 2019; 8:jcm8020231. [PMID: 30744214 PMCID: PMC6406466 DOI: 10.3390/jcm8020231] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 01/31/2019] [Accepted: 02/06/2019] [Indexed: 12/16/2022] Open
Abstract
Since the clinical benefit of lung recruitment maneuvers (LRMs) is still conflicting, we performed this prospective, randomized, controlled study to investigate whether LRMs should be used in the routine management of acute respiratory distress syndrome (ARDS). This trial was conducted in four intensive care units (ICUs) to compare application of a modified stepwise LRMs with solely lung-protective ventilation in patients with moderate to severe ARDS within 72 h from the onset. The primary outcome was 28-day mortality, and the secondary outcomes were ventilator-free days and ICU-free days. We collected data on 120 ARDS patients from 2009 to 2012, and there was no difference in 28-day mortality between the two groups (28.3% vs. 30.0%, p = 0.84). However, among survivors, patients in the LRM group had a significant longer median duration of ventilator-free days (18 vs. 13 days; p = 0.04) and ICU-free days (16 vs. 11 days; p = 0.03) at 28 days than in the control group. The respiratory system compliance was significantly higher in the LRM group from day 1 to day 7. The occurrence rate of barotrauma was similar in both groups. We concluded that LRMs combined with lung-protective ventilation in early ARDS may improve patient outcomes.
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Affiliation(s)
- Shu-Chen Kung
- Department of Respiratory Therapy, Chi Mei Medical Center, Liouying, Tainan 73657, Taiwan.
| | - Yi-Li Hung
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan.
- School of Medicine, College of Medicine, Fu Jen Catholic University, Xinzhuang Dist., New Taipei City 24205, Taiwan (R.O.C).
| | - Wan-Ling Chen
- Department of Respiratory Therapy, Chi Mei Medical Center, Liouying, Tainan 73657, Taiwan.
| | - Ching-Min Wang
- Department of Internal Medicine, Chi Mei Medical Center, Liouying, Tainan 73657, Taiwan.
| | - Hui-Chun Chang
- Department of Respiratory Therapy, Chi Mei Medical Center, Liouying, Tainan 73657, Taiwan.
| | - Wei-Lun Liu
- School of Medicine, College of Medicine, Fu Jen Catholic University, Xinzhuang Dist., New Taipei City 24205, Taiwan (R.O.C).
- Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City 24352, Taiwan (R.O.C.).
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506
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Barnes T, Enk D. Ventilation for low dissipated energy achieved using flow control during both inspiration and expiration. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2019. [DOI: 10.1016/j.tacc.2018.09.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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507
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Abstract
Abstract
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
Background
Patients with initial mild acute respiratory distress syndrome are often underrecognized and mistakenly considered to have low disease severity and favorable outcomes. They represent a relatively poorly characterized population that was only classified as having acute respiratory distress syndrome in the most recent definition. Our primary objective was to describe the natural course and the factors associated with worsening and mortality in this population.
Methods
This study analyzed patients from the international prospective Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) who had initial mild acute respiratory distress syndrome in the first day of inclusion. This study defined three groups based on the evolution of severity in the first week: “worsening” if moderate or severe acute respiratory distress syndrome criteria were met, “persisting” if mild acute respiratory distress syndrome criteria were the most severe category, and “improving” if patients did not fulfill acute respiratory distress syndrome criteria any more from day 2.
Results
Among 580 patients with initial mild acute respiratory distress syndrome, 18% (103 of 580) continuously improved, 36% (210 of 580) had persisting mild acute respiratory distress syndrome, and 46% (267 of 580) worsened in the first week after acute respiratory distress syndrome onset. Global in-hospital mortality was 30% (172 of 576; specifically 10% [10 of 101], 30% [63 of 210], and 37% [99 of 265] for patients with improving, persisting, and worsening acute respiratory distress syndrome, respectively), and the median (interquartile range) duration of mechanical ventilation was 7 (4, 14) days (specifically 3 [2, 5], 7 [4, 14], and 11 [6, 18] days for patients with improving, persisting, and worsening acute respiratory distress syndrome, respectively). Admissions for trauma or pneumonia, higher nonpulmonary sequential organ failure assessment score, lower partial pressure of alveolar oxygen/fraction of inspired oxygen, and higher peak inspiratory pressure were independently associated with worsening.
Conclusions
Most patients with initial mild acute respiratory distress syndrome continue to fulfill acute respiratory distress syndrome criteria in the first week, and nearly half worsen in severity. Their mortality is high, particularly in patients with worsening acute respiratory distress syndrome, emphasizing the need for close attention to this patient population.
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508
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Positive end-expiratory pressure titration with electrical impedance tomography and pressure-volume curve in severe acute respiratory distress syndrome. Ann Intensive Care 2019; 9:7. [PMID: 30656479 PMCID: PMC6336593 DOI: 10.1186/s13613-019-0484-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 01/06/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The study objective was to compare titration of positive end-expiratory pressure (PEEP) with electrical impedance tomography (EIT) and with ventilator-embedded pressure-volume loop in severe acute respiratory distress syndrome (ARDS). METHODS We have designed a prospective study with historical control group. Twenty-four severe ARDS patients (arterial oxygen partial pressure to fractional inspired oxygen ratio, PaO2/FiO2 < 100 mmHg) were included in the EIT group and examined prospectively. Data from another 31 severe ARDS patients were evaluated retrospectively (control group). All patients were receiving medical care under identical general support guidelines and protective mechanical ventilation. The PEEP level selected in the EIT group was the intercept point of cumulated collapse and overdistension percentages curves. In the control group, optimal PEEP was selected 2 cmH2O above the lower inflection point on the static pressure-volume curve. RESULTS Patients in the EIT group were younger (P < 0.05), and their mean plateau pressure was 1.5 cmH2O higher (P < 0.01). No differences in other baseline parameters such as APACHE II score, PaO2/FiO2, initial PEEP, driving pressure, tidal volume, and respiratory system compliance were found. Two hours after the first PEEP titration, significantly higher PEEP, compliance, and lower driving pressure were found in the EIT group (P < 0.01). Hospital survival rates were 66.7% (16 of 24 patients) in the EIT group and 48.4% (15 of 31) in the control group. Identical rates were found regarding the weaning success rate: 66.7% in the EIT group and 48.4% in the control group. CONCLUSION In severe ARDS patients, it was feasible and safe to guide PEEP titration with EIT at the bedside. As compared with pressure-volume curve, the EIT-guided PEEP titration may be associated with improved oxygenation, compliance, driving pressure, and weaning success rate. The findings encourage further randomized control study with a larger sample size and potentially less bias in the baseline data. Trial Registration NCT03112512.
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509
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Abstract
Sepsis is defined as organ dysfunction resulting from the host's deleterious response to infection. One of the most common organs affected is the kidneys, resulting in sepsis associated acute kidney injury (SA-AKI) that contributes to the morbidity and mortality of sepsis. A growing body of knowledge has illuminated the clinical risk factors, pathobiology, response to treatment, and elements of renal recovery that have advanced our ability to prevent, detect, and treat SA-AKI. Despite these advances, SA-AKI remains an important concern and clinical burden, and further study is needed to reduce the acute and chronic consequences. This review summarizes the relevant evidence, with a focus on the risk factors, early recognition and diagnosis, treatment, and long term consequences of SA-AKI. In addition to literature pertaining to SA-AKI specifically, pertinent sepsis and acute kidney injury literature relevant to SA-AKI was included.
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Affiliation(s)
- Jason T Poston
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago
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510
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Zheng X, Jiang Y, Jia H, Ma W, Han Y, Li W. Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) versus low PEEP on patients with moderate-severe acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials. Ther Adv Respir Dis 2019; 13:1753466619858228. [PMID: 31269867 PMCID: PMC6611025 DOI: 10.1177/1753466619858228] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 04/30/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Setting a positive end-expiratory pressure (PEEP) on patients with acute respiratory distress syndrome (ARDS) receiving mechanical ventilation has been an issue of great contention. Therefore, we aimed to determine effects of lung recruitment maneuver (RM) and titrated PEEP versus low PEEP on adult patients with moderate-severe ARDS. METHODS Data sources and study selection proceeded as follows: PubMed, Ovid, EBSCO, and Cochrane Library databases were searched from 2003 to May 2018. Original clinical randomized controlled trials which met the eligibility criteria were included. To compare the prognosis between the titrated PEEP and low PEEP groups on patients with moderate-severe ARDS (PaO2/FiO2 < 200 mmHg). Heterogeneity was quantified through the I2 statistic. Egger's test and funnel plots were used to assess publication bias. RESULTS No difference was found in 28-day mortality and ICU mortality (OR = 0.97, 95% CI (0.61-1.52), p = 0.88; OR = 1.14, 95% CI (0.91-1.43), p = 0.26, respectively). Only ventilator-free days, length of stay in the ICU, length of stay in hospital, and incidence of barotrauma could be systematically reviewed owing to bias and extensive heterogeneity. CONCLUSION No difference was observed in the RM between the titrated PEEP and the low PEEP in 28-day mortality and ICU mortality on patients with moderate-severe ARDS.
