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Chiumello D, Sferrazza Papa GF, Artigas A, Bouhemad B, Grgic A, Heunks L, Markstaller K, Pellegrino GM, Pisani L, Rigau D, Schultz MJ, Sotgiu G, Spieth P, Zompatori M, Navalesi P. ERS statement on chest imaging in acute respiratory failure. Eur Respir J 2019; 54:13993003.00435-2019. [PMID: 31248958 DOI: 10.1183/13993003.00435-2019] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 05/16/2019] [Indexed: 12/17/2022]
Abstract
Chest imaging in patients with acute respiratory failure plays an important role in diagnosing, monitoring and assessing the underlying disease. The available modalities range from plain chest X-ray to computed tomography, lung ultrasound, electrical impedance tomography and positron emission tomography. Surprisingly, there are presently no clear-cut recommendations for critical care physicians regarding indications for and limitations of these different techniques.The purpose of the present European Respiratory Society (ERS) statement is to provide physicians with a comprehensive clinical review of chest imaging techniques for the assessment of patients with acute respiratory failure, based on the scientific evidence as identified by systematic searches. For each of these imaging techniques, the panel evaluated the following items: possible indications, technical aspects, qualitative and quantitative analysis of lung morphology and the potential interplay with mechanical ventilation. A systematic search of the literature was performed from inception to September 2018. A first search provided 1833 references. After evaluating the full text and discussion among the committee, 135 references were used to prepare the current statement.These chest imaging techniques allow a better assessment and understanding of the pathogenesis and pathophysiology of patients with acute respiratory failure, but have different indications and can provide additional information to each other.
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Affiliation(s)
- Davide Chiumello
- SC Anestesia e Rianimazione, Ospedale San Paolo - Polo Universitario, ASST Santi Paolo e Carlo, Milan, Italy.,Dipartimento di Scienze della Salute, Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy
| | | | - Antonio Artigas
- Corporacion Sanitaria, Universitaria Parc Tauli, CIBER de Enfermedades Respiratorias Autonomous University of Barcelona, Sabadell, Spain.,Intensive Care Dept, University Hospitals Sagrado Corazon - General de Cataluna, Quiron Salud, Barcelona-Sant Cugat del Valles, Spain
| | - Belaid Bouhemad
- Service d'Anesthésie - Réanimation, Université Bourgogne - Franche Comtè, lncumr 866L, Dijon, France
| | - Aleksandar Grgic
- Dept of Nuclear Medicine, Saarland University Medical Center, Homburg, Germany
| | - Leo Heunks
- Dept of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Klaus Markstaller
- Dept of Anesthesia, General Intensive Care Medicine and Pain Therapy, Medical University of Vienna, Vienna, Austria
| | - Giulia M Pellegrino
- Dipartimento di Scienze della Salute, Centro Ricerca Coordinata di Insufficienza Respiratoria, Università degli Studi di Milano, Milan, Italy.,Casa di Cura del Policlinico, Dipartimento di Scienze Neuroriabilitative, Milan, Italy
| | - Lara Pisani
- Respiratory and Critical Care Unit, Alma Mater Studiorum, University of Bologna, Sant'Orsola Malpighi Hospital, Bologna, Italy
| | | | - Marcus J Schultz
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Dept of Clinical and Experimental Medicine, University of Sassari, Sassari, Italy
| | - Peter Spieth
- Dept of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.,Center for Clinical Research and Management Education, Division of Health Care Sciences, Dresden International University, Dresden, Germany
| | | | - Paolo Navalesi
- Anaesthesia and Intensive Care, Department of Medical and Surgical Sciences, University of Magna Graecia, Catanzaro, Italy
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Does Regional Lung Strain Correlate With Regional Inflammation in Acute Respiratory Distress Syndrome During Nonprotective Ventilation? An Experimental Porcine Study. Crit Care Med 2019. [PMID: 29528946 DOI: 10.1097/ccm.0000000000003072] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
OBJECTIVE It is known that ventilator-induced lung injury causes increased pulmonary inflammation. It has been suggested that one of the underlying mechanisms may be strain. The aim of this study was to investigate whether lung regional strain correlates with regional inflammation in a porcine model of acute respiratory distress syndrome. DESIGN Retrospective analysis of CT images and positron emission tomography images using [F]fluoro-2-deoxy-D-glucose. SETTING University animal research laboratory. SUBJECTS Seven piglets subjected to experimental acute respiratory distress syndrome and five ventilated controls. INTERVENTIONS Acute respiratory distress syndrome was induced by repeated lung lavages, followed by 210 minutes of injurious mechanical ventilation using low positive end-expiratory pressures (mean, 4 cm H2O) and high inspiratory pressures (mean plateau pressure, 45 cm H2O). All animals were subsequently studied with CT scans acquired at end-expiration and end-inspiration, to obtain maps of volumetric strain (inspiratory volume - expiratory volume)/expiratory volume, and dynamic positron emission tomography imaging. Strain maps and positron emission tomography images were divided into 10 isogravitational horizontal regions-of-interest, from which spatial correlation was calculated for each animal. MEASUREMENTS AND MAIN RESULTS The acute respiratory distress syndrome model resulted in a decrease in respiratory system compliance (20.3 ± 3.4 to 14.0 ± 4.9 mL/cm H2O; p < 0.05) and oxygenation (PaO2/FIO2, 489 ± 80 to 92 ± 59; p < 0.05), whereas the control animals did not exhibit changes. In the acute respiratory distress syndrome group, strain maps showed a heterogeneous distribution with a greater concentration in the intermediate gravitational regions, which was similar to the distribution of [F]fluoro-2-deoxy-D-glucose uptake observed in the positron emission tomography images, resulting in a positive spatial correlation between both variables (median R = 0.71 [0.02-0.84]; p < 0.05 in five of seven animals), which was not observed in the control animals. CONCLUSION In this porcine acute respiratory distress syndrome model, regional lung strain was spatially correlated with regional inflammation, supporting that strain is a relevant and prominent determinant of ventilator-induced lung injury.
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Follow the Voxel-A New Method for the Analysis of Regional Strain in Lung Injury. Crit Care Med 2019; 46:1033-1035. [PMID: 29762413 DOI: 10.1097/ccm.0000000000003109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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54
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Cereda M, Xin Y, Rizi RR. Acute Respiratory Distress Syndrome: Can Data from the Sick Guide Care for the Healthy? Am J Respir Crit Care Med 2019; 198:830-832. [PMID: 29787308 DOI: 10.1164/rccm.201804-0627ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Maurizio Cereda
- 1 Department of Anesthesiology and Critical Care University of Pennsylvania Philadelphia, Pennsylvania and
| | - Yi Xin
- 2 Department of Radiology University of Pennsylvania Philadelphia, Pennsylvania
| | - Rahim R Rizi
- 2 Department of Radiology University of Pennsylvania Philadelphia, Pennsylvania
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Cereda M, Xin Y, Goffi A, Herrmann J, Kaczka DW, Kavanagh BP, Perchiazzi G, Yoshida T, Rizi RR. Imaging the Injured Lung: Mechanisms of Action and Clinical Use. Anesthesiology 2019; 131:716-749. [PMID: 30664057 PMCID: PMC6692186 DOI: 10.1097/aln.0000000000002583] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Acute respiratory distress syndrome (ARDS) consists of acute hypoxemic respiratory failure characterized by massive and heterogeneously distributed loss of lung aeration caused by diffuse inflammation and edema present in interstitial and alveolar spaces. It is defined by consensus criteria, which include diffuse infiltrates on chest imaging-either plain radiography or computed tomography. This review will summarize how imaging sciences can inform modern respiratory management of ARDS and continue to increase the understanding of the acutely injured lung. This review also describes newer imaging methodologies that are likely to inform future clinical decision-making and potentially improve outcome. For each imaging modality, this review systematically describes the underlying principles, technology involved, measurements obtained, insights gained by the technique, emerging approaches, limitations, and future developments. Finally, integrated approaches are considered whereby multimodal imaging may impact management of ARDS.
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Affiliation(s)
- Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, ON, Canada
| | - Jacob Herrmann
- Departments of Anesthesia and Biomedical Engineering, University of Iowa, IA
| | - David W. Kaczka
- Departments of Anesthesia, Radiology, and Biomedical Engineering, University of Iowa, IA
| | | | - Gaetano Perchiazzi
- Hedenstierna Laboratory and Uppsala University Hospital, Uppsala University, Sweden
| | - Takeshi Yoshida
- Hospital for Sick Children, University of Toronto, ON, Canada
| | - Rahim R. Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
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A Window on the Lung: Molecular Imaging as a Tool to Dissect Pathophysiologic Mechanisms of Acute Lung Disease. CONTRAST MEDIA & MOLECULAR IMAGING 2019; 2019:1510507. [PMID: 31531003 PMCID: PMC6732639 DOI: 10.1155/2019/1510507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 05/08/2019] [Indexed: 11/21/2022]
Abstract
In recent years, imaging has given a fundamental contribution to our understanding of the pathophysiology of acute lung diseases. Several methods have been developed based on computed tomography (CT), positron emission tomography (PET), and magnetic resonance (MR) imaging that allow regional, in vivo measurement of variables such as lung strain, alveolar size, metabolic activity of inflammatory cells, ventilation, and perfusion. Because several of these methods are noninvasive, they can be successfully translated from animal models to patients. The aim of this paper is to review the advances in knowledge that have been accrued with these imaging modalities on the pathophysiology of acute respiratory distress syndrome (ARDS), ventilator-induced lung injury (VILI), asthma and chronic obstructive pulmonary disease (COPD).
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Yoshida T, Amato MBP, Grieco DL, Chen L, Lima CAS, Roldan R, Morais CCA, Gomes S, Costa ELV, Cardoso PFG, Charbonney E, Richard JCM, Brochard L, Kavanagh BP. Esophageal Manometry and Regional Transpulmonary Pressure in Lung Injury. Am J Respir Crit Care Med 2019; 197:1018-1026. [PMID: 29323931 DOI: 10.1164/rccm.201709-1806oc] [Citation(s) in RCA: 140] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Esophageal manometry is the clinically available method to estimate pleural pressure, thus enabling calculation of transpulmonary pressure (Pl). However, many concerns make it uncertain in which lung region esophageal manometry reflects local Pl. OBJECTIVES To determine the accuracy of esophageal pressure (Pes) and in which regions esophageal manometry reflects pleural pressure (Ppl) and Pl; to assess whether lung stress in nondependent regions can be estimated at end-inspiration from Pl. METHODS In lung-injured pigs (n = 6) and human cadavers (n = 3), Pes was measured across a range of positive end-expiratory pressure, together with directly measured Ppl in nondependent and dependent pleural regions. All measurements were obtained with minimal nonstressed volumes in the pleural sensors and esophageal balloons. Expiratory and inspiratory Pl was calculated by subtracting local Ppl or Pes from airway pressure; inspiratory Pl was also estimated by subtracting Ppl (calculated from chest wall and respiratory system elastance) from the airway plateau pressure. MEASUREMENTS AND MAIN RESULTS In pigs and human cadavers, expiratory and inspiratory Pl using Pes closely reflected values in dependent to middle lung (adjacent to the esophagus). Inspiratory Pl estimated from elastance ratio reflected the directly measured nondependent values. CONCLUSIONS These data support the use of esophageal manometry in acute respiratory distress syndrome. Assuming correct calibration, expiratory Pl derived from Pes reflects Pl in dependent to middle lung, where atelectasis usually predominates; inspiratory Pl estimated from elastance ratio may indicate the highest level of lung stress in nondependent "baby" lung, where it is vulnerable to ventilator-induced lung injury.
