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Algaba Á, Nin N. Maniobras de reclutamiento alveolar en el síndrome de distrés respiratorio agudo. Med Intensiva 2013; 37:355-62. [DOI: 10.1016/j.medin.2013.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Revised: 01/29/2013] [Accepted: 01/30/2013] [Indexed: 01/14/2023]
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Clinical review: Helmet and non-invasive mechanical ventilation in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:223. [PMID: 23680299 PMCID: PMC3672531 DOI: 10.1186/cc11875] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Non-invasive mechanical ventilation (NIV) has proved to be an excellent technique in selected critically ill patients with different forms of acute respiratory failure. However, NIV can fail on account of the severity of the disease and technical problems, particularly at the interface. The helmet could be an alternative interface compared to face mask to improve NIV success. We performed a clinical review to investigate the main physiological and clinical studies assessing the efficacy and related issues of NIV delivered with a helmet. A computerized search strategy of MEDLINE/PubMed (January 2000 to May 2012) and EMBASE (January 2000 to May 2012) was conducted limiting the search to retrospective, prospective, nonrandomized and randomized trials. We analyzed 152 studies from which 33 were selected, 12 physiological and 21 clinical (879 patients). The physiological studies showed that NIV with helmet could predispose to CO₂ rebreathing and increase the patients' ventilator asynchrony. The main indications for NIV were acute cardiogenic pulmonary edema, hypoxemic acute respiratory failure (community-acquired pneumonia, postoperative and immunocompromised patients) and hypercapnic acute respiratory failure. In 9 of the 21 studies the helmet was compared to a face mask during either continous positive airway pressure or pressure support ventilation. In eight studies oxygenation was similar in the two groups, while the intubation rate was similar in four and lower in three studies for the helmet group compared to face mask group. The outcome was similar in six studies. The tolerance was better with the helmet in six of the studies. Although these data are limited, NIV delivered by helmet could be a safe alternative to the face mask in patients with acute respiratory failure.
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Nakahashi S, Gando S, Ishikawa T, Wada T, Yanagida Y, Kubota N, Uegaki S, Hayakawa M, Sawamura A. Effectiveness of end-expiratory lung volume measurements during the lung recruitment maneuver for patients with atelectasis. J Crit Care 2013; 28:534.e1-5. [PMID: 23337480 DOI: 10.1016/j.jcrc.2012.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 10/26/2012] [Accepted: 11/11/2012] [Indexed: 11/15/2022]
Abstract
PURPOSE The aim of this study was to determine whether the relative change in the end-expiratory lung volume (EELV) obtained by the recruitment maneuver (RM) can serve as an indicator of the change in the P/F ratio. MATERIALS AND METHODS The effects of the intermittent stepwise increases in the RM (peak inspiratory pressure, 45, 50, and 55 cm H2O) were compared in 21 patients with atelectasis under mechanical ventilation. The EELV, the ratio of arterial oxygen concentration to the fraction of inspired oxygen P/F ratio, and relative change rate (Δ) in these parameters were evaluated after each RM. RESULTS A greater improvement in the EELV (1157 ± 344 mL vs 1469 ± 396 mL) and P/F ratio (250 ± 99 vs 320 ± 92) was observed after the RM. The ΔEELV was correlated with the ΔP/F ratio (ρ = 0.73, P < .01) and was identified as an accurate predictor of the improvement of the ΔP/F ratio by the receiver operating characteristic curve (the area under the curve, 0.93; P < .01). CONCLUSIONS These results suggest that the ΔEELV obtained by intermittent stepwise RM can serve as an indicator of the change in the P/F ratio.
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Affiliation(s)
- Susumu Nakahashi
- Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Hokkaido University Graduate School of Medicine, N15W7 Kita-ku, Sapporo 060-8638, Japan.
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Trojik T, Shosholcheva M, Radulovska-Chabukovska J, Lovach-Chepujnoska M. Evaluation of effects of repetitive recruitment maneuvers. Acta Inform Med 2013; 20:85-9. [PMID: 23322958 PMCID: PMC3544327 DOI: 10.5455/aim.2012.20.85-89] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 05/30/2012] [Indexed: 01/11/2023] Open
Abstract
Introduction: acute respiratory failure is manifested clinically as patient with variable degrees of respiratory distress, but characteristically an abnormal arterial blood partial pressure of oxygen or carbon dioxide. The application of mechanical ventilation in this setting can be life saving. Goals: The aim of this study is to evaluate the effects of two recruitment maneuvers not only on oxygenation, but on aeration of the lung as well. For that purpose chest x ray and thoracic computed tomography scan (CT) of the lung were used as safe and objective methods for evaluation the impact of recruitment maneuvers on aeration of the lung. CT scan and chest x ray were performed before recruitment maneuvers as confirmation of diagnose and one day after the last recruitment maneuvers. Material and methods: Sixty patients who met ar DS criteria of the american european consensus conference were included in this study. This study was conducted in iCU in our hospital between november 2009 and December 2011. Patients were orally intubated, sedated with 0, 2-0, 4 μg/kg /min and midazolam 4 mg/h, and ventilated with evita 2 Dura ventilator (Dragger germany). According to the recom-mendation of the Consensus Conference of the american College of Chest physician all patients had an arterial catheter and cen-tral venous catheter. Hemodynamic data were collected from Data Ohmeda monitors. Gas analyses were mesured from blood samples taken from arteria radialis. Partial pressure of oxygen of mixed blood was messured from blood sample taken from v jugularis interior. We used arterial blood colection syringe Bd preset, and blood samples were analyzed with aVl 995HB blood gas analiser. Results: Hemodynamic changes: there wasn’t any differences in heart rate, and mean arterial blood pressure before the recruitment five minutes and sixty minutes after the recruitment in both groups. respiratory mechanics: Highest values of the compliance are achived during the recruitment manouver in both groups. There was better improvment in compliance during the e sigh recruitment maneouver, then in Cpap recruitment maneouver. There was improvement in chest X ray in both groups. 93,4% of patients in the Cpap group and 96,7% in e sigh group. CT scan: in Cpap group there were 8 patients with focal changes and 22 patients with diffusse changes. in e sigh group 29 patients had diffuse changes of the lung and one patient had focal changes. We noticed that there was better improvment in aeration in patients with diffuse changes of the lung 96.7% in e sigh group and 73,3% in Cpapgroup. In patient with focal changes there was improvment in 26,7% in e sigh group and 3,3% in Cpap group. We noticed that there was better improvmnet in aeration in patients with diffuse changes than in patients with focal changes. E sigh maneuver had better impact on aeration of the lung then Cpap recruitment maneuver. Conclusion: In our study we proved that e sigh recruitment maneuvers better improved oxygenation in arterial blood than Cpap recruitment maneuver. Repetative e sigh manouvers proved to be essential for arDS patients. They reopened collapsed alveolli and improved aeration of the lung which was confirmed by X ray and CT scan as an objective methods for verification of lung condition.
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Affiliation(s)
- Tatjana Trojik
- University Clinic for surgical diseases of "St. Naum Ohridski", Skopje R Macedonia ; University Clinic for surgical diseases of "St. Naum Ohridski", Skopje R Macedonia ; University Clinic for surgical diseases of "St. Naum Ohridski", Skopje R Macedonia
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Vlemincx E, Van Diest I, Van den Bergh O. Imposing respiratory variability patterns. Appl Psychophysiol Biofeedback 2013; 37:153-60. [PMID: 22419514 DOI: 10.1007/s10484-012-9187-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
To ensure respiratory stability and flexibility, healthy breathing shows balanced variability consisting of considerable correlated variability (parameters of each breath are correlated to parameters of adjoining breaths) and some random variability. Sighing resets this balance when respiration lacks variability or becomes excessively irregular. The present study aimed to investigate the effect of imposed patterns of breathing variability on sighing and self-reported (dis)comfort. Spontaneous breathing was compared to imposed non-variable, correlated and random breathing. Results show that executing imposed breathing is difficult, demanding, and induces tension. Sigh occurrence following spontaneous and imposed breathing patterns could be predicted by self-reported discomfort and increased random variability. However, including non-variable, correlated and random breathing patterns only, the effects of self-reported discomfort on sigh occurrence override the effects of altered breathing variability.