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Affiliation(s)
- Xi Zheng
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yijia Jiang
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Huimiao Jia
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wenliang Ma
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yue Han
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wenxiong Li
- Surgical Intensive Care Unit, Beijing Chao-Yang Hospital, Capital Medical University, 8 Gongren Tiyuchang Nanlu, Chaoyang District, Beijing, 100020, China
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511
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Bello G, Blanco P. Lung Ultrasonography for Assessing Lung Aeration in Acute Respiratory Distress Syndrome: A Narrative Review. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:27-37. [PMID: 29732586 DOI: 10.1002/jum.14671] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 03/16/2018] [Accepted: 04/03/2018] [Indexed: 06/08/2023]
Abstract
Acute respiratory distress syndrome (ARDS) constitutes a high burden for intensive care units. Although several methods are proposed to monitor aeration in ARDS, availability, costs, simplicity, and hazards (eg, ionizing radiation) limit the use of many of them at patients' bedsides. Given the widespread use of lung ultrasonography (US) in intensive care units, research is growing regarding its use to monitor aeration in patients with ARDS. We reviewed the actual role of lung US in ARDS and its potential impact in practice. Lung US can be readily used for assessing aeration, although, as a main limitation, a normal lung cannot be distinguished from hyperinflation. Additionally, an improvement in aeration by lung US does not always correlate with an increase in oxygenation. Lung US can be considered the main imaging method for monitoring aeration in ARDS, but in view of its limitations, it should not be used in isolation. Further studies are needed to validate lung US in large ARDS populations.
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Affiliation(s)
- Gabriela Bello
- Intensive Care Unit, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay
- Hospital Policial, Montevideo, Uruguay
| | - Pablo Blanco
- Ecodiagnóstico-Centro de Diagnóstico por Imágenes, Necochea, Argentina
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512
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Abstract
The acute respiratory distress syndrome (ARDS) is a common cause of respiratory failure in critically ill patients and is defined by the acute onset of noncardiogenic pulmonary oedema, hypoxaemia and the need for mechanical ventilation. ARDS occurs most often in the setting of pneumonia, sepsis, aspiration of gastric contents or severe trauma and is present in ~10% of all patients in intensive care units worldwide. Despite some improvements, mortality remains high at 30-40% in most studies. Pathological specimens from patients with ARDS frequently reveal diffuse alveolar damage, and laboratory studies have demonstrated both alveolar epithelial and lung endothelial injury, resulting in accumulation of protein-rich inflammatory oedematous fluid in the alveolar space. Diagnosis is based on consensus syndromic criteria, with modifications for under-resourced settings and in paediatric patients. Treatment focuses on lung-protective ventilation; no specific pharmacotherapies have been identified. Long-term outcomes of patients with ARDS are increasingly recognized as important research targets, as many patients survive ARDS only to have ongoing functional and/or psychological sequelae. Future directions include efforts to facilitate earlier recognition of ARDS, identifying responsive subsets of patients and ongoing efforts to understand fundamental mechanisms of lung injury to design specific treatments.
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513
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Fichtner F, Moerer O, Laudi S, Weber-Carstens S, Nothacker M, Kaisers U. Mechanical Ventilation and Extracorporeal Membrane Oxygena tion in Acute Respiratory Insufficiency. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:840-847. [PMID: 30722839 PMCID: PMC6375070 DOI: 10.3238/arztebl.2018.0840] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 06/18/2018] [Accepted: 09/12/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Mechanical ventilation is life-saving for patients with acute respiratory insufficiency. In a German prevalence study, 13.6% of patients in intensive care units received mechanical ventilation for more than 12 hours; 20% of these patients received mechanical ventilation as treatment for acute respiratory distress syndrome (ARDS). The new S3 guideline is the first to contain recommendations for the entire process of treatment in these groups of patients (indications, ventilation modes/parameters, ac- companying measures, treatments for refractory impairment of gas exchange, weaning, and follow-up care). METHODS This guideline was developed according to the GRADE methods. Pertinent publications were identified by a systematic search of the literature, the quality of the evidence was evaluated, a risk/benefit assessment was conducted, and recommendations were issued by interdisciplinary consensus. RESULTS Mechanical ventilation is recommended as primary treatment for patients with severe ARDS. In other patient groups, non-in- vasive ventilation can lower mortality. If mechanical ventilation is needed, ventilation modes allowing spontaneous breathing seem beneficial (quality of evidence [QoE]: very low). Protective ventilation (high positive end-expiratory pressure, low tidal volume, limited peak pressure) improve the survival of ARDS patients (QoE: high). If a severe impairment of gas exchange is present, prone posi- tioning lessens mortality (QoE: high). Veno-venous extracorporeal membrane oxygenation (vvECMO) has not unequivocally been shown to improve survival. Early mobilization and weaning protocols can shorten the duration of ventilation (QoE: moderate). CONCLUSION Recommendations for patients undergoing mechanical ventilation include lung-protective ventilation, early sponta- neous breathing and mobilization, weaning protocols, and, for those with severe impairment of gas exchange, prone positioning. It is further recommended that patients with ARDS and refractory impairment of gas exchange should be transferred to an ARDS/ECMO center, where extracorporeal methods should be applied only after application of all other therapeutic options.
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Affiliation(s)
- Falk Fichtner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig
| | - Onnen Moerer
- Center for Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen
| | - Sven Laudi
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig
| | - Steffen Weber-Carstens
- Department of Anesthesiology and Operative Intensive Care Medicin, Charité–Universitätsklinikum Berlin
| | - Monika Nothacker
- AWMF-Institute for Medical Knowledge Management (AWMF-IMWi), AWMF office Berlin
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514
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Abstract
Acute Respiratory Distress Syndrome (ARDS) is a well-described disease process that can have numerous underlying causes, is commonly seen in the critical care setting, and is often under-recognized. ARDS is characterized by pulmonary edema with refractory hypoxemia, and was traditionally associated with a high mortality rate. The past few decades have generated many studies examining therapeutic interventions for ARDS; however, there are few Level 1 evidence-based interventions to this day that have been shown to improve mortality and outcomes. Lung protective ventilation remains the most studied and evidence-based intervention for the treatment of ARDS.
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Affiliation(s)
- Hemanshu Prabhakar
- Department of Neuroanaesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Zulfiqar Ali
- Division of Neuroanesthesiology, Department of Anesthesiology, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir India
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515
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Keddissi JI, Youness HA, Jones KR, Kinasewitz GT. Fluid management in Acute Respiratory Distress Syndrome: A narrative review. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2018; 55:1-8. [PMID: 31297439 PMCID: PMC6591787 DOI: 10.29390/cjrt-2018-016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute Respiratory Distress Syndrome remains a major source of morbidity and mortality in the modern intensive care unit (ICU). Major advances in the understanding and management of this condition were made in the last two decades. The use of low tidal ventilation is a well-established therapy. Conservative fluid management is now another cornerstone of management. However, much remains to be understood in this arena. Assessing volume status in these patients may be challenging and the tools available to do so are far from perfect. Several dynamic measures including pulse pressures variation are used. Ultrasound of the lungs and the vascular system may also have a role. In addition, the type of fluid to administer when needed is still open to debate. Finally, supportive measures in these patients, early during their ICU stay and later after discharge continue to be crucial for survival and adequate recovery.
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Affiliation(s)
- Jean I Keddissi
- Section of Pulmonary, Critical Care and Sleep Medicine, The Oklahoma City VA HealthCare System and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Houssein A Youness
- Section of Pulmonary, Critical Care and Sleep Medicine, The Oklahoma City VA HealthCare System and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Kellie R Jones
- Section of Pulmonary, Critical Care and Sleep Medicine, The Oklahoma City VA HealthCare System and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Gary T Kinasewitz
- Section of Pulmonary, Critical Care and Sleep Medicine, The Oklahoma City VA HealthCare System and the University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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516
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Knudsen L, Lopez-Rodriguez E, Berndt L, Steffen L, Ruppert C, Bates JHT, Ochs M, Smith BJ. Alveolar Micromechanics in Bleomycin-induced Lung Injury. Am J Respir Cell Mol Biol 2018; 59:757-769. [PMID: 30095988 PMCID: PMC6293074 DOI: 10.1165/rcmb.2018-0044oc] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 06/29/2018] [Indexed: 12/22/2022] Open
Abstract
Lung injury results in intratidal alveolar recruitment and derecruitment and alveolar collapse, creating stress concentrators that increase strain and aggravate injury. In this work, we sought to describe alveolar micromechanics during mechanical ventilation in bleomycin-induced lung injury and surfactant replacement therapy. Structure and function were assessed in rats 1 day and 3 days after intratracheal bleomycin instillation and after surfactant replacement therapy. Pulmonary system mechanics were measured during ventilation with positive end-expiratory pressures (PEEPs) between 1 and 10 cm H2O, followed by perfusion fixation at end-expiratory pressure at airway opening (Pao) values of 1, 5, 10, and 20 cm H2O for quantitative analyses of lung structure. Lung structure and function were used to parameterize a physiologically based, multicompartment computational model of alveolar micromechanics. In healthy controls, the numbers of open alveoli remained stable in a range of Pao = 1-20 cm H2O, whereas bleomycin-challenged lungs demonstrated progressive alveolar derecruitment with Pao < 10 cm H2O. At Day 3, ∼40% of the alveoli remained closed at high Pao, and alveolar size heterogeneity increased. Simulations of injured lungs predicted that alveolar recruitment pressures were much greater than the derecruitment pressures, so that minimal intratidal recruitment and derecruitment occurred during mechanical ventilation with a tidal volume of 10 ml/kg body weight over a range of PEEPs. However, the simulations also predicted a dramatic increase in alveolar strain with injury that we attribute to alveolar interdependence. These findings suggest that in progressive lung injury, alveolar collapse with increased distension of patent (open) alveoli dominates alveolar micromechanics. PEEP and surfactant substitution reduce alveolar collapse and dynamic strain but increase static strain.