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Affiliation(s)
- Takeshi Yoshida
- 1 Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,2 Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, and.,3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Domenico Luca Grieco
- 1 Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,2 Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, and.,5 Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione "Policlinico universitario A. Gemelli," Rome, Italy.,6 Cardiac Arrest and Ventilation International Association for Research, Laboratoire d'anatomie, Université du Québec à Trois-Rivières et Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, Canada
| | - Lu Chen
- 1 Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,2 Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, and
| | | | - Rollin Roldan
- 4 Divisao de Pneumologia and.,7 Unidad de Cuidados Intensivos, Hospital Rebagliati, Lima, Perú
| | | | | | | | - Paulo F G Cardoso
- 8 Disciplina de Cirurgia Torácica, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Emmanuel Charbonney
- 6 Cardiac Arrest and Ventilation International Association for Research, Laboratoire d'anatomie, Université du Québec à Trois-Rivières et Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, Canada.,9 Centre de Recherche de l'Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada; and
| | - Jean-Christophe M Richard
- 6 Cardiac Arrest and Ventilation International Association for Research, Laboratoire d'anatomie, Université du Québec à Trois-Rivières et Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, Canada.,10 Department of Pre-Hospital and Emergency Medicine, General Hospital of Annecy, Annecy, France
| | - Laurent Brochard
- 1 Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,6 Cardiac Arrest and Ventilation International Association for Research, Laboratoire d'anatomie, Université du Québec à Trois-Rivières et Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, Canada
| | - Brian P Kavanagh
- 2 Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, and.,3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Morais CCA, Koyama Y, Yoshida T, Plens GM, Gomes S, Lima CAS, Ramos OPS, Pereira SM, Kawaguchi N, Yamamoto H, Uchiyama A, Borges JB, Vidal Melo MF, Tucci MR, Amato MBP, Kavanagh BP, Costa ELV, Fujino Y. High Positive End-Expiratory Pressure Renders Spontaneous Effort Noninjurious. Am J Respir Crit Care Med 2019; 197:1285-1296. [PMID: 29323536 DOI: 10.1164/rccm.201706-1244oc] [Citation(s) in RCA: 140] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
RATIONALE In acute respiratory distress syndrome (ARDS), atelectatic solid-like lung tissue impairs transmission of negative swings in pleural pressure (Ppl) that result from diaphragmatic contraction. The localization of more negative Ppl proportionally increases dependent lung stretch by drawing gas either from other lung regions (e.g., nondependent lung [pendelluft]) or from the ventilator. Lowering the level of spontaneous effort and/or converting solid-like to fluid-like lung might render spontaneous effort noninjurious. OBJECTIVES To determine whether spontaneous effort increases dependent lung injury, and whether such injury would be reduced by recruiting atelectatic solid-like lung with positive end-expiratory pressure (PEEP). METHODS Established models of severe ARDS (rabbit, pig) were used. Regional histology (rabbit), inflammation (positron emission tomography; pig), regional inspiratory Ppl (intrabronchial balloon manometry), and stretch (electrical impedance tomography; pig) were measured. Respiratory drive was evaluated in 11 patients with ARDS. MEASUREMENTS AND MAIN RESULTS Although injury during muscle paralysis was predominantly in nondependent and middle lung regions at low (vs. high) PEEP, strong inspiratory effort increased injury (indicated by positron emission tomography and histology) in dependent lung. Stronger effort (vs. muscle paralysis) caused local overstretch and greater tidal recruitment in dependent lung, where more negative Ppl was localized and greater stretch was generated. In contrast, high PEEP minimized lung injury by more uniformly distributing negative Ppl, and lowering the magnitude of spontaneous effort (i.e., deflection in esophageal pressure observed in rabbits, pigs, and patients). CONCLUSIONS Strong effort increased dependent lung injury, where higher local lung stress and stretch was generated; effort-dependent lung injury was minimized by high PEEP in severe ARDS, which may offset need for paralysis.
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Affiliation(s)
- Caio C A Morais
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Yukiko Koyama
- 2 Intensive Care Unit, Osaka University Hospital, Suita, Japan
| | - Takeshi Yoshida
- 2 Intensive Care Unit, Osaka University Hospital, Suita, Japan.,3 Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Glauco M Plens
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Susimeire Gomes
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Cristhiano A S Lima
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Ozires P S Ramos
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Sérgio M Pereira
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Naomasa Kawaguchi
- 4 The Department of Pathology, School of Allied Health Sciences, Osaka University Graduate School of Medicine, Suita, Japan
| | - Hirofumi Yamamoto
- 4 The Department of Pathology, School of Allied Health Sciences, Osaka University Graduate School of Medicine, Suita, Japan
| | | | - João B Borges
- 5 Hedenstierna Laboratory, Department of Surgical Sciences, Section of Anesthesiology & Critical Care, Uppsala University, Uppsala, Sweden; and
| | - Marcos F Vidal Melo
- 6 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard University, Boston, Massachusetts
| | - Mauro R Tucci
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Marcelo B P Amato
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Brian P Kavanagh
- 3 Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Eduardo L V Costa
- 1 Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Yuji Fujino
- 2 Intensive Care Unit, Osaka University Hospital, Suita, Japan
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Bitker L, Costes N, Le Bars D, Lavenne F, Orkisz M, Hernandez Hoyos M, Benzerdjeb N, Devouassoux M, Richard JC. Noninvasive quantification of macrophagic lung recruitment during experimental ventilation-induced lung injury. J Appl Physiol (1985) 2019; 127:546-558. [PMID: 31169472 DOI: 10.1152/japplphysiol.00825.2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Macrophagic lung infiltration is pivotal in the development of lung biotrauma because of ventilation-induced lung injury (VILI). We assessed the performance of [11C](R)-PK11195, a positron emission tomography (PET) radiotracer binding the translocator protein, to quantify macrophage lung recruitment during experimental VILI. Pigs (n = 6) were mechanically ventilated under general anesthesia, using protective ventilation settings (baseline). Experimental VILI was performed by titrating tidal volume to reach a transpulmonary end-inspiratory pressure (∆PL) of 35-40 cmH2O. We acquired PET/computed tomography (CT) lung images at baseline and after 4 h of VILI. Lung macrophages were quantified in vivo by the standardized uptake value (SUV) of [11C](R)-PK11195 measured in PET on the whole lung and in six lung regions and ex vivo on lung pathology at the end of experiment. Lung mechanics were extracted from CT images to assess their association with the PET signal. ∆PL increased from 9 ± 1 cmH2O under protective ventilation, to 36 ± 6 cmH2O during experimental VILI. Compared with baseline, whole-lung [11C](R)-PK11195 SUV significantly increased from 1.8 ± 0.5 to 2.9 ± 0.5 after experimental VILI. Regional [11C](R)-PK11195 SUV was positively associated with the magnitude of macrophage recruitment in pathology (P = 0.03). Compared with baseline, whole-lung CT-derived dynamic strain and tidal hyperinflation increased significantly after experimental VILI, from 0.6 ± 0 to 2.0 ± 0.4, and 1 ± 1 to 43 ± 19%, respectively. On multivariate analysis, both were significantly associated with regional [11C](R)-PK11195 SUV. [11C](R)-PK11195 lung uptake (a proxy of lung inflammation) was increased by experimental VILI and was associated with the magnitude of dynamic strain and tidal hyperinflation.NEW & NOTEWORTHY We assessed the performance of [11C](R)-PK11195, a translocator protein-specific positron emission tomography (PET) radiotracer, to quantify macrophage lung recruitment during experimental ventilation-induced lung injury (VILI). In this proof-of-concept study, we showed that the in vivo quantification of [11C](R)-PK11195 lung uptake in PET reflected the magnitude of macrophage lung recruitment after VILI. Furthermore, increased [11C](R)-PK11195 lung uptake was associated with harmful levels of dynamic strain and tidal hyperinflation applied to the lungs.
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Affiliation(s)
- Laurent Bitker
- Service de Médecine Intensive et Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, CREATIS Unité Mixte de Recherche 5220, U1206, Villeurbanne, France.,Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France
| | | | - Didier Le Bars
- Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France.,CERMEP - Imagerie du Vivant, Bron, France
| | | | - Maciej Orkisz
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, CREATIS Unité Mixte de Recherche 5220, U1206, Villeurbanne, France.,Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France
| | - Marcela Hernandez Hoyos
- Systems and Computing Engineering Department, School of Engineering, Universidad de los Andes, Bogota, Colombia
| | - Nazim Benzerdjeb
- Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France.,Centre d'Anatomie et Cytologie Pathologique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Mojgan Devouassoux
- Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France.,Centre d'Anatomie et Cytologie Pathologique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Jean-Christophe Richard
- Service de Médecine Intensive et Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, CREATIS Unité Mixte de Recherche 5220, U1206, Villeurbanne, France.,Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France
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Grune J, Tabuchi A, Kuebler WM. Alveolar dynamics during mechanical ventilation in the healthy and injured lung. Intensive Care Med Exp 2019; 7:34. [PMID: 31346797 PMCID: PMC6658629 DOI: 10.1186/s40635-019-0226-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 02/13/2019] [Indexed: 02/12/2023] Open
Abstract
Mechanical ventilation is a life-saving therapy in patients with acute respiratory distress syndrome (ARDS). However, mechanical ventilation itself causes severe co-morbidities in that it can trigger ventilator-associated lung injury (VALI) in humans or ventilator-induced lung injury (VILI) in experimental animal models. Therefore, optimization of ventilation strategies is paramount for the effective therapy of critical care patients. A major problem in the stratification of critical care patients for personalized ventilation settings, but even more so for our overall understanding of VILI, lies in our limited insight into the effects of mechanical ventilation at the actual site of injury, i.e., the alveolar unit. Unfortunately, global lung mechanics provide for a poor surrogate of alveolar dynamics and methods for the in-depth analysis of alveolar dynamics on the level of individual alveoli are sparse and afflicted by important limitations. With alveolar dynamics in the intact lung remaining largely a "black box," our insight into the mechanisms of VALI and VILI and the effectiveness of optimized ventilation strategies is confined to indirect parameters and endpoints of lung injury and mortality.In the present review, we discuss emerging concepts of alveolar dynamics including alveolar expansion/contraction, stability/instability, and opening/collapse. Many of these concepts remain still controversial, in part due to limitations of the different methodologies applied. We therefore preface our review with an overview of existing technologies and approaches for the analysis of alveolar dynamics, highlighting their individual strengths and limitations which may provide for a better appreciation of the sometimes diverging findings and interpretations. Joint efforts combining key technologies in identical models to overcome the limitations inherent to individual methodologies are needed not only to provide conclusive insights into lung physiology and alveolar dynamics, but ultimately to guide critical care patient therapy.
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Affiliation(s)
- Jana Grune
- Institute of Physiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, 10117 Berlin, Germany
| | - Arata Tabuchi
- Institute of Physiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Wolfgang M. Kuebler
- Institute of Physiology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, 10117 Berlin, Germany
- The Keenan Research Centre for Biomedical Science at St. Michael’s, Toronto, Canada
- Departments of Surgery and Physiology, University of Toronto, Toronto, Canada
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Wang L, Cao Y, Gorshkov B, Zhou Y, Yang Q, Xu J, Ma Q, Zhang X, Wang J, Mao X, Zeng X, Su Y, Verin AD, Hong M, Liu Z, Huo Y. Ablation of endothelial Pfkfb3 protects mice from acute lung injury in LPS-induced endotoxemia. Pharmacol Res 2019; 146:104292. [PMID: 31167111 DOI: 10.1016/j.phrs.2019.104292] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/15/2019] [Accepted: 05/30/2019] [Indexed: 12/29/2022]
Abstract
Acute lung injury (ALI) is one of the leading causes of death in sepsis. Endothelial inflammation and dysfunction play a prominent role in development of ALI. Glycolysis is the predominant bioenergetic pathway for endothelial cells (ECs). However, the role of EC glycolysis in ALI of sepsis remains unclear. Here we show that both the expression and activity of PFKFB3, a key glycolytic activator, were markedly increased in lipopolysaccharide (LPS)-treated human pulmonary arterial ECs (HPAECs) in vitro and in lung ECs of mice challenged with LPS in vivo. PFKFB3 knockdown significantly reduced LPS-enhanced glycolysis in HPAECs. Compared with LPS-challenged wild-type mice, endothelial-specific Pfkfb3 knockout (Pfkfb3ΔVEC) mice exhibited reduced endothelium permeability, lower pulmonary edema, and higher survival rate. This was accompanied by decreased expression of intracellular adhesion molecule-1 (Icam-1) and vascular cell adhesion molecule 1 (Vcam-1), as well as decreased neutrophil and macrophage infiltration to the lung. Consistently, PFKFB3 silencing or PFKFB3 inhibition in HPAECs and human pulmonary microvascular ECs (HPMVECs) significantly downregulated LPS-induced expression of ICAM-1 and VCAM-1, and monocyte adhesion to human pulmonary ECs. In contrast, adenovirus-mediated PFKFB3 overexpression upregulated ICAM-1 and VCAM-1 expression in HPAECs. Mechanistically, PFKFB3 silencing suppressed LPS-induced nuclear translocation of nuclear factor κB (NF-κB)-p65, and NF-κB inhibitors abrogated PFKFB3-induced expression of ICAM-1 and VCAM-1. Finally, administration of the PFKFB3 inhibitor 3PO also reduced the inflammatory response of vascular endothelium and protected mice from LPS-induced ALI. Overall, these findings suggest that targeting PFKFB3-mediated EC glycolysis is an efficient therapeutic strategy for ALI in sepsis.
