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Fan E, Wilcox ME, Brower RG, Stewart TE, Mehta S, Lapinsky SE, Meade MO, Ferguson ND. Recruitment maneuvers for acute lung injury: a systematic review. Am J Respir Crit Care Med 2008; 178:1156-63. [PMID: 18776154 DOI: 10.1164/rccm.200802-335oc] [Citation(s) in RCA: 203] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE There are conflicting data regarding the safety and efficacy of recruitment maneuvers (RMs) in patients with acute lung injury (ALI). OBJECTIVES To summarize the physiologic effects and adverse events in adult patients with ALI receiving RMs. METHODS Systematic review of case series, observational studies, and randomized clinical trials with pooling of study-level data. MEASUREMENTS AND MAIN RESULTS Forty studies (1,185 patients) met inclusion criteria. Oxygenation (31 studies; 636 patients) was significantly increased after an RM (PaO2): 106 versus 193 mm Hg, P = 0.001; and PaO2/FiO2 ratio: 139 versus 251 mm Hg, P < 0.001). There were no persistent, clinically significant changes in hemodynamic parameters after an RM. Ventilatory parameters (32 studies; 548 patients) were not significantly altered by an RM, except for higher PEEP post-RM (11 versus 16 cm H2O; P = 0.02). Hypotension (12%) and desaturation (9%) were the most common adverse events (31 studies; 985 patients). Serious adverse events (e.g., barotrauma [1%] and arrhythmias [1%]) were infrequent. Only 10 (1%) patients had their RMs terminated prematurely due to adverse events. CONCLUSIONS Adult patients with ALI receiving RMs experienced a significant increase in oxygenation, with few serious adverse events. Transient hypotension and desaturation during RMs is common but is self-limited without serious short-term sequelae. Given the uncertain benefit of transient oxygenation improvements in patients with ALI and the lack of information on their influence on clinical outcomes, the routine use of RMs cannot be recommended or discouraged at this time. RMs should be considered for use on an individualized basis in patients with ALI who have life-threatening hypoxemia.
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Affiliation(s)
- Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Abstract
OBJECTIVE The aim of this study is to test the hypothesis that recruitment maneuvers (RMs) might act differently in models of pulmonary (p) and extrapulmonary (exp) acute lung injury (ALI) with similar transpulmonary pressure changes. DESIGN Prospective, randomized, controlled experimental study. SETTING University research laboratory. SUBJECTS Wistar rats were randomly divided into four groups. In control groups, sterile saline solution was intratracheally (0.1 mL, Cp) or intraperitoneally (1 mL, Cexp) injected, whereas ALI animals received Escherichia coli lipopolysaccharide intratracheally (100 microg, ALIp) or intraperitoneally (1 mg, ALIexp). After 24 hrs, animals were mechanically ventilated (tidal volume, 6 mL/kg; positive end-expiratory pressure, 5 cm H2O) and three RMs (pressure inflations to 40 cm H2O for 40 secs, 1 min apart) applied. MEASUREMENTS AND MAIN RESULTS PaO2, lung resistive and viscoelastic pressures, static elastance, lung histology (light and electron microscopy), and type III procollagen messenger RNA expression in pulmonary tissue were measured before RMs and at the end of 1 hr of mechanical ventilation. Mechanical variables, gas exchange, and the fraction of area of alveolar collapse were similar in both ALI groups. After RMs, lung resistive and viscoelastic pressures and static elastance decreased more in ALIexp (255%, 180%, and 118%, respectively) than in ALIp (103%, 59%, and 89%, respectively). The amount of atelectasis decreased more in ALIexp than in ALIp (from 58% to 19% and from 59% to 33%, respectively). RMs augmented type III procollagen messenger RNA expression only in the ALIp group (19%), associated with worsening in alveolar epithelium injury but no capillary endothelium lesion, whereas the ALIexp group showed a minor detachment of the alveolar capillary membrane. CONCLUSIONS Given the same transpulmonary pressures, RMs are more effective at opening collapsed alveoli in ALIexp than in ALIp, thus improving lung mechanics and oxygenation with limited damage to alveolar epithelium.
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Constantin JM, Jaber S, Futier E, Cayot-Constantin S, Verny-Pic M, Jung B, Bailly A, Guerin R, Bazin JE. Respiratory effects of different recruitment maneuvers in acute respiratory distress syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:R50. [PMID: 18416847 PMCID: PMC2447604 DOI: 10.1186/cc6869] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2008] [Revised: 03/31/2008] [Accepted: 04/16/2008] [Indexed: 12/11/2022]
Abstract
Introduction Alveolar derecruitment may occur during low tidal volume ventilation and may be prevented by recruitment maneuvers (RMs). The aim of this study was to compare two RMs in acute respiratory distress syndrome (ARDS) patients. Methods Nineteen patients with ARDS and protective ventilation were included in a randomized crossover study. Both RMs were applied in each patient, beginning with either continuous positive airway pressure (CPAP) with 40 cm H2O for 40 seconds or extended sigh (eSigh) consisting of a positive end-expiratory pressure maintained at 10 cm H2O above the lower inflection point of the pressure-volume curve for 15 minutes. Recruited volume, arterial partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2), and hemodynamic parameters were recorded before (baseline) and 5 and 60 minutes after RM. All patients had a lung computed tomography (CT) scan before study inclusion. Results Before RM, PaO2/FiO2 was 151 ± 61 mm Hg. Both RMs increased oxygenation, but the increase in PaO2/FiO2 was significantly higher with eSigh than CPAP at 5 minutes (73% ± 25% versus 44% ± 28%; P < 0.001) and 60 minutes (68% ± 23% versus 35% ± 22%; P < 0.001). Only eSigh significantly increased recruited volume at 5 and 60 minutes (21% ± 22% and 21% ± 25%; P = 0.0003 and P = 0.001, respectively). The only difference between responders and non-responders was CT lung morphology. Eleven patients were considered as recruiters with eSigh (10 with diffuse loss of aeration) and 6 with CPAP (5 with diffuse loss of aeration). During CPAP, 2 patients needed interruption of RM due to a drop in systolic arterial pressure. Conclusion Both RMs effectively increase oxygenation, but CPAP failed to increase recruited volume. When the lung is recruited with an eSigh adapted for each patient, alveolar recruitment and oxygenation are superior to those observed with CPAP.
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Affiliation(s)
- Jean-Michel Constantin
- General Intensive Care Unit, Hotel-Dieu Hospital, University Hospital of Clermont-Ferrand, Boulevard L, Malfreyt, 63058 Clermond-Ferrand, France.
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Pulmonary and extrapulmonary acute respiratory distress syndrome: myth or reality? Curr Opin Crit Care 2008; 14:50-5. [DOI: 10.1097/mcc.0b013e3282f2405b] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Morrow B, Futter M, Argent A. A recruitment manoeuvre performed after endotracheal suction does not increase dynamic compliance in ventilated paediatric patients: a randomised controlled trial. ACTA ACUST UNITED AC 2007; 53:163-9. [PMID: 17725473 DOI: 10.1016/s0004-9514(07)70023-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
QUESTION Does a recruitment manoeuvre after suctioning have any immediate or short-term effect on ventilation and gas exchange in mechanically-ventilated paediatric patients? DESIGN Randomised controlled trial with concealed allocation, assessor blinding, and intention-to-treat analysis. PARTICIPANTS Forty-eight paediatric patients with heterogeneous lung pathology. Fourteen patients were subsequently excluded from analysis due to large leaks around the endotracheal tube. INTERVENTION The experimental group received a single standardised suctioning procedure followed five minutes later by a standardised recruitment manoeuvre. The control group received only the single suctioning procedure. OUTCOME MEASURES Measurements of ventilation (dynamic lung compliance, expiratory airway resistance, mechanical and spontaneous expired tidal volume, respiratory rate) and gas exchange (transcutaneous oxygen saturation) were recorded, on three occasions before and on two occasions after the recruitment manoeuvre, using a respiratory profile monitor. RESULTS There was no difference between the experimental and the control group in dynamic compliance, expired airway resistance, or oxygen saturation either immediately after the recruitment manoeuvre, or after 25 minutes. The experimental group decreased mechanical expired tidal volume by 0.3 ml/kg (95% CI 0.1 to 0.6), increased spontaneous expired tidal volume by 0.3 ml/kg (95% CI 0.0 to 0.6), and increased total respiratory rate by 3 bpm (95% CI 1 to 4) immediately after the recruitment manoeuvre compared with the control group, but these differences disappeared after 25 minutes. CONCLUSION There is insufficient evidence to support performing recruitment manoeuvres after suctioning infants and children.