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Affiliation(s)
- Elke Vlemincx
- Department of Psychology, Research Group on Health Psychology, University of Leuven, Leuven, Belgium.
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Vlemincx E, Abelson JL, Lehrer PM, Davenport PW, Van Diest I, Van den Bergh O. Respiratory variability and sighing: a psychophysiological reset model. Biol Psychol 2012; 93:24-32. [PMID: 23261937 DOI: 10.1016/j.biopsycho.2012.12.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 11/29/2012] [Accepted: 12/02/2012] [Indexed: 11/30/2022]
Abstract
Whereas respiratory psychophysiological research has mainly studied respiratory time and volume, variability in these parameters has been largely disregarded, even though it may provide important information about respiratory regulation. The present paper reviews the literature on respiratory variability and elaborates on the importance of assessing various components of respiratory variability when studying the interrelationships between emotions and breathing. A model is proposed that predicts specific action tendencies related to emotions to disturb the balance between various respiratory variability components depending on valence by arousal and control dimensions. The central focus of the paper is sighing. The causes and consequences of sighing are reviewed and integrated in the proposed model in which sighing is hypothesized to function as a resetter in the regulation of both breathing and emotions, because it restores a balance in respiratory variability fractions and causes relief.
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Affiliation(s)
- Elke Vlemincx
- Research Group on Health Psychology, Department of Psychology, University of Leuven, Belgium.
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Aldenkortt M, Lysakowski C, Elia N, Brochard L, Tramèr MR. Ventilation strategies in obese patients undergoing surgery: a quantitative systematic review and meta-analysis. Br J Anaesth 2012; 109:493-502. [PMID: 22976857 DOI: 10.1093/bja/aes338] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Pathophysiological changes due to obesity may complicate mechanical ventilation during general anaesthesia. The ideal ventilation strategy is expected to optimize gas exchange and pulmonary mechanics and to reduce the risk of respiratory complications. METHODS Systematic search (databases, bibliographies, to March 2012, all languages) was performed for randomized trials testing intraoperative ventilation strategies in obese patients (BMI ≥ 30 kg m(-2)), and reporting on gas exchange, pulmonary mechanics, or pulmonary complications. Meta-analyses were performed when data from at least three studies or 100 patients could be combined. RESULTS Thirteen studies (505 obese surgical patients) reported on a variety of ventilation strategies: pressure- or volume-controlled ventilation (PCV, VCV), various tidal volumes, and different PEEP or recruitment manoeuvres (RM), and combinations thereof. Definitions and reporting of endpoints were inconsistent. In five trials (182 patients), RM added to PEEP compared with PEEP alone improved intraoperative PaO2/FIO2 ratio [weighted mean difference (WMD), 16.2 kPa; 95% confidence interval (CI), 8.0-24.4] and increased respiratory system compliance (WMD, 14 ml cm H(2)O(-1); 95% CI, 8-20). Arterial pressure remained unchanged. In four trials (100 patients) comparing PCV with VCV, there was no difference in PaO2/FIO2 ratio, tidal volume, or arterial pressure. Comparison of further ventilation strategies or combination of other outcomes was not feasible. Data on postoperative complications were seldom reported. CONCLUSIONS The ideal intraoperative ventilation strategy in obese patients remains obscure. There is some evidence that RM added to PEEP compared with PEEP alone improves intraoperative oxygenation and compliance without adverse effects. There is no evidence of any difference between PCV and VCV.
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Affiliation(s)
- M Aldenkortt
- Division of Anaesthesia, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva 14, Switzerland.
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TANG R, HUANG Y, CHEN Q, HUI X, LI Y, YU Q, ZHAO H, YANG Y, QIU H. Relationship between regional lung compliance and ventilation homogeneity in the supine and prone position. Acta Anaesthesiol Scand 2012; 56:1191-9. [PMID: 22834873 DOI: 10.1111/j.1399-6576.2012.02741.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND The prone position (PP) improves ventilation homogeneity in acute respiratory distress syndrome. The aim of this study was to investigate whether the alleviation of ventilation inhomogeneity in PP was due to changes in regional lung compliance. METHODS Ten lung-lavaged piglets were mechanically ventilated in supine position (SP) and in PP. In each position, positive end-expiratory pressure (PEEP) was reduced from 20 to 6 cmH(2)O in steps of 2 cmH(2)O every 10 min after full lung recruitment. Respiratory mechanics, blood gas, haemodynamic data and whole-lung computed tomography scans were recorded at each PEEP. The compliances of normally aerated (C(normal)) and newly recruited (C(recruited)) lung regions were calculated. Open lung PEEP (OL-PEEP) was defined as the lowest PEEP to maintain full lung recruitment. RESULTS At OL-PEEP, PP significantly increased normally aerated lung regions, decreased poorly aerated and hyperinflated lung regions and decreased tidal recruitment and hyperinflation. C(normal) was significantly reduced in PP compared with SP (12.8 ± 4.2 ml/cmH(2)O vs. 20.1 ± 6.2 ml/cmH(2)O, P < 0.001), whereas C(recruited) was increased in PP (13.9 ± 3.9 ml/cmH(2)O vs. 9.4 ± 2.4 ml/cmH(2)O, P < 0.001). C(normal) was correlated with hyperinflated lung regions at end-expiration (rho = 0.67) and end-inspiration (rho = 0.56) at OL-PEEP. C(recruited) was correlated with normally (r(2) = 0.36) and poorly aerated lung regions (rho = -0.58) at OL-PEEP. CONCLUSION This surfactant-depleted model shows that the improvement of ventilation homogeneity in PP is related to an increase in C(recruited) and a decrease in C(normal).
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Affiliation(s)
- R. TANG
- Department of Critical Care Medicine; Zhong-Da Hospital, School of Medicine Southeast University; Nanjing; China
| | - Y. HUANG
- Department of Critical Care Medicine; Zhong-Da Hospital, School of Medicine Southeast University; Nanjing; China
| | - Q. CHEN
- Department of Critical Care Medicine; Zhong-Da Hospital, School of Medicine Southeast University; Nanjing; China
| | - X. HUI
- Department of Critical Care Medicine; Zhong-Da Hospital, School of Medicine Southeast University; Nanjing; China
| | - Y. LI
- Department of Critical Care Medicine; Zhong-Da Hospital, School of Medicine Southeast University; Nanjing; China
| | - Q. YU
- Department of Critical Care Medicine; Zhong-Da Hospital, School of Medicine Southeast University; Nanjing; China
| | - H. ZHAO
- Department of Critical Care Medicine; Zhong-Da Hospital, School of Medicine Southeast University; Nanjing; China
| | - Y. YANG
- Department of Critical Care Medicine; Zhong-Da Hospital, School of Medicine Southeast University; Nanjing; China
| | - H. QIU
- Department of Critical Care Medicine; Zhong-Da Hospital, School of Medicine Southeast University; Nanjing; China
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Increased extravascular lung water reduces the efficacy of alveolar recruitment maneuver in acute respiratory distress syndrome. Crit Care Res Pract 2012; 2012:606528. [PMID: 22649717 PMCID: PMC3356898 DOI: 10.1155/2012/606528] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 02/20/2012] [Indexed: 11/30/2022] Open
Abstract
Introduction. In acute respiratory distress syndrome (ARDS) the recruitment maneuver (RM) is used to reexpand atelectatic areas of the lungs aiming to improve arterial oxygenation. The goal of our paper was to evaluate the response to RM, as assessed by measurements of extravascular lung water index (EVLWI) in ARDS patients. Materials and Methods. Seventeen adult ARDS patients were enrolled into a prospective study. Patients received protective ventilation. The RM was performed by applying a continuous positive airway pressure of 40 cm H2O for 40 sec. The efficacy of the RM was assessed 5 min later. Patients were identified as responders if PaO2/FiO2 increased by >20% above the baseline. EVLWI was assessed by transpulmonary thermodilution before the RM, and patients were divided into groups of low EVLWI (<10 mL/kg) and high EVLWI (≥10 mL/kg). Results. EVLWI was increased in 12 patients. Following RM, PaO2/FiO2 increased by 33 (4–65) % in the patients with low EVLWI, whereas those in
the high EVLWI group experienced a change by only −1((−13)–(+5)) % (P = 0.035). Conclusion. In ARDS, the response to a recruitment maneuver might be related to the severity of pulmonary edema. In patients with incresed EVLWI, the recruitment maneuver is less effective.
