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Salvianolic Acid A Protects against Lipopolysaccharide-Induced Acute Lung Injury by Inhibiting Neutrophil NETosis. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:7411824. [PMID: 35910849 PMCID: PMC9334034 DOI: 10.1155/2022/7411824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/21/2022] [Accepted: 06/26/2022] [Indexed: 11/24/2022]
Abstract
Salvianolic acid A (SAA) is one of bioactive polyphenol extracted from a Salvia miltiorrhiza (Danshen), which was widely used to treat cardiovascular disease in traditional Chinese medicine. SAA has been reported to be protective in cardiovascular disease and ischemia injury, with anti-inflammatory and antioxidative effect, but its role in acute lung injury (ALI) is still unknown. In this study, we sought to investigate the therapeutic effects of SAA in a murine model of lipopolysaccharide- (LPS-) induced ALI. The optimal dose of SAA was determined by comparing the attenuation of lung injury score after administration of SAA at three different doses (low, 5 mg/kg; medium, 10 mg/kg; and, high 15 mg/kg). Dexamethasone (DEX) was used as a positive control for SAA. Here, we showed that the therapeutic effect of SAA (10 mg/kg) against LPS-induced pathologic injury in the lungs was comparable to DEX. SAA and DEX attenuated the increased W/D ratio and the protein level, counts of total cells and neutrophils, and cytokine levels in the BALF of ALI mice similarly. The oxidative stress was also relieved by SAA and DEX according to the superoxide dismutase and malondialdehyde. NET level in the lungs was elevated in the injured lung while SAA and DEX reduced it significantly. LPS induced phosphorylation of Src, Raf, MEK, and ERK in the lungs, which was inhibited by SAA and DEX. NET level and phosphorylation level of Src/Raf/MEK/ERK pathway in the neutrophils from acute respiratory distress syndrome (ARDS) patients were also inhibited by SAA and DEX in vitro, but the YEEI peptide reversed the protective effect of SAA completely. The inhibition of NET release by SAA was also reversed by YEEI peptide in LPS-challenged neutrophils from healthy volunteers. Our data demonstrated that SAA ameliorated ALI via attenuating inflammation, oxidative stress, and neutrophil NETosis. The mechanism of such protective effect might involve the inhibition of Src activation.
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Zhou L, Yang R, Xue C, Chen Z, Jiang W, He S, Zhang X. Biphasic positive airway pressure spontaneous breathing attenuates lung injury in an animal model of severe acute respiratory distress syndrome. BMC Anesthesiol 2022; 22:228. [PMID: 35842600 PMCID: PMC9287822 DOI: 10.1186/s12871-022-01763-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 07/05/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To compare the effects of unassisted spontaneous breathing (SB) and complete muscle paralysis (PC) on early severe acute respiratory distress syndrome (ARDS) in an animal model, and to explore the possibility of biphasic positive airway pressure (BIPAP) as lung protective ventilation support for patients in the early stage of severe ARDS. METHODS Twelve healthy beagle dogs between the ages of 10 and 15 months were randomly divided into two groups: the SB group (BIPAPSB) and the PC group (BIPAPPC). Arterial blood samples were drawn before modelling. Arterial blood gas analysis and mechanical tests were conducted. The animal model of severe ARDS was established using a deep intravenous injection of oleic acid, and BIPAP ventilation was performed for 8 hours. Lung tissue and blood were taken to detect lung function, inflammatory reactions and degree of pathological damage. RESULTS At the beginning of the experiment, there was no significant difference in the arterial blood gas analysis between the two groups (p > 0.05). After successful modelling, the oxygenation index and the end-expiratory lung volume in the SB group were significantly higher than those in the PC group 8 hours after MV. Pathologically, the wet-dry ratio and pathological score of the PC group were higher than those of the SB group; the lung injury in the gravity-dependent area in the SB group was less than that in the PC group (p< 0.05). CONCLUSIONS In the early stage of severe ARDS induced by oleic acid, compared with PC, retention of the BIPAP mode of SB can reduce the risk of lung injury and improve respiratory function.