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Affiliation(s)
- Lars Knudsen
- Institute of Functional and Applied Anatomy, and
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover, Member of the German Center for Lung Research (DZL) Hannover Medical School, Hannover, Germany
- REBIRTH, Cluster of Excellence, Hannover, Germany
| | - Elena Lopez-Rodriguez
- Institute of Functional and Applied Anatomy, and
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover, Member of the German Center for Lung Research (DZL) Hannover Medical School, Hannover, Germany
- REBIRTH, Cluster of Excellence, Hannover, Germany
| | | | | | - Clemens Ruppert
- Department of Internal Medicine, and
- Universities of Giessen and Marburg Lung Center, Member of the German Center for Lung Research (DZL), Justus Liebig University Giessen, Giessen, Germany
| | | | - Matthias Ochs
- Institute of Functional and Applied Anatomy, and
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover, Member of the German Center for Lung Research (DZL) Hannover Medical School, Hannover, Germany
- REBIRTH, Cluster of Excellence, Hannover, Germany
| | - Bradford J. Smith
- Department of Bioengineering, University of Colorado Denver, Denver, Colorado
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517
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Miura MC, Ribeiro de Carvalho CR, Yamada da Silveira LT, de Moraes Regenga M, Petri Damiani L, Fu C. The effects of recruitment maneuver during noninvasive ventilation after coronary bypass grafting: A randomized trial. J Thorac Cardiovasc Surg 2018; 156:2170-2177.e1. [DOI: 10.1016/j.jtcvs.2018.05.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 04/23/2018] [Accepted: 05/14/2018] [Indexed: 12/16/2022]
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518
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Derwall M, Martin L, Rossaint R. The acute respiratory distress syndrome: pathophysiology, current clinical practice, and emerging therapies. Expert Rev Respir Med 2018; 12:1021-1029. [PMID: 30431366 DOI: 10.1080/17476348.2018.1548280] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION More than fifty years after the first description of acute respiratory distress syndrome (ARDS) by Ashbaugh and colleagues, no specific treatment of the underlying pathophysiological processes is available. The current therapeutic regime is comprised of supportive measures such as lung protective ventilation, restrictive fluid management, paralyzing drugs, and prone positioning. Although vast improvements have been made in ARDS-treatment during the last five decades, mortality among patients with severe ARDS remains at an unacceptable rate of 45%. Areas covered: This article reviews the evolution of the currently used definition, established pathophysiological mechanism, highlights the current best clinical practice to treat ARDS, gives a brief outlook on cutting edge trends in ARDS research and closes with an expert opinion on the subject. Expert commentary: Individualizing the provided measures to specific genotypes is the key challenge in ARDS research today. The ongoing digital revolution will help to individualize ARDS-treatment and will therefore presumably improve survival and quality of life.
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Affiliation(s)
- Matthias Derwall
- a Klinik für Anästhesiologie , Uniklinik RWTH Aachen, Medizinische Fakultät RWTH Aachen , Aachen , Germany.,b Klinik für Operative Intensivmedizin und Intermediate Care , Uniklinik RWTH Aachen, Medizinische Fakultät RWTH Aachen , Aachen , Germany
| | - Lukas Martin
- a Klinik für Anästhesiologie , Uniklinik RWTH Aachen, Medizinische Fakultät RWTH Aachen , Aachen , Germany.,b Klinik für Operative Intensivmedizin und Intermediate Care , Uniklinik RWTH Aachen, Medizinische Fakultät RWTH Aachen , Aachen , Germany
| | - Rolf Rossaint
- a Klinik für Anästhesiologie , Uniklinik RWTH Aachen, Medizinische Fakultät RWTH Aachen , Aachen , Germany.,b Klinik für Operative Intensivmedizin und Intermediate Care , Uniklinik RWTH Aachen, Medizinische Fakultät RWTH Aachen , Aachen , Germany
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519
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Guo L, Xie J, Huang Y, Pan C, Yang Y, Qiu H, Liu L. Higher PEEP improves outcomes in ARDS patients with clinically objective positive oxygenation response to PEEP: a systematic review and meta-analysis. BMC Anesthesiol 2018; 18:172. [PMID: 30447683 PMCID: PMC6240288 DOI: 10.1186/s12871-018-0631-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 10/29/2018] [Indexed: 01/04/2023] Open
Abstract
Background Mortality in patients with acute respiratory distress syndrome (ARDS) remains high. These patients require mechanical ventilation strategies that include high positive end-expiratory pressure (PEEP). It remains controversial whether high PEEP can improve outcomes for ARDS patients, especially patients who show improvement in oxygenation in response to PEEP. In this meta-analysis, we aimed to evaluate the effects of high PEEP on ARDS patients. Methods We electronically searched randomized controlled trials (RCTs) reported in the MEDLINE, CENTRAL, EMBASE, CINAHL and Web of Science databases from January 1990 to December 2017. Meta-analyses of the effects of PEEP on survival in adults with ARDS were conducted using the methods recommended by the Cochrane Collaboration. Results A total of 3612 patients from nine randomized controlled trials (RCTs) were included. There were 1794 and 1818 patients in the high and low PEEP groups, respectively. Hospital mortality showed no significant difference between the high and low PEEP groups (RR = 0.92; 95% CI, 0.79 to 1.07; P = 0.26). Similar results were found for 28-d mortality (RR = 0.88; 95% CI, 0.72 to 1.07; P = 0.19) and ICU mortality (RR = 0.83; 95% CI, 0.65 to 1.07; P = 0.15). The risk of clinically objectified barotrauma was not significantly different between the high and low PEEP groups (RR = 1.24; 95% CI, 0.74 to 2.09, P = 0.41). In the subgroup of ARDS patients who responded to increased PEEP by improved oxygenation (from 6 RCTs), high PEEP significantly reduced hospital mortality (RR = 0.83; 95% CI 0.69 to 0.98; P = 0.03), ICU mortality (RR = 0.74; 95% CI, 0.56 to 0.98; P = 0.04),but the 28-d mortality was not decreased(RR = 0.83; 95% CI, 0.67 to 1.01; P = 0.07). For ARDS patients in the low PEEP group who received a PEEP level lower than 10 cmH2O (from 6 RCTs), ICU mortality was lower in the high PEEP group than the low PEEP group (RR = 0.65; 95% CI, 0.45 to 0.94; P = 0.02). Conclusions For ARDS patients who responded to increased PEEP by improved oxygenation, high PEEP could reduce hospital mortality, ICU mortality and 28-d mortality. High PEEP does not increase the risk of clinically objectified barotrauma. Electronic supplementary material The online version of this article (10.1186/s12871-018-0631-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lanqi Guo
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Jianfeng Xie
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yingzi Huang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Chun Pan
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yi Yang
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Ling Liu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China.