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Albert RK. The role of ventilation-induced surfactant dysfunction and atelectasis in causing acute respiratory distress syndrome. Am J Respir Crit Care Med 2012; 185:702-8. [PMID: 22227381 DOI: 10.1164/rccm.201109-1667pp] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
This Pulmonary Perspective describes a new pathophysiologic scenario by which the acute respiratory distress syndrome (ARDS) might develop, summarizes the literature on which this new scenario is based, and discusses the resulting implications with respect to patient management. Rather than ARDS occurring as a result of the inflammatory response associated with predisposing risk factors, the proposed scenario theorizes that the initiating problem is atelectasis that develops as a result of a surfactant abnormality that is caused by spontaneous or mechanical ventilation, together with our current approaches to patient positioning and sedation. The proposed pathophysiology implies that ventilation-induced lung injury occurs before, and causes, ARDS (rather than developing after the fact and only serving to magnify the existing injury) and that some instances of ARDS are iatrogenic. If the proposed scenario is correct, it also implies that at least some instances of ARDS might be prevented by implementing a number of simple, safe modifications in patient care.
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Affiliation(s)
- Richard K Albert
- Department of Medicine, Denver Health, Denver, Colorado 80204-4507, USA.
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Del Sorbo L, Goffi A, Ranieri VM. Mechanical ventilation during acute lung injury: current recommendations and new concepts. Presse Med 2011; 40:e569-83. [PMID: 22104487 DOI: 10.1016/j.lpm.2011.05.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 05/05/2011] [Accepted: 05/13/2011] [Indexed: 01/08/2023] Open
Abstract
Despite a very large body of investigations, no effective pharmacological therapies have been found to cure acute lung injury. Hence, supportive care with mechanical ventilation remains the cornerstone of treatment. However, several experimental and clinical studies showed that mechanical ventilation, especially at high tidal volumes and pressures, can cause or aggravate ALI. Therefore, current clinical recommendations are developed with the aim of avoiding ventilator-induced lung injury (VILI) by limiting tidal volume and distending ventilatory pressure according to the results of the ARDS Network trial, which has been to date the only intervention that has showed success in decreasing mortality in patients with ALI/ARDS. In the past decade, a very large body of investigations has determined significant achievements on the pathophysiological knowledge of VILI. Therefore, new perspectives, which will be reviewed in this article, have been defined in terms of the efficiency and efficacy of recognizing, monitoring and treating VILI, which will eventually lead to further significant improvement of outcome in patients with ARDS.
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Affiliation(s)
- Lorenzo Del Sorbo
- Università di Torino, Dipartimento di Anestesiologia e Medicina degli Stati Critici, Ospedale S. Giovanni Battista-Molinette, 10126 Torino, Italy
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Recruitability, recruitment, and tidal volume interactions: Is biologically variable ventilation a possible answer?*. Crit Care Med 2011; 39:1839-40. [DOI: 10.1097/ccm.0b013e31821b82dd] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Rival G, Patry C, Floret N, Navellou JC, Belle E, Capellier G. Prone position and recruitment manoeuvre: the combined effect improves oxygenation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R125. [PMID: 21575205 PMCID: PMC3218988 DOI: 10.1186/cc10235] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/22/2011] [Revised: 04/20/2011] [Accepted: 05/16/2011] [Indexed: 12/15/2022]
Abstract
Introduction Among the various methods for improving oxygenation while decreasing the risk of ventilation-induced lung injury in patients with acute respiratory distress syndrome (ARDS), a ventilation strategy combining prone position (PP) and recruitment manoeuvres (RMs) can be practiced. We studied the effects on oxygenation of both RM and PP applied in early ARDS patients. Methods We conducted a prospective study. Sixteen consecutive patients with early ARDS fulfilling our criteria (ratio of arterial oxygen partial pressure to fraction of inspired oxygen (PaO2/FiO2) 98.3 ± 28 mmHg; positive end expiratory pressure, 10.7 ± 2.8 cmH2O) were analysed. Each patient was ventilated in both the supine position (SP) and the PP (six hours in each position). A 45 cmH2O extended sigh in pressure control mode was performed at the beginning of SP (RM1), one hour after turning to the PP (RM2) and at the end of the six-hour PP period (RM3). Results The mean arterial oxygen partial pressure (PaO2) changes after RM1, RM2 and RM3 were 9.6%, 15% and 19%, respectively. The PaO2 improvement after a single RM was significant after RM3 only (P < 0.05). Improvements in PaO2 level and PaO2/FiO2 ratio were transient in SP but durable during PP. PaO2/FiO2 ratio peaked at 218 mmHg after RM3. PaO2/FiO2 changes were significant only after RM3 and in the pulmonary ARDS group (P = 0.008). This global strategy had a benefit with regard to oxygenation: PaO2/FiO2 ratio increased from 98.3 mmHg to 165.6 mmHg 13 hours later at the end of the study (P < 0.05). Plateau airway pressures decreased after each RM and over the entire PP period and significantly after RM3 (P = 0.02). Some reversible side effects such as significant blood arterial pressure variations were found when extended sighs were performed. Conclusions In our study, interventions such as a 45 cmH2O extended sigh during PP resulted in marked oxygenation improvement. Combined RM and PP led to the highest increase in PaO2/FiO2 ratio without major clinical side effects.
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Affiliation(s)
- Gilles Rival
- Service de pneumologie, Centre Hospitalier Régional et Universitaire de Besançon, 3 Bd. Fleming, Besançon, France.
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Influence of lung collapse distribution on the physiologic response to recruitment maneuvers during noninvasive continuous positive airway pressure. Intensive Care Med 2011; 37:1095-102. [PMID: 21567113 DOI: 10.1007/s00134-011-2239-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Accepted: 03/14/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Noninvasive continuous positive airway pressure (n-CPAP) has been proposed for the treatment of hypoxemic acute respiratory failure (h-ARF). Recruitment maneuvers were shown to improve oxygenation, i.e., the ratio of arterial oxygen tension to inspiratory oxygen fraction (PaO2/FiO2), during either invasive mechanical ventilation, and n-CPAP, with a response depending on the distribution of lung collapse. We hypothesized that, during n-CPAP, early h-ARF patients with bilateral (B(L)) distribution of lung involvement would benefit from recruitment maneuvers more than those with unilateral (U(L)) involvement. METHODS To perform a recruitment maneuver, once a minute we increased the pressure applied to the airway from 10 cmH2O to 25 cmH2O for 8 s (SIGH). We enrolled 24 patients with h-ARF (12 B(L) and 12 U(L)) who underwent four consecutive trials: (1) 30 min breathing through a Venturi mask (V(MASK)), (2) 1 h n-CPAP (n-CPAP1), (3) 1 h n-CPAP plus SIGH (n-CPAP(SIGH)), and (4) 1 h n-CPAP (n-CPAP2). RESULTS Compared to V(MASK), n-CPAP at 10 cmH2O delivered via a helmet, increased PaO2/FiO2 and decreased dyspnea in both B(L) and U(L); furthermore, it reduced the respiratory rate and brought PaCO2 up to normal in B(L) only. Compared to n-CPAP, n-CPAP(SIGH) significantly improved PaO2/FiO2 in B(L) (225 ± 88 vs. 308 ± 105, respectively), whereas it produced no further improvement in PaO2/FiO2 in U(L) (232 ± 72 vs. 231 ± 77, respectively). SIGH did not affect hemodynamics in both groups. CONCLUSIONS Compared to n-CPAP, n-CPAP(SIGH) further improved arterial oxygenation in B(L) patients, whereas it produced no additional benefit in those with U(L).