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Duff JP, Rosychuk RJ, Joffe AR. The safety and efficacy of sustained inflations as a lung recruitment maneuver in pediatric intensive care unit patients. Intensive Care Med 2007; 33:1778-86. [PMID: 17607560 DOI: 10.1007/s00134-007-0764-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2006] [Accepted: 06/05/2007] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess the safety and efficacy of sustained inflations (SI) as lung recruitment maneuvers (RMs) in ventilated pediatric intensive care unit (PICU) patients. DESIGN Observational, prospective data collection. SETTING Tertiary-care PICU. PATIENTS AND PARTICIPANTS Thirty-two consecutive ventilated pediatric patients. INTERVENTIONS An SI (30-40 cmH(2)O for 15-20 s) was performed following a ventilator disconnection, suctioning, hypoxemia, or routinely every 12 h. Physiologic variables were recorded for 6 h after each SI. All other management was at the attending physician's discretion. The change in variables from pre-SI to post-SI (at 2, 10, and 15 min, 1, 2, 3, 4, 5, and 6 h) was compared using mixed models to account for repeated measures in the same patient. MEASUREMENTS AND RESULTS 93 RMs were performed on 32 patients (ages 11 days to 14 years). RMs were done after suctioning (58/93, 62%), ventilator disconnect (5/93, 5%), desaturation (8/93, 9%), or routinely (22/93, 24%). Seven of 93 RMs (7.5%) were interrupted for patient agitation, and 2/93 (2.2%) for transient bradycardia. There was no evidence of statistically significant changes in systolic blood pressure, heart rate, or oxygen saturation as measured by pulse oximetry from pre-RM to post-RM, and there were no air leaks. In three patients with altered intracranial compliance, three of eight RM were associated with a spike of intracranial pressure. There was a sustained significant decrease in FiO(2) by 6.1% lasting up to 6 h post-RM. CONCLUSIONS RMs (as SI) are safe in ventilated PICU patients and are associated with a significant reduction in oxygen requirements for the 6 h after the RM.
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Affiliation(s)
- Jonathan P Duff
- Division of Critical Care Medicine, Stollery Children's Hospital, University of Alberta, 8440-112 Street, 3A3.19 WMC, T6G 2B7, Edmonton, Alberta, Canada.
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Turner DA, Arnold JH. Insights in pediatric ventilation: timing of intubation, ventilatory strategies, and weaning. Curr Opin Crit Care 2007; 13:57-63. [PMID: 17198050 DOI: 10.1097/mcc.0b013e32801297f9] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Mechanical ventilation is a common intervention provided by pediatric intensivists. This fact notwithstanding, the management of mechanical ventilation in pediatrics is largely guided by a few pediatric trials along with careful interpretation and application of adult data. RECENT FINDINGS A low tidal volume, pressure limited approach to mechanical ventilation as established by the Acute Respiratory Distress Syndrome Network investigators, has become the prevailing practice in pediatric intensive care. Studies by these investigators suggest that high positive end expiratory pressure and recruitment maneuvers are not uniformly beneficial. High frequency oscillatory ventilation continues to be evaluated in an attempt to provide 'open lung' ventilation. Airway pressure release ventilation is a newer mode of ventilation that may combine the 'open lung' approach with spontaneous breathing. Prone positioning was demonstrated in a recent pediatric trial to have no effect on outcome, while calfactant was found to potentially improve outcomes in pediatric acute respiratory distress syndrome. Ventilator weaning protocols may not be as useful in pediatrics as in adults. Systemic corticosteroids decrease the incidence of post extubation stridor and may reduce reintubation rates. SUMMARY Mechanical ventilation with pressure limitation and low tidal volumes has become customary in pediatric intensive care units, and this lung protective approach will continue into the foreseeable future. Further investigation is warranted regarding use of high frequency oscillatory ventilation, airway pressure release ventilation, and surfactant to assist pediatric intensivists in application of these therapies.
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Affiliation(s)
- David A Turner
- Harvard Medical School and Department of Anesthesia, Division of Critical Care Medicine, Children's Hospital, Boston, Massachusetts, USA.
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Allen GB, Leclair T, Cloutier M, Thompson-Figueroa J, Bates JHT. The response to recruitment worsens with progression of lung injury and fibrin accumulation in a mouse model of acid aspiration. Am J Physiol Lung Cell Mol Physiol 2007; 292:L1580-9. [PMID: 17351059 DOI: 10.1152/ajplung.00483.2006] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Reopening the injured lung with deep inflation (DI) and positive end-expiratory pressure (PEEP) likely depends on the duration and severity of acute lung injury (ALI), key features of which include increased alveolar permeability and fibrin accumulation. We hypothesized that the response to DI and PEEP would worsen as ALI evolves and that this would correspond with increasing accumulation of alveolar fibrin. C57BL/6 mice were anesthetized and aspirated 75 μl of HCl (pH 1.8) or buffered normal saline. Subgroups were reanesthetized 4, 14, 24, and 48 h later. Following DI, tissue damping (G) and elastance (H) were measured periodically at PEEP of 1, 3, and 6 cmH2O, and air within the lung (thoracic gas volume) was quantified by microcomputed tomography. Following DI, G and H increased with time during progressive lung derecruitment, the latter confirmed by microcomputed tomography. The rise in H was greater in acid-injured mice than in controls ( P < 0.05) and also increased from 4 to 48 h after acid aspiration, reflecting progressively worsening injury. The rise in H was reduced by PEEP, but this effect was significantly blunted by 48 h ( P < 0.05), also confirmed by thoracic gas volume. Lung permeability and alveolar fibrin also increased over the 48-h study period, accompanied by increasing levels and transcription of the fibrinolysis inhibitor plasminogen activator inhibitor-1. Lung injury worsens progressively in mice during the 48 h following acid aspiration. This injury manifests as progressively increasing alveolar instability, likely due to surfactant dysfunction caused by increasing levels of alveolar protein and fibrin.
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Affiliation(s)
- Gilman B Allen
- Vermont Lung Center, Department of Medicine, University of Vermont, Burlington, Vermont, USA.
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60
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Papadakos PJ, Lachmann B. The open lung concept of mechanical ventilation: the role of recruitment and stabilization. Crit Care Clin 2007; 23:241-50, ix-x. [PMID: 17368168 DOI: 10.1016/j.ccc.2006.12.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This article describes the pathophysiologic basis and clinical role for lung recruitment maneuvers. It reviews the literature and presents the authors' clinical experience of over 15 years in the collaboration between Erasmus MC and the University of Rochester. The authors are hopeful that these lung-protective strategies are presented in a useful format that may be useful to the practicing intensivist, thus bringing laboratory and clinical research to bedside practice.
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Affiliation(s)
- Peter J Papadakos
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Box 604, 601 Elmwood Avenue, Rochester, NY 14642, USA.
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Verbrugge SJC, Lachmann B, Kesecioglu J. Lung protective ventilatory strategies in acute lung injury and acute respiratory distress syndrome: from experimental findings to clinical application. Clin Physiol Funct Imaging 2007; 27:67-90. [PMID: 17309528 DOI: 10.1111/j.1475-097x.2007.00722.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
This review addresses the physiological background and the current status of evidence regarding ventilator-induced lung injury and lung protective strategies. Lung protective ventilatory strategies have been shown to reduce mortality from adult respiratory distress syndrome (ARDS). We review the latest knowledge on the progression of lung injury by mechanical ventilation and correlate the findings of experimental work with results from clinical studies. We describe the experimental and clinical evidence of the effect of lung protective ventilatory strategies and open lung strategies on the progression of lung injury and current controversies surrounding these subjects. We describe a rational strategy, the open lung strategy, to accomplish an open lung, which may further prevent injury caused by mechanical ventilation. Finally, the clinician is offered directions on lung protective ventilation in the early phase of ARDS which can be applied on the intensive care unit.
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Affiliation(s)
- Serge J C Verbrugge
- Department of Intensive Care Medicine, University Medical Center Utrecht, Utrecht, The Netherlands.
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62
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Lapinsky SE, Mehta S. ARDS--shake, rattle, and roll! Crit Care Med 2007; 35:303-4. [PMID: 17197775 DOI: 10.1097/01.ccm.0000251845.70488.2d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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63
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Rice TW, Bernard GR. Acute lung injury and the acute respiratory distress syndrome: challenges in clinical trial design. Clin Chest Med 2007; 27:733-54; abstract xi. [PMID: 17085259 DOI: 10.1016/j.ccm.2006.06.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Despite significant advances in the understanding of the complex pathophysiology, only a limited number of new treatments for acute lung injury (ALI) have emerged in the last 2 decades. This article discusses some of the challenges that remain in conducting clinical research in patients who have ALI and acute respiratory distress syndrome. New definitions that incorporate prognostic measures and reduce patient heterogeneity will allow more efficient enrollment of patients. Delineating outcomes attributable to the lung injury will improve the power of studies to detect significant treatment effects. Future collaborative studies will be needed to investigate longer-term clinical outcomes.