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Affiliation(s)
- Lina Wang
- Drug Discovery Center, State Key Laboratory of Chemical Oncogenomics, Key Laboratory of Chemical Genomics, Peking University Shenzhen Graduate School, Shenzhen 518055, China; Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA
| | - Yapeng Cao
- Drug Discovery Center, State Key Laboratory of Chemical Oncogenomics, Key Laboratory of Chemical Genomics, Peking University Shenzhen Graduate School, Shenzhen 518055, China; Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA
| | - B Gorshkov
- Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA
| | - Yaqi Zhou
- Drug Discovery Center, State Key Laboratory of Chemical Oncogenomics, Key Laboratory of Chemical Genomics, Peking University Shenzhen Graduate School, Shenzhen 518055, China
| | - Qiuhua Yang
- Drug Discovery Center, State Key Laboratory of Chemical Oncogenomics, Key Laboratory of Chemical Genomics, Peking University Shenzhen Graduate School, Shenzhen 518055, China; Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA
| | - Jiean Xu
- Drug Discovery Center, State Key Laboratory of Chemical Oncogenomics, Key Laboratory of Chemical Genomics, Peking University Shenzhen Graduate School, Shenzhen 518055, China; Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA
| | - Qian Ma
- Drug Discovery Center, State Key Laboratory of Chemical Oncogenomics, Key Laboratory of Chemical Genomics, Peking University Shenzhen Graduate School, Shenzhen 518055, China; Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA
| | - Xiaoyu Zhang
- Drug Discovery Center, State Key Laboratory of Chemical Oncogenomics, Key Laboratory of Chemical Genomics, Peking University Shenzhen Graduate School, Shenzhen 518055, China; Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA
| | - Jingjing Wang
- Drug Discovery Center, State Key Laboratory of Chemical Oncogenomics, Key Laboratory of Chemical Genomics, Peking University Shenzhen Graduate School, Shenzhen 518055, China
| | - Xiaoxiao Mao
- Drug Discovery Center, State Key Laboratory of Chemical Oncogenomics, Key Laboratory of Chemical Genomics, Peking University Shenzhen Graduate School, Shenzhen 518055, China
| | - Xianqiu Zeng
- Drug Discovery Center, State Key Laboratory of Chemical Oncogenomics, Key Laboratory of Chemical Genomics, Peking University Shenzhen Graduate School, Shenzhen 518055, China
| | - Yunchao Su
- Department of Pharmacology & Toxicology, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA
| | - A D Verin
- Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA
| | - Mei Hong
- Drug Discovery Center, State Key Laboratory of Chemical Oncogenomics, Key Laboratory of Chemical Genomics, Peking University Shenzhen Graduate School, Shenzhen 518055, China
| | - Zhiping Liu
- Drug Discovery Center, State Key Laboratory of Chemical Oncogenomics, Key Laboratory of Chemical Genomics, Peking University Shenzhen Graduate School, Shenzhen 518055, China; Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA.
| | - Yuqing Huo
- Vascular Biology Center, Medical College of Georgia, Augusta University, Augusta, GA, 30912, USA.
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Mellenthin MM, Seong SA, Roy GS, Bartolák-Suki E, Hamlington KL, Bates JHT, Smith BJ. Using injury cost functions from a predictive single-compartment model to assess the severity of mechanical ventilator-induced lung injuries. J Appl Physiol (1985) 2019; 127:58-70. [PMID: 31046518 DOI: 10.1152/japplphysiol.00770.2018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Identifying safe ventilation patterns for patients with acute respiratory distress syndrome remains challenging because of the delicate balance between gas exchange and selection of ventilator settings to prevent further ventilator-induced lung injury (VILI). Accordingly, this work seeks to link ventilator settings to graded levels of VILI to identify injury cost functions that predict injury by using a computational model to process pressures and flows measured at the airway opening. Pressure-volume loops were acquired over the course of ~2 h of mechanical ventilation in four different groups of BALB/c mice. A cohort of these animals were subjected to an injurious bronchoalveolar lavage before ventilation. The data were analyzed with a single-compartment model that predicts recruitment/derecruitment and tissue distension at each time step in measured pressure-volume loops. We compared several injury cost functions to markers of VILI-induced blood-gas barrier disruption. Of the cost functions considered, we conclude that mechanical power dissipation and strain heterogeneity are the best at distinguishing between graded levels of injury and are good candidates for forecasting the development of VILI. NEW & NOTEWORTHY This work uses a predictive single-compartment model and injury cost functions to assess graded levels of mechanical ventilator-induced lung injury. The most promising measures include strain heterogeneity and mechanical power dissipation.
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Affiliation(s)
| | - Siyeon A Seong
- College of Medicine, University of Vermont , Burlington, Vermont
| | - Gregory S Roy
- College of Medicine, University of Vermont , Burlington, Vermont
| | | | - Katharine L Hamlington
- College of Medicine, University of Vermont , Burlington, Vermont.,University of Colorado at Children's Hospital Colorado , Aurora, Colorado
| | - Jason H T Bates
- College of Medicine, University of Vermont , Burlington, Vermont
| | - Bradford J Smith
- Department of Bioengineering, University of Colorado Denver , Aurora, Colorado.,College of Medicine, University of Vermont , Burlington, Vermont
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Feasibility and safety of extracorporeal CO2 removal to enhance protective ventilation in acute respiratory distress syndrome: the SUPERNOVA study. Intensive Care Med 2019; 45:592-600. [DOI: 10.1007/s00134-019-05567-4] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 02/09/2019] [Indexed: 10/27/2022]
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Abstract
BACKGROUND Lower tidal volumes are increasingly used in acute respiratory distress syndrome, but mortality has changed little in the last 20 yr. Therefore, in addition to ventilator settings, it is important to target molecular mediators of injury. Sepsis and other inflammatory states increase circulating concentrations of Gas6, a ligand for the antiinflammatory receptor Axl, and of a soluble decoy form of Axl. We investigated the effects of lung stretch on Axl signaling. METHODS We used a mouse model of early injury from high tidal volume and assessed the effects of inhibiting Axl on in vivo lung injury (using an antagonist R428, n = 4/group). We further determined the effects of stretch on Axl activation using in vitro lung endothelial cells. RESULTS High tidal volume caused mild injury (compliance decreased 6%) as intended, and shedding of the Axl receptor (soluble Axl in bronchoalveolar fluid increased 77%). The Axl antagonist R428 blocked the principal downstream Axl target (suppressor of cytokine signaling 3 [SOCS3]) but did not worsen lung physiology or inflammation. Cyclic stretch in vitro caused Axl to become insensitive to activation by its agonist, Gas6. Finally, in vitro Axl responses were rescued by blocking stretch-activated calcium channels (using guanidinium chloride [GdCl3]), and the calcium ionophore ionomycin replicated the effect of stretch. CONCLUSIONS These data suggest that lung endothelial cell overdistention activates ion channels, and the resultant influx of Ca inactivates Axl. Downstream inactivation of Axl by stretch was not anticipated; preventing this would be required to exploit Axl receptors in reducing lung injury.
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Continuous Negative Abdominal Pressure Reduces Ventilator-induced Lung Injury in a Porcine Model. Anesthesiology 2019; 129:163-172. [PMID: 29708892 DOI: 10.1097/aln.0000000000002236] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND In supine patients with acute respiratory distress syndrome, the lung typically partitions into regions of dorsal atelectasis and ventral aeration ("baby lung"). Positive airway pressure is often used to recruit atelectasis, but often overinflates ventral (already aerated) regions. A novel approach to selective recruitment of dorsal atelectasis is by "continuous negative abdominal pressure." METHODS A randomized laboratory study was performed in anesthetized pigs. Lung injury was induced by surfactant lavage followed by 1 h of injurious mechanical ventilation. Randomization (five pigs in each group) was to positive end-expiratory pressure (PEEP) alone or PEEP with continuous negative abdominal pressure (-5 cm H2O via a plexiglass chamber enclosing hindlimbs, pelvis, and abdomen), followed by 4 h of injurious ventilation (high tidal volume, 20 ml/kg; low expiratory transpulmonary pressure, -3 cm H2O). The level of PEEP at the start was ≈7 (vs. ≈3) cm H2O in the PEEP (vs. PEEP plus continuous negative abdominal pressure) groups. Esophageal pressure, hemodynamics, and electrical impedance tomography were recorded, and injury determined by lung wet/dry weight ratio and interleukin-6 expression. RESULTS All animals survived, but cardiac output was decreased in the PEEP group. Addition of continuous negative abdominal pressure to PEEP resulted in greater oxygenation (PaO2/fractional inspired oxygen 316 ± 134 vs. 80 ± 24 mmHg at 4 h, P = 0.005), compliance (14.2 ± 3.0 vs. 10.3 ± 2.2 ml/cm H2O, P = 0.049), and homogeneity of ventilation, with less pulmonary edema (≈10% less) and interleukin-6 expression (≈30% less). CONCLUSIONS Continuous negative abdominal pressure added to PEEP reduces ventilator-induced lung injury in a pig model compared with PEEP alone, despite targeting identical expiratory transpulmonary pressure.
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Russotto V, Bellani G, Foti G. Respiratory mechanics in patients with acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:382. [PMID: 30460256 DOI: 10.21037/atm.2018.08.32] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Despite the recognition of its iatrogenic potential, mechanical ventilation remains the mainstay of respiratory support for patients with acute respiratory distress syndrome (ARDS). The low volume ventilation has been recognized as the only method to reduce mortality of ARDS patients and plateau pressure as the lighthouse for delivering safe ventilation. Recent investigations suggest that a ventilation based on lung mechanics (tidal ventilation tailored to the available lung volume able to receive it, i.e., driving pressure) is a successful approach to improve outcome. However, currently available bedside mechanical variables do not consider regional mechanical properties of ARDS affected lungs, which include the role of local stress risers at the boundaries of areas with different aeration. A unifying approach considers lung-related causes and ventilation-related causes of lung injury. These last may be incorporated in the mechanical power (i.e., amount of mechanical energy transferred per unit of time). Ventilation-induced lung injury (which includes the self-inflicted lung injury of a spontaneously breathing patient) can therefore be prevented by the adoption of measures promoting an increase of ventilable lung and its homogeneity and by delivering lower levels of mechanical power. Prone position promotes lung homogeneity without increasing the delivered mechanical power. This review describes the recent developments on respiratory mechanics in ARDS patients, providing both bedside and research insights from the most updated evidence.