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Affiliation(s)
- Leilei Zhou
- School of Clinical Medicine, Guizhou Medical University, Guiyang, 550004, China
| | - Rui Yang
- Department of Internal Medicine, Guiyang First People's Hospital, Guiyang, China
| | - Chunju Xue
- School of Clinical Medicine, Guizhou Medical University, Guiyang, 550004, China
| | - Zongyu Chen
- School of Clinical Medicine, Guizhou Medical University, Guiyang, 550004, China
| | - Wenqing Jiang
- School of Clinical Medicine, Guizhou Medical University, Guiyang, 550004, China
| | - Shuang He
- School of Clinical Medicine, Guizhou Medical University, Guiyang, 550004, China
| | - Xianming Zhang
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China.
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Weaver L, Saffaran S, Chikhani M, Laffey JG, Scott TE, Camporota L, Hardman JG, Bates DG. Why Reduced Inspiratory Pressure Could Determine Success of Non-Invasive Ventilation in Acute Hypoxic Respiratory Failure. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2022; 2022:3265-3268. [PMID: 36085857 DOI: 10.1109/embc48229.2022.9871901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The magnitude of inspiratory effort relief within the first 2 hours of non-invasive ventilation for hypoxic respiratory failure was shown in a recent exploratory clinical study to be an early and accurate predictor of outcome at 24 hours. We simulated the application of non-invasive ventilation to three patients whose physiological and clinical characteristics match the data in that study. Reductions in inspiratory effort corresponding to reductions of esophageal pressure swing greater than 10 cmH2O more than halved the values of total lung stress, driving pressure, power and transpulmonary pressure swing. In the absence of significant reductions in inspiratory pressure, multiple indicators of lung injury increased after application of non-invasive ventilation. Clinical Relevance- We show using computer simulation that reduced inspiratory pressure after application of noninvasive ventilation translates directly into large reductions in multiple well-established indicators of lung injury, providing a potential physiological explanation for recent clinical findings.
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Sun Q, Xia Y, Qin H, Zhang W, Wang J, Ning Y, Dong Y. MEF2 intervened LPS-induced acute lung injury by binding to KLF2 promoter and modulating macrophage phenotype. Int Immunopharmacol 2022; 108:108873. [DOI: 10.1016/j.intimp.2022.108873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/09/2022] [Accepted: 05/14/2022] [Indexed: 11/27/2022]
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Flinspach AN, Zinn S, Zacharowski K, Balaban Ü, Herrmann E, Adam EH. Electroencephalogram-Based Evaluation of Impaired Sedation in Patients with Moderate to Severe COVID-19 ARDS. J Clin Med 2022; 11:jcm11123494. [PMID: 35743572 PMCID: PMC9224742 DOI: 10.3390/jcm11123494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 06/02/2022] [Accepted: 06/10/2022] [Indexed: 02/01/2023] Open
Abstract
The sedation management of patients with severe COVID-19 is challenging. Processed electroencephalography (pEEG) has already been used for sedation management before COVID-19 in critical care, but its applicability in COVID-19 has not yet been investigated. We performed this prospective observational study to evaluate whether the patient sedation index (PSI) obtained via pEEG may adequately reflect sedation in ventilated COVID-19 patients. Statistical analysis was performed by linear regression analysis with mixed effects. We included data from 49 consecutive patients. None of the patients received neuromuscular blocking agents by the time of the measurement. The mean value of the PSI was 20 (±23). The suppression rate was determined to be 14% (±24%). A deep sedation equivalent to the Richmond Agitation and Sedation Scale of −3 to −4 (correlation expected PSI 25−50) in bedside examination was noted in 79.4% of the recordings. Linear regression analysis revealed a significant correlation between the sedative dosages of propofol, midazolam, clonidine, and sufentanil (p < 0.01) and the sedation index. Our results showed a distinct discrepancy between the RASS and the determined PSI. However, it remains unclear to what extent any discrepancy is due to the electrophysiological effects of neuroinflammation in terms of pEEG alteration, to the misinterpretation of spinal or vegetative reflexes during bedside evaluation, or to other causes.
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Affiliation(s)
- Armin Niklas Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt, Germany; (S.Z.); (K.Z.); (E.H.A.)
- Correspondence: ; Tel.: +49-69-6301-5868
| | - Sebastian Zinn
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt, Germany; (S.Z.); (K.Z.); (E.H.A.)