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Affiliation(s)
- Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232-2650, USA.
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64
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Baik HJ, Kim YJ, Kim JH, Sohn JE. Effect of Recruiting Maneuvers in a Patient with Acute Lung Injury after Femoral Nailing -A case report-. Korean J Anesthesiol 2007. [DOI: 10.4097/kjae.2007.52.6.s91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Hee Jung Baik
- Department of Anesthesiology and Pain Medicine, School of Mediciane, Ewha Womans University, Seoul, Korea
| | - Youn Jin Kim
- Department of Anesthesiology and Pain Medicine, School of Mediciane, Ewha Womans University, Seoul, Korea
| | - Jong Hak Kim
- Department of Anesthesiology and Pain Medicine, School of Mediciane, Ewha Womans University, Seoul, Korea
| | - Jeong Eun Sohn
- Department of Anesthesiology and Pain Medicine, School of Mediciane, Ewha Womans University, Seoul, Korea
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Demory D, Michelet P, Arnal JM, Donati S, Forel JM, Gainnier M, Brégeon F, Papazian L. High-frequency oscillatory ventilation following prone positioning prevents a further impairment in oxygenation*. Crit Care Med 2007; 35:106-11. [PMID: 17133185 DOI: 10.1097/01.ccm.0000251128.60336.fe] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVE The improvement in oxygenation with prone positioning is not persistent when patients with acute respiratory distress syndrome (ARDS) are turned supine. High-frequency oscillatory ventilation (HFOV) aims to maintain an open lung volume by the application of a constant mean airway pressure. The aim of this study was to show that HFOV is able to prevent the impairment in oxygenation when ARDS patients are turned back from the prone to the supine position. DESIGN Prospective, comparative randomized study. SETTING A medical intensive care unit. PATIENTS Forty-three ARDS patients with a Pao2/Fio2 ratio <150 at positive end-expiratory pressure > or =5 cm H2O. INTERVENTIONS After an optimization period, the patients were assigned to one of three groups: a) conventional lung-protective mechanical ventilation in the prone position (12 hrs) followed by a 12-hr period of conventional lung-protective mechanical ventilation in the supine position (CV(prone)-CV(supine)); b) conventional lung-protective mechanical ventilation in the supine position (12 hrs) followed by HFOV in the supine position (12 hrs) (CV(supine)-HFOV(supine)); or c) conventional lung-protective mechanical ventilation in the prone position (12 hrs) followed by HFOV in the supine position (CV(prone)-HFOV(supine) group). MEASUREMENTS AND MAIN RESULTS Pao2/Fio2 ratio was higher at the end of the study period in the CV(prone)-HFOV(supine) group than in the CV(prone)-CV(supine) group (p < .02). Venous admixture at the end of the study period was lower in the CV(prone)-HFOV(supine) group than in the two other groups. CONCLUSIONS HFOV maintained the improvement in oxygenation related to prone positioning when ARDS patients were returned to the supine position.
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Affiliation(s)
- Didier Demory
- Service de Réanimation Médicale, Hôpital Sainte-Marguerite, Université de la Méditerranée, Marseille, France
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Chung KS, Park BH, Shin SY, Jeon HH, Park SC, Kang SM, Park MS, Han CH, Kim CJ, Lee SM, Kim SK, Chang J, Kim SK, Kim YS. The Effect and Safety of Alveolar Recruitment Maneuver using Pressure-Controlled Ventilation in Acute Lung Injury and Acute Respiratory Distress Syndrome. Tuberc Respir Dis (Seoul) 2007. [DOI: 10.4046/trd.2007.63.5.423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Kyung Soo Chung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Hoon Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Yun Shin
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Han Ho Jeon
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seon Cheol Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Shin Myung Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Moo Suk Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Chest Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Hoon Han
- Department of Internal Medicine, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
| | - Chong Ju Kim
- Department of Internal Medicine, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
| | - Sun Min Lee
- Department of Internal Medicine, National Health Insurance Corporation Ilsan Hospital, Goyang, Korea
| | - Se Kyu Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Chest Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Chang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Chest Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kyu Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Chest Disease, Yonsei University College of Medicine, Seoul, Korea
| | - Young Sam Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
- Institute of Chest Disease, Yonsei University College of Medicine, Seoul, Korea
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Lungenversagen. CHIRURGISCHE INTENSIVMEDIZIN 2007. [PMCID: PMC7121608 DOI: 10.1007/978-3-211-29682-0_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Das akute Lungenversagen ist eine schwere diffuse entzündliche Erkrankung der Lunge. Nach der „American-European Consensus Conference“ (Bernard et al., 1994) wird zwischen einem ARDS — acute respiratory distress syndrom und einem ALI — acute lung injury unterschieden.
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Abstract
BACKGROUND Severe respiratory failure (including acute lung injury and acute respiratory distress syndrome) continues to be associated with significant mortality and morbidity in patients of all ages. OBJECTIVE To review the laboratory and clinical data in support of and future directions for the advanced treatment of severe respiratory failure. DATA SOURCES MEDLINE/PubMed search of all relevant primary and review articles. DATA SYNTHESIS Our understanding of lung pathophysiology and the role of ventilator-induced lung injury through basic science investigation has led to advances in lung protective strategies for the mechanical ventilation support of patients with severe respiratory failure. Specific modalities reviewed include low-tidal volume ventilation, permissive hypercapnia, the open lung approach, recruitment maneuvers, airway pressure release ventilation, high-frequency oscillatory ventilation, prone positioning, and extracorporeal life support. The pharmacologic strategies (including corticosteroids, surfactant, and nitric oxide) investigated for the treatment of severe respiratory failure are also reviewed. CONCLUSION In patients with severe respiratory failure, an incremental approach to the management of severe hypoxemia requires implementation of the strategies reviewed, with knowledge of the evidence base to support these strategies.
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Affiliation(s)
- Mark R Hemmila
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, USA
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Parker CM, Heyland DK, Groll D, Caeser M. Mechanism of injury influences quality of life in survivors of acute respiratory distress syndrome. Intensive Care Med 2006; 32:1895-900. [PMID: 16983550 DOI: 10.1007/s00134-006-0344-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2005] [Accepted: 07/24/2006] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Growing evidence suggests that acute respiratory distress syndrome (ARDS) occurring as a consequence of primary (direct) lung injury differs from that resulting from secondary (indirect) lung injury in terms of radiographic appearance, response to interventions, and outcomes. We examined whether there are differences in quality of life (QOL) in survivors of ARDS attributable to the mechanism of underlying lung injury. DESIGN AND SETTING Prospective observational cohort study in 54 intensive care units in Canada and the United States. PATIENTS AND PARTICIPANTS Survivors of ARDS (n=73) were grouped according to underlying cause of ARDS (i.e., primary vs. secondary lung injury) and followed prospectively for 12months. MEASUREMENTS AND RESULTS QOL was assessed using the Medical Outcomes Study 36-item Short Form Health Survey (SF-36) and the St. George's Respiratory Questionnaire (SGRQ), and spirometry was performed at each outpatient follow-up visit. At 3months mortality and QOL outcomes were similar between the groups, but by 12months patients with primary lung injury had significantly better QOL scores in four of eight SF-36 domains and in two of three domains of the SGRQ. Differences were not attributable to duration of ICU or hospital length of stay, duration of mechanical ventilation, comorbidities prior to the index illness, or differences in spirometry during the follow-up period. CONCLUSIONS QOL in survivors of ARDS appears to be influenced by the mechanism of lung injury (primary vs. secondary), lending support to the concept that ARDS is a heterogeneous condition.
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Affiliation(s)
- Chris M Parker
- Department of Medicine, Queen's University, Kingston, Canada
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Maggiore SM, Antonelli M. Expanding our horizons beyond the intensive care unit: does mechanism of lung injury influence the quality of life in ARDS survivors? Intensive Care Med 2006; 32:1683-5. [PMID: 16957902 DOI: 10.1007/s00134-006-0345-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2006] [Accepted: 07/24/2006] [Indexed: 10/24/2022]
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Marini JJ. Limitations of clinical trials in acute lung injury and acute respiratory distress syndrome. Curr Opin Crit Care 2006; 12:25-31. [PMID: 16394780 DOI: 10.1097/01.ccx.0000198996.22072.4a] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To review the challenges and limitations of randomized clinical trials in acute respiratory distress syndrome, with special emphasis on those pertaining to ventilatory management. RECENT FINDINGS Superbly executed randomized trials of ventilatory strategy have garnered deserved attention from the critical care community and yet have illustrated the limitations of our current approach to clinical research in this area. Inexact definitions, incomplete mechanistic understanding of complex pathophysiology, inappropriate outcome variables, diverse therapeutic environments, lengthy data acquisition time and ethical constraints on trial design limit the applicability of randomized control trial methodology to acute respiratory distress syndrome and acute lung injury. As yet, clinical practice does not seem to have been greatly impacted by the implications of completed randomized controlled trials per se. Recent issues, both ethical and interpretive, regarding control group participants have raised troubling and theoretically important issues that are yet to be fully resolved. SUMMARY Without tighter definitions of the condition under treatment, more specific targets for interventions to act upon, stratification that recognizes key interactive elements, and cointerventions based on better mechanistic understanding, randomized controlled trials of new drugs, ventilatory strategy, and other management approaches in acute respiratory distress syndrome are likely to remain a blunt instrument for investigation. As valuable as they are for calling important therapeutic principles to attention and for helping to suggest general guidelines for care, the limitations of randomized controlled trials for treating the individual with acute respiratory distress syndrome must be acknowledged.