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Affiliation(s)
- Vincenzo Russotto
- Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Giacomo Bellani
- Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy.,University of Milano Bicocca, Milano, Italy
| | - Giuseppe Foti
- Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy.,University of Milano Bicocca, Milano, Italy
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Gotti M, Chiumello D, Cressoni M, Guanziroli M, Brioni M, Safaee Fakhr B, Chiurazzi C, Colombo A, Massari D, Algieri I, Lonati C, Cadringher P, Taccone P, Pizzocri M, Fumagalli J, Rosso L, Palleschi A, Benti R, Zito F, Valenza F, Gattinoni L. Inflammation and primary graft dysfunction after lung transplantation: CT-PET findings. Minerva Anestesiol 2018; 84:1169-1177. [DOI: 10.23736/s0375-9393.18.12651-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Mauri T, Foti G, Fornari C, Constantin JM, Guerin C, Pelosi P, Ranieri M, Conti S, Tubiolo D, Rondelli E, Lovisari F, Fossali T, Spadaro S, Grieco DL, Navalesi P, Calamai I, Becher T, Roca O, Wang YM, Knafelj R, Cortegiani A, Mancebo J, Brochard L, Pesenti A. Pressure support ventilation + sigh in acute hypoxemic respiratory failure patients: study protocol for a pilot randomized controlled trial, the PROTECTION trial. Trials 2018; 19:460. [PMID: 30157955 PMCID: PMC6114230 DOI: 10.1186/s13063-018-2828-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 07/28/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Adding cyclic short sustained inflations (sigh) to assisted ventilation yields optimizes lung recruitment, decreases heterogeneity and reduces inspiratory effort in patients with acute hypoxemic respiratory failure (AHRF). These findings suggest that adding sigh to pressure support ventilation (PSV) might decrease the risk of lung injury, shorten weaning and improve clinical outcomes. Thus, we conceived a pilot trial to test the feasibility of adding sigh to PSV (the PROTECTION study). METHODS PROTECTION is an international randomized controlled trial that will be conducted in 23 intensive care units (ICUs). Patients with AHRF who have been intubated from 24 h to 7 days and undergoing PSV from 4 to 24 h will be enrolled. All patients will first undergo a 30-min sigh test by adding sigh to clinical PSV for 30 min to identify early oxygenation responders. Then, patients will be randomized to PSV or PSV + sigh until extubation, ICU discharge, death or day 28. Sigh will be delivered as a 3-s pressure control breath delivered once per minute at 30 cmH2O. Standardized protocols will guide ventilation settings, switch back to controlled ventilation, use of rescue treatments, performance of spontaneous breathing trial, extubation and reintubation. The primary endpoint of the study will be to verify the feasibility of PSV + sigh evaluated through reduction of failure to remain on assisted ventilation during the first 28 days in the PSV + sigh group versus standard PSV (15 vs. 22%). Failure will be defined by switch back to controlled ventilation for more than 24 h or use of rescue treatments or reintubation within 48 h from elective extubation. Setting the power to 80% and first-risk order to 5%, the computed size of the trial is 129 patients per arm. DISCUSSION PROTECTION is a pilot randomized controlled trial testing the feasibility of adding sigh to PSV. If positive, it will provide physicians with an effective addition to standard PSV for lung protection, able to reduce failure of assisted ventilation. PROTECTION will provide the basis for a future larger trial aimed at verifying the impact of PSV + sigh on 28-day survival and ventilator-free days. TRIAL REGISTRATION ClinicalTrials.gov, NCT03201263 . Registered on 28 June 2017.
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Affiliation(s)
- Tommaso Mauri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Giuseppe Foti
- ASST Monza, University of Milan-Bicocca, Monza, Italy
| | - Carla Fornari
- Research Centre on Public Health, School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Jean-Michel Constantin
- Department of Preoperative Medicine, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Claude Guerin
- Service de Réanimation Médicale, Hôpital de la Croix Rousse, Lyon, France
| | - Paolo Pelosi
- Department of Surgical and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Marco Ranieri
- Department of Anesthesia and Intensive Care Medicine, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Sara Conti
- Research Centre on Public Health, School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Daniela Tubiolo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Egle Rondelli
- ASST Monza, University of Milan-Bicocca, Monza, Italy
| | - Federica Lovisari
- Department of Anesthesia and Critical Care, Niguarda Hospital, University of Milan-Bicocca, Milan, Italy
| | - Tommaso Fossali
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco - Luigi Sacco Hospital, Milan, Italy
| | - Savino Spadaro
- Department of morphology, surgery and experimental medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, Ferrara, Italy
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, IRCCS Fondazione Policlinico A. Gemelli, Rome, Italy
| | - Paolo Navalesi
- Dipartimento di Scienze Mediche e Chirurgiche, Università Magna Graecia di Catanzaro, Azienda Ospedaliera Universitaria Mater Domini, Catanzaro, Italy
| | - Italo Calamai
- AUSL Toscana Centro, Unit of Anesthesia and Resuscitation, San Giuseppe Hospital, Empoli, Italy
| | - Tobias Becher
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Oriol Roca
- Critical Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Yu-Mei Wang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Rihard Knafelj
- Center for Internal Intensive medicine (MICU), University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Andrea Cortegiani
- Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Antonio Pesenti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy. .,Anesthesia and Critical Care, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy. .,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
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Xin Y, Cereda M, Hamedani H, Pourfathi M, Siddiqui S, Meeder N, Kadlecek S, Duncan I, Profka H, Rajaei J, Tustison NJ, Gee JC, Kavanagh BP, Rizi RR. Unstable Inflation Causing Injury. Insight from Prone Position and Paired Computed Tomography Scans. Am J Respir Crit Care Med 2018; 198:197-207. [PMID: 29420904 PMCID: PMC6058981 DOI: 10.1164/rccm.201708-1728oc] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 02/08/2018] [Indexed: 01/16/2023] Open
Abstract
RATIONALE It remains unclear how prone positioning improves survival in acute respiratory distress syndrome. Using serial computed tomography (CT), we previously reported that "unstable" inflation (i.e., partial aeration with large tidal density swings, indicating increased local strain) is associated with injury progression. OBJECTIVES We prospectively tested whether prone position contains the early propagation of experimental lung injury by stabilizing inflation. METHODS Injury was induced by tracheal hydrochloric acid in rats; after randomization to supine or prone position, injurious ventilation was commenced using high tidal volume and low positive end-expiratory pressure. Paired end-inspiratory (EI) and end-expiratory (EE) CT scans were acquired at baseline and hourly up to 3 hours. Each sequential pair (EI, EE) of CT images was superimposed in parametric response maps to analyze inflation. Unstable inflation was then measured in each voxel in both dependent and nondependent lung. In addition, five pigs were imaged (EI and EE) prone versus supine, before and (1 hour) after hydrochloric acid aspiration. MEASUREMENTS AND MAIN RESULTS In rats, prone position limited lung injury propagation and increased survival (11/12 vs. 7/12 supine; P = 0.01). EI-EE densities, respiratory mechanics, and blood gases deteriorated more in supine versus prone rats. At baseline, more voxels with unstable inflation occurred in dependent versus nondependent regions when supine (41 ± 6% vs. 18 ± 7%; P < 0.01) but not when prone. In supine pigs, unstable inflation predominated in dorsal regions and was attenuated by prone positioning. CONCLUSIONS Prone position limits the radiologic progression of early lung injury. Minimizing unstable inflation in this setting may alleviate the burden of acute respiratory distress syndrome.
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Affiliation(s)
- Yi Xin
- Department of Radiology and
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | - Natalie Meeder
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | - Nicholas J. Tustison
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Virginia; and
| | | | - Brian P. Kavanagh
- Department of Critical Care Medicine and
- Department of Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Looking closer at acute respiratory distress syndrome: the role of advanced imaging techniques. Curr Opin Crit Care 2018; 23:30-37. [PMID: 27906709 DOI: 10.1097/mcc.0000000000000380] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW Advanced imaging techniques have provided invaluable insights in understanding of acute respiratory distress syndrome (ARDS) and the effect of therapeutic strategies, thanks to the possibility of gaining regional information and moving from simple 'anatomical' information to in-vivo functional imaging. RECENT FINDINGS Computed tomography (CT) led to the understanding of several ARDS mechanisms and interaction with mechanical ventilation. It is nowadays frequently part of routine diagnostic workup, often leading to treatment changes. Moreover, CT is a reference for novel techniques both in clinical and preclinical studies. Bedside transthoracic lung ultrasound allows semiquantitative regional analysis of lung aeration, identifies ARDS lung morphology and response to therapeutic maneuvers. Electrical impedance tomography is a radiation-free, functional, bedside, imaging modality which allows a real-time monitoring of regional ventilation. Finally, positron emission tomography (PET) is a functional imaging technique that allows to trace physiologic processes, by administration of a radioactive molecule. PET with FDG has been applied to patients with ARDS, thanks to its ability to track the inflammatory cells activity. SUMMARY Progresses in lung imaging are key to individualize therapy, diagnosis, and pathophysiological mechanism at play in any patient at any specified time, helping to move toward personalized medicine for ARDS.
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Moraes L, Silva PL, Thompson A, Santos CL, Santos RS, Fernandes MVS, Morales MM, Martins V, Capelozzi VL, de Abreu MG, Pelosi P, Rocco PRM. Impact of Different Tidal Volume Levels at Low Mechanical Power on Ventilator-Induced Lung Injury in Rats. Front Physiol 2018; 9:318. [PMID: 29670537 PMCID: PMC5893648 DOI: 10.3389/fphys.2018.00318] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 03/15/2018] [Indexed: 01/06/2023] Open
Abstract
Tidal volume (VT) has been considered the main determinant of ventilator-induced lung injury (VILI). Recently, experimental studies have suggested that mechanical power transferred from the ventilator to the lungs is the promoter of VILI. We hypothesized that, as long as mechanical power is kept below a safe threshold, high VT should not be injurious. The present study aimed to investigate the impact of different VT levels and respiratory rates (RR) on lung function, diffuse alveolar damage (DAD), alveolar ultrastructure, and expression of genes related to inflammation [interleukin (IL)-6], alveolar stretch (amphiregulin), epithelial [club cell secretory protein (CC)16] and endothelial [intercellular adhesion molecule (ICAM)-1] cell injury, and extracellular matrix damage [syndecan-1, decorin, and metalloproteinase (MMP)-9] in experimental acute respiratory distress syndrome (ARDS) under low-power mechanical ventilation. Twenty-eight Wistar rats received Escherichia coli lipopolysaccharide intratracheally. After 24 h, 21 animals were randomly assigned to ventilation (2 h) with low mechanical power at three different VT levels (n = 7/group): (1) VT = 6 mL/kg and RR adjusted to normocapnia; (2) VT = 13 mL/kg; and 3) VT = 22 mL/kg. In the second and third groups, RR was adjusted to yield low mechanical power comparable to that of the first group. Mechanical power was calculated as [(ΔP,L2/Est,L)/2]× RR (ΔP,L = transpulmonary driving pressure, Est,L = static lung elastance). Seven rats were not mechanically ventilated (NV) and were used for molecular biology analysis. Mechanical power was comparable among groups, while VT gradually increased. ΔP,L and mechanical energy were higher in VT = 22 mL/kg than VT = 6 mL/kg and VT = 13 mL/kg (p < 0.001 for both). Accordingly, DAD score increased in VT = 22 mL/kg compared to VT = 6 mL/kg and VT = 13 mL/kg [23(18.5–24.75) vs. 16(12–17.75) and 16(13.25–18), p < 0.05, respectively]. VT = 22 mL/kg was associated with higher IL-6, amphiregulin, CC16, MMP-9, and syndecan-1 mRNA expression and lower decorin expression than VT = 6 mL/kg. Multiple linear regression analyses indicated that VT was able to predict changes in IL-6 and CC16, whereas ΔP,L predicted pHa, oxygenation, amphiregulin, and syndecan-1 expression. In the model of ARDS used herein, even at low mechanical power, high VT resulted in VILI. VT control seems to be more important than RR control to mitigate VILI.