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt, Germany; (S.Z.); (K.Z.); (E.H.A.)
| | - Ümniye Balaban
- Department of Biostatistics and Mathematical Modelling, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt, Germany; (Ü.B.); (E.H.)
| | - Eva Herrmann
- Department of Biostatistics and Mathematical Modelling, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt, Germany; (Ü.B.); (E.H.)
| | - Elisabeth Hannah Adam
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt, Germany; (S.Z.); (K.Z.); (E.H.A.)
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Helmet noninvasive support in hypoxemic respiratory failure. Intensive Care Med 2022; 48:1072-1075. [PMID: 35713668 DOI: 10.1007/s00134-022-06737-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/11/2022] [Indexed: 11/05/2022]
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Silva PL, Ball L, Rocco PRM, Pelosi P. Physiological and Pathophysiological Consequences of Mechanical Ventilation. Semin Respir Crit Care Med 2022; 43:321-334. [PMID: 35439832 DOI: 10.1055/s-0042-1744447] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Mechanical ventilation is a life-support system used to ensure blood gas exchange and to assist the respiratory muscles in ventilating the lung during the acute phase of lung disease or following surgery. Positive-pressure mechanical ventilation differs considerably from normal physiologic breathing. This may lead to several negative physiological consequences, both on the lungs and on peripheral organs. First, hemodynamic changes can affect cardiovascular performance, cerebral perfusion pressure (CPP), and drainage of renal veins. Second, the negative effect of mechanical ventilation (compression stress) on the alveolar-capillary membrane and extracellular matrix may cause local and systemic inflammation, promoting lung and peripheral-organ injury. Third, intra-abdominal hypertension may further impair lung and peripheral-organ function during controlled and assisted ventilation. Mechanical ventilation should be optimized and personalized in each patient according to individual clinical needs. Multiple parameters must be adjusted appropriately to minimize ventilator-induced lung injury (VILI), including: inspiratory stress (the respiratory system inspiratory plateau pressure); dynamic strain (the ratio between tidal volume and the end-expiratory lung volume, or inspiratory capacity); static strain (the end-expiratory lung volume determined by positive end-expiratory pressure [PEEP]); driving pressure (the difference between the respiratory system inspiratory plateau pressure and PEEP); and mechanical power (the amount of mechanical energy imparted as a function of respiratory rate). More recently, patient self-inflicted lung injury (P-SILI) has been proposed as a potential mechanism promoting VILI. In the present chapter, we will discuss the physiological and pathophysiological consequences of mechanical ventilation and how to personalize mechanical ventilation parameters.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
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Karageorgos V, Proklou A, Vaporidi K. Lung and diaphragm protective ventilation: a synthesis of recent data. Expert Rev Respir Med 2022; 16:375-390. [PMID: 35354361 DOI: 10.1080/17476348.2022.2060824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION : To adhere to the Hippocratic Oath, to "first, do no harm", we need to make every effort to minimize the adverse effects of mechanical ventilation. Our understanding of the mechanisms of ventilator-induced lung injury (VILI) and ventilator-induced diaphragm dysfunction (VIDD) has increased in recent years. Research focuses now on methods to monitor lung stress and inhomogeneity and targets we should aim for when setting the ventilator. In parallel, efforts to promote early assisted ventilation to prevent VIDD have revealed new challenges, such as titrating inspiratory effort and synchronizing the mechanical with the patients' spontaneous breaths, while at the same time adhering to lung-protective targets. AREAS COVERED This is a narrative review of the key mechanisms contributing to VILI and VIDD and the methods currently available to evaluate and mitigate the risk of lung and diaphragm injury. EXPERT OPINION Implementing lung and diaphragm protective ventilation requires individualizing the ventilator settings, and this can only be accomplished by exploiting in everyday clinical practice the tools available to monitor lung stress and inhomogeneity, inspiratory effort, and patient-ventilator interaction.