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Affiliation(s)
- John J Marini
- University of Minnesota, Minneapolis/St Paul, Minnesota 55101, USA.
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72
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Wolf S, Plev DV, Trost HA, Lumenta CB. Open lung ventilation in neurosurgery: an update on brain tissue oxygenation. ACTA NEUROCHIRURGICA. SUPPLEMENT 2006; 95:103-5. [PMID: 16463830 DOI: 10.1007/3-211-32318-x_22] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Recently, we showed the feasibility of ventilating neurosurgical patients with acute intracranial pathology and concomitant acute respiratory distress syndrome (ARDS) according the so-called Open Lung approach. This technique consists of low tidal volume, elevated positive expiratory pressure (PEEP) level and initial recruitment maneuvers to open up collapsed alveoli. In this report, we focus on our experience to guide recruitment with brain tissue oxygenation (pbrO2) probes. We studied recruitment maneuvers in thirteen patients with ARDS and acute brain injury such as subarachnoid hemorrhage and traumatic brain injury. A pbrO2 probe was implanted in brain tissue at risk for hypoxia. Recruitment maneuvers were performed at an inspired oxygen frcation (FiO2) of 1.0 and a PEEP level of 30 40 cmH2O for 40 seconds. The mean FiO2 necessary for normoxemia could be decreased from 0.85 +/- 0.17 before recruitment to 0.55 +/- 0.12 after 24 hours, while mean PbrO2 (24.6 mmHg before recruitment) did not change. At a mean of 17 minutes after the first recruitment maneuver, PbrO2 showed peak a value of 35.6 +/- 16.6 mmHg, reflecting improvement in arterial oxygenation at an FiO2 of 1.0. Brain tissue oxygenation monitoring provides a useful adjunct to estimate the effects of recruitment maneuvers and ventilator settings in neurosurgical patients with acute lung injury.
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Affiliation(s)
- S Wolf
- Department of Neurosurgery, Academic Hospital Munich-Bogenhausen, Technical University of Munich, Munich, Germany.
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73
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Abstract
OBJECTIVE To summarize the pathophysiology and treatment of acute lung injury and acute respiratory distress syndrome (ARDS) during pregnancy. DATA SOURCE Review of select articles from MEDLINE, including published abstracts, case reports, observational studies, controlled trials, review articles, and institutional experience. DATA SUMMARY ARDS occurs in pregnancy and may have unique causes. Despite extensive clinical research to improve the management of ARDS, mortality remains high, and few strategies have shown a mortality benefit. Furthermore, in most published studies, pregnancy is an exclusionary criterion, and thus, few treatments have been adequately evaluated in obstetric populations. The treatment of ARDS in pregnancy is extrapolated from studies performed in the general ARDS patient population, with consideration given to the normal physiologic changes of pregnancy. In general, the best support of the fetus is support of the mother. From the age of viability (24-26 wks at most institutions) until full term, decisions regarding delivery should be made based primarily on the standard obstetric indications. CONCLUSIONS Little evidence exists regarding the management of ARDS specifically in pregnancy, and thus, treatment approaches must be drawn from studies performed in a general patient population. A multidisciplinary approach involving maternal-fetal medicine, neonatology, anesthesiology, and intensivist clinicians is essential to optimizing maternal and fetal outcomes.
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Affiliation(s)
- Daniel E Cole
- Pulmonary and Critical Care Flight, Wilford Hall Medical Center, Lackland Air Force Base, TX, USA
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74
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Bein T, Calzia E. Open up the lung, but smooth and gentle, please! Intensive Care Med 2005; 31:1603-4. [PMID: 16177919 DOI: 10.1007/s00134-005-2800-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2005] [Accepted: 08/05/2005] [Indexed: 11/30/2022]
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75
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Hinz J, Moerer O, Quintel M. Rekrutierungsmanöver bei Patienten mit Lungenversagen. Anaesthesist 2005; 54:1111-9. [PMID: 16075254 DOI: 10.1007/s00101-005-0906-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Recruitment maneuvers have been proposed as an adjunct to mechanical ventilation to re-expand collapsed lung regions. Although, in most patients recruitment maneuvers improve gas exchange a controversial discussion on recruitment maneuvers remains. This article reviews the physiological and patho-physiological backgrounds of recruitment maneuvers. The different recruitment maneuvers and possible monitoring are discussed as well as the influence of recruitment on other organs. Furthermore, we discuss whether recruitment maneuvers are useful if patients with acute lung injury or acute respiratory distress syndrome are ventilated with a lung-protective strategy.
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Affiliation(s)
- J Hinz
- Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin, Georg-August-Universität, Göttingen.
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76
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Odenstedt H, Lindgren S, Olegård C, Erlandsson K, Lethvall S, Aneman A, Stenqvist O, Lundin S. Slow moderate pressure recruitment maneuver minimizes negative circulatory and lung mechanic side effects: evaluation of recruitment maneuvers using electric impedance tomography. Intensive Care Med 2005; 31:1706-14. [PMID: 16177920 DOI: 10.1007/s00134-005-2799-6] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2005] [Accepted: 08/05/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the efficacy of different lung recruitment maneuvers using electric impedance tomography. DESIGN AND SETTING Experimental study in animal model of acute lung injury in an animal research laboratory. SUBJECTS Fourteen pigs with saline lavage induced lung injury. INTERVENTIONS Lung volume, regional ventilation distribution, gas exchange, and hemodynamics were monitored during three different recruitment procedures: (a) vital capacity maneuver to an inspiratory pressure of 40 cmH2O (ViCM), (b) pressure-controlled recruitment maneuver with peak pressure 40 and PEEP 20 cmH2O, both maneuvers repeated three times for 30 s (PCRM), and (c) a slow recruitment with PEEP elevation to 15 cmH2O with end inspiratory pauses for 7 s twice per minute over 15 min (SLRM). MEASUREMENTS AND RESULTS Improvement in lung volume, compliance, and gas exchange were similar in all three procedures 15 min after recruitment. Ventilation in dorsal regions of the lungs increased by 60% as a result of increased regional compliance. During PCRM compliance decreased by 50% in the ventral region. Cardiac output decreased by 63+/-4% during ViCM, 44+/-2% during PCRM, and 21+/-3% during SLRM. CONCLUSIONS In a lavage model of acute lung injury alveolar recruitment can be achieved with a slow lower pressure recruitment maneuver with less circulatory depression and negative lung mechanic side effects than with higher pressure recruitment maneuvers. With electric impedance tomography it was possible to monitor lung volume changes continuously.
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Affiliation(s)
- Helena Odenstedt
- Department of Anesthesia and Intensive Care, Sahlgrenska University Hospital, 41345, Gothenburg, Sweden.
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77
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Coakes J. Combining High-Frequency Oscillatory Ventilation and Recruitment Maneuvers in Adults with Early Acute Respiratory Distress Syndrome: The Treatment with Oscillation and an Open Lung Strategy (TOOLS) Trial Pilot Study. J Intensive Care Soc 2005. [DOI: 10.1177/175114370500600223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Rouby JJ, Lu Q. Bench-to-bedside review: adjuncts to mechanical ventilation in patients with acute lung injury. Crit Care 2005; 9:465-71. [PMID: 16277735 PMCID: PMC1297606 DOI: 10.1186/cc3763] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Mechanical ventilation is indispensable for the survival of patients with acute lung injury and acute respiratory distress syndrome. However, excessive tidal volumes and inadequate lung recruitment may contribute to mortality by causing ventilator-induced lung injury. This bench-to-bedside review presents the scientific rationale for using adjuncts to mechanical ventilation aimed at optimizing lung recruitment and preventing the deleterious consequences of reduced tidal volume. To enhance CO2 elimination when tidal volume is reduced, the following are possible: first, ventilator respiratory frequency can be increased without necessarily generating intrinsic positive end-expiratory pressure; second, instrumental dead space can be reduced by replacing the heat and moisture exchanger with a conventional humidifier; and third, expiratory washout can be used for replacing the CO2-laden gas present at end expiration in the instrumental dead space by a fresh gas (this method is still experimental). For optimizing lung recruitment and preventing lung derecruitment there are the following possibilities: first, recruitment manoeuvres may be performed in the most hypoxaemic patients before implementing the preset positive end-expiratory pressure or after episodes of accidental lung derecruitment; second, the patient can be turned to the prone position; third, closed-circuit endotracheal suctioning is to be preferred to open endotracheal suctioning.