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Spontaneously regulated vs. controlled ventilation of acute lung injury/acute respiratory distress syndrome. Curr Opin Crit Care 2011; 17:24-9. [PMID: 21157317 DOI: 10.1097/mcc.0b013e328342726e] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW To present an updated discussion of those aspects of controlled positive pressure breathing and retained spontaneous regulation of breathing that impact the management of patients whose tissue oxygenation is compromised by acute lung injury. RECENT FINDINGS The recent introduction of ventilation techniques geared toward integrating natural breathing rhythms into even the earliest phase of acute respiratory distress syndrome support (e.g., airway pressure release, proportional assist ventilation, and neurally adjusted ventilatory assist), has stimulated a burst of new investigations. SUMMARY Optimizing gas exchange, avoiding lung injury, and preserving respiratory muscle strength and endurance are vital therapeutic objectives for managing acute lung injury. Accordingly, comparing the physiology and consequences of breathing patterns that preserve and eliminate breathing effort has been a theme of persisting investigative interest throughout the several decades over which it has been possible to sustain cardiopulmonary life support outside the operating theater.
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Guerin C, Debord S, Leray V, Delannoy B, Bayle F, Bourdin G, Richard JC. Efficacy and safety of recruitment maneuvers in acute respiratory distress syndrome. Ann Intensive Care 2011; 1:9. [PMID: 21906333 PMCID: PMC3224504 DOI: 10.1186/2110-5820-1-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 04/19/2011] [Indexed: 11/13/2022] Open
Abstract
Recruitment maneuvers (RM) consist of a ventilatory strategy that increases the transpulmonary pressure transiently to reopen the recruitable lung units in acute respiratory distress syndrome (ARDS). The rationales to use RM in ARDS are that there is a massive loss of aerated lung and that once the end-inspiratory pressure surpasses the regional critical opening pressure of the lung units, those units are likely to reopen. There are different methods to perform RM when using the conventional ICU ventilator. The three RM methods that are mostly used and investigated are sighs, sustained inflation, and extended sigh. There is no standardization of any of the above RM. Meta-analysis recommended not to use RM in routine in stable ARDS patients but to run them in case of life-threatening hypoxemia. There are some concerns regarding the safety of RM in terms of hemodynamics preservation and lung injury as well. The rapid rising in pressure can be a factor that explains the potential harmful effects of the RM. In this review, we describe the balance between the beneficial effects and the harmful consequences of RM. Recent animal studies are discussed.
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Affiliation(s)
- Claude Guerin
- Service de Réanimation Médicale, Hôpital de la Croix-Rousse, 103 Grande Rue de la Croix-Rousse, Lyon, 69004 France.
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Huh JW, Hong SB, Lim CM, Koh Y. Effect of the alveolar recruitment manoeuvre on haemodynamic parameters in patients with acute respiratory distress syndrome: relationship with oxygenation. Respirology 2011; 15:1220-5. [PMID: 20920128 DOI: 10.1111/j.1440-1843.2010.01852.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVE Although the alveolar recruitment manoeuvre (ARM) is considered to be an optimal method of recruiting collapsed alveoli in a short period, the haemodynamic effects of the ARM have not been investigated. The aim of this study was to assess whether the ARM causes haemodynamic instability in patients with ARDS, and any relationship this might have with arterial oxygenation. METHODS Twenty-eight patients with ARDS (16 responders and 12 non-responders), who were admitted to the medical intensive care unit of a university-affiliated hospital, were enrolled in the study. ARM, using the extended sigh method, was performed within 48 h of the onset of ARDS. Haemodynamic parameters were measured at baseline, during the ARM, and at 2 min, 30 min and 1 h after the ARM. RESULTS Responders and non-responders showed no significant changes in blood pressure or cardiac index during or after ARM. Mean pulmonary artery pressure (MPAP), pulmonary vascular resistance index (PVRI) and right ventricular stroke work index (RVSWI) were transiently increased compared with baseline, in responders and non-responders. During and after ARM, the systemic vascular resistance index was significantly higher in non-responders than in responders. CONCLUSIONS Some haemodynamic parameters (MPAP, PVRI and RVSWI) changed significantly during ARM. However, these haemodynamic changes were minimal, transient and probably have no clinical significance.
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Affiliation(s)
- Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, College of Medicine, University of Ulsan, Songpa-gu, Seoul, Korea
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69
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70
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Rocco PRM, Pelosi P, de Abreu MG. Pros and cons of recruitment maneuvers in acute lung injury and acute respiratory distress syndrome. Expert Rev Respir Med 2010; 4:479-89. [PMID: 20658909 DOI: 10.1586/ers.10.43] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In patients with acute lung injury and acute respiratory distress syndrome, a protective mechanical ventilation strategy characterized by low tidal volumes has been associated with reduced mortality. However, such a strategy may result in alveolar collapse, leading to cyclic opening and closing of atelectatic alveoli and distal airways. Thus, recruitment maneuvers (RMs) have been used to open up collapsed lungs, while adequate positive end-expiratory pressure (PEEP) levels may counteract alveolar derecruitment during low tidal volume ventilation, improving respiratory function and minimizing ventilator-associated lung injury. Nevertheless, considerable uncertainty remains regarding the appropriateness of RMs. The most commonly used RM is conventional sustained inflation, associated with respiratory and cardiovascular side effects, which may be minimized by newly proposed strategies: prolonged or incremental PEEP elevation; pressure-controlled ventilation with fixed PEEP and increased driving pressure; pressure-controlled ventilation applied with escalating PEEP and constant driving pressure; and long and slow increase in pressure. The efficiency of RMs may be affected by different factors, including the nature and extent of lung injury, capability of increasing inspiratory transpulmonary pressures, patient positioning and cardiac preload. Current evidence suggests that RMs can be used before setting PEEP, after ventilator circuit disconnection or as a rescue maneuver to overcome severe hypoxemia; however, their routine use does not seem to be justified at present. The development of new lung recruitment strategies that have fewer hemodynamic and biological effects on the lungs, as well as randomized clinical trials analyzing the impact of RMs on morbidity and mortality of acute lung injury/acute respiratory distress syndrome patients, are warranted.
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Affiliation(s)
- Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute of Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha do Fundão-21941-902, Rio de Janeiro, RJ, Brazil.
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71
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Sarkar S, Bhattacharya P, Kumar I, Mandal KS. Changes of splanchnic perfusion after applying positive end expiratory pressure in patients with acute respiratory distress syndrome. Indian J Crit Care Med 2010; 13:12-6. [PMID: 19881173 PMCID: PMC2772258 DOI: 10.4103/0972-5229.53109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Positive end-expiratory pressure (PEEP) improves oxygenation and can prevent ventilator- induced lung injury in patients with acute respiratory distress syndrome (ARDS). Nevertheless, PEEP can also induce detrimental effects by its influence on the cardiovascular system. The purpose of this study was to assess the effects of PEEP on gastric mucosal perfusion while applying a protective ventilatory strategy in patients with ARDS. Materials and Methods: Thirty-two patients were included in the study. A pressure–volume curve was traced and ideal PEEP, defined as lower inflection point + 2cmH2O, was determined. Gastric tonometry was measured continuously (Tonocap). After baseline measurements, 10, 15 and 20cmH2O PEEP and ideal PEEP were applied for 30 min each. By the end of each period, hemodynamics, CO2 gap (gastric minus arterial partial pressures), and ventilatory measurements were taken. Results: PEEP had no effect on CO2 gap (median [range], baseline: 18 [2–30] mmHg; PEEP 10: 18 [0–40] mmHg; PEEP 15: 17 [0–39] mmHg; PEEP 20: 16 [4–39] mmHg; ideal PEEP: 19 [9–39] mmHg; P = 0.19). Cardiac index also remained unchanged (baseline: 4.7 [2.6–6.2] l min−1 m−2; PEEP 10: 4.4 [2.5–7] l min−1 m−2; PEEP 15: 4.4 [2.2–6.8] l min−1 m−2; PEEP 20: 4.8 [2.4–6.3] l min−1 m−2; ideal PEEP: 4.9 [2.4–6.3] l min−1 m−2; P = 0.09). Conclusion: PEEP of 10–20 cmH2O does not affect splanchnic perfusion and is hemodynamically well tolerated in most patients with ARDS, including those receiving inotropic supports.