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520
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Lagier D, Fischer F, Fornier W, Fellahi JL, Colson P, Cholley B, Jaber S, Baumstarck K, Guidon C. A perioperative surgeon-controlled open-lung approach versus conventional protective ventilation with low positive end-expiratory pressure in cardiac surgery with cardiopulmonary bypass (PROVECS): study protocol for a randomized controlled trial. Trials 2018; 19:624. [PMID: 30424770 PMCID: PMC6234562 DOI: 10.1186/s13063-018-2967-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 10/08/2018] [Indexed: 12/16/2022] Open
Abstract
Background Postoperative pulmonary complications (PPCs) are frequent after on-pump cardiac surgery. Cardiac surgery results in a complex pulmonary insult leading to high susceptibility to perioperative pulmonary atelectasis. For technical reasons, ventilator settings interact with the surgical procedure and traditionally, low levels of positive end-expiratory pressure (PEEP) have been used. The objective is to compare a perioperative, multimodal and surgeon-controlled open-lung approach with conventional protective ventilation with low PEEP to prevent PPCs in patients undergoing cardiac surgery. Methods/design The perioperative open-lung protective ventilation in cardiac surgery (PROVECS) trial is a multicenter, two-arm, randomized controlled trial. In total, 494 patients scheduled for elective cardiac surgery with cardiopulmonary bypass (CPB) and aortic cross-clamp will be randomized into one of the two treatment arms. In the experimental group, systematic recruitment maneuvers and perioperative high PEEP (8 cmH2O) are associated with ultra-protective ventilation during CPB. In this group, the settings of the ventilator are controlled by surgeons in relation to standardized protocol deviations. In the control group, no recruitment maneuvers, low levels of PEEP (2 cmH2O) and continuous positive airway pressure during CPB (2 cmH2O) are used. Low tidal volumes (6–8 mL/kg of predicted body weight) are used before and after CPB in each group. The primary endpoint is a composite of the single PPCs evaluated during the first 7 postoperative days. Discussion The PROVECS trial will be the first multicenter randomized controlled trial to evaluate the impact of a perioperative and multimodal open-lung ventilatory strategy on the occurrence of PPCs after on-pump cardiac surgery. The trial design includes standardized surgeon-controlled protocol deviations that guarantee a pragmatic approach. The results will help anesthesiologists and surgeons aiming to optimize ventilatory settings during cardiac surgery. Trial registration Clinical Trials.gov, NCT 02866578. Registered on 15 August 2016. Last updated 11 July 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2967-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David Lagier
- Department of Cardiovascular Anesthesiology and Critical Care Medicine, La Timone University Hospital, AP-HM and Aix-Marseille University, 264 rue saint Pierre, 13005, cedex 5, Marseille, France.
| | - François Fischer
- Department of Cardiovascular and Thoracic Anesthesiology, Nouvel Hôpital Civil, Strasbourg, France
| | - William Fornier
- Department of Anesthesiology and Critical Care Medicine, Louis Pradel University Hospital and University Claude Bernard, 28 Avenue du Doyen Lépine, 69677, Bron, France
| | - Jean-Luc Fellahi
- Department of Anesthesiology and Critical Care Medicine, Louis Pradel University Hospital and University Claude Bernard, 28 Avenue du Doyen Lépine, 69677, Bron, France
| | - Pascal Colson
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve University Hospital, 371 Avenue du Doyen Gaston Giraud, 34295, Montpellier, France
| | - Bernard Cholley
- Department of Anesthesiology and Critical Care Medicine, Hôpital Européen Georges Pompidou, AP-HP and University Paris Descartes-Sorbonne Paris Cité, 20 Rue Leblanc, 75015, Paris, France
| | - Samir Jaber
- Department of Anesthesiology and Critical Care Medicine, Saint Eloi University Hospital, 80 Avenue Augustin Fliche, 34295, Montpellier, France
| | - Karine Baumstarck
- Unité de Recherche EA3279, Aix-Marseille University, 27 bd Jean Moulin, Marseille, cedex 5, 13385, Marseille, France
| | - Catherine Guidon
- Department of Cardiovascular Anesthesiology and Critical Care Medicine, La Timone University Hospital, AP-HM and Aix-Marseille University, 264 rue saint Pierre, 13005, cedex 5, Marseille, France
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521
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Use of Recruitment Maneuvers in Patients With Acute Respiratory Distress Syndrome. Dimens Crit Care Nurs 2018; 37:135-143. [PMID: 29596290 DOI: 10.1097/dcc.0000000000000298] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a deadly complication in critically ill patients that causes significant morbidity and mortality. Patients with ARDS are seen across intensive care unit settings, with treatment being largely supportive involving techniques through mechanical ventilation. Using low-tidal-volume ventilation is a standard of practice for patients with ARDS, as a lung protection strategy; however, alveolar decruitment may occur. Recruitment maneuvers can recruit collapsed alveoli and promote oxygenation. There are several methods of recruitment maneuvers-each with varying levels and durations of positive end-expiratory pressure. It is still uncertain which method is the best. The evidence for the efficacy of recruitment maneuvers has shown a decrease in intensive care unit mortality, but strong evidence is lacking for its routine use, and the decision to use recruitment maneuvers should be based on individual characteristics and responses. This article reviews management of ARDS, recruitment maneuver techniques, and clinical application through a case study.
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522
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Recruitment manoeuvres dislodge mucus towards the distal airways in an experimental model of severe pneumonia. Br J Anaesth 2018; 122:269-276. [PMID: 30686313 DOI: 10.1016/j.bja.2018.07.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/12/2018] [Accepted: 07/23/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Recruitment manoeuvres generate a transient increase in trans-pulmonary pressure that could open collapsed alveoli. Recruitment manoeuvres might generate very high inspiratory airflows. We evaluated whether recruitment manoeuvres could displace respiratory secretions towards the distal airways and impair gas exchange in a porcine model of bacterial pneumonia. METHODS We conducted a prospective randomised study in 10 mechanically ventilated pigs. Pneumonia was produced by direct intra-bronchial introduction of Pseudomonas aeruginosa. Four recruitment manoeuvres were applied randomly: extended sigh (ES), maximal recruitment strategy (MRS), sudden increase in driving pressure and PEEP (SI-PEEP), and sustained inflation (SI). Mucus transport was assessed by fluoroscopic tracking of radiopaque disks before and during each recruitment manoeuvre. The effects of each RM on gas exchange were assessed 15 min after the intervention. RESULTS Before recruitment manoeuvres, mucus always cleared towards the glottis. Conversely, mucus was displaced towards the distal airways in 28.6% ES applications and 50% of all other recruitment manoeuvres (P=0.053). Median mucus velocity was 1.26 mm min-1 [0.48-3.89] before each recruitment manoeuvre, but was reversed (P=0.007) during ES [0.10 mm min-1 [-0.04-1.00]], MRS [0.10 mm min-1 [-0.4-0.48]], SI-PEEP [0.02 mm min-1 [-0.14-0.34]], and SI [0.10 mm min-1 [-0.63-0.75]]. When PaO2 failed to improve after recruitment manoeuvre, mucus was displaced towards the distal airways in 68.7% of the cases, compared with 31.2% recruitment manoeuvres associated with improved PaO2 (odds ratio: 4.76 (95% confidence interval: 1.13-19.97). CONCLUSIONS Recruitment manoeuvres dislodge mucus distally, irrespective of airflow generated by different recruitment manoeuvres. Further investigation in humans is warranted to corroborate these pre clinical findings, as there may be limited benefits associated with lung recruitment in pneumonia.
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523
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Abstract
Ventilator-induced lung injury develops from interactions between the lung parenchyma and applied mechanical power. In acute respiratory distress syndrome, the lung is smaller size with an inhomogeneous structure. The same mechanical force applied on a reduced parenchyma would produce volutrauma; the concentration of mechanical forces at inhomogeneous interfaces produces atelectrauma. Higher positive end-expiratory pressures favor volutrauma and reduce atelectrauma; lower values do the opposite. Volutrauma and atelectrauma harms and benefits, however, seem to be equivalent at 5 to 15 cm H2O. At values greater than 15 cm H2O, the risk of damage outweighs the benefits of major atelectrauma prevention.
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524
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Fielding-Singh V, Matthay MA, Calfee CS. Beyond Low Tidal Volume Ventilation: Treatment Adjuncts for Severe Respiratory Failure in Acute Respiratory Distress Syndrome. Crit Care Med 2018; 46:1820-1831. [PMID: 30247273 PMCID: PMC6277052 DOI: 10.1097/ccm.0000000000003406] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Despite decades of research, the acute respiratory distress syndrome remains associated with significant morbidity and mortality. This Concise Definitive Review provides a practical and evidence-based summary of treatments in addition to low tidal volume ventilation and their role in the management of severe respiratory failure in acute respiratory distress syndrome. DATA SOURCES We searched the PubMed database for clinical trials, observational studies, and review articles describing treatment adjuncts in acute respiratory distress syndrome patients, including high positive end-expiratory pressure strategies, recruitment maneuvers, high-frequency oscillatory ventilation, neuromuscular blockade, prone positioning, inhaled pulmonary vasodilators, extracorporeal membrane oxygenation, glucocorticoids, and renal replacement therapy. STUDY SELECTION AND DATA EXTRACTION Results were reviewed by the primary author in depth. Disputed findings and conclusions were then reviewed with the other authors until consensus was achieved. DATA SYNTHESIS Severe respiratory failure in acute respiratory distress syndrome may present with refractory hypoxemia, severe respiratory acidosis, or elevated plateau airway pressures despite lung-protective ventilation according to acute respiratory distress syndrome Network protocol. For severe hypoxemia, first-line treatment adjuncts include high positive end-expiratory pressure strategies, recruitment maneuvers, neuromuscular blockade, and prone positioning. For refractory acidosis, we recommend initial modest liberalization of tidal volumes, followed by neuromuscular blockade and prone positioning. For elevated plateau airway pressures, we suggest first decreasing tidal volumes, followed by neuromuscular blockade, modification of positive end-expiratory pressure, and prone positioning. Therapies such as inhaled pulmonary vasodilators, glucocorticoids, and renal replacement therapy have significantly less evidence in favor of their use and should be considered second line. Extracorporeal membrane oxygenation may be life-saving in selected patients with severe acute respiratory distress syndrome but should be used only when other alternatives have been applied. CONCLUSIONS Severe respiratory failure in acute respiratory distress syndrome often necessitates the use of treatment adjuncts. Evidence-based application of these therapies in acute respiratory distress syndrome remains a significant challenge. However, a rational stepwise approach with frequent monitoring for improvement or harm can be achieved.