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Affiliation(s)
- Jean-Jacques Rouby
- Professor of Anesthesiology and Critical Care Medicine, Director of the Surgical Intensive Care Unit Pierre Viars, La Pitié-Salpêtrière Hospital, University of Paris, Paris, France
| | - Qin Lu
- Praticien Hospitalier, Surgical Intensive Care Unit Pierre Viars, Department of Anesthesiology, Research Coordinator, La Pitié-Salpêtrière Hospital, Paris, France
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Medoff BD, Shepard JAO, Smith RN, Kratz A. Case records of the Massachusetts General Hospital. Case 17-2005. A 22-year-old woman with back and leg pain and respiratory failure. N Engl J Med 2005; 352:2425-34. [PMID: 15944428 DOI: 10.1056/nejmcpc059012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Benjamin D Medoff
- Pulmonary and Critical Care Unit, Center for Immunology and Inflammatory Diseases, Department of Medicine, Massachusetts General Hospital, USA
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80
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Tugrul S, Cakar N, Akinci O, Ozcan PE, Disci R, Esen F, Telci L, Akpir K. Time required for equilibration of arterial oxygen pressure after setting optimal positive end-expiratory pressure in acute respiratory distress syndrome. Crit Care Med 2005; 33:995-1000. [PMID: 15891327 DOI: 10.1097/01.ccm.0000163402.29767.7b] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the time course of Pao2 change following the setting of optimal positive end-expiratory pressure (PEEP) in patients with acute respiratory distress syndrome (ARDS). DESIGN Prospective clinical study. SETTING Multidisciplinary intensive care unit of a university hospital. PATIENTS Twenty-five consecutive patients with ARDS. INTERVENTIONS ARDS was diagnosed during pressure-regulated volume control ventilation with tidal volume of 7 mL/kg actual body weight, respiratory rate of 12 breaths/min, inspiratory/expiratory ratio of 1:2, Fio2 of 1, and PEEP of 5 cm H2O. A critical care attending physician obtained pressure volume curves and determined the lower inflection point. Following a rest period of 30 mins with initial ventilation variables, PEEP was set at 2 cm H2O above the lower inflection point, and serial blood samples were collected during 1-hr ventilation with optimal PEEP. Arterial blood gas analyses were performed at 1, 3, 5, 7, 9, 11, 15, 20, 30, 45, and 60 mins. MEASUREMENTS AND MAIN RESULTS Twenty-five patients were found eligible for the study. Three patients were excluded due to deterioration of oxygen saturation and hemodynamic instability following the initiation of optimal PEEP. Eight cases (36%) were considered to be of pulmonary origin and 14 cases (64%) of extrapulmonary origin. Optimal PEEP levels were 14 +/- 3 cm H2O and 14 +/- 4 cm H2O in pulmonary and extrapulmonary ARDS, respectively. Pao2 demonstrated a 130 +/- 101% increase at the end of 1-hr period in total study population. This improvement did not differ significantly between pulmonary and extrapulmonary forms of ARDS (135 +/- 118% vs. 127 +/- 95%, p = .8). Mean 90% oxygenation time was found to be 20 +/- 19 mins. In the subset of patients with ARDS of pulmonary origin, 90% oxygenation time was 25 +/- 26 mins, whereas it was 17 +/- 15 mins in patients with ARDS of extrapulmonary origin (p = .8). CONCLUSIONS Our data showed that 20 mins would be adequate for obtaining a blood gas sample in ARDS patients with pulmonary and extrapulmonary origin after application of optimal PEEP 2 cm H2O above the lower inflection point.
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Affiliation(s)
- Simru Tugrul
- Department of Anesthesiology, Istanbul Medical Faculty, Istanbul, Turkey
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81
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Koh WJ, Suh GY, Han J, Lee SH, Kang EH, Chung MP, Kim H, Kwon OJ. Recruitment maneuvers attenuate repeated derecruitment-associated lung injury. Crit Care Med 2005; 33:1070-6. [PMID: 15891338 DOI: 10.1097/01.ccm.0000162909.05340.ae] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Repeated derecruitments of previously recruited lungs can exacerbate lung injuries during mechanical ventilation. The aim of this study was to assess lung injury associated with repeated derecruitments and to assess whether this type of injury could be attenuated by recruitment maneuvers. DESIGN Prospective, randomized, experimental animal study. SETTING University laboratory. SUBJECTS New Zealand White rabbits. INTERVENTIONS Twenty-one rabbits were ventilated in pressure-controlled mode with constant tidal volume (10 mL/kg). After lung injury was induced by repeated saline lavage, positive end-expiratory pressure (PEEP) at a lower inflection point was applied for 3 hrs. The control group (n = 7) received ventilation with the same PEEP for 3 hrs without derecruitments. In the derecruitment group (n = 7), derecruitment was repeatedly induced by intentional disconnection of the ventilatory circuit for 1 min every 10 mins for 3 hrs. In the recruitment maneuver group (n = 7), continuous positive airway pressure of 30 cm H2O was applied for 30 secs after each derecruitment. MEASUREMENTS AND MAIN RESULTS After PEEP levels were increased to lower the inflection point value, Pao2 increased to >500 mm Hg in all groups. Increased Pao2 persisted at >450 mm Hg in the control and recruitment maneuver groups, whereas progressive declines in arterial oxygen levels were observed in the derecruitment group (median, 381.1 mm Hg [interquartile range, 350.1-466.7 mm Hg] at 2 hrs and 318.2 mm Hg [214.3-414.9 mm Hg] at 3 hrs, p < .05 compared with other groups). Histologically, there was significantly increased hyaline membrane formation in alveolar ducts in the derecruitment group compared with the control group (p = .005). Also, significantly more membranous and respiratory bronchiolar injuries were observed in the derecruitment group compared with the control and recruitment maneuver group (p < .005). CONCLUSIONS These findings suggest that repeated derecruitments could induce lung injuries during mechanical ventilation, and recruitment maneuvers may attenuate derecruitment-associated lung injuries.
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Affiliation(s)
- Won-Jung Koh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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82
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Ferguson ND, Chiche JD, Kacmarek RM, Hallett DC, Mehta S, Findlay GP, Granton JT, Slutsky AS, Stewart TE. Combining high-frequency oscillatory ventilation and recruitment maneuvers in adults with early acute respiratory distress syndrome: The Treatment with Oscillation and an Open Lung Strategy (TOOLS) Trial pilot study*. Crit Care Med 2005; 33:479-86. [PMID: 15753735 DOI: 10.1097/01.ccm.0000155785.23200.9e] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the safety, feasibility, and lung-recruitment efficacy of an explicit ventilation protocol combining high-frequency oscillatory ventilation and recruitment maneuvers. DESIGN Prospective, multiple-center, single-intervention pilot study. SETTING Four university-affiliated intensive care units. PATIENTS Twenty-five patients with early acute respiratory distress syndrome and severe oxygenation failure. INTERVENTIONS Patients were transitioned from standardized conventional ventilation to high-frequency oscillatory ventilation beginning with an initial cycle of up to three sustained inflation recruitment maneuvers (40 cm H2O x 40 secs), followed by a decremental titration of Fio2 and then mean airway pressure. Recruitment maneuvers were repeated for hypoxemia and routinely at least twice daily if the Fio2 was >0.4. A specific protocol was used for weaning high-frequency oscillatory ventilation, for transitioning to conventional ventilation, and for judging intolerance of conventional ventilation whereby patients should be put back on high-frequency oscillatory ventilation. MEASUREMENTS AND MAIN RESULTS Patients (median [interquartile range] Acute Physiology and Chronic Health Evaluation II, 24 [19-32]; age, 50 [41-64]) were enrolled after 13 (range, 6-51) hrs of conventional ventilation. Following the initial cycle of recruitment, the mean (+/-sd) Pao2/Fio2 increased significantly compared with standardized conventional ventilation (200 +/- 117 vs. 92 +/- 36 mm Hg, p < .001). After a mean of 12 hrs of high-frequency oscillatory ventilation, the mean Fio2 was significantly reduced compared with prestudy levels (0.5 +/- 0.2 vs. 0.9 +/- 0.1, p < .001). A median of seven (four to 11) recruitment maneuvers was performed per patient over the study period, with only eight of 244 (3.3%) being aborted. Six of 19 patients transitioned to conventional ventilation (32%) were deemed intolerant and were switched back to high-frequency oscillatory ventilation. Protocol adherence was excellent with documented rates >90%. CONCLUSIONS The combination of high-frequency oscillatory ventilation and recruitment maneuvers resulted in rapid and sustained improvement in oxygenation, likely through lung recruitment. This explicit high-frequency oscillatory ventilation protocol appears well tolerated, feasible, and physiologically sound.