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Affiliation(s)
- Suman Sarkar
- Department of Anesthesiology, Intensive Care Unit, IMS Banaras Hindu University, Varanasi-221 105, Uttar Pradesh, India.
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72
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Chacko J, Rani U. Alveolar recruitment maneuvers in acute lung injury/acute respiratory distress syndrome. Indian J Crit Care Med 2010; 13:1-6. [PMID: 19881171 PMCID: PMC2772255 DOI: 10.4103/0972-5229.53107] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Mechanical ventilation can worsen lung damage in acute lung injury and acute respiratory distress syndrome. The use of low tidal volumes is one of the strategies that has been shown to reduce lung injury and improve outcomes in this situation. However, low tidal volumes may lead to alveolar derecruitment and worsening of hypoxia. Recruitment maneuvers along with positive end-expiratory pressure may help to prevent derecruitment. Although recruitment maneuvers have been shown to improve oxygenation, improved clinical outcomes have not been demonstrated. The optimal recruitment strategy and the type of patients who might benefit are also unclear. This review summarizes the impact of recruitment maneuvers on lung mechanics and physiology, techniques of application, and the clinical situations in which they may be useful.
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Affiliation(s)
- Jose Chacko
- Multidisciplinary Intensive Care Unit, Manipal Hospital, Bangalore, India.
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73
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Esan A, Hess DR, Raoof S, George L, Sessler CN. Severe hypoxemic respiratory failure: part 1--ventilatory strategies. Chest 2010; 137:1203-16. [PMID: 20442122 DOI: 10.1378/chest.09-2415] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Approximately 16% of deaths in patients with ARDS results from refractory hypoxemia, which is the inability to achieve adequate arterial oxygenation despite high levels of inspired oxygen or the development of barotrauma. A number of ventilator-focused rescue therapies that can be used when conventional mechanical ventilation does not achieve a specific target level of oxygenation are discussed. A literature search was conducted and narrative review written to summarize the use of high levels of positive end-expiratory pressure, recruitment maneuvers, airway pressure-release ventilation, and high-frequency ventilation. Each therapy reviewed has been reported to improve oxygenation in patients with ARDS. However, none of them have been shown to improve survival when studied in heterogeneous populations of patients with ARDS. Moreover, none of the therapies has been reported to be superior to another for the goal of improving oxygenation. The goal of improving oxygenation must always be balanced against the risk of further lung injury. The optimal time to initiate rescue therapies, if needed, is within 96 h of the onset of ARDS, a time when alveolar recruitment potential is the greatest. A variety of ventilatory approaches are available to improve oxygenation in the setting of refractory hypoxemia and ARDS. Which, if any, of these approaches should be used is often determined by the availability of equipment and clinician bias.
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Affiliation(s)
- Adebayo Esan
- Division of Pulmonary and Critical Care Medicine, New York Methodist Hospital, 506 Sixth St, Brooklyn, NY 11215, USA
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74
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Ma B, Bates JHT. Modeling the complex dynamics of derecruitment in the lung. Ann Biomed Eng 2010; 38:3466-77. [PMID: 20552275 DOI: 10.1007/s10439-010-0095-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Accepted: 06/03/2010] [Indexed: 11/24/2022]
Abstract
Recruitment maneuvers using deep inflations (DI) have long been used clinically with the objective of recruiting collapsed regions of the lung. Considerable uncertainty continues to exist, however, as to how best to employ recruitment maneuvers or even if they should be used routinely at all for patients receiving mechanical ventilation. Much of this uncertainty may arise from a lack of understanding about the dynamic nature of recruitment and derecruitment. To shed some light on this complex issue, we developed a time-dependent computational model of recruitment and derecruitment in the lung based on a symmetrically bifurcating airway tree in which each branch has a critical closing and opening pressure as well as pressure-dependent opening and closing speeds. Starting from the fully open state, the model underwent regular ventilation for 8 min followed by a series of identical DIs separated by 5 min of identical regular ventilation. We found that the geographical nature and extent of derecruitment before and 5 min after each DI were not always the same, demonstrating that the model exhibits multiple stable states. We conclude that the effectiveness of a recruitment maneuver is not only simply a function of the duration and magnitude of a DI, but may also have an unpredictable component arising from the distributed bi-stable nature of the derecruitment process itself.
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Affiliation(s)
- Baoshun Ma
- Vermont Lung Center, Department of Medicine, University of Vermont College of Medicine, 149 Beaumont Ave., HSRF 228, Burlington, VT 05405, USA
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75
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Continuous flow biphasic positive airway pressure by helmet in patients with acute hypoxic respiratory failure: effect on oxygenation. Intensive Care Med 2010; 36:1688-1694. [PMID: 20521025 DOI: 10.1007/s00134-010-1925-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2009] [Accepted: 03/23/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE We investigated the effects of periodical high pressure breaths (SIGH) or biphasic positive pressure ventilation (BIPAP) during helmet continuous positive airway pressure (CPAP) in patients with acute hypoxic respiratory failure. METHODS We used a recently developed electromechanical expiratory valve (TwinPAP, StarMed, Mirandola, Italy), which is time-cycled between two customizable positive end-expiratory pressure (PEEP) levels. We studied 21 patients (67 ± 17 years old) undergoing helmet CPAP. Continuous flow CPAP system was set at 60 l/min flow rate while maintaining clinical FiO(2) (51 ± 15%). Five steps, lasting 1 h each, were applied: (1) spontaneous breathing with PEEP 0 cmH(2)O (SB), (2) CPAP with PEEP 8 cmH(2)O (CPAP(basal)), (3) low PEEP, 8 cmH(2)O, for 25 s and high PEEP, 25 cmH(2)O, for 5 s (SIGH), (4) low PEEP, 8 cmH(2)O, for 3 s and high PEEP, 20 cmH(2)O, for 3 s (BIPAP), (5) CPAP with PEEP 8 cmH(2)O (CPAP(final)). We randomized the sequence of SIGH and BIPAP. RESULTS PaO(2) was significantly higher during all steps compared to SB. When compared to CPAP(basal), both SIGH and BIPAP induced a further increase in PaO(2). PaO(2) during SIGH and BIPAP were not different. The oxygenation improvement was maintained during CPAP(final). CONCLUSIONS Superimposed, nonsynchronized positive pressure breaths delivered during helmet CPAP by means of the TwinPAP system may improve oxygenation in patients with acute hypoxemic respiratory failure, even at a rate as low as two breaths per minute.
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76
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Role of absolute lung volume to assess alveolar recruitment in acute respiratory distress syndrome patients. Crit Care Med 2010; 38:1300-7. [DOI: 10.1097/ccm.0b013e3181d8cb51] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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77
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Park KJ, Oh YJ, Chang HJ, Sheen SS, Choi J, Lee KS, Park JH, Hwang SC. Acute hemodynamic effects of recruitment maneuvers in patients with acute respiratory distress syndrome. J Intensive Care Med 2009; 24:376-82. [PMID: 19846416 DOI: 10.1177/0885066609344952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The recruitment maneuver (RM) in acute respiratory distress syndrome (ARDS) can cause hemodynamic derangement. We evaluated circulatory and cardiac changes during RMs. METHODS We performed sustained inflation (SI) with a pressure of 40 cm H(2)O for 30 seconds as an RM on 22 patients with ARDS. Blood pressure (BP) and heart rate were recorded immediately before, every 10 seconds during, and 30 seconds after the RM. Ventricular dimensions were obtained simultaneously using M-mode echocardiography, and tissue Doppler imaging was performed on the left ventricular wall. RESULTS Mean, systolic, and diastolic BP decreased at 20 and 30 seconds during 30-second RMs (mean BP: 92 +/- 12 at baseline to 83 +/- 18 mm Hg at the end of the RM, P < .05) and subsequently recovered. Heart rate decreased at 10 and 20 seconds during the RM, and tended to increase afterward. Both ventricular dimensions decreased significantly during the RM. The left ventricular ejection fraction and peak velocity of the left ventricle during systole remained stable. The fractional changes in mean BP and left ventricular end-diastolic dimension during the RMs were correlated significantly with each other (r(s) = 0.59). Static compliance of the respiratory system (Crs) was lower in patients with mean BP change > or =15% than in patients in whom the change was <15% (P < .05). CONCLUSIONS A transient decrease in mean BP was observed during the RM, and its degree was correlated with the preload decrease, while cardiac contractility was maintained.