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Affiliation(s)
- Vikram Fielding-Singh
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles, Los Angeles, CA
| | - Michael A. Matthay
- Departments of Medicine and Anesthesia, Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA
| | - Carolyn S. Calfee
- Departments of Medicine and Anesthesia, Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA
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525
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Lavana J, Shekar K. Oscillating between prone ventilation and ECMO? J Thorac Dis 2018; 10:S4144-S4146. [PMID: 30631577 DOI: 10.21037/jtd.2018.10.71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Jayshree Lavana
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Critical Care Research Group, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, Queensland, Australia.,Critical Care Research Group, University of Queensland, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support (ACTIONS), Brisbane, QLD, Australia
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526
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Serpa Neto A, Deliberato RO, Johnson AEW, Bos LD, Amorim P, Pereira SM, Cazati DC, Cordioli RL, Correa TD, Pollard TJ, Schettino GPP, Timenetsky KT, Celi LA, Pelosi P, Gama de Abreu M, Schultz MJ. Mechanical power of ventilation is associated with mortality in critically ill patients: an analysis of patients in two observational cohorts. Intensive Care Med 2018; 44:1914-1922. [PMID: 30291378 DOI: 10.1007/s00134-018-5375-6] [Citation(s) in RCA: 263] [Impact Index Per Article: 43.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 09/10/2018] [Indexed: 12/21/2022]
Abstract
PURPOSE Mechanical power (MP) may unify variables known to be related to development of ventilator-induced lung injury. The aim of this study is to examine the association between MP and mortality in critically ill patients receiving invasive ventilation for at least 48 h. METHODS This is an analysis of data stored in the databases of the MIMIC-III and eICU. Critically ill patients receiving invasive ventilation for at least 48 h were included. The exposure of interest was MP. The primary outcome was in-hospital mortality. RESULTS Data from 8207 patients were analyzed. Median MP during the second 24 h was 21.4 (16.2-28.1) J/min in MIMIC-III and 16.0 (11.7-22.1) J/min in eICU. MP was independently associated with in-hospital mortality [odds ratio per 5 J/min increase (OR) 1.06 (95% confidence interval (CI) 1.01-1.11); p = 0.021 in MIMIC-III, and 1.10 (1.02-1.18); p = 0.010 in eICU]. MP was also associated with ICU mortality, 30-day mortality, and with ventilator-free days, ICU and hospital length of stay. Even at low tidal volume, high MP was associated with in-hospital mortality [OR 1.70 (1.32-2.18); p < 0.001] and other secondary outcomes. Finally, there is a consistent increase in the risk of death with MP higher than 17.0 J/min. CONCLUSION High MP of ventilation is independently associated with higher in-hospital mortality and several other outcomes in ICU patients receiving invasive ventilation for at least 48 h.
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Affiliation(s)
- Ary Serpa Neto
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands.
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 700, São Paulo, Brazil.
- Laboratory for Critical Care Research, Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - Rodrigo Octavio Deliberato
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 700, São Paulo, Brazil
- Laboratory for Critical Care Research, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Big Data Analytics Group, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Alistair E W Johnson
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, MIT, Cambridge, MA, USA
| | - Lieuwe D Bos
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands
| | - Pedro Amorim
- Department of Innovation, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Denise Carnieli Cazati
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 700, São Paulo, Brazil
| | - Ricardo L Cordioli
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 700, São Paulo, Brazil
| | - Thiago Domingos Correa
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 700, São Paulo, Brazil
| | - Tom J Pollard
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, MIT, Cambridge, MA, USA
| | - Guilherme P P Schettino
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 700, São Paulo, Brazil
| | - Karina T Timenetsky
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Albert Einstein Avenue, 700, São Paulo, Brazil
| | - Leo A Celi
- Laboratory for Computational Physiology, Institute for Medical Engineering and Science, MIT, Cambridge, MA, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marcus J Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, The Netherlands
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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527
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Vianna FSL, Pfeilsticker FJDA, Serpa Neto A. Driving pressure in obese patients with acute respiratory distress syndrome: one size fits all? J Thorac Dis 2018; 10:S3957-S3960. [PMID: 30631526 DOI: 10.21037/jtd.2018.09.31] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Felipe S L Vianna
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
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528
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Affiliation(s)
- John J Marini
- Department of Medicine, Pulmonary and Critical Care, University of Minnesota, Minneapolis, MN, USA
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529
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Gattinoni L, Quintel M, Marini JJ. Volutrauma and atelectrauma: which is worse? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:264. [PMID: 30360756 PMCID: PMC6203268 DOI: 10.1186/s13054-018-2199-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 09/24/2018] [Indexed: 12/16/2022]
Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
| | - Michael Quintel
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, Regions Hospital and University of Minnesota, Minneapolis/St. Paul, Minnesota, USA
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530
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Krebs J, Pelosi P, Rocco PRM, Hagmann M, Luecke T. Positive end-expiratory pressure titrated according to respiratory system mechanics or to ARDSNetwork table did not guarantee positive end-expiratory transpulmonary pressure in acute respiratory distress syndrome. J Crit Care 2018; 48:433-442. [PMID: 30336419 DOI: 10.1016/j.jcrc.2018.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 10/06/2018] [Accepted: 10/08/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE Pulmonary recruitment and positive end-expiratory pressure (PEEP) titrated according to minimal static elastance of the respiratory system (PEEPEstat,RS) compared to PEEP set according to the ARDSNetwork table (PEEPARDSNetwork) as a strategy to prevent ventilator-associated lung injury (VALI) in patients with acute respiratory distress syndrome (ARDS) increases mortality. Alternatively, avoiding negative end-expiratory transpulmonary pressure has been discussed as superior PEEP titration strategy. Therefore, we tested whether PEEPEstat,RS or PEEPARDSNetwork prevent negative end-expiratory transpulmonary pressure in ARDS patients. MATERIAL AND METHODS Thirteen patients with moderate to severe ARDS were studied at PEEPARDSNetwork versus PEEPEstat,RS. Patients were then grouped post hoc according to the end-expiratory transpulmonary pressure (positive or negative). RESULTS 7 out of 13 patients showed negative end-expiratory transpulmonary pressures (Ptp-) with both strategies (PEEPARDSNetwork: - 5.4 ± 3.5 vs. 2.2 ± 3.7 cm H2O, p = .005; PEEPEstat,RS: - 3.6 ± 1.5 vs. 3.5 ± 3.3 cm H2O, p < .001). Ptp- was associated with higher intra-abdominal pressure and lower end-expiratory lung volume with both PEEP strategies. CONCLUSIONS In patients with moderate-to-severe ARDS, PEEP titrated according to the minimal static elastance of the respiratory system or according to the ARDSNetwork table did not prevent negative end-expiratory transpulmonary pressure.
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Affiliation(s)
- Joerg Krebs
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68165 Mannheim, Germany.
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, Ospedale Policlinico San Martino - IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Av. Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão, 21941-902 Rio de Janeiro, RJ, Brazil
| | - Michael Hagmann
- Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68165 Mannheim, Germany.
| | - Thomas Luecke
- Department of Anaesthesiology and Critical Care Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer Ufer 1-3, 68165 Mannheim, Germany.
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531
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Russotto V, Bellani G, Foti G. Respiratory mechanics in patients with acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:382. [PMID: 30460256 DOI: 10.21037/atm.2018.08.32] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Despite the recognition of its iatrogenic potential, mechanical ventilation remains the mainstay of respiratory support for patients with acute respiratory distress syndrome (ARDS). The low volume ventilation has been recognized as the only method to reduce mortality of ARDS patients and plateau pressure as the lighthouse for delivering safe ventilation. Recent investigations suggest that a ventilation based on lung mechanics (tidal ventilation tailored to the available lung volume able to receive it, i.e., driving pressure) is a successful approach to improve outcome. However, currently available bedside mechanical variables do not consider regional mechanical properties of ARDS affected lungs, which include the role of local stress risers at the boundaries of areas with different aeration. A unifying approach considers lung-related causes and ventilation-related causes of lung injury. These last may be incorporated in the mechanical power (i.e., amount of mechanical energy transferred per unit of time). Ventilation-induced lung injury (which includes the self-inflicted lung injury of a spontaneously breathing patient) can therefore be prevented by the adoption of measures promoting an increase of ventilable lung and its homogeneity and by delivering lower levels of mechanical power. Prone position promotes lung homogeneity without increasing the delivered mechanical power. This review describes the recent developments on respiratory mechanics in ARDS patients, providing both bedside and research insights from the most updated evidence.