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Affiliation(s)
- Lillian Moraes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro L Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Alessandra Thompson
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Cintia L Santos
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Raquel S Santos
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcos V S Fernandes
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcelo M Morales
- Laboratory of Cellular and Molecular Physiology, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Vanessa Martins
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,Department of Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Vera L Capelozzi
- Department of Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Marcelo G de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Therapy, University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Yoshida T, Engelberts D, Otulakowski G, Katira B, Ferguson ND, Brochard L, Amato MBP, Kavanagh BP. Continuous negative abdominal pressure: mechanism of action and comparison with prone position. J Appl Physiol (1985) 2018; 125:107-116. [PMID: 29596015 DOI: 10.1152/japplphysiol.01125.2017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
We recently reported that continuous negative abdominal pressure (CNAP) could recruit dorsal atelectasis in experimental lung injury and that oxygenation improved at different transpulmonary pressure values compared with increases in airway pressure (Yoshida T, Engelberts D, Otulakowski G, Katira BH, Post M, Ferguson ND, Brochard L, Amato MBP, Kavanagh BP. Am J Respir Crit Care Med 197: 534-537, 2018). The mechanism of recruitment with CNAP is uncertain, and its impact compared with a commonly proposed alternative approach to recruitment, prone positioning, is not known. We hypothesized that CNAP recruits lung by decreasing the vertical pleural pressure (Ppl) gradient (i.e., difference between dependent and nondependent Ppl), thought to be one mechanism of action of prone positioning. An established porcine model of lung injury (surfactant depletion followed by ventilator-induced lung injury) was used. CNAP was applied using a plexiglass chamber that completely enclosed the abdomen at a constant negative pressure (-5 cmH2O). Lungs were recruited to maximal positive end-expiratory pressure (PEEP; 25 cmH2O) and deflated in steps of PEEP (2 cmH2O, 10 min each). CNAP lowered the Ppl in dependent but not in nondependent lung, and therefore, in contrast to PEEP, it narrowed the vertical Ppl gradient. CNAP increased respiratory system compliance and oxygenation and appeared to selectively displace the posterior diaphragm caudad (computerized tomography images). Compared with prone position without CNAP, CNAP in the supine position was associated with higher arterial partial pressure of oxygen and compliance, as well as greater homogeneity of ventilation. The mechanism of action of CNAP appears to be via selective narrowing of the vertical gradient of Ppl. CNAP appears to offer physiological advantages over prone positioning. NEW & NOTEWORTHY Continuous negative abdominal pressure reduces the vertical gradient in (dependent vs. nondependent) pleural pressure and increases oxygenation and lung compliance; it is more effective than prone positioning at comparable levels of positive end-expiratory pressure.
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Affiliation(s)
- Takeshi Yoshida
- Physiology and Experimental Medicine, Hospital for Sick Children , Toronto, Ontario , Canada.,Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto , Toronto, Ontario , Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto , Toronto, Ontario , Canada
| | - Doreen Engelberts
- Physiology and Experimental Medicine, Hospital for Sick Children , Toronto, Ontario , Canada
| | - Gail Otulakowski
- Physiology and Experimental Medicine, Hospital for Sick Children , Toronto, Ontario , Canada
| | - Bhushan Katira
- Physiology and Experimental Medicine, Hospital for Sick Children , Toronto, Ontario , Canada.,Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto , Toronto, Ontario , Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto , Toronto, Ontario , Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto , Toronto, Ontario , Canada.,Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital , Toronto, Ontario , Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto , Toronto, Ontario , Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto, Ontario , Canada
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , Brazil
| | - Brian P Kavanagh
- Physiology and Experimental Medicine, Hospital for Sick Children , Toronto, Ontario , Canada.,Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto , Toronto, Ontario , Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto , Toronto, Ontario , Canada
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Yoshida T, Amato MBP, Kavanagh BP. Understanding spontaneous vs. ventilator breaths: impact and monitoring. Intensive Care Med 2018; 44:2235-2238. [PMID: 29574574 DOI: 10.1007/s00134-018-5145-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 03/19/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Takeshi Yoshida
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
- Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto do Coração (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Brian P Kavanagh
- Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
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Wohlrab P, Kraft F, Tretter V, Ullrich R, Markstaller K, Klein KU. Recent advances in understanding acute respiratory distress syndrome. F1000Res 2018; 7. [PMID: 29568488 PMCID: PMC5840611 DOI: 10.12688/f1000research.11148.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2018] [Indexed: 12/17/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by acute diffuse lung injury, which results in increased pulmonary vascular permeability and loss of aerated lung tissue. This causes bilateral opacity consistent with pulmonary edema, hypoxemia, increased venous admixture, and decreased lung compliance such that patients with ARDS need supportive care in the intensive care unit to maintain oxygenation and prevent adverse outcomes. Recently, advances in understanding the underlying pathophysiology of ARDS led to new approaches in managing these patients. In this review, we want to focus on recent scientific evidence in the field of ARDS research and discuss promising new developments in the treatment of this disease.
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Affiliation(s)
- Peter Wohlrab
- Department of Anaesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Felix Kraft
- Department of Anaesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Verena Tretter
- Department of Anaesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Roman Ullrich
- Department of Anaesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Klaus Markstaller
- Department of Anaesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
| | - Klaus Ulrich Klein
- Department of Anaesthesia, General Intensive Care and Pain Management, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria
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75
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Pourfathi M, Cereda M, Chatterjee S, Xin Y, Kadlecek S, Duncan I, Hamedani H, Siddiqui S, Profka H, Ehrich J, Ruppert K, Rizi RR. Lung Metabolism and Inflammation during Mechanical Ventilation; An Imaging Approach. Sci Rep 2018; 8:3525. [PMID: 29476083 PMCID: PMC5824838 DOI: 10.1038/s41598-018-21901-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 02/13/2018] [Indexed: 12/20/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a major cause of mortality in critically ill patients. Patients are currently managed by protective ventilation and alveolar recruitment using positive-end expiratory pressure (PEEP). However, the PEEP's effect on both pulmonary metabolism and regional inflammation is poorly understood. Here, we demonstrate the effect of PEEP on pulmonary anaerobic metabolism in mechanically ventilated injured rats, using hyperpolarized carbon-13 imaging. Pulmonary lactate-to-pyruvate ratio was measured in 21 rats; 14 rats received intratracheal instillation of hydrochloric-acid, while 7 rats received sham saline. 1 hour after acid/saline instillation, PEEP was lowered to 0 cmH2O in 7 injured rats (ZEEP group) and in all sham rats; PEEP was continued in the remaining 7 injured rats (PEEP group). Pulmonary compliance, oxygen saturation, histological injury scores, ICAM-1 expression and myeloperoxidase expression were measured. Lactate-to-pyruvate ratio progressively increased in the dependent lung during mechanical ventilation at ZEEP (p < 0.001), but remained unchanged in PEEP and sham rats. Lactate-to-pyruvate ratio was correlated with hyaline membrane deposition (r = 0.612), edema severity (r = 0.663), ICAM-1 (r = 0.782) and myeloperoxidase expressions (r = 0.817). Anaerobic pulmonary metabolism increases during lung injury progression and is contained by PEEP. Pulmonary lactate-to-pyruvate ratio may indicate in-vivo neutrophil activity due to atelectasis.
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Affiliation(s)
- Mehrdad Pourfathi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department Electrical and Systems Engineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Shampa Chatterjee
- Department of Physiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Stephen Kadlecek
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Ian Duncan
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Hooman Hamedani
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Sarmad Siddiqui
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - Harrilla Profka
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Ehrich
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Kai Ruppert
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Rahim R Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA.
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Lung volumes and lung volume recruitment in ARDS: a comparison between supine and prone position. Ann Intensive Care 2018; 8:25. [PMID: 29445887 PMCID: PMC5812959 DOI: 10.1186/s13613-018-0371-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/08/2018] [Indexed: 12/26/2022] Open
Abstract
Background The use of positive end-expiratory pressure (PEEP) and prone position (PP) is common in the management of severe acute respiratory distress syndrome patients (ARDS). We conducted this study to analyze the variation in lung volumes and PEEP-induced lung volume recruitment with the change from supine position (SP) to PP in ARDS patients. Methods The investigation was conducted in a multidisciplinary intensive care unit. Patients who met the clinical criteria of the Berlin definition for ARDS were included. The responsible physician set basal PEEP. To avoid hypoxemia, FiO2 was increased to 0.8 1 h before starting the protocol. End-expiratory lung volume (EELV) and functional residual capacity (FRC) were measured using the nitrogen washout/washin technique. After the procedures in SP, the patients were turned to PP and 1 h later the same procedures were made in PP. Results Twenty-three patients were included in the study, and twenty were analyzed. The change from SP to PP significantly increased FRC (from 965 ± 397 to 1140 ± 490 ml, p = 0.008) and EELV (from 1566 ± 476 to 1832 ± 719 ml, p = 0.008), but PEEP-induced lung volume recruitment did not significantly change (269 ± 186 ml in SP to 324 ± 188 ml in PP, p = 0.263). Dynamic strain at PEEP decreased with the change from SP to PP (0.38 ± 0.14 to 0.33 ± 0.13, p = 0.040). Conclusions As compared to supine, prone position increases resting lung volumes and decreases dynamic lung strain. Electronic supplementary material The online version of this article (10.1186/s13613-018-0371-0) contains supplementary material, which is available to authorized users.
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The peroxisome proliferator-activated receptor agonist pioglitazone and 5-lipoxygenase inhibitor zileuton have no effect on lung inflammation in healthy volunteers by positron emission tomography in a single-blind placebo-controlled cohort study. PLoS One 2018; 13:e0191783. [PMID: 29414995 PMCID: PMC5802889 DOI: 10.1371/journal.pone.0191783] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 01/11/2018] [Indexed: 11/22/2022] Open
Abstract
Background Anti-inflammatory drug development efforts for lung disease have been hampered in part by the lack of noninvasive inflammation biomarkers and the limited ability of animal models to predict efficacy in humans. We used 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET) in a human model of lung inflammation to assess whether pioglitazone, a peroxisome proliferator-activated receptor-γ (PPAR-γ) agonist, and zileuton, a 5-lipoxygenase inhibitor, reduce lung inflammation. Methods For this single center, single-blind, placebo-controlled cohort study, we enrolled healthy volunteers sequentially into the following treatment cohorts (N = 6 per cohort): pioglitazone plus placebo, zileuton plus placebo, or dual placebo prior to bronchoscopic endotoxin instillation. 18F-FDG uptake pre- and post-endotoxin was quantified as the Patlak graphical analysis-determined Ki (primary outcome measure). Secondary outcome measures included the mean standard uptake value (SUVmean), post-endotoxin bronchoalveolar lavage (BAL) cell counts and differentials and blood adiponectin and urinary leukotriene E4 (LTE4) levels, determined by enzyme-linked immunosorbent assay, to verify treatment compliance. One- or two-way analysis of variance assessed for differences among cohorts in the outcome measures (expressed as mean ± standard deviation). Results Ten females and eight males (29±6 years of age) completed all study procedures except for one volunteer who did not complete the post-endotoxin BAL. Ki and SUVmean increased in all cohorts after endotoxin instillation (Ki increased by 0.0021±0.0019, 0.0023±0.0017, and 0.0024±0.0020 and SUVmean by 0.47±0.14, 0.55±0.15, and 0.54±0.38 in placebo, pioglitazone, and zileuton cohorts, respectively, p<0.001) with no differences among treatment cohorts (p = 0.933). Adiponectin levels increased as expected with pioglitazone treatment but not urinary LTE4 levels as expected with zileuton treatment. BAL cell counts (p = 0.442) and neutrophil percentage (p = 0.773) were similar among the treatment cohorts. Conclusions Endotoxin-induced lung inflammation in humans is not responsive to pioglitazone or zileuton, highlighting the challenge in translating anti-inflammatory drug efficacy results from murine models to humans. Trial registration ClinicalTrials.gov NCT01174056.