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Affiliation(s)
- Niall D Ferguson
- Department of Medicine, Division of Respirology, and the Interdepartmental Division of Critical Care Medicine, University Health Network and Mount Sinai Hospital, University of Toronto, Toronto, Canada
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83
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Rocco PRM, Zin WA. Pulmonary and extrapulmonary acute respiratory distress syndrome: are they different? Curr Opin Crit Care 2005; 11:10-7. [PMID: 15659940 DOI: 10.1097/00075198-200502000-00003] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE OF REVIEW Acute respiratory distress syndrome has been considered a morphologic and functional expression of lung injury caused by a variety of insults. Two distinct forms of acute respiratory distress syndrome/acute lung injury are described, because there are differences between pulmonary acute respiratory distress syndrome (direct effects on lung cells) and extrapulmonary acute respiratory distress syndrome (reflecting lung involvement in a more distant systemic inflammatory response). This article will focus on the differences in lung histology and morphology, respiratory mechanics, and response to ventilatory strategies and pharmacologic therapies in pulmonary and extrapulmonary acute respiratory distress syndrome. RECENT FINDINGS Many researchers recognize that experimental pulmonary and extrapulmonary acute respiratory distress syndrome are not identical. In addition, clinical studies have described the detection of differences radiographically, functionally, and by analysis of the responses to therapeutic interventions (ventilatory strategies, positive end-expiratory pressure, prone position, drugs). However, there are contradictions among the different studies addressing these issues, which could be attributed to the fact that the distinction between pulmonary and extrapulmonary acute respiratory distress syndrome is not always clear and simple. Furthermore, there may be frequent overlapping in pathogenetic mechanisms and morphologic alterations. SUMMARY The understanding of acute respiratory distress syndrome needs to take into account its origin. If each pathogenetic mechanism were to be considered, clinical management would be more precise, and probably the outcome could include real amelioration.
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Affiliation(s)
- Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Rio de Janeiro, Brazil
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84
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Menezes SLS, Bozza PT, Neto HCCF, Laranjeira AP, Negri EM, Capelozzi VL, Zin WA, Rocco PRM. Pulmonary and extrapulmonary acute lung injury: inflammatory and ultrastructural analyses. J Appl Physiol (1985) 2005; 98:1777-83. [PMID: 15649870 DOI: 10.1152/japplphysiol.01182.2004] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
To test whether pulmonary and extrapulmonary acute lung injury (ALI) of identical mechanical compromise would express diverse morphological patterns and immunological pathways. For this purpose, a model of pulmonary (p) and extrapulmonary (exp) ALI with similar functional changes was developed and pulmonary morphology (light and electron microscopy), cytokines levels, and neutrophilic infiltration in the bronchoalveolar lavage fluid (BALF), elastic and collagen fiber content in the alveolar septa, and neutrophil apoptosis in the lung parenchyma were analyzed. BALB/c mice were divided into four groups. In control groups, saline was intratracheally (it, 0.05 ml) instilled and intraperitoneally (ip, 0.5 ml) injected, respectively. In the ALIp and ALIexp groups, mice received E. coli lipopolysaccharide (10 microg it and 125 microg ip, respectively). The changes in lung resistive and viscoelastic pressures and in static elastance, alveolar collapse, and cell content in lung tissue were similar in the ALIp and ALIexp groups. The ALIp group presented a threefold increase in KC (murine function homolog to IL-8) and IL-10 levels in the BALF in relation to ALIexp, whereas IL-6 level showed a twofold increase in ALIp. Neutrophils in the BALF were more frequent in ALIp than in ALIexp. ALIp showed more extensive injury of alveolar epithelium, intact capillary endothelium, and apoptotic neutrophils, whereas the ALIexp group presented interstitial edema and intact type I and II cells and endothelial layer. In conclusion, given the same pulmonary mechanical dysfunction independently of the etiology of ALI, insult in pulmonary epithelium yielded more pronounced inflammatory responses, which induce ultrastructural morphological changes.
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Affiliation(s)
- Sara L S Menezes
- Laboratory of Respiration Physiology, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Ilha do Fundã, Rio de Janeiro, Brazil
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85
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Oczenski W, Hörmann C, Keller C, Lorenzl N, Kepka A, Schwarz S, Fitzgerald RD. Recruitment maneuvers during prone positioning in patients with acute respiratory distress syndrome. Crit Care Med 2005; 33:54-61; quiz 62. [PMID: 15644648 DOI: 10.1097/01.ccm.0000149853.47651.f0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate the interaction of recruitment maneuvers and prone positioning on gas exchange and venous admixture in patients with early extrapulmonary acute respiratory distress syndrome ventilated with high levels of positive end-expiratory pressure. We hypothesized that a sustained inflation performed after 6 hrs of prone positioning would induce sustained improvement in oxygenation (Pao2/Fio2) and venous admixture. DESIGN Prospective, interventional study. SETTING Tertiary care, postoperative intensive care unit. PATIENTS Fifteen patients with early extrapulmonary acute respiratory distress syndrome. INTERVENTIONS After 6 hrs of prone positioning, a sustained inflation was performed with 50 cm H2O maintained for 30 secs. Data were recorded in supine position, after 6 hrs of prone positioning, at 3, 30, and 180 mins following the sustained inflation. MEASUREMENTS AND MAIN RESULTS A response to prone positioning was observed in nine of 15 patients leading to an improvement of Pao2/Fio2 (147 +/- 37 torr vs. 225 +/- 77 torr, p = .005) and venous admixture (35.4 +/- 8.3% vs. 28.9 +/- 9.8%, p = .001). Six patients did not respond to prone positioning. Following the sustained inflation, the responders to prone positioning showed a further increase of Pao2/Fio2 and decrease of venous admixture at 3 mins (Pao2/Fio2, 225 +/- 77 torr vs. 368 +/- 90 torr, p = .018; venous admixture, 28.9 +/- 9.8% vs. 18.9 +/- 6.7%, p = .05). In all six nonresponders to prone positioning, an improvement of Pao2/Fio2 and venous admixture occurred at 3 mins following the sustained inflation (128 +/- 18 torr vs. 277 +/- 59 torr, p = .03; venous admixture, 34.2 +/- 6.0% vs. 23.8 +/- 6.3%, p = .05). The beneficial effects of the sustained inflation remained significantly elevated over 3 hrs in responders and nonresponders to prone positioning. CONCLUSION In patients with early extrapulmonary acute respiratory distress syndrome, a sustained inflation performed after 6 hrs of prone positioning induced further and sustained improvement of oxygenation and venous admixture in both responders and nonresponders to prone positioning.
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Affiliation(s)
- Wolfgang Oczenski
- Department of Anesthesia and Intensive Care and the Ludwig Boltzmann Institute for Economics of Medicine in Anesthesia and Intensive Care, City of Vienna Hospital-Lainz, Vienna, Austria
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Lim SC, Adams AB, Simonson DA, Dries DJ, Broccard AF, Hotchkiss JR, Marini JJ. Intercomparison of recruitment maneuver efficacy in three models of acute lung injury*. Crit Care Med 2004; 32:2371-7. [PMID: 15599138 DOI: 10.1097/01.ccm.0000147445.73344.3a] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the relative efficacy of three forms of recruitment maneuvers in diverse models of acute lung injury characterized by differing pathoanatomy. DESIGN We compared three recruiting maneuver (RM) techniques at three levels of post-RM positive end-expiratory pressure in three distinct porcine models of acute lung injury: oleic acid injury; injury induced purely by the mechanical stress of high-tidal airway pressures; and pneumococcal pneumonia. SETTING Laboratory in a clinical research facility. SUBJECTS Twenty-eight anesthetized mixed-breed pigs (23.8 +/- 2.6 kg). INTERVENTIONS The RM techniques tested were sustained inflation, extended sigh or incremental positive end-expiratory pressure, and pressure-controlled ventilation. PRIMARY MEASUREMENTS Oxygenation and end-expiratory lung volume. MAIN RESULTS The post-RM positive end-expiratory pressure level was the major determinant of post-maneuver PaO2, independent of the RM technique. The pressure-controlled ventilation RM caused a lasting increase of PaO2 in the ventilator-induced lung injury model, but in oleic acid injury and pneumococcal pneumonia, there were no sustained oxygenation differences for any RM technique (sustained inflation, incremental positive end-expiratory pressure, or pressure-controlled ventilation) that differed from raising positive end-expiratory pressure without RM. CONCLUSIONS Recruitment by pressure-controlled ventilation is equivalent or superior to sustained inflation, with the same peak pressure in all tested models of acute lung injury, despite its lower mean airway pressure and reduced risk for hemodynamic compromise. Although RM may improve PaO2 in certain injury settings when traditional tidal volumes are used, sustained improvement depends on the post-RM positive end-expiratory pressure value.