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Affiliation(s)
- Vlasios Karageorgos
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Athanasia Proklou
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Katerina Vaporidi
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
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Umbrello M, Antonucci E, Muttini S. Neurally Adjusted Ventilatory Assist in Acute Respiratory Failure-A Narrative Review. J Clin Med 2022; 11:jcm11071863. [PMID: 35407471 PMCID: PMC9000024 DOI: 10.3390/jcm11071863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/10/2022] [Accepted: 03/25/2022] [Indexed: 02/08/2023] Open
Abstract
Maintaining spontaneous breathing has both potentially beneficial and deleterious consequences in patients with acute respiratory failure, depending on the balance that can be obtained between the protecting and damaging effects on the lungs and the diaphragm. Neurally adjusted ventilatory assist (NAVA) is an assist mode, which supplies the respiratory system with a pressure proportional to the integral of the electrical activity of the diaphragm. This proportional mode of ventilation has the theoretical potential to deliver lung- and respiratory-muscle-protective ventilation by preserving the physiologic defense mechanisms against both lung overdistention and ventilator overassistance, as well as reducing the incidence of diaphragm disuse atrophy while maintaining patient–ventilator synchrony. This narrative review presents an overview of NAVA technology, its basic principles, the different methods to set the assist level and the findings of experimental and clinical studies which focused on lung and diaphragm protection, machine–patient interaction and preservation of breathing pattern variability. A summary of the findings of the available clinical trials which investigate the use of NAVA in acute respiratory failure will also be presented and discussed.
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Müller‐Wirtz LM, Behne F, Kermad A, Wagenpfeil G, Schroeder M, Sessler DI, Volk T, Meiser A. Isoflurane promotes early spontaneous breathing in ventilated intensive care patients: A post hoc subgroup analysis of a randomized trial. Acta Anaesthesiol Scand 2022; 66:354-364. [PMID: 34870852 DOI: 10.1111/aas.14010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Spontaneous breathing is desirable in most ventilated patients. We therefore studied the influence of isoflurane versus propofol sedation on early spontaneous breathing in ventilated surgical intensive care patients and evaluated potential mediation by opioids and arterial carbon dioxide during the first 20 h of study sedation. METHODS We included a single-center subgroup of 66 patients, who participated in a large multi-center trial assessing efficacy and safety of isoflurane sedation, with 33 patients each randomized to isoflurane or propofol sedation. Both sedatives were titrated to a sedation depth of -4 to -1 on the Richmond Agitation Sedation Scale. The primary outcome was the fraction of time during which patients breathed spontaneously. RESULTS Baseline characteristics of isoflurane and propofol-sedated patients were well balanced. There were no substantive differences in management or treatment aside from sedation, and isoflurane and propofol provided nearly identical sedation depths. The mean fraction of time spent spontaneously breathing was 82% [95% CI: 69, 90] in patients sedated with isoflurane compared to 35% [95% CI: 22, 51] in those assigned to propofol: median difference: 61% [95% CI: 14, 89], p < .001. After adjustments for sufentanil dose and arterial carbon dioxide partial pressure, patients sedated with isoflurane were twice as likely to breathe spontaneously than those sedated with propofol: adjusted risk ratio: 2.2 [95%CI: 1.4, 3.3], p < .001. CONCLUSIONS Isoflurane compared to propofol sedation promotes early spontaneous breathing in deeply sedated ventilated intensive care patients. The benefit appears to be a direct effect isoflurane rather than being mediated by opioids or arterial carbon dioxide.
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Affiliation(s)
- Lukas M. Müller‐Wirtz
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
- Outcomes Research Consortium Cleveland Ohio USA
| | - Florian Behne
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
| | - Azzeddine Kermad
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
| | - Gudrun Wagenpfeil
- Institute for Medical Biometry Epidemiology and Medical Informatics (IMBEI) Saarland University Faculty of Medicine Homburg Germany
| | - Matthias Schroeder
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
| | - Daniel I. Sessler
- Outcomes Research Consortium Cleveland Ohio USA
- Department of Outcomes Research Anesthesiology Institute Cleveland Clinic Cleveland Ohio USA
| | - Thomas Volk
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
- Outcomes Research Consortium Cleveland Ohio USA
| | - Andreas Meiser
- Department of Anaesthesiology Intensive Care and Pain Therapy Saarland University Medical Center Saarland University Faculty of Medicine Homburg Germany