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Affiliation(s)
- Vincenzo Russotto
- Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Giacomo Bellani
- Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy.,University of Milano Bicocca, Milano, Italy
| | - Giuseppe Foti
- Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy.,University of Milano Bicocca, Milano, Italy
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532
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Baedorf Kassis E, Loring SH, Talmor D. Should we titrate peep based on end-expiratory transpulmonary pressure?-yes. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:390. [PMID: 30460264 DOI: 10.21037/atm.2018.06.35] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Ventilator management of patients with acute respiratory distress syndrome (ARDS) has been characterized by implementation of basic physiology principles by minimizing harmful distending pressures and preventing lung derecruitment. Such strategies have led to significant improvements in outcomes. Positive end expiratory pressure (PEEP) is an important part of a lung protective strategy but there is no standardized method to set PEEP level. With widely varying types of lung injury, body habitus and pulmonary mechanics, the use of esophageal manometry has become important for personalization and optimization of mechanical ventilation in patients with ARDS. Esophageal manometry estimates pleural pressures, and can be used to differentiate the chest wall and lung (transpulmonary) contributions to the total respiratory system mechanics. Elevated pleural pressures may result in negative transpulmonary pressures at end expiration, leading to lung collapse. Measuring the esophageal pressures and adjusting PEEP to make transpulmonary pressures positive can decrease atelectasis, derecruitment of lung, and cyclical opening and closing of airways and alveoli, thus optimizing lung mechanics and oxygenation. Although there is some spatial and positional artifact, esophageal pressures in numerous animal and human studies in healthy, obese and critically ill patients appear to be a good estimate for the "effective" pleural pressure. Multiple studies have illustrated the benefit of using esophageal pressures to titrate PEEP in patients with obesity and with ARDS. Esophageal pressure monitoring provides a window into the unique physiology of a patient and helps improve clinical decision making at the bedside.
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Affiliation(s)
- Elias Baedorf Kassis
- Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen H Loring
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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533
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Silva PL, Rocco PRM. The basics of respiratory mechanics: ventilator-derived parameters. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:376. [PMID: 30460250 DOI: 10.21037/atm.2018.06.06] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Mechanical ventilation is a life-support system used to maintain adequate lung function in patients who are critically ill or undergoing general anesthesia. The benefits and harms of mechanical ventilation depend not only on the operator's setting of the machine (input), but also on their interpretation of ventilator-derived parameters (outputs), which should guide ventilator strategies. Once the inputs-tidal volume (VT), positive end-expiratory pressure (PEEP), respiratory rate (RR), and inspiratory airflow (V')-have been adjusted, the following outputs should be measured: intrinsic PEEP, peak (Ppeak) and plateau (Pplat) pressures, driving pressure (ΔP), transpulmonary pressure (PL), mechanical energy, mechanical power, and intensity. During assisted mechanical ventilation, in addition to these parameters, the pressure generated 100 ms after onset of inspiratory effort (P0.1) and the pressure-time product per minute (PTP/min) should also be evaluated. The aforementioned parameters should be seen as a set of outputs, all of which need to be strictly monitored at bedside in order to develop a personalized, case-by-case approach to mechanical ventilation. Additionally, more clinical research to evaluate the safe thresholds of each parameter in injured and uninjured lungs is required.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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534
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Satalin J, Habashi NM, Nieman GF. Never give the lung the opportunity to collapse. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2018. [DOI: 10.1016/j.tacc.2018.05.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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535
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Morton SE, Dickson J, Chase JG, Docherty P, Desaive T, Howe SL, Shaw GM, Tawhai M. A virtual patient model for mechanical ventilation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2018; 165:77-87. [PMID: 30337083 DOI: 10.1016/j.cmpb.2018.08.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 07/24/2018] [Accepted: 08/08/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Mechanical ventilation (MV) is a primary therapy for patients with acute respiratory failure. However, poorly selected ventilator settings can cause further lung damage due to heterogeneity of healthy and damaged alveoli. Varying positive-end-expiratory-pressure (PEEP) to a point of minimum elastance is a lung protective ventilator strategy. However, even low levels of PEEP can lead to ventilator induced lung injury for individuals with highly inflamed pulmonary tissue. Hence, models that could accurately predict peak inspiratory pressures after changes to PEEP could improve clinician confidence in attempting potentially beneficial treatment strategies. METHODS This study develops and validates a physiologically relevant respiratory model that captures elastance and resistance via basis functions within a well-validated single compartment lung model. The model can be personalised using information available at a low PEEP to predict lung mechanics at a higher PEEP. Proof of concept validation is undertaken with data from four patients and eight recruitment manoeuvre arms. RESULTS Results show low error when predicting upwards over the clinically relevant pressure range, with the model able to predict peak inspiratory pressure with less than 10% error over 90% of the range of PEEP changes up to 12 cmH2O. CONCLUSIONS The results provide an in-silico model-based means of predicting clinically relevant responses to changes in MV therapy, which is the foundation of a first virtual patient for MV.
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Affiliation(s)
- S E Morton
- Department of Mechanical Engineering, University of Canterbury, New Zealand.
| | - J Dickson
- Department of Mechanical Engineering, University of Canterbury, New Zealand.
| | - J G Chase
- Department of Mechanical Engineering, University of Canterbury, New Zealand.
| | - P Docherty
- Department of Mechanical Engineering, University of Canterbury, New Zealand.
| | - T Desaive
- GIGA Cardiovascular Science, University of Liege, Liege, Belgium.
| | - S L Howe
- Department of Mechanical Engineering, University of Canterbury, New Zealand.
| | - G M Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch, New Zealand.
| | - M Tawhai
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand.
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536
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Pelosi P, Ball L. Should we titrate ventilation based on driving pressure? Maybe not in the way we would expect. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:389. [PMID: 30460263 DOI: 10.21037/atm.2018.09.48] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Mechanical ventilation maintains adequate gas exchange in patients during general anaesthesia, as well as in critically ill patients without and with acute respiratory distress syndrome (ARDS). Optimization of mechanical ventilation is important to minimize ventilator induced lung injury and improve outcome. Tidal volume (VT), positive end-expiratory pressure (PEEP), respiratory rate (RR), plateau pressures as well as inspiratory oxygen are the main parameters to set mechanical ventilation. Recently, the driving pressure (∆P), i.e., the difference of the plateau pressure and end-expiratory pressure of the respiratory system or of the lung, has been proposed as a key role parameter to optimize mechanical ventilation parameters. The ∆P depends on the VT as well as on the relative balance between the amount of aerated and/or overinflated lung at end-expiration and end-inspiration at different levels of PEEP. During surgery, higher ∆P, mainly due to VT, was progressively associated with an increased risk to develop post-operative pulmonary complications; in two large randomized controlled trials the reduction in ∆P by PEEP did not result in better outcome. In non-ARDS patients, ∆P was not found even associated with morbidity and mortality. In ARDS patients, an association between ∆P (higher than 13-15 cmH2O) and mortality has been reported. In several randomized controlled trials, when ∆P was minimized by the use of higher PEEP with or without recruitment manoeuvres, this strategy resulted in equal or even higher mortality. No clear data are currently available about the interpretation and clinical use of ∆P during assisted ventilation. In conclusion, ∆P is an indicator of severity of the lung disease, is related to VT size and associated with complications and mortality. We advocate the use of ∆P to optimize individually VT but not PEEP in mechanically ventilated patients with and without ARDS.
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Affiliation(s)
- Paolo Pelosi
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy.,Policlinico San Martino, IRCCS per l'Oncologia, Genova, Italy
| | - Lorenzo Ball
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy.,Policlinico San Martino, IRCCS per l'Oncologia, Genova, Italy
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537
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Conditional Hemodynamic Tolerance to Decremental Recruitment of the “Open Lung”*. Crit Care Med 2018; 46:1694-1695. [DOI: 10.1097/ccm.0000000000003304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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538
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Vasques F, Duscio E, Pasticci I, Romitti F, Vassalli F, Quintel M, Gattinoni L. Is the mechanical power the final word on ventilator-induced lung injury?-we are not sure. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:395. [PMID: 30460269 DOI: 10.21037/atm.2018.08.17] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Francesco Vasques
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Eleonora Duscio
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Iacopo Pasticci
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Francesco Vassalli
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Michael Quintel
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
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539
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Barbas CSV, Palazzo RF. Should we titrate mechanical ventilation based on driving pressure?-yes. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:393. [PMID: 30460267 DOI: 10.21037/atm.2018.06.26] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Recent reports revealed that lower respiratory driving pressure is associated with better ARDS patients survival during invasive mechanical ventilation and less pulmonary complications in surgical patients and at risk ICU patients without ARDS, makes the best understanding of this subject primordial for the future application of mechanical ventilatory support.