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Spadaro S, Mauri T, Böhm SH, Scaramuzzo G, Turrini C, Waldmann AD, Ragazzi R, Pesenti A, Volta CA. Variation of poorly ventilated lung units (silent spaces) measured by electrical impedance tomography to dynamically assess recruitment. Crit Care 2018; 22:26. [PMID: 29386048 PMCID: PMC5793388 DOI: 10.1186/s13054-017-1931-7] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 12/26/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Assessing alveolar recruitment at different positive end-expiratory pressure (PEEP) levels is a major clinical and research interest because protective ventilation implies opening the lung without inducing overdistention. The pressure-volume (P-V) curve is a validated method of assessing recruitment but reflects global characteristics, and changes at the regional level may remain undetected. The aim of the present study was to compare, in intubated patients with acute hypoxemic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS), lung recruitment measured by P-V curve analysis, with dynamic changes in poorly ventilated units of the dorsal lung (dependent silent spaces [DSSs]) assessed by electrical impedance tomography (EIT). We hypothesized that DSSs might represent a dynamic bedside measure of recruitment. METHODS We carried out a prospective interventional study of 14 patients with AHRF and ARDS admitted to the intensive care unit undergoing mechanical ventilation. Each patient underwent an incremental/decremental PEEP trial that included five consecutive phases: PEEP 5 and 10 cmH2O, recruitment maneuver + PEEP 15 cmH2O, then PEEP 10 and 5 cmH2O again. We measured, at the end of each phase, recruitment from previous PEEP using the P-V curve method, and changes in DSS were continuously monitored by EIT. RESULTS PEEP changes induced alveolar recruitment as assessed by the P-V curve method and changes in the amount of DSS (p < 0.001). Recruited volume measured by the P-V curves significantly correlated with the change in DSS (rs = 0.734, p < 0.001). Regional compliance of the dependent lung increased significantly with rising PEEP (median PEEP 5 cmH2O = 11.9 [IQR 10.4-16.7] ml/cmH2O, PEEP 15 cmH2O = 19.1 [14.2-21.3] ml/cmH2O; p < 0.001), whereas regional compliance of the nondependent lung decreased from PEEP 5 cmH2O to PEEP 15 cmH2O (PEEP 5 cmH2O = 25.3 [21.3-30.4] ml/cmH2O, PEEP 15 cmH2O = 20.0 [16.6-22.8] ml/cmH2O; p <0.001). By increasing the PEEP level, the center of ventilation moved toward the dependent lung, returning to the nondependent lung during the decremental PEEP steps. CONCLUSIONS The variation of DSSs dynamically measured by EIT correlates well with lung recruitment measured using the P-V curve technique. EIT might provide useful information to titrate personalized PEEP. TRIAL REGISTRATION ClinicalTrials.gov, NCT02907840 . Registered on 20 September 2016.
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Affiliation(s)
- Savino Spadaro
- Department of Morphology Surgery and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, 8, Aldo Moro, 44124 Ferrara, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Ca’ Granda, University of Milan, Milan, Italy
| | | | - Gaetano Scaramuzzo
- Department of Morphology Surgery and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, 8, Aldo Moro, 44124 Ferrara, Italy
| | - Cecilia Turrini
- Department of Morphology Surgery and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, 8, Aldo Moro, 44124 Ferrara, Italy
| | | | - Riccardo Ragazzi
- Department of Morphology Surgery and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, 8, Aldo Moro, 44124 Ferrara, Italy
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS (Istituto di Ricovero e Cura a Carattere Scientifico) Ca’ Granda, University of Milan, Milan, Italy
| | - Carlo Alberto Volta
- Department of Morphology Surgery and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, 8, Aldo Moro, 44124 Ferrara, Italy
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Kim GW, Koh Y, Lim CM, Huh JW, Jung SH, Kim JB, Hong SB. The effect of an improvement of experience and training in extracorporeal membrane oxygenation management on clinical outcomes. Korean J Intern Med 2018; 33:121-129. [PMID: 27017393 PMCID: PMC5768527 DOI: 10.3904/kjim.2015.027] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 06/27/2015] [Accepted: 07/14/2015] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND/AIMS The use of extracorporeal membrane oxygenation (ECMO) is spreading rapidly, with successful procedures reported in the ECMO for Severe Adult Respiratory failure (CESAR) trial and treatment of the H1N1 pandemic. However, ECMO is associated with a high mortality rate. This study aimed to show that increased experience and improved teamwork through education may reduce the mortality rate associated with ECMO. METHODS A retrospective study was performed. Data were collected from January 1, 2009, to December 31, 2011. The data were divided into two periods: 2009/2010 (period 1) and 2011 (period 2). The protocol and training program were applied during period 2. RESULTS Seventy-six patients were included. The most common disease requiring ECMO support was pneumonia (43.4%). ECMO was applied within 7 days in 76.3% of patients. The primary outcomes, such as Intensive Care Unit (ICU) and hospital mortality rates, were higher during period 1 (91.3%) than period 2 (66.7%, p = 0.013). A multivariate analysis revealed that ECMO weaning failure was the only factor associated with ICU and hospital mortality (ICU mortality: hazard ratio [HR], 11.349; 95% confidence interval [CI], 1.281 to 100.505; p = 0.029; hospital mortality: HR, 17.976; 95% CI, 2.263 to 142.777; p = 0.006). CONCLUSIONS The mortality rate associated with the ECMO procedure decreased following the ECMO training program. However, applying the training program to ECMO management is not an independent factor for the mortality rate. Further studies should be performed to help reduce the mortality rate associated with ECMO.
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Affiliation(s)
- Go-Woon Kim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
- Correspondence to Sang-Bum Hong, M.D. Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Tel: +82-2-3010-3893 Fax: +82-2-3010-6968 E-mail:
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Mauri T, Lazzeri M, Bellani G, Zanella A, Grasselli G. Respiratory mechanics to understand ARDS and guide mechanical ventilation. Physiol Meas 2017; 38:R280-H303. [PMID: 28967868 DOI: 10.1088/1361-6579/aa9052] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE As precision medicine is becoming a standard of care in selecting tailored rather than average treatments, physiological measurements might represent the first step in applying personalized therapy in the intensive care unit (ICU). A systematic assessment of respiratory mechanics in patients with the acute respiratory distress syndrome (ARDS) could represent a step in this direction, for two main reasons. Approach and Main results: On the one hand, respiratory mechanics are a powerful physiological method to understand the severity of this syndrome in each single patient. Decreased respiratory system compliance, for example, is associated with low end expiratory lung volume and more severe lung injury. On the other hand, respiratory mechanics might guide protective mechanical ventilation settings. Improved gravitationally dependent regional lung compliance could support the selection of positive end-expiratory pressure and maximize alveolar recruitment. Moreover, the association between driving airway pressure and mortality in ARDS patients potentially underlines the importance of sizing tidal volume on respiratory system compliance rather than on predicted body weight. SIGNIFICANCE The present review article aims to describe the main alterations of respiratory mechanics in ARDS as a potent bedside tool to understand severity and guide mechanical ventilation settings, thus representing a readily available clinical resource for ICU physicians.
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Affiliation(s)
- Tommaso Mauri
- Department of Pathophysiology and Transplantation, University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy. Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milan, Italy
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López Sanchez M. Ventilación mecánica en pacientes tratados con membrana de oxigenación extracorpórea (ECMO). Med Intensiva 2017; 41:491-496. [DOI: 10.1016/j.medin.2016.12.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 12/13/2016] [Accepted: 12/14/2016] [Indexed: 01/19/2023]
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Henderson WR, Chen L, Amato MBP, Brochard LJ. Fifty Years of Research in ARDS. Respiratory Mechanics in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017; 196:822-833. [PMID: 28306327 DOI: 10.1164/rccm.201612-2495ci] [Citation(s) in RCA: 111] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Acute respiratory distress syndrome is a multifactorial lung injury that continues to be associated with high levels of morbidity and mortality. Mechanical ventilation, although lifesaving, is associated with new iatrogenic injury. Current best practice involves the use of small Vt, low plateau and driving pressures, and high levels of positive end-expiratory pressure. Collectively, these interventions are termed "lung-protective ventilation." Recent investigations suggest that individualized measurements of pulmonary mechanical variables rather than population-based ventilation prescriptions may be used to set the ventilator with the potential to improve outcomes beyond those achieved with standard lung protective ventilation. This review outlines the measurement and application of clinically applicable pulmonary mechanical concepts, such as plateau pressures, driving pressure, transpulmonary pressures, stress index, and measurement of strain. In addition, the concept of the "baby lung" and the utility of dynamic in addition to static measures of pulmonary mechanical variables are discussed.
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Affiliation(s)
- William R Henderson
- 1 Division of Critical Care Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lu Chen
- 2 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,3 Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; and
| | - Marcelo B P Amato
- 4 Cardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), University of São Paulo, São Paulo, Brazil
| | - Laurent J Brochard
- 2 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,3 Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; and
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83
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Bugedo G, Retamal J, Bruhn A. Driving pressure: a marker of severity, a safety limit, or a goal for mechanical ventilation? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:199. [PMID: 28774316 PMCID: PMC5543756 DOI: 10.1186/s13054-017-1779-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Guillermo Bugedo
- Departamento de Medicina Intensiva, Pontificia Universidad Catolica de Chile, Marcoleta 367, Zip code 6510260, Santiago, Chile.
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Pontificia Universidad Catolica de Chile, Marcoleta 367, Zip code 6510260, Santiago, Chile
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Pontificia Universidad Catolica de Chile, Marcoleta 367, Zip code 6510260, Santiago, Chile
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84
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Sklar MC, Fan E, Goligher EC. High-Frequency Oscillatory Ventilation in Adults With ARDS: Past, Present, and Future. Chest 2017; 152:1306-1317. [PMID: 28684287 DOI: 10.1016/j.chest.2017.06.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/29/2017] [Accepted: 06/16/2017] [Indexed: 01/12/2023] Open
Abstract
High-frequency oscillatory ventilation (HFOV) is a unique mode of mechanical ventilation that uses nonconventional gas exchange mechanisms to deliver ventilation at very low tidal volumes and high frequencies. The properties of HFOV make it a potentially ideal mode to prevent ventilator-induced lung injury in patients with ARDS. Despite a compelling physiological basis and promising experimental data, large randomized controlled trials have not detected an improvement in survival with the use of HFOV, and its use as an early lung-protective strategy in patients with ARDS may be harmful. Nevertheless, HFOV still has an important potential role in the management of refractory hypoxemia. Careful attention should be paid to right ventricular function and lung stress when applying HFOV. This review discusses the physiological principles, clinical evidence, practical applications, and future prospects for the use of HFOV in patients with ARDS.
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Affiliation(s)
- Michael C Sklar
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada.
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85
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Ball L, Vercesi V, Costantino F, Chandrapatham K, Pelosi P. Lung imaging: how to get better look inside the lung. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:294. [PMID: 28828369 DOI: 10.21037/atm.2017.07.20] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
In the last years, imaging has played a key role in the diagnosis and monitoring and critical illness, including acute respiratory distress syndrome (ARDS). Chest X-ray (CXR) and computed tomography (CT) are the conventional techniques most performed in the critically ill patients, the latter being the gold standard to assess lung aeration in ARDS patients. In addition, two bedside techniques are now gaining popularity alongside the conventional ones: lung ultrasound (LUS) and electrical impedance tomography (EIT). These techniques do not involve the use of ionizing radiations, are non-invasive and relatively easy to use, and are under extensive investigation as a complement, and for some application a substitution of conventional techniques. At last, positron emission tomography (PET) and magnetic resonance imaging (MRI) can provide functional information on the lung and respiratory function, and are increasingly used in research to improve the understanding of the pathophysiological mechanisms underlying ARDS. The purpose of this review is to give an up-to-date overview of the conventional and emerging imaging techniques available the diagnosis and management of patients with ARDS.
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Affiliation(s)
- Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Veronica Vercesi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Federico Costantino
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Karthikka Chandrapatham
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Ospedale Policlinico San Martino-IRCCS per l'Oncologia, Genoa, Italy
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86
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Umbrello M, Marino A, Chiumello D. Tidal volume in acute respiratory distress syndrome: how best to select it. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:287. [PMID: 28828362 DOI: 10.21037/atm.2017.06.51] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Mechanical ventilation is the type of organ support most widely provided in the intensive care unit. However, this form of support does not constitute a cure for acute respiratory distress syndrome (ARDS), as it mainly works by buying time for the lungs to heal while contributing to the maintenance of vital gas exchange. Moreover, it can further damage the lung, leading to the development of a particular form of lung injury named ventilator-induced lung injury (VILI). Experimental evidence accumulated over the last 30 years highlighted the factors associated with an injurious form of mechanical ventilation. The present paper illustrates the physiological effects of delivering a tidal volume to the lungs of patients with ARDS, and suggests an approach to tidal volume selection. The relationship between tidal volume and the development of VILI, the so called volotrauma, will be reviewed. The still actual suggestion of a lung-protective ventilatory strategy based on the use of low tidal volumes scaled to the predicted body weight (PBW) will be presented, together with newer strategies such as the use of airway driving pressure as a surrogate for the amount of ventilatable lung tissue or the concept of strain, i.e., the ratio between the tidal volume delivered relative to the resting condition, that is the functional residual capacity (FRC). An ultra-low tidal volume strategy with the use of extracorporeal carbon dioxide removal (ECCO2R) will be presented and discussed. Eventually, the role of other ventilator-related parameters in the generation of VILI will be considered (namely, plateau pressure, airway driving pressure, respiratory rate (RR), inspiratory flow), and the promising unifying framework of mechanical power will be presented.