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Affiliation(s)
- Sung-Chul Lim
- Department of Pulmonary/Critical Care Medicine, Regions Hospital, University of Minnesota, St. Paul, MN, USA
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88
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Lapinsky SE, Mehta S. Bench-to-bedside review: Recruitment and recruiting maneuvers. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2004; 9:60-5. [PMID: 15693985 PMCID: PMC1065091 DOI: 10.1186/cc2934] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
In patients with acute respiratory distress syndrome (ARDS), the lung comprises areas of aeration and areas of alveolar collapse, the latter producing intrapulmonary shunt and hypoxemia. The currently suggested strategy of ventilation with low lung volumes can aggravate lung collapse and potentially produce lung injury through shear stress at the interface between aerated and collapsed lung, and as a result of repetitive opening and closing of alveoli. An 'open lung strategy' focused on alveolar patency has therefore been recommended. While positive end-expiratory pressure prevents alveolar collapse, recruitment maneuvers can be used to achieve alveolar recruitment. Various recruitment maneuvers exist, including sustained inflation to high pressures, intermittent sighs, and stepwise increases in positive end-expiratory pressure or peak inspiratory pressure. In animal studies, recruitment maneuvers clearly reverse the derecruitment associated with low tidal volume ventilation, improve gas exchange, and reduce lung injury. Data regarding the use of recruitment maneuvers in patients with ARDS show mixed results, with increased efficacy in those with short duration of ARDS, good compliance of the chest wall, and in extrapulmonary ARDS. In this review we discuss the pathophysiologic basis for the use of recruitment maneuvers and recent evidence, as well as the practical application of the technique.
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Affiliation(s)
- Stephen E Lapinsky
- Intensive Care Unit, Mount Sinai Hospital, and Interdepartmental Division of Critical Care, University of Toronto,Toronto, Canada.
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Affiliation(s)
- David Johnson
- Department of Anesthesia, Royal University Hospital, Saskatoon, Saskatchewan S7N 0W8, Canada.
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90
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Kim SJ, Oh BJ, Lee JS, Lim CM, Shim TS, Lee SD, Kim WS, Kim DS, Kim WD, Koh Y. Recovery from lung injury in survivors of acute respiratory distress syndrome: difference between pulmonary and extrapulmonary subtypes. Intensive Care Med 2004; 30:1960-3. [PMID: 15241588 DOI: 10.1007/s00134-004-2374-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2003] [Accepted: 06/03/2004] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To determine whether long-term outcome differs between acute respiratory distress syndrome (ARDS) resulting from pulmonary (ARDSp) and extrapulmonary (ARDSexp) causes. DESIGN Observational study. SETTING Medical intensive care unit of a university hospital. PATIENTS Twenty-nine ARDS patients (16 ARDSp and 13 ARDSexp) who survived over 6 months after diagnosis. MEASUREMENTS AND RESULTS The two groups did not differ according to demographic data and severity indices on admission. The duration of ICU stay (median 21 days [interquartile range, 12-43 days] vs 12 [6.5-20] days, p=0.097) tended to be longer and total ventilation time (360 [96-700] h vs 144 [42.5-216] h, p=0.045) were longer in the patients with ARDSp. The ARDSp patients showed more severe abnormalities on thin-section computed tomography (CT), including ground-glass opacity (GGO; 6 [3-16] vs 0 [0-2.5], p=0.002), reticular density (12 [8-14] vs 5 [2-9], p=0.033) and the sum of all four patterns of lesion (20 [11-27] vs 5 [2-12], p=0.006). There were no between-group differences in Spitzer's Quality of Life index and the Chronic Respiratory Questionnaire. CONCLUSIONS These results suggest that ARDSp would leave more severe lung sequelae than ARDSexp, but the clinical relevance of their difference is questionable.
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Affiliation(s)
- Sun Jong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, 138-736 Songpa-gu, Seoul, Korea
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91
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Varpula T, Valta P, Niemi R, Takkunen O, Hynynen M, Pettilä VV. Airway pressure release ventilation as a primary ventilatory mode in acute respiratory distress syndrome. Acta Anaesthesiol Scand 2004; 48:722-31. [PMID: 15196105 DOI: 10.1111/j.0001-5172.2004.00411.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Airway pressure release ventilation (APRV) is a ventilatory mode, which allows unsupported spontaneous breathing at any phase of the ventilatory cycle. Airway pressure release ventilation as compared with pressure support (PS), another partial ventilatory mode, has been shown to improve gas exchange and cardiac output. We hypothesized whether the use of APRV with maintained unsupported spontaneous breathing as an initial mode of ventilatory support promotes faster recovery from respiratory failure in patients with acute respiratory distress syndrome (ARDS) than PS combined with synchronized intermittent ventilation (SIMV-group). METHODS In a randomized trial 58 patients were randomized to receive either APRV or SIMV after a predefined stabilization period. Both groups shared common physiological targets, and uniform principles of general care were followed. RESULTS Inspiratory pressure was significantly lower in the APRV-group (25.9 +/- 0.6 vs. 28.6 +/- 0.7 cmH2O) within the first week of the study (P = 0.007). PEEP-levels and physiological variables (PaO2/FiO2-ratio, PaCO2, pH, minute ventilation, mean arterial pressure, cardiac output) were comparable between the groups. At day 28, the number of ventilator-free days was similar (13.4 +/- 1.7 in the APRV-group and 12.2 +/- 1.5 in the SIMV-group), as was the mortality (17% and 18%, respectively). CONCLUSION We conclude that when used as a primary ventilatory mode in patients with ARDS, APRV did not differ from SIMV with PS in clinically relevant outcome.
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Affiliation(s)
- T Varpula
- Department of Anesthesiology and Intensive Care Medicine, Jorvi Hospital, Helsinki University Hospital, Espoo, Finland.
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92
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Schreiter D, Reske A, Stichert B, Seiwerts M, Bohm SH, Kloeppel R, Josten C. Alveolar recruitment in combination with sufficient positive end-expiratory pressure increases oxygenation and lung aeration in patients with severe chest trauma. Crit Care Med 2004; 32:968-75. [PMID: 15071387 DOI: 10.1097/01.ccm.0000120050.85798.38] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Investigation of oxygenation and lung aeration during mechanical ventilation according to the open lung concept in patients with acute lung injury or acute respiratory distress syndrome. DESIGN Retrospective analysis. SETTING Surgical intensive care unit of a university hospital. PATIENTS We retrospectively identified 17 patients with acute lung injury/acute respiratory distress syndrome due to pulmonary contusion who had thoracic helical computed tomography scans before and after ventilation with the open lung concept. INTERVENTIONS Baseline ventilation consisted of low tidal volumes (< or =6 mL/kg) and positive end-expiratory pressure (PEEP; 5-17 cm H2O). We briefly applied high inspiratory pressures for opening up collapsed alveoli. External PEEP and intrinsic PEEP were combined to keep recruited lung units open. We generated intrinsic PEEP by pressure-cycled high-frequency inverse ratio ventilation (80 min, inspiratory/expiratory ratio 2:1) and maintained our ventilatory strategy for 24 hrs. Then, after reducing total PEEP by decreasing respiratory rate, Pao2/Fio2 ratio was reevaluated. If it remained >300 mm Hg, weaning was started. If not, previous ventilator settings were resumed for another 24 hrs after recruiting the lungs once again. MEASUREMENTS AND MAIN RESULTS Physiologic variables and ventilator settings were obtained from routine charts. Data from computed tomography before and after the open lung concept were analyzed for volumetric quantification of lung aeration and collapse. All results are presented as median and range. During baseline ventilation, PEEP was 10 (range, 5-17) cm H2O and after recruitment 21 (range, 18-26) cm H2O. Opening pressures were 65 (range, 50-80) cm H2O. After recruitment, Pao2/Fio2 ratio was higher in all patients. Total lung volume increased from 2915 (range, 1952-4941) to 4247 (range, 2285-6355) mL and normally aerated volume from 1742 (range, 774-2941) to 2971 (range, 1270-5232) mL. Atelectasis decreased significantly from 604 (range, 147-1538) to 106 (range, 0-736) mL. Hyperinflation increased significantly from 5 (range, 0-188) to 62 (range, 1-424) mL, whereas poor aeration did not change substantially from 649 (range, 302-1292) to 757 (range, 350-1613) mL. No hemodynamic problems occurred. CONCLUSIONS Lung recruitment increased arterial oxygenation, normally aerated lung volume, and total lung volume while decreasing the amount of collapsed tissue. These results indicate that the open lung concept is a reasonable mode of ventilation for patients with severe chest trauma.