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Affiliation(s)
- Kwang Joo Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, South Korea.
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78
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Riva D, Contador R, Baez-Garcia C, Xisto D, Cagido V, Martini S, Morales M, Rocco P, Faffe D, Zin W. Recruitment maneuver: RAMP versus CPAP pressure profile in a model of acute lung injury. Respir Physiol Neurobiol 2009; 169:62-8. [DOI: 10.1016/j.resp.2009.08.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Revised: 08/18/2009] [Accepted: 08/19/2009] [Indexed: 12/21/2022]
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79
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Comparison of four methods of lung volume recruitment during high frequency oscillatory ventilation. Intensive Care Med 2009; 35:1990-8. [DOI: 10.1007/s00134-009-1628-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2009] [Accepted: 08/18/2009] [Indexed: 10/20/2022]
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80
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Li Y, Wei H. Lipopolysaccharide “two-hit” induced refractory hypoxemia acute respiratory distress model in rats. ACTA ACUST UNITED AC 2009; 29:470-5. [DOI: 10.1007/s11596-009-0416-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2009] [Indexed: 01/11/2023]
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81
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Lanza F, Damasceno M, Leme F, Yagui A, Paiva K, Luque A, Beppu O. Variable positive end-expiratory pressure can maintain oxygenation in experimental acute respiratory distress syndrome induced by oleic acid in dogs. Braz J Med Biol Res 2009; 42:731-7. [DOI: 10.1590/s0100-879x2009000800007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Accepted: 06/08/2009] [Indexed: 11/21/2022] Open
Affiliation(s)
- F.C. Lanza
- Universidade Federal de São Paulo, Brasil; Centro Universitário São Camilo, Brasil
| | | | - F. Leme
- Universidade Federal de São Paulo, Brasil
| | | | - K.C. Paiva
- Universidade Federal de São Paulo, Brasil
| | - A. Luque
- Centro Universitário São Camilo, Brasil; Universidade de São Paulo, Brasil
| | - O.S. Beppu
- Universidade Federal de São Paulo, Brasil
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82
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Sundaresan A, Yuta T, Hann CE, Chase JG, Shaw GM. A minimal model of lung mechanics and model-based markers for optimizing ventilator treatment in ARDS patients. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2009; 95:166-180. [PMID: 19327863 DOI: 10.1016/j.cmpb.2009.02.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/16/2008] [Revised: 12/22/2008] [Accepted: 02/20/2009] [Indexed: 05/27/2023]
Abstract
A majority of patients admitted to the Intensive Care Unit (ICU) require some form of respiratory support. In the case of Acute Respiratory Distress Syndrome (ARDS), the patient often requires full intervention from a mechanical ventilator. ARDS is also associated with mortality rate as high as 70%. Despite many recent studies on ventilator treatment of the disease, there are no well established methods to determine the optimal Positive End-Expiratory Pressure (PEEP) or other critical ventilator settings for individual patients. A model of fundamental lung mechanics is developed based on capturing the recruitment status of lung units. The main objective of this research is to develop a minimal model that is clinically effective in determining PEEP. The model was identified for a variety of different ventilator settings using clinical data. The fitting error was between 0.1% and 4% over the inflation limb and between 0.3% and 13% over the deflation limb at different PEEP settings. The model produces good correlation with clinical data, and is clinically applicable due to the minimal number of patient specific parameters to identify. The ability to use this identified patient specific model to optimize ventilator management is demonstrated by its ability to predict the patient specific response of PEEP changes before clinically applying them. Predictions of recruited lung volume change with change in PEEP have a median absolute error of 1.87% (IQR: 0.93-4.80%; 90% CI: 0.16-11.98%) for inflation and a median of 5.76% (IQR: 2.71-10.50%; 90% CI: 0.43-17.04%) for deflation, across all data sets and PEEP values (N=34predictions). This minimal model thus provides a clinically useful and relatively simple platform for continuous patient specific monitoring of lung unit recruitment for a patient.
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Affiliation(s)
- Ashwath Sundaresan
- Center for BioEngineering, Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand.
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83
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Gernoth C, Wagner G, Pelosi P, Luecke T. Respiratory and haemodynamic changes during decremental open lung positive end-expiratory pressure titration in patients with acute respiratory distress syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R59. [PMID: 19374751 PMCID: PMC2689506 DOI: 10.1186/cc7786] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Revised: 03/06/2009] [Accepted: 04/17/2009] [Indexed: 12/27/2022]
Abstract
Introduction To investigate haemodynamic and respiratory changes during lung recruitment and decremental positive end-expiratory pressure (PEEP) titration for open lung ventilation in patients with acute respiratory distress syndrome (ARDS) a prospective, clinical trial was performed involving 12 adult patients with ARDS treated in the surgical intensive care unit in a university hospital. Methods A software programme (Open Lung Tool™) incorporated into a standard ventilator controlled the recruitment (pressure-controlled ventilation with fixed PEEP at 20 cmH2O and increased driving pressures at 20, 25 and 30 cmH2O for two minutes each) and PEEP titration (PEEP lowered by 2 cmH2O every two minutes, with tidal volume set at 6 ml/kg). The open lung PEEP (OL-PEEP) was defined as the PEEP level yielding maximum dynamic respiratory compliance plus 2 cmH2O. Gas exchange, respiratory mechanics and central haemodynamics using the Pulse Contour Cardiac Output Monitor (PiCCO™), as well as transoesophageal echocardiography were measured at the following steps: at baseline (T0); during the final recruitment step with PEEP at 20 cmH2O and driving pressure at 30 cmH2O, (T20/30); at OL-PEEP, following another recruitment manoeuvre (TOLP). Results The ratio of partial pressure of arterial oxygen (PaO2) to fraction of inspired oxygen (FiO2) increased from T0 to TOLP (120 ± 59 versus 146 ± 64 mmHg, P < 0.005), as did dynamic respiratory compliance (23 ± 5 versus 27 ± 6 ml/cmH2O, P < 0.005). At constant PEEP (14 ± 3 cmH2O) and tidal volumes, peak inspiratory pressure decreased (32 ± 3 versus 29 ± 3 cmH2O, P < 0.005), although partial pressure of arterial carbon dioxide (PaCO2) was unchanged (58 ± 22 versus 53 ± 18 mmHg). No significant decrease in mean arterial pressure, stroke volume or cardiac output occurred during the recruitment (T20/30). However, left ventricular end-diastolic area decreased at T20/30 due to a decrease in the left ventricular end-diastolic septal-lateral diameter, while right ventricular end-diastolic area increased. Right ventricular function, estimated by the right ventricular Tei-index, deteriorated during the recruitment manoeuvre, but improved at TOLP. Conclusions A standardised open lung strategy increased oxygenation and improved respiratory system compliance. No major haemodynamic compromise was observed, although the increase in right ventricular Tei-index and right ventricular end-diastolic area and the decrease in left ventricular end-diastolic septal-lateral diameter during the recruitment suggested an increased right ventricular stress and strain. Right ventricular function was significantly improved at TOLP compared with T0, although left ventricular function was unchanged, indicating effective lung volume optimisation.