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Affiliation(s)
- Michele Umbrello
- UOC Anestesia e Rianimazione, Ospedale San Paolo-ASST Santi Paolo e Carlo, Milano, Italy
| | - Antonella Marino
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy
| | - Davide Chiumello
- UOC Anestesia e Rianimazione, Ospedale San Paolo-ASST Santi Paolo e Carlo, Milano, Italy.,Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy
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87
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Laffey JG, Kavanagh BP. FiftyYears ofResearch inARDS.Insight into Acute Respiratory Distress Syndrome. From Models to Patients. Am J Respir Crit Care Med 2017; 196:18-28. [DOI: 10.1164/rccm.201612-2415ci] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- John G. Laffey
- Department of Anesthesia
- Department of Critical Care Medicine, and
- Keenan Centre for Biomedical Research, St. Michael’s Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine
- Department of Anesthesia, and
| | - Brian P. Kavanagh
- Interdepartmental Division of Critical Care Medicine
- Department of Anesthesia, and
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada; and
- Department of Critical Care Medicine
- Department of Anesthesia, and
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88
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Cereda M, Xin Y, Hamedani H, Bellani G, Kadlecek S, Clapp J, Guerra L, Meeder N, Rajaei J, Tustison NJ, Gee JC, Kavanagh BP, Rizi RR. Tidal changes on CT and progression of ARDS. Thorax 2017. [PMID: 28634220 PMCID: PMC5738538 DOI: 10.1136/thoraxjnl-2016-209833] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Background Uncertain prediction of outcome in acute respiratory distress syndrome (ARDS) impedes individual patient management and clinical trial design. Objectives To develop a radiological metric of injurious inflation derived from matched inspiratory and expiratory CT scans, calibrate it in a model of experimental lung injury, and test it in patients with ARDS. Methods 73 anaesthetised rats (acid aspiration model) were ventilated (protective or non-protective) for up to 4 hours to generate a spectrum of lung injury. CT was performed (inspiratory and expiratory) at baseline each hour, paired inspiratory and expiratory images were superimposed and voxels tracked in sequential scans. In nine patients with ARDS, paired inspiratory and expiratory CT scans from the first intensive care unit week were analysed. Results In experimental studies, regions of lung with unstable inflation (ie, partial or reversible airspace filling reflecting local strain) were the areas in which subsequent progression of injury was greatest in terms of progressive infiltrates (R=0.77) and impaired compliance (R=0.67, p<0.01). In patients with ARDS, a threshold fraction of tissue with unstable inflation was apparent: >28% in all patients who died and ≤28% in all who survived, whereas segregation of survivors versus non-survivors was not possible based on oxygenation or lung mechanics. Conclusions A single set of superimposed inspiratory–expiratory CT scans may predict progression of lung injury and outcome in ARDS; if these preliminary results are validated, this could facilitate clinical trial recruitment and individualised care.
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Affiliation(s)
- Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Hooman Hamedani
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Giacomo Bellani
- Department of Emergency and Intensive Care, University of Milan-Bicocca, Monza, Italy
| | - Stephen Kadlecek
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Justin Clapp
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Luca Guerra
- Department of Nuclear Medicine, University of Milan-Bicocca, Monza, Italy
| | - Natalie Meeder
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennia Rajaei
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicholas J Tustison
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, Viriginia, USA
| | - James C Gee
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brian P Kavanagh
- Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rahim R Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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89
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Mauri T, Grasselli G, Pesenti A. Systematic assessment of advanced respiratory physiology: precision medicine entering real-life ICU? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017. [PMID: 28623930 PMCID: PMC5473990 DOI: 10.1186/s13054-017-1720-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- Tommaso Mauri
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy. .,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy. .,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
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90
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Ventilatory Management During Normothermic Ex Vivo Lung Perfusion: Effects on Clinical Outcomes. Transplantation 2017; 100:1128-35. [PMID: 26425874 DOI: 10.1097/tp.0000000000000929] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND During ex vivo lung perfusion (EVLP), fixed ventilator settings and monitoring of compliance are used to prevent ventilator-induced lung injury (VILI). Analysis of the airway pressure-time curve (stress index) has been proposed to assess the presence of VILI. We tested whether currently proposed ventilator settings expose lungs to VILI during EVLP and whether the stress index could identify VILI better than compliance. METHODS Flow, volume, and airway opening pressure were collected continuously during EVLP. Durations of mechanical ventilation, intensive care unit (ICU) and hospital lengths of stay were recorded in lung recipients. RESULTS Fourteen lungs underwent EVLP and were transplanted. In 5 lungs, 95 ± 2% of the stress index values were within the 0.95 to 1.05 range (protected); in the remaining nine lungs, 69 ± 1% of the values were greater than 1.05 and 15 ± 3% were less than 0.95 (nonprotected). There was a significant (P < 0.05) increase in cytokine concentrations after 4 hours of EVLP in the nonprotected lungs. Durations of mechanical ventilation, ICU, and hospital lengths of stay were shorter in recipients of protected than that of nonprotected lungs (P < 0.05). There was no correlation between compliance during EVLP and duration of mechanical ventilation or ICU and hospital lengths of stay in recipients, but the stress index during EVLP was significantly correlated with the duration of mechanical ventilation and with ICU and hospital lengths of stay (P < 0.05). CONCLUSIONS This small, preliminary study shows that ventilator settings currently proposed for EVLP may expose lungs to VILI. Use of the stress index to personalize ventilator settings needs to be tested in further clinical studies.
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91
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Sahetya SK, Goligher EC, Brower RG. Fifty Years of Research in ARDS. Setting Positive End-Expiratory Pressure in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017; 195:1429-1438. [PMID: 28146639 PMCID: PMC5470753 DOI: 10.1164/rccm.201610-2035ci] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 02/01/2017] [Indexed: 11/16/2022] Open
Abstract
Positive end-expiratory pressure (PEEP) has been used during mechanical ventilation since the first description of acute respiratory distress syndrome (ARDS). In the subsequent decades, many different strategies for optimally titrating PEEP have been proposed. Higher PEEP can improve arterial oxygenation, reduce tidal lung stress and strain, and promote more homogenous ventilation by preventing alveolar collapse at end expiration. However, PEEP may also cause circulatory depression and contribute to ventilator-induced lung injury through alveolar overdistention. The overall effect of PEEP is primarily related to the balance between the number of alveoli that are recruited to participate in ventilation and the amount of lung that is overdistended when PEEP is applied. Techniques to assess lung recruitment from PEEP may help to direct safer and more effective PEEP titration. Some PEEP titration strategies attempt to weigh beneficial effects on arterial oxygenation and on prevention of cyclic alveolar collapse with the harmful potential of overdistention. One method for PEEP titration is a PEEP/FiO2 table that prioritizes support for arterial oxygenation. Other methods set PEEP based on mechanical parameters, such as the plateau pressure, respiratory system compliance, or transpulmonary pressure. No single method of PEEP titration has been shown to improve clinical outcomes compared with other approaches of setting PEEP. Future trials should focus on identifying individuals who respond to higher PEEP with recruitment and on clinically important outcomes (e.g., mortality).
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Affiliation(s)
- Sarina K. Sahetya
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; and
- Department of Medicine, Division of Respirology, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Roy G. Brower
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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92
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Comparative Effects of Volutrauma and Atelectrauma on Lung Inflammation in Experimental Acute Respiratory Distress Syndrome. Crit Care Med 2017; 44:e854-65. [PMID: 27035236 DOI: 10.1097/ccm.0000000000001721] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Volutrauma and atelectrauma promote ventilator-induced lung injury, but their relative contribution to inflammation in ventilator-induced lung injury is not well established. The aim of this study was to determine the impact of volutrauma and atelectrauma on the distribution of lung inflammation in experimental acute respiratory distress syndrome. DESIGN Laboratory investigation. SETTING University-hospital research facility. SUBJECTS Ten pigs (five per group; 34.7-49.9 kg) INTERVENTIONS : Animals were anesthetized and intubated, and saline lung lavage was performed. Lungs were separated with a double-lumen tube. Following lung recruitment and decremental positive end-expiratory pressure trial, animals were randomly assigned to 4 hours of ventilation of the left (ventilator-induced lung injury) lung with tidal volume of approximately 3 mL/kg and 1) high positive end-expiratory pressure set above the level where dynamic compliance increased more than 5% during positive end-expiratory pressure trial (volutrauma); or 2) low positive end-expiratory pressure to achieve driving pressure comparable with volutrauma (atelectrauma). The right (control) lung was kept on continuous positive airway pressure of 20 cm H2O, and CO2 was partially removed extracorporeally. MEASUREMENTS AND MAIN RESULTS Regional lung aeration, specific [F]fluorodeoxyglucose uptake rate, and perfusion were assessed using computed and positron emission tomography. Volutrauma yielded higher [F]fluorodeoxyglucose uptake rate in the ventilated lung compared with atelectrauma (median [interquartile range], 0.017 [0.014-0.025] vs 0.013 min [0.010-0.014 min]; p < 0.01), mainly in central lung regions. Volutrauma yielded higher [F]fluorodeoxyglucose uptake rate in ventilator-induced lung injury versus control lung (0.017 [0.014-0.025] vs 0.011 min [0.010-0.016 min]; p < 0.05), whereas atelectrauma did not. Volutrauma decreased blood fraction at similar perfusion and increased normally as well as hyperaerated lung compartments and tidal hyperaeration. Atelectrauma yielded higher poorly and nonaerated lung compartments, and tidal recruitment. Driving pressure increased in atelectrauma. CONCLUSIONS In this model of acute respiratory distress syndrome, volutrauma promoted higher lung inflammation than atelectrauma at comparable low tidal volume and lower driving pressure, suggesting that static stress and strain are major determinants of ventilator-induced lung injury.
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93
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Mauri T, Turrini C, Eronia N, Grasselli G, Volta CA, Bellani G, Pesenti A. Physiologic Effects of High-Flow Nasal Cannula in Acute Hypoxemic Respiratory Failure. Am J Respir Crit Care Med 2017; 195:1207-1215. [DOI: 10.1164/rccm.201605-0916oc] [Citation(s) in RCA: 262] [Impact Index Per Article: 37.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, IRCCS (Institute for Treatment and Research) Ca’ Granda Maggiore Policlinico Hospital Foundation, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Cecilia Turrini
- Department of Anesthesia, Critical Care and Emergency, IRCCS (Institute for Treatment and Research) Ca’ Granda Maggiore Policlinico Hospital Foundation, Milan, Italy
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Nilde Eronia
- Department of Emergency, San Gerardo Hospital, Monza, Italy; and
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, IRCCS (Institute for Treatment and Research) Ca’ Granda Maggiore Policlinico Hospital Foundation, Milan, Italy
| | - Carlo Alberto Volta
- Department of Morphology, Surgery and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Giacomo Bellani
- Department of Emergency, San Gerardo Hospital, Monza, Italy; and
- Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, IRCCS (Institute for Treatment and Research) Ca’ Granda Maggiore Policlinico Hospital Foundation, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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94
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Amado-Rodríguez L, Del Busto C, García-Prieto E, Albaiceta GM. Mechanical ventilation in acute respiratory distress syndrome: The open lung revisited. Med Intensiva 2017; 41:550-558. [PMID: 28238441 DOI: 10.1016/j.medin.2016.12.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 12/26/2016] [Indexed: 02/02/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is still related to high mortality and morbidity rates. Most patients with ARDS will require ventilatory support. This treatment has a direct impact upon patient outcome and is associated to major side effects. In this regard, ventilator-associated lung injury (VALI) is the main concern when this technique is used. The ultimate mechanisms of VALI and its management are under constant evolution. The present review describes the classical mechanisms of VALI and how they have evolved with recent findings from physiopathological and clinical studies, with the aim of analyzing the clinical implications derived from them. Lastly, a series of knowledge-based recommendations are proposed that can be helpful for the ventilator assisted management of ARDS at the patient bedside.