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Affiliation(s)
- Carmen Silvia Valente Barbas
- Pneumology and Intensive Care Medicine, University of São Paulo, São Paulo, Brazil.,Adult ICU, Albert Einstein Hospital, São Paulo, Brazil
| | - Roberta Fittipaldi Palazzo
- Pulmonary and Intensive Care, Albert Einstein Hospital São Paulo, Brazil.,Pneumology, University of São Paulo, São Paulo, Brazil
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540
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Huhle R, Serpa Neto A, Schultz MJ, Gama de Abreu M. Is mechanical power the final word on ventilator-induced lung injury?-no. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:394. [PMID: 30460268 DOI: 10.21037/atm.2018.09.65] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Despite being a promising idea that combines several variables related to ventilator-induced lung injury (VILI), the concept of mechanical power (MP) carries a number of limitations, leaves several open questions, lacks proper modelling of positive end-expiratory pressure (PEEP) effects and, more importantly, does not respect the amount of lung tissue subjected to MP. First, the assessment of MP as a measure for development of VILI would have the highest relevance when volume displacement and related pressure changes are measured directly within the lung. Thus, ideally the relationship between MP delivered to the total respiratory system, and that delivered to lung tissue is discerned. Second, MP as defined today relates to the inspiratory phase only, and it is very possible that the expiratory phase will also play a role. Third, the calculation of MP during spontaneous breathing is challenging as airway pressure, flow and esophageal pressure are affected counter-directionally and simultaneously overlapping by the action of the ventilator and the respiratory muscles. Fourth, in its current form, MP is modelled with a positive linear relationship with PEEP, which is based on incorrect mathematical modelling to integrate the role of PEEP into MP. Fifth, the present equation used to calculate MP is qualitatively in disagreement with clinical data on VILI. The reduction of MP to its elastic part, might not only result in a higher association with VILI, but also amplifies an indirect U-shaped relationship with PEEP.
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Affiliation(s)
- Robert Huhle
- Pulmonary Engineering Group; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein; São Paulo, Brazil.,Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.,Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group; Department of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
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541
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Marini JJ. Should we titrate positive end-expiratory pressure based on an end-expiratory transpulmonary pressure? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:391. [PMID: 30460265 DOI: 10.21037/atm.2018.08.22] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Arguments continue to swirl regarding the need for and best method of positive end-expiratory pressure (PEEP) titration. An appropriately conducted decremental method that uses modest peak pressures for the recruiting maneuver (RM), a lung protective tidal excursion, relatively small PEEP increments and appropriate timing intervals is currently the most logical and attractive option, particularly when the esophageal balloon pressure (Pes) is used to calculate transpulmonary driving pressures relevant to the lung. The setting of PEEP by the Pes-guided end-expiratory pressure at the 'polarity transition' point of the transmural end-expiratory pressure is quite relevant to the locale of the esophageal balloon catheter. Its desirability, however, is limited by its tendency to encourage PEEP levels that are higher than most other PEEP titration methods. These Pes-set PEEP values promote higher mean airway pressures and are likely to be unnecessary when small tidal driving pressures are in use. Because high airway pressures increase global lung stress and risk hemodynamic compromise, the Pes-determined PEEP would seem associated with a relatively high hazard to benefit ratio for many patients.
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Affiliation(s)
- John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN, USA
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542
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Alviar CL, Miller PE, McAreavey D, Katz JN, Lee B, Moriyama B, Soble J, van Diepen S, Solomon MA, Morrow DA. Positive Pressure Ventilation in the Cardiac Intensive Care Unit. J Am Coll Cardiol 2018; 72:1532-1553. [PMID: 30236315 PMCID: PMC11032173 DOI: 10.1016/j.jacc.2018.06.074] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 12/16/2022]
Abstract
Contemporary cardiac intensive care units (CICUs) provide care for an aging and increasingly complex patient population. The medical complexity of this population is partly driven by an increased proportion of patients with respiratory failure needing noninvasive or invasive positive pressure ventilation (PPV). PPV often plays an important role in the management of patients with cardiogenic pulmonary edema, cardiogenic shock, or cardiac arrest, and those undergoing mechanical circulatory support. Noninvasive PPV, when appropriately applied to selected patients, may reduce the need for invasive mechanical PPV and improve survival. Invasive PPV can be lifesaving, but has both favorable and unfavorable interactions with left and right ventricular physiology and carries a risk of complications that influence CICU mortality. Effective implementation of PPV requires an understanding of the underlying cardiac and pulmonary pathophysiology. Cardiologists who practice in the CICU should be proficient with the indications, appropriate selection, potential cardiopulmonary interactions, and complications of PPV.
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Affiliation(s)
- Carlos L Alviar
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida
| | - P Elliott Miller
- Division of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Dorothea McAreavey
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Jason N Katz
- Divisions of Cardiology and Pulmonary and Critical Care Medicine, University of North Carolina, Center for Heart and Vascular Care Chapel Hill, Chapel Hill, North Carolina
| | - Burton Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Brad Moriyama
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Jeffrey Soble
- Division of Cardiovascular Medicine, Rush University Medical Center, Chicago, Illinois
| | - Sean van Diepen
- Department of Critical Care and Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Michael A Solomon
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland; Cardiovascular Branch, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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543
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Barnes T, van Asseldonk D, Enk D. Minimisation of dissipated energy in the airways during mechanical ventilation by using constant inspiratory and expiratory flows - Flow-controlled ventilation (FCV). Med Hypotheses 2018; 121:167-176. [PMID: 30396474 DOI: 10.1016/j.mehy.2018.09.038] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/16/2018] [Accepted: 09/22/2018] [Indexed: 12/16/2022]
Abstract
It has been suggested that energy dissipation in the airways during mechanical ventilation is associated with an increased probability of ventilator induced lung injury (VILI). We hypothesise that energy dissipation in the airways may be minimised by ventilating with constant flow during both the inspiration and expiration phases of the respiratory cycle. We present a simple analysis and numerical calculations that support our hypothesis and show that for ventilation with minimum dissipated energy not only should the flows during inspiration and expiration be controlled to be constant and continuous, but the ventilation should also be undertaken with an I:E ratio that is close to 1:1.
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Affiliation(s)
- Tom Barnes
- University of Greenwich, Park Row, London SE10 9LE, United Kingdom.
| | - Dirk van Asseldonk
- Ventinova Medical, Meerenakkerplein 7, 5652 BJ Eindhoven, The Netherlands
| | - Dietmar Enk
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Münster (UKM), Albert-Schweitzer-Campus 1, 48149 Münster, Germany; University of Greenwich, Park Row, London SE10 9LE, United Kingdom
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544
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Driving-pressure-independent protective effects of open lung approach against experimental acute respiratory distress syndrome. Crit Care 2018; 22:228. [PMID: 30243301 PMCID: PMC6151188 DOI: 10.1186/s13054-018-2154-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 08/08/2018] [Indexed: 12/16/2022] Open
Abstract
Background The open lung approach (OLA) reportedly has lung-protective effects against acute respiratory distress syndrome (ARDS). Recently, lowering of the driving pressure (ΔP), rather than improvement in lung aeration per se, has come to be considered as the primary lung-protective mechanism of OLA. However, the driving pressure-independent protective effects of OLA have never been evaluated in experimental studies. We here evaluated whether OLA shows protective effects against experimental ARDS even when the ΔP is not lowered. Methods Lipopolysaccharide was intratracheally administered to rats to establish experimental ARDS. After 24 h, rats were mechanically ventilated and randomly allocated to the OLA or control group. In the OLA group, 5 cmH2O positive end-expiratory pressure (PEEP) and recruitment maneuver (RM) were applied. Neither PEEP nor RM was applied to the rats in the control group. Dynamic ΔP was kept at 15 cmH2O in both groups. After 6 h of mechanical ventilation, rats in both groups received RM to inflate reversible atelectasis of the lungs. Arterial blood gas analysis, lung computed tomography, histological evaluation, and comprehensive biochemical analysis were performed. Results OLA significantly improved lung aeration, arterial oxygenation, and gas exchange. Even after RM in both groups, the differences in these parameters between the two groups persisted, indicating that the atelectasis-induced respiratory dysfunction observed in the control group is not an easily reversible functional problem. Lung histological damage was severe in the dorsal dependent area in both groups, but was attenuated by OLA. White blood cell counts, protein concentrations, and tissue injury markers in the broncho-alveolar lavage fluid (BALF) were higher in the control than in the OLA group. Furthermore, levels of CXCL-7, a platelet-derived chemokine, were higher in the BALF from the control group, indicating that OLA protects the lungs by suppressing platelet activation. Conclusions OLA shows protective effects against experimental ARDS, even when the ΔP is not decreased. In addition to reducing ΔP, maintaining lung aeration seems to be important for lung protection in ARDS. Electronic supplementary material The online version of this article (10.1186/s13054-018-2154-2) contains supplementary material, which is available to authorized users.