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Affiliation(s)
- Dierk Schreiter
- Surgical Intensive Care Unit, Department of Surgery, University Hospital Leipzig, Leipzig, Germany.
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Perng WC, Wu CP, Chu SJ, Kang BH, Huang KL. EFFECT OF HYPERBARIC OXYGEN ON ENDOTOXIN-INDUCED LUNG INJURY IN RATS. Shock 2004; 21:370-5. [PMID: 15179139 DOI: 10.1097/00024382-200404000-00013] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Oxygen therapy remains the main component of the ventilation strategy for treatment of patients with acute lung injury. Hyperbaric oxygen therapy (HBO(2)) is the intermittent administration of 100% oxygen at pressure greater than sea level and has been applied widely to alleviate a variety of hypoxia-related tissue injuries. The purpose of this study was to evaluate the effect of hyperbaric oxygen on acute lung injury induced by intratracheal spraying of lipopolysaccharide (LPS) in rats. Male Sprague-Dawley rats underwent implantation of a carotid artery catheter under general anesthesia. Aerosolized LPS was delivered twice into the lungs via intratracheal puncture. Animals were either breathing room air (n = 27) or subjected to hyperbaric oxygen (HBO(2)) exposure (n = 27) 1 h after LPS spraying. Acute lung injury was evaluated 5 h and 24 h later. Compared with the control group, intratracheal spraying of LPS caused profound hypoxemia, greater wet/dry weight ratio (W/D) of the lung (5.67 +/- 0.22 vs. 4.98 +/- 0.19), and higher protein concentration (1706 +/- 168 vs. 200 +/- 90 mg/L) and LDH activity (129 +/- 30 vs. 46 +/- 15, mAbs/min) in bronchoalveolar lavage (BAL) fluid. Intratracheal spraying of LPS also caused significant WBC sequestration in the lung tissue. HBO2 treatment significantly reverted hypoxemia, reduced lung injury measures evaluated at 5 and 24 h, and enhanced 24-h animal survival rate (chi = 5.08, P = 0.024). The malondialdehyde (MDA) concentrations in lung tissue and serum were both increased after LPS spraying. Neither single HBO(2) therapy nor five sequential daily treatments enhanced MDA production in lung tissue or serum. Our results suggested that hyperbaric oxygen might reduce acute lung injury caused by intratracheal spraying of LPS in rats. This treatment modality is not associated with enhancement of oxidative stress to the lung.
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Affiliation(s)
- Wann-Cherng Perng
- Division of Chest Medicine, Department of Internal Medicine, Tri-Service General Hospital, Taipei, Taiwan Republic of China
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Gainnier M, Michelet P, Thirion X, Arnal JM, Sainty JM, Papazian L. Prone position and positive end-expiratory pressure in acute respiratory distress syndrome. Crit Care Med 2004; 31:2719-26. [PMID: 14668607 DOI: 10.1097/01.ccm.0000094216.49129.4b] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE To determine whether positive end-expiratory pressure (PEEP) and prone position present a synergistic effect on oxygenation and if the effect of PEEP is related to computed tomography scan lung characteristic. DESIGN Prospective randomized study. SETTING French medical intensive care unit. PATIENTS Twenty-five patients with acute respiratory distress syndrome. INTERVENTIONS After a computed tomography scan was obtained, measurements were performed in all patients at four different PEEP levels (0, 5, 10, and 15 cm H2O) applied in random order in both supine and prone positions. MEASUREMENTS AND MAIN RESULTS Analysis of variance showed that PEEP (p <.001) and prone position (p <.001) improved oxygenation, whereas the type of infiltrates did not influence oxygenation. PEEP and prone position presented an additive effect on oxygenation. Patients presenting diffuse infiltrates exhibited an increase of Pao2/Fio2 related to PEEP whatever the position, whereas patients presenting localized infiltrates did not have improved oxygenation status when PEEP was increased in both positions. Prone position (p <.001) and PEEP (p <.001) reduced the true pulmonary shunt. Analysis of variance showed that prone position (p <.001) and PEEP (p <.001) reduced the true pulmonary shunt. The decrease of the shunt related to PEEP was more pronounced in patients presenting diffuse infiltrates. A lower inflection point was identified in 22 patients (88%) in both supine and prone positions. There was no difference in mean lower inflection point value between the supine and the prone positions (8.8 +/- 2.7 cm H2O vs. 8.4 +/- 3.4 cm H2O, respectively). CONCLUSIONS PEEP and prone positioning present additive effects. The prone position, not PEEP, improves oxygenation in patients with acute respiratory distress syndrome with localized infiltrates.
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Affiliation(s)
- Marc Gainnier
- Service de Réanimation Médicale, Hôpitax Sud, Marseille, France
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Estenssoro E, Dubin A, Laffaire E, Canales HS, Sáenz G, Moseinco M, Bachetti P. Impact of positive end-expiratory pressure on the definition of acute respiratory distress syndrome. Intensive Care Med 2003; 29:1936-42. [PMID: 12955187 DOI: 10.1007/s00134-003-1943-4] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2003] [Accepted: 07/16/2003] [Indexed: 11/27/2022]
Abstract
OBJECTIVE We examined whether PEEP during the first hours of ARDS can induce such a change in oxygenation that could mask fulfillment of the AECC criteria of a PaO(2)/FIO(2) </= 200 essential for ARDS diagnosis. DESIGN AND SETTING Observational, prospective cohort in two medical-surgical ICU in teaching hospitals. PATIENTS 48 consecutive patients who met AECC criteria of ARDS on 0 PEEP (ZEEP) at the moment of diagnosis. MEASUREMENTS AND RESULTS PaO(2)/FIO(2) and lung mechanics were recorded on admission (0 h) to the ICU on ZEEP, and after 6, 12, and 24 h on PEEP levels selected by attending physicians. Lung Injury Score (LIS) was calculated at 0 and 24 h. PaO(2)/FIO(2) rose significantly from 121+/-45 on ZEEP at 0 h, to 234+/-85 on PEEP of 12.8+/-3.7 cmH(2)O after 24 h. LIS did not change significantly (2.34+/-0.53 vs. 2.42+/-0.62). These variables behaved similarly in pulmonary and extrapulmonary ARDS, and in survivors and nonsurvivors. After 24 h only 18 patients (38%) still had a PaO(2)/FIO(2) of 200 or lower. Their mortality was similar to that in the remaining patients (61% vs. 53%). CONCLUSIONS The use of PEEP improved oxygenation such that one-half of patients after 6 h, and most after 24 h did not fulfill AECC hypoxemia criteria of ARDS. However, LIS remained stable in the overall series. These results suggest that PEEP level should be taken into consideration for ARDS diagnosis.
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Affiliation(s)
- Elisa Estenssoro
- Servicio de Terapia Intensiva, Hospital Interzonal General de Agudos General San Martín, 1900, la Plata, Argentina.
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Piacentini E, Villagrá A, López-Aguilar J, Blanch L. Clinical review: the implications of experimental and clinical studies of recruitment maneuvers in acute lung injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2003; 8:115-21. [PMID: 15025772 PMCID: PMC420020 DOI: 10.1186/cc2364] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Mechanical ventilation can cause and perpetuate lung injury if alveolar overdistension, cyclic collapse, and reopening of alveolar units occur. The use of low tidal volume and limited airway pressure has improved survival in patients with acute lung injury or acute respiratory distress syndrome. The use of recruitment maneuvers has been proposed as an adjunct to mechanical ventilation to re-expand collapsed lung tissue. Many investigators have studied the benefits of recruitment maneuvers in healthy anesthetized patients and in patients ventilated with low positive end-expiratory pressure. However, it is unclear whether recruitment maneuvers are useful when patients with acute lung injury or acute respiratory distress syndrome are ventilated with high positive end-expiratory pressure, and in the presence of lung fibrosis or a stiff chest wall. Moreover, it is unclear whether the use of high airway pressures during recruitment maneuvers can cause bacterial translocation. This article reviews the intrinsic mechanisms of mechanical stress, the controversy regarding clinical use of recruitment maneuvers, and the interactions between lung infection and application of high intrathoracic pressures.
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Affiliation(s)
- Enrique Piacentini
- Research Fellow, Critical Care Centre, Hospital de Sabadell, Institut Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Ana Villagrá
- Research Fellow, Critical Care Centre, Hospital de Sabadell, Institut Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Josefina López-Aguilar
- Researcher, Critical Care Centre, Hospital de Sabadell, Institut Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Lluis Blanch
- Executive Director, Critical Care Centre, Hospital de Sabadell, Institut Universitari Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
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