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Affiliation(s)
- L Amado-Rodríguez
- Unidad de Gestión Clínica de Medicina Intensiva, Hospital Valle del Nalón, Langreo, Spain
| | - C Del Busto
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - E García-Prieto
- Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - G M Albaiceta
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Oviedo, Spain; Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain.
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95
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Morelli A, Del Sorbo L, Pesenti A, Ranieri VM, Fan E. Extracorporeal carbon dioxide removal (ECCO 2R) in patients with acute respiratory failure. Intensive Care Med 2017; 43:519-530. [PMID: 28132075 DOI: 10.1007/s00134-016-4673-0] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 12/29/2016] [Indexed: 12/14/2022]
Abstract
PURPOSE To review the available knowledge related to the use of ECCO2R as adjuvant strategy to mechanical ventilation (MV) in various clinical settings of acute respiratory failure (ARF). METHODS Expert opinion and review of the literature. RESULTS ECCO2R may be a promising adjuvant therapeutic strategy for the management of patients with severe exacerbations of COPD and for the achievement of protective or ultra-protective ventilation in patients with ARDS without life-threatening hypoxemia. Given the observational nature of most of the available clinical data and differences in technical features and performances of current devices, the balance of risks and benefits for or against ECCO2R in such patient populations remains unclear CONCLUSIONS: ECCO2R is currently an experimental technique rather than an accepted therapeutic strategy in ARF-its safety and efficacy require confirmation in clinical trials.
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Affiliation(s)
- Andrea Morelli
- Department of Anesthesiology and Intensive Care, Policlinico Umberto 1, Sapienza University of Rome, Rome, Italy
| | - Lorenzo Del Sorbo
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Extracorporeal Life Support Program, Toronto General Hospital, 585 University Avenue, PMB 11-123, Toronto, ON, M5G 2N2, Canada
| | - Antonio Pesenti
- Fondazione IRCCS Ca' Granda, Ospendale Maggiore Policlinico and Department of Pathophysiology and Transplantation, Universita degli Studi di Milano, Milan, Italy
| | - V Marco Ranieri
- Department of Anesthesiology and Intensive Care, Policlinico Umberto 1, Sapienza University of Rome, Rome, Italy
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. .,Extracorporeal Life Support Program, Toronto General Hospital, 585 University Avenue, PMB 11-123, Toronto, ON, M5G 2N2, Canada.
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96
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Chen DL, Cheriyan J, Chilvers ER, Choudhury G, Coello C, Connell M, Fisk M, Groves AM, Gunn RN, Holman BF, Hutton BF, Lee S, MacNee W, Mohan D, Parr D, Subramanian D, Tal-Singer R, Thielemans K, van Beek EJR, Vass L, Wellen JW, Wilkinson I, Wilson FJ. Quantification of Lung PET Images: Challenges and Opportunities. J Nucl Med 2017; 58:201-207. [PMID: 28082432 DOI: 10.2967/jnumed.116.184796] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 01/10/2017] [Indexed: 01/03/2023] Open
Abstract
Millions of people are affected by respiratory diseases, leading to a significant health burden globally. Because of the current insufficient knowledge of the underlying mechanisms that lead to the development and progression of respiratory diseases, treatment options remain limited. To overcome this limitation and understand the associated molecular changes, noninvasive imaging techniques such as PET and SPECT have been explored for biomarker development, with 18F-FDG PET imaging being the most studied. The quantification of pulmonary molecular imaging data remains challenging because of variations in tissue, air, blood, and water fractions within the lungs. The proportions of these components further differ depending on the lung disease. Therefore, different quantification approaches have been proposed to address these variabilities. However, no standardized approach has been developed to date. This article reviews the data evaluating 18F-FDG PET quantification approaches in lung diseases, focusing on methods to account for variations in lung components and the interpretation of the derived parameters. The diseases reviewed include acute respiratory distress syndrome, chronic obstructive pulmonary disease, and interstitial lung diseases such as idiopathic pulmonary fibrosis. Based on review of prior literature, ongoing research, and discussions among the authors, suggested considerations are presented to assist with the interpretation of the derived parameters from these approaches and the design of future studies.
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Affiliation(s)
- Delphine L Chen
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Joseph Cheriyan
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom.,Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Edwin R Chilvers
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Gourab Choudhury
- Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Martin Connell
- Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Marie Fisk
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Ashley M Groves
- Institute of Nuclear Medicine, University College London, London, United Kingdom
| | - Roger N Gunn
- Imanova Ltd., London, United Kingdom.,Department of Medicine, Imperial College London, London, United Kingdom
| | - Beverley F Holman
- Institute of Nuclear Medicine, University College London, London, United Kingdom
| | - Brian F Hutton
- Institute of Nuclear Medicine, University College London, London, United Kingdom
| | - Sarah Lee
- Medical Image Analysis Consultant, London, United Kingdom
| | - William MacNee
- Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Divya Mohan
- Clinical Discovery, Respiratory Therapy Area Unit, GlaxoSmithKline R&D, King of Prussia, Pennsylvania
| | - David Parr
- University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
| | | | - Ruth Tal-Singer
- Clinical Discovery, Respiratory Therapy Area Unit, GlaxoSmithKline R&D, King of Prussia, Pennsylvania
| | - Kris Thielemans
- Institute of Nuclear Medicine, University College London, London, United Kingdom
| | - Edwin J R van Beek
- Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Laurence Vass
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Jeremy W Wellen
- Worldwide Research and Development, Pfizer, Inc., Cambridge, Massachusetts; and
| | - Ian Wilkinson
- Department of Medicine, University of Cambridge, Cambridge, United Kingdom.,Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Frederick J Wilson
- Experimental Medicine Imaging, GlaxoSmithKline, Stevenage, United Kingdom
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97
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Bedside assessment of the effects of positive end-expiratory pressure on lung inflation and recruitment by the helium dilution technique and electrical impedance tomography. Intensive Care Med 2016; 42:1576-1587. [DOI: 10.1007/s00134-016-4467-4] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 07/28/2016] [Indexed: 11/26/2022]
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98
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Impact of Recruitment on Static and Dynamic Lung Strain in Acute Respiratory Distress Syndrome. Anesthesiology 2016; 124:443-52. [PMID: 26569171 DOI: 10.1097/aln.0000000000000946] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Lung strain, defined as the ratio between end-inspiratory volume and functional residual capacity, is a marker of the mechanical load during ventilation. However, changes in lung volumes in response to pressures may occur in injured lungs and modify strain values. The objective of this study was to clarify the role of recruitment in strain measurements. METHODS Six oleic acid-injured pigs were ventilated at positive end-expiratory pressure (PEEP) 0 and 10 cm H2O before and after a recruitment maneuver (PEEP = 20 cm H2O). Lung volumes were measured by helium dilution and inductance plethysmography. In addition, six patients with moderate-to-severe acute respiratory distress syndrome were ventilated with three strategies (peak inspiratory pressure/PEEP: 20/8, 32/8, and 32/20 cm H2O). Lung volumes were measured in computed tomography slices acquired at end-expiration and end-inspiration. From both series, recruited volume and lung strain (total, dynamic, and static) were computed. RESULTS In the animal model, recruitment caused a significant decrease in dynamic strain (from [mean ± SD] 0.4 ± 0.12 to 0.25 ± 0.07, P < 0.01), while increasing the static component. In patients, total strain remained constant for the three ventilatory settings (0.35 ± 0.1, 0.37 ± 0.11, and 0.32 ± 0.1, respectively). Increases in tidal volume had no significant effects. Increasing PEEP constantly decreased dynamic strain (0.35 ± 0.1, 0.32 ± 0.1, and 0.04+0.03, P < 0.05) and increased static strain (0, 0.06 ± 0.06, and 0.28 ± 0.11, P < 0.05). The changes in dynamic and total strain among patients were correlated to the amount of recruited volume. An analysis restricted to the changes in normally aerated lung yielded similar results. CONCLUSION Recruitment causes a shift from dynamic to static strain in early acute respiratory distress syndrome.
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99
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End-Expiratory Lung Volume in Patients with Acute Respiratory Distress Syndrome: A Time Course Analysis. Lung 2016; 194:527-34. [PMID: 27169535 DOI: 10.1007/s00408-016-9892-1] [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: 02/17/2016] [Accepted: 05/02/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Lung injury can be caused by ventilation and non-physiological lung stress (transpulmonary pressure) and strain [inflated volume over functional residual capacity ratio (FRC)]. FRC is severely decreased in patients with acute respiratory distress syndrome (ARDS). End-expiratory lung volume (EELV) is FRC plus lung volume increased by the applied positive end-expiratory pressure (PEEP). Measurement using the modified nitrogen multiple breath washout technique may help titrating PEEP during ARDS and allow determining dynamic lung strain (tidal volume over EELV) in patients ventilated with PEEP. In this observational study, we measured EELV for up to seven consecutive days in patients with ARDS at different PEEP levels. RESULTS Thirty sedated patients with ARDS (10 mild, 14 moderate, 6 severe) underwent decremental PEEP testing (20, 15, 10, 5 cm H2O) for up to 7 days after inclusion. At all PEEP levels examined, over a period of 7 days the measured absolute EELVs showed no significant change over time [PEEP 20 cm H2O 2464 ml at day 1 vs. 2144 ml at day 7 (p = 0.78), PEEP 15 cm H2O 2226 ml vs. 1990 ml (p = 0.36), PEEP 10 1835 ml vs. 1858 ml (p = 0.76) and PEEP 5 cm H2O 1487 ml vs. 1612 ml (p = 0.37)]. In relation to the predicted body weight (pbw), no significant change in EELV/kg pbw over time could be detected either at any PEEP level or over time [PEEP 20 36 ml/kg pbw at day 1 vs. 33 ml/kg pbw at day 7 (p = 0.66); PEEP 15 33 vs. 29 ml/kg pbw (p = 0.32); PEEP 10 27 vs. 27 ml/kg pbw (p = 0.70) and PEEP 5 22 vs. 24 ml/kg pbw (p = 0.70)]. Oxygenation significantly improved over time from PaO2/FiO2 of 169 mmHg at day 1 to 199 mmHg at day 7 (p < 0.01). CONCLUSIONS EELV did not change significantly for up to 7 days in patients with ARDS. By contrast, PaO2/FiO2 improved significantly. Bedside measurement of EELV may be a novel approach to individualise lung-protective ventilation on the basis of calculation of dynamic strain as the ratio of VT to EELV.
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100
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Donoso A, Arriagada D, Contreras D, Ulloa D, Neumann M. [Respiratory monitoring of pediatric patients in the Intensive Care Unit]. BOLETIN MEDICO DEL HOSPITAL INFANTIL DE MEXICO 2016; 73:149-165. [PMID: 29421202 DOI: 10.1016/j.bmhimx.2016.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 01/29/2016] [Accepted: 02/02/2016] [Indexed: 06/08/2023] Open
Abstract
Respiratory monitoring plays an important role in the care of children with acute respiratory failure. Therefore, its proper use and correct interpretation (recognizing which signals and variables should be prioritized) should help to a better understanding of the pathophysiology of the disease and the effects of therapeutic interventions. In addition, ventilated patient monitoring, among other determinations, allows to evaluate various parameters of respiratory mechanics, know the status of the different components of the respiratory system and guide the adjustments of ventilatory therapy. In this update, the usefulness of several techniques of respiratory monitoring including conventional respiratory monitoring and more recent methods are described. Moreover, basic concepts of mechanical ventilation, their interpretation and how the appropriate analysis of the information obtained can cause an impact on the clinical management of the patient are defined.
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Affiliation(s)
| | | | - Dina Contreras
- Hospital Clínico Metropolitano La Florida, Santiago, Chile
| | - Daniela Ulloa
- Hospital Clínico Metropolitano La Florida, Santiago, Chile
| | - Megan Neumann
- Hospital Clínico Metropolitano La Florida, Santiago, Chile
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