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545
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Dissipation of energy during the respiratory cycle: conditional importance of ergotrauma to structural lung damage. Curr Opin Crit Care 2018; 24:16-22. [PMID: 29176330 DOI: 10.1097/mcc.0000000000000470] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE OF REVIEW To describe and put into context recent conceptual advances regarding the relationship of energy load and power to ventilator-induced lung injury (VILI). RECENT FINDINGS Investigative emphasis regarding VILI has almost exclusively centered on the static characteristics of the individual tidal cycle - tidal volume, plateau pressure, positive end-expiratory pressure, and driving pressure. Although those static characteristics of the tidal cycle are undeniably important, the 'dynamic' characteristics of ventilation must not be ignored. To inflict the nonrupturing damage we identify as VILI, work must be performed and energy expended by high stress cycles applied at rates that exceed the capacity of endogenous repair. Machine power, the pace at which the work performing energy load is applied by the ventilator, has received increasing scrutiny as a candidate for the proximate and integrative cause of VILI. SUMMARY Although the unmodified values of machine-delivered energy or power (which are based on airway pressures and tidal volumes) cannot serve unconditionally as a rigid and quantitative guide to ventilator adjustment for lung protection, bedside consideration of the dynamics of ventilation and potential for ergotrauma represents a clear conceptual advance that complements the static parameters of the individual tidal cycle that with few exceptions have held our scientific attention.
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546
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Khemani RG, Parvathaneni K, Yehya N, Bhalla AK, Thomas NJ, Newth CJL. Reply to Tremlett and Kanthimathinathan and to Koopman and Kneyber. Am J Respir Crit Care Med 2018; 198:823-824. [DOI: 10.1164/rccm.201806-1039le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Robinder G. Khemani
- Children’s Hospital Los AngelesLos Angeles, California
- University of Southern CaliforniaLos Angeles, California
| | - Kaushik Parvathaneni
- Children’s Hospital Los AngelesLos Angeles, California
- University of Southern CaliforniaLos Angeles, California
| | - Nadir Yehya
- University of PennsylvaniaPhiladelphia, Pennsylvaniaand
| | - Anoopindar K. Bhalla
- Children’s Hospital Los AngelesLos Angeles, California
- University of Southern CaliforniaLos Angeles, California
| | - Neal J. Thomas
- Penn State Hershey Children’s HospitalHershey, Pennsylvania
| | - Christopher J. L. Newth
- Children’s Hospital Los AngelesLos Angeles, California
- University of Southern CaliforniaLos Angeles, California
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547
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Camilo LM, Motta-Ribeiro GC, de Ávila MB, Paula LFSC, de Abreu MB, Carvalho AR, Zin WA. Variable Ventilation Associated With Recruitment Maneuver Minimizes Tissue Damage and Pulmonary Inflammation in Anesthetized Lung-Healthy Rats. Anesth Analg 2018; 127:784-791. [DOI: 10.1213/ane.0000000000003582] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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548
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Cortes-Puentes GA, Oeckler RA, Marini JJ. Physiology-guided management of hemodynamics in acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:353. [PMID: 30370280 DOI: 10.21037/atm.2018.04.40] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Skillfully implemented mechanical ventilation (MV) may prove of immense benefit in restoring physiologic homeostasis. However, since hemodynamic instability is a primary factor influencing mortality in acute respiratory distress syndrome (ARDS), clinicians should be vigilant regarding the potentially deleterious effects of MV on right ventricular (RV) function and pulmonary vascular mechanics (PVM). During both spontaneous and positive pressure MV (PPMV), tidal changes in pleural pressure (PPL), transpulmonary pressure (PTP, the difference between alveolar pressure and PPL), and lung volume influence key components of hemodynamics: preload, afterload, heart rate, and myocardial contractility. Acute cor pulmonale (ACP), which occurs in 20-25% of ARDS cases, emerges from negative effects of lung pathology and inappropriate changes in PPL and PTP on the pulmonary microcirculation during PPMV. Functional, minimally invasive hemodynamic monitoring for tracking cardiac performance and output adequacy is integral to effective care. In this review we describe a physiology-based approach to the management of hemodynamics in the setting of ARDS: avoiding excessive cardiac demand, regulating fluid balance, optimizing heart rate, and keeping focus on the pulmonary circuit as cornerstones of effective hemodynamic management for patients in all forms of respiratory failure.
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Affiliation(s)
| | - Richard A Oeckler
- Department of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Regions Hospital, St Paul, MN, USA
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549
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Jabaudon M, Blondonnet R, Pereira B, Cartin-Ceba R, Lichtenstern C, Mauri T, Determann RM, Drabek T, Hubmayr RD, Gajic O, Uhle F, Coppadoro A, Pesenti A, Schultz MJ, Ranieri MV, Brodska H, Mrozek S, Sapin V, Matthay MA, Constantin JM, Calfee CS. Plasma sRAGE is independently associated with increased mortality in ARDS: a meta-analysis of individual patient data. Intensive Care Med 2018; 44:1388-1399. [PMID: 30051136 PMCID: PMC6132684 DOI: 10.1007/s00134-018-5327-1] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Accepted: 07/17/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE The soluble receptor for advanced glycation end-products (sRAGE) is a marker of lung epithelial injury and alveolar fluid clearance (AFC), with promising values for assessing prognosis and lung injury severity in acute respiratory distress syndrome (ARDS). Because AFC is impaired in most patients with ARDS and is associated with higher mortality, we hypothesized that baseline plasma sRAGE would predict mortality, independently of two key mediators of ventilator-induced lung injury. METHODS We conducted a meta-analysis of individual data from 746 patients enrolled in eight prospective randomized and observational studies in which plasma sRAGE was measured in ARDS articles published through March 2016. The primary outcome was 90-day mortality. Using multivariate and mediation analyses, we tested the association between baseline plasma sRAGE and mortality, independently of driving pressure and tidal volume. RESULTS Higher baseline plasma sRAGE [odds ratio (OR) for each one-log increment, 1.18; 95% confidence interval (CI) 1.01-1.38; P = 0.04], driving pressure (OR for each one-point increment, 1.04; 95% CI 1.02-1.07; P = 0.002), and tidal volume (OR for each one-log increment, 1.98; 95% CI 1.07-3.64; P = 0.03) were independently associated with higher 90-day mortality in multivariate analysis. Baseline plasma sRAGE mediated a small fraction of the effect of higher ΔP on mortality but not that of higher VT. CONCLUSIONS Higher baseline plasma sRAGE was associated with higher 90-day mortality in patients with ARDS, independently of driving pressure and tidal volume, thus reinforcing the likely contribution of alveolar epithelial injury as an important prognostic factor in ARDS. Registration: PROSPERO (ID: CRD42018100241).
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Affiliation(s)
- Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 1 Place Lucie Aubrac, 63003, Clermont-Ferrand Cedex 1, France.
- CNRS, UMR 6293, INSERM U1103, GReD, Université Clermont Auvergne, Clermont-Ferrand, France.
| | - Raiko Blondonnet
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 1 Place Lucie Aubrac, 63003, Clermont-Ferrand Cedex 1, France
- CNRS, UMR 6293, INSERM U1103, GReD, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit, Department of Clinical Research and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | | | - Tomas Drabek
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Rolf D Hubmayr
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Ognjen Gajic
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Florian Uhle
- Department of Anesthesiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Andrea Coppadoro
- Department of Emergency Medicine, San Gerardo Hospital, Monza, Italy
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Marcus J Schultz
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Bangkok, Thailand
| | - Marco V Ranieri
- Department of Surgical Sciences, Molinette Hospital, City of Health and Science, University of Turin, Turin, Italy
| | - Helena Brodska
- Institute of Clinical Biochemistry and Laboratory Diagnostics, Faculty of Medicine, General University Hospital, Charles University, Prague, Czech Republic
| | - Ségolène Mrozek
- Department of Anesthesia and Intensive Care, University Hospital of Toulouse, University Toulouse 3 Paul Sabatier, Toulouse, France
| | - Vincent Sapin
- CNRS, UMR 6293, INSERM U1103, GReD, Université Clermont Auvergne, Clermont-Ferrand, France
- Department of Medical Biochemistry and Molecular Biology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Michael A Matthay
- Division of Pulmonary and Critical Care Medicine, Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
| | - Jean-Michel Constantin
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 1 Place Lucie Aubrac, 63003, Clermont-Ferrand Cedex 1, France
- CNRS, UMR 6293, INSERM U1103, GReD, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Carolyn S Calfee
- Division of Pulmonary and Critical Care Medicine, Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
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Mi MY, Matthay MA, Morris AH. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med 2018; 379:884-887. [PMID: 30157406 DOI: 10.1056/nejmclde1804601] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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