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Affiliation(s)
- Christian Gernoth
- Department of Anesthesiology and Critical Care Medicine, University Hospital Mannheim, Faculty of Medicine, University of Heidelberg, Theodor-Kutzer Ufer, 68165 Mannheim, Germany
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84
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Bercker S, Busch T, Donaubauer B, Schreiter D, Kaisers U. Beatmung und Volumentherapie beim akuten Lungenversagen. Anaesthesist 2009; 58:410-4. [DOI: 10.1007/s00101-009-1525-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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85
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Steimback PW, Oliveira GP, Rzezinski AF, Silva PL, Garcia CSNB, Rangel G, Morales MM, Lapa E Silva JR, Capelozzi VL, Pelosi P, Rocco PRM. Effects of frequency and inspiratory plateau pressure during recruitment manoeuvres on lung and distal organs in acute lung injury. Intensive Care Med 2009; 35:1120-8. [PMID: 19221714 DOI: 10.1007/s00134-009-1439-y] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2008] [Accepted: 01/26/2009] [Indexed: 02/06/2023]
Abstract
PURPOSE To evaluate the effects of frequency and inspiratory plateau pressure (Pplat) during recruitment manoeuvres (RMs) on lung and distal organs in acute lung injury (ALI). METHODS We studied paraquat-induced ALI rats. At 24 h, rats were anesthetized and RMs were applied using continuous positive airway pressure (CPAP, 40 cmH(2)O/40 s) or three-different sigh strategies: (a) 180 sighs/h and Pplat = 40 cmH(2)O (S180/40), (b) 10 sighs/h and Pplat = 40 cmH(2)O (S10/40), and (c) 10 sighs/h and Pplat = 20 cmH(2)O (S10/20). RESULTS S180/40 yielded alveolar hyperinflation and increased lung and kidney epithelial cell apoptosis as well as type III procollagen (PCIII) mRNA expression. S10/40 resulted in a reduction in epithelial cell apoptosis and PCIII expression. Static elastance and alveolar collapse were higher in S10/20 than S10/40. CONCLUSIONS The reduction in sigh frequency led to a protective effect on lung and distal organs, while the combination with reduced Pplat worsened lung mechanics and histology.
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Affiliation(s)
- Paula W Steimback
- Laboratory of Pulmonary Investigation, Instituto de Biofísica Carlos Chagas Filho, C.C.S., Universidade Federal do Rio de Janeiro, Ilha do Fundão, Rio de Janeiro, RJ 21941-902, Brazil
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86
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Kasim I, Gulyas M, Almgren B, Högman M. A recruitment breath manoeuvre directly after endotracheal suction improves lung function: an experimental study in pigs. Ups J Med Sci 2009; 114:129-35. [PMID: 19736601 PMCID: PMC2852766 DOI: 10.1080/03009730903177357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Atelectasis occurs after a well performed endotracheal suction. Clinical studies have shown that recruitment manoeuvres added after endotracheal suction during mechanical ventilation restore lung function. Repetitive lung over-distension is, however, harmful for the lung, and the effects of adding a larger breath, recruitment breath, directly after repeated endotracheal suction were therefore investigated. METHODS Twelve healthy anaesthetized pigs were randomized into two groups: one without and one with a recruitment breath manoeuvre (RBM), i.e. a breath 15 cmH(2)O above inspiratory pressure for 10 s during pressure-controlled ventilation. The pigs were suctioned every hour for 4 hours with an open suction system. RESULTS At the end of the study there was a statistically significant difference between the group given RBM and that without with respect to PaCO(2), tidal volume (V(T)), and compliance (Crs). Without RBM, the PaCO(2) increased from 4.6+/-0.4 to 6.1+/-1.5 kPa, V(T) decreased from 345+/-39 to 247+/-71 mL, and Crs decreased from 28+/-6 to 18+/-5 mL/cmH(2)O. There was no change in PaCO(2) or Crs when a RBM was given. Morphological analysis revealed no differences in aeration of apical and central lung parenchyma. In the basal lung parenchyma there were, however, greater areas with normal lung parenchyma and less atelectasis after RBM. CONCLUSIONS Atelectasis created by endotracheal suction can be opened by inflating the lung for a short duration with low pressure, without over-distension, immediately after suction.
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Affiliation(s)
| | | | - Birgitta Almgren
- 3Karolinska Institute, Department of Clinical Sciences, Division of Anaesthesia and Intensive Care, Danderyd University HospitalStockholmSweden
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87
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Hyperinflation using pressure support ventilation improves secretion clearance and respiratory mechanics in ventilated patients with pulmonary infection: a randomised crossover trial. ACTA ACUST UNITED AC 2009; 55:249-54. [DOI: 10.1016/s0004-9514(09)70004-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Ryu HG, Bahk JH, Lee HJ, Im JG. Effect of recruitment and body positioning on lung volume and oxygenation in acute lung injury model. Anaesth Intensive Care 2009; 36:792-7. [PMID: 19115646 DOI: 10.1177/0310057x0803600607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The mechanism of oxygenation improvement after recruitment manoeuvres or prone positioning in acute lung injury or acute respiratory distress syndrome is still unclear. We tried to determine the mechanism responsible for the effects of recruitment manoeuvres or prone positioning on lung aeration using a whole lung computed tomography scan in an oleic acid induced acute lung injury canine model. Twelve adult mongrel dogs were allocated into either the supine group (n=6) or the prone group (n=6). After the establishment of acute lung injury, three recruitment manoeuvres were performed at one-hour intervals. Haemodynamic and ventilatory variables, arterial blood gas analyses and CT scans of the whole lung were obtained 90 minutes after oleic acid injection and five minutes before and after each recruitment manoeuvre. Recruitment manoeuvres in the supine position improved oxygenation (P=0.025) that correlated with increase of the poorly- and well-aerated dorsal (dependent) lung volume (r=0.436, P=0.016). Prone positioning increased oxygenation (P=0.004) that also correlated with increase of the poorly- and well-aerated dorsal (nondependent) lung volume (r=0.787, P<0.001). However, the recruitment manoeuvre in the prone position had no effect on oxygenation despite an increase in ventral (dependent) lung volume. The increase in PaO2 after recruitment manoeuvres in the supine position or after prone positioning is related to the increase of the poorly- and well-aerated dorsal lung.
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Affiliation(s)
- H G Ryu
- Department of Anesthesiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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89
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Varelmann D, Muders T, Zinserling J, Guenther U, Magnusson A, Hedenstierna G, Putensen C, Wrigge H. Cardiorespiratory effects of spontaneous breathing in two different models of experimental lung injury: a randomized controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:R135. [PMID: 18980696 PMCID: PMC2646345 DOI: 10.1186/cc7108] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2008] [Revised: 10/03/2008] [Accepted: 11/04/2008] [Indexed: 12/20/2022]
Abstract
Introduction Acute lung injury (ALI) can result from various insults to the pulmonary tissue. Experimental and clinical data suggest that spontaneous breathing (SB) during pressure-controlled ventilation (PCV) in ALI results in better lung aeration and improved oxygenation. Our objective was to evaluate whether the addition of SB has different effects in two different models of ALI. Methods Forty-four pigs were randomly assigned to ALI resulting either from hydrochloric acid aspiration (HCl-ALI) or from increased intra-abdominal pressure plus intravenous oleic acid injections (OA-ALI) and were ventilated in PCV mode either with SB (PCV + SB) or without SB (PCV – SB). Cardiorespiratory variables were measured at baseline after induction of ALI and after 4 hours of treatment (PCV + SB or PCV – SB). Finally, density distributions and end-expiratory lung volume (EELV) were assessed by thoracic spiral computed tomography. Results PCV + SB improved arterial partial pressure of oxygen/inspiratory fraction of oxygen (PaO2/FiO2) by a reduction in intrapulmonary shunt fraction in HCl-ALI from 27% ± 6% to 23% ± 13% and in OA-ALI from 33% ± 19% to 26% ± 18%, whereas during PCV – SB PaO2/FiO2 deteriorated and shunt fraction increased in the HCl group from 28% ± 8% to 37% ± 17% and in the OA group from 32% ± 12% to 47% ± 17% (P < 0.05 for interaction time and treatment, but not ALI type). PCV + SB also resulted in higher EELV (HCl-ALI: 606 ± 171 mL, OA-ALI: 439 ± 90 mL) as compared with PCV – SB (HCl-ALI: 372 ± 130 mL, OA-ALI: 192 ± 51 mL, with P < 0.05 for interaction of time, treatment, and ALI type). Conclusions SB improves oxygenation, reduces shunt fraction, and increases EELV in both models of ALI.
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Affiliation(s)
- Dirk Varelmann
- Department of Anesthesiology and Intensive Care Medicine, University of Bonn, Sigmund-Freud-Strasse 25, D-53105 Bonn, Germany.
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Abstract
OBJECTIVE Acute respiratory distress syndrome is a common disorder associated with significant mortality and morbidity. The aim of this article is to critically evaluate the definition of acute respiratory distress syndrome and examine the impact the definition has on clinical practice and research. DATA SOURCES Articles from a MEDLINE search (1950 to August 2007) using the Medical Subject Heading respiratory distress syndrome, adult, diagnosis, limited to the English language and human subjects, their relevant bibliographies, and personal collections, were reviewed. DATA SYNTHESIS The definition of acute respiratory distress syndrome is important to researchers, clinicians, and administrators alike. It has evolved significantly over the last 40 years, culminating in the American-European Consensus Conference definition, which was published in 1994. Although the American-European Consensus Conference definition is widely used, it has some important limitations that may impact on the conduct of clinical research, on resource allocation, and ultimately on the bedside management of such patients. These limitations stem partially from the fact that as defined, acute respiratory distress syndrome is a heterogeneous entity and also involve the reliability and validity of the criteria used in the definition. This article critically evaluates the American-European Consensus Conference definition and its limitations. Importantly, it highlights how these limitations may contribute to clinical trials that have failed to detect a potential true treatment effect. Finally, recommendations are made that could be considered in future definition modifications with an emphasis on the significance of accurately identifying the target population in future trials and subsequently in clinical care. CONCLUSION How acute respiratory distress syndrome is defined has a significant impact on the results of randomized, controlled trials and epidemiologic studies. Changes to the current American-European Consensus Conference definition are likely to have an important role in advancing the understanding and management of acute respiratory distress syndrome.
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91
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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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92
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MacIntyre NR. Is there a best way to set positive expiratory-end pressure for mechanical ventilatory support in acute lung injury? Clin Chest Med 2008; 29:233-9, v. [PMID: 18440433 DOI: 10.1016/j.ccm.2008.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Airspace collapse is a hallmark of parenchymal lung injury. Strategies to reopen and maintain patency of these regions offer three advantages: improved gas exchange, less lung injury, and improved lung compliance. Elevations in intrathoracic pressure to achieve these goals, however, may overdistend healthier lung regions and compromise cardiac function. Positive expiratory-end pressure is a widely used technique to maintain alveolar patency, but its beneficial effects must be balanced against its harmful effects.
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Affiliation(s)
- Neil R MacIntyre
- Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Box 3911, Room 1120, Erwin Road, Durham, NC 27710, USA.
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93
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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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Pestaña D, Royo C, Hernández-Gancedo C, Martínez-Casanova E, Criado A. [Hemodynamic variability caused by pressure-volume plotting and alveolar recruitment maneuvers in patients with adult respiratory distress syndrome]. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2008; 55:348-354. [PMID: 18693660 DOI: 10.1016/s0034-9356(08)70590-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
OBJECTIVES The plotting of pressure-volume curves and the performance of alveolar recruitment maneuvers are common practices in the care of patients with adult respiratory distress syndrome (ARDS), even though potentially harmful hemodynamic effects are associated with sustaining a high intrathoracic pressure. Our aim was to analyze hemodynamic and ventilatory changes related to these 2 maneuvers and to assess the short-term effectiveness of recruitment. PATIENTS AND METHODS The patients had ARDS and were being monitored with a catheter connected to a PiCCO system. All measurements were taken in sinus rhythm and with adequate vascular filling. Values recorded during plotting of the quasistatic pressure-volume curve and the recruitment maneuver (sustained airway pressure of 40 cm H2O) were the cardiac index, mean arterial pressure, heart rate, systolic volume index, and oxygen saturation (SpO2). Blood gas measurements were recorded before the maneuvers and 15 minutes afterwards. RESULTS All parameters decreased significantly in the 14 patients studied. The mean (SD) maximum decreases, from which all patients recovered within 2 minutes, were as follows: cardiac index, 26% (16%); mean arterial pressure, 6% (6%); heart rate, 4% (5%), systolic volume index, 21% (15%); and SpO2, 3% (3%). Significant increases in PaO2 (7% [6%]) and the ratio of PaO2 to the fraction of inspired oxygen were recorded after the recruitment maneuver (P=.016 and P=.014, respectively), but the changes were not clinically significant. CONCLUSIONS The hemodynamic disturbances associated with the alveolar recruitment maneuver based on sustaining a high end-expiratory pressure and the minor improvement in oxygenation achieved as a result suggest that the routine use of that maneuver in ARDS patients is of questionable value.
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Affiliation(s)
- D Pestaña
- Servicio de Anestesiología y Reanimación, Residencia General, Hospital Universitario La Paz, Madrid.
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95
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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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96
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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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97
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Agarwal R, Srinivas R, Nath A, Jindal SK. Is the mortality higher in the pulmonary vs the extrapulmonary ARDS? A meta analysis. Chest 2007; 133:1463-1473. [PMID: 17989150 DOI: 10.1378/chest.07-2182] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND AND AIM ARDS can occur from the following two pathogenetic pathways: a direct pulmonary injury (ARDSp); and an indirect injury (ARDSexp). The predisposing clinical factor can influence the pathogenesis and clinical outcome of ARDS. This metaanalysis was aimed at evaluating whether there is any difference in mortality between the two groups. METHODS We searched the MEDLINE, EMBASE, and CINAHL databases for relevant studies published from 1987 to 2007, and included studies that have reported mortality in the two groups of ARDS. We calculated the odds ratio (OR) and 95% confidence interval (CI) to assess mortality in patients with ARDSp vs patients with ARDSexp and pooled the results using three different statistical models. RESULTS Our search yielded 34 studies. In all, the studies involved 4,311 patients with 2,330 patients in the ARDSp group and 1,981 patients in the ARDSexp group. The OR of mortality in ARDSp group compared to the ARDSexp group was 1.11 (95% CI, 0.88 to 1.39), as determined by the random-effects model; 1.04 (95% CI, 0.92 to 1.18), as determined by the fixed-effects model; and 1.04 (95% CI, 0.92 to 1.18), as determined by the exact method, indicating that mortality is similar in the two groups. The mortality was no different whether the studies were classified as prospective (OR, 1.15; 95% CI, 0.87 to 1.51) or retrospective (OR, 1.01; 95% CI, 0.61 to 1.69); small (OR, 1.11; 95% CI, 0.77 to 1.60) or large (OR, 1.1; 95% CI, 0.82 to 1.49); or observational (OR, 1.10; 95% CI, 0.82 to 1.49) or interventional (OR, 0.97; 95% CI, 0.79 to 1.19). There was methodological and statistical heterogeneity (I(2), 50.9%; 95% CI, 21.3 to 66.2%; chi(2) statistic, 67.22; p = 0.0004). CONCLUSIONS The results of this study suggest that there is no difference in mortality between these two groups. Further studies should focus on specific etiologies within the subgroups rather than focusing on the broader division of ARDSp and ARDSexp.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajagopala Srinivas
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Alok Nath
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surinder K Jindal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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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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Abstract
Patients admitted to the ICU after severe trauma require frequent procedures in the operating room, particularly in cases where a damage control strategy is used. The ventilatory management of these patients in the operating room can be particularly challenging. These patients often have severely impaired respiratory mechanics because of acute lung injury and abdominal compartment syndrome. Consequently, the pressure and flow generation capabilities of standard anesthesia ventilators may be inadequate to support ventilation and gas exchange. This article presents the problems that may be encountered in patients who have severe abdominal and lung injuries, and the current management concepts used in caring for these patients in the critical care setting, to provide guidelines for the anesthetist faced with these patients in the operating room.
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Affiliation(s)
- Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, HUP - 781A Dulles, 3400 Spruce Street 4283, Philadelphia, PA 19104, 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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