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Ang CYS, Chiew YS, Vu LH, Cove ME. Quantification of respiratory effort magnitude in spontaneous breathing patients using Convolutional Autoencoders. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 215:106601. [PMID: 34973606 DOI: 10.1016/j.cmpb.2021.106601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/14/2021] [Accepted: 12/20/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Spontaneous breathing (SB) effort during mechanical ventilation (MV) is an important metric of respiratory drive. However, SB effort varies due to a variety of factors, including evolving pathology and sedation levels. Therefore, assessment of SB efforts needs to be continuous and non-invasive. This is important to prevent both over- and under-assistance with MV. In this study, a machine learning model, Convolutional Autoencoder (CAE) is developed to quantify the magnitude of SB effort using only bedside MV airway pressure and flow waveform. METHOD The CAE model was trained using 12,170,655 simulated SB flow and normal flow data (NB). The paired SB and NB flow data were simulated using a Gaussian Effort Model (GEM) with 5 basis functions. When the CAE model is given a SB flow input, it is capable of predicting a corresponding NB flow for the SB flow input. The magnitude of SB effort (SBEMag) is then quantified as the difference between the SB and NB flows. The CAE model was used to evaluate the SBEMag of 9 pressure control/ support datasets. Results were validated using a mean squared error (MSE) fitting between clinical and training SB flows. RESULTS The CAE model was able to produce NB flows from the clinical SB flows with the median SBEMag of the 9 datasets being 25.39% [IQR: 21.87-25.57%]. The absolute error in SBEMag using MSE validation yields a median of 4.77% [IQR: 3.77-8.56%] amongst the cohort. This shows the ability of the GEM to capture the intrinsic details present in SB flow waveforms. Analysis also shows both intra-patient and inter-patient variability in SBEMag. CONCLUSION A Convolutional Autoencoder model was developed with simulated SB and NB flow data and is capable of quantifying the magnitude of patient spontaneous breathing effort. This provides potential application for real-time monitoring of patient respiratory drive for better management of patient-ventilator interaction.
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Affiliation(s)
| | - Yeong Shiong Chiew
- School of Engineering, Monash University Malaysia, Bandar Sunway, Malaysia.
| | - Lien Hong Vu
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Health System, Singapore
| | - Matthew E Cove
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Health System, Singapore
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Jain P. Noninvasive Ventilation by Helmet vs Face Mask in COVID-19 Pneumonia: Emerging Evidence and Need of the Hour. Indian J Crit Care Med 2022; 26:256-258. [PMID: 35519921 PMCID: PMC9015939 DOI: 10.5005/jp-journals-10071-24159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Jain P. Noninvasive Ventilation by Helmet vs Face Mask in COVID-19 Pneumonia: Emerging Evidence and Need of the Hour. Indian J Crit Care Med 2022;26(3):256–258.
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Affiliation(s)
- Puneet Jain
- Puneet Jain, Department of Pediatrics, Pacific Medical College and Hospital, Udaipur, Rajasthan, India, Phone: +91 9786625720, e-mail:
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Defining Failure of Noninvasive Ventilation for Acute Respiratory Distress Syndrome: Have We Succeeded? Ann Am Thorac Soc 2022; 19:167-169. [PMID: 35103563 PMCID: PMC8867363 DOI: 10.1513/annalsats.202109-1059ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Camporota L, Cronin JN, Busana M, Gattinoni L, Formenti F. Pathophysiology of coronavirus-19 disease acute lung injury. Curr Opin Crit Care 2022; 28:9-16. [PMID: 34907979 PMCID: PMC8711311 DOI: 10.1097/mcc.0000000000000911] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW More than 230 million people have tested positive for severe acute respiratory syndrome-coronavirus-2 infection globally by September 2021. The infection affects primarily the function of the respiratory system, where ∼20% of infected individuals develop coronavirus-19 disease (COVID-19) pneumonia. This review provides an update on the pathophysiology of the COVID-19 acute lung injury. RECENT FINDINGS In patients with COVID-19 pneumonia admitted to the intensive care unit, the PaO2/FiO2 ratio is typically <26.7 kPa (200 mmHg), whereas lung volume appears relatively unchanged. This hypoxaemia is likely determined by a heterogeneous mismatch of pulmonary ventilation and perfusion, mainly associated with immunothrombosis, endothelialitis and neovascularisation. During the disease, lung weight, elastance and dead space can increase, affecting respiratory drive, effort and dyspnoea. In some severe cases, COVID-19 pneumonia may lead to irreversible pulmonary fibrosis. SUMMARY This review summarises the fundamental pathophysiological features of COVID-19 in the context of the respiratory system. It provides an overview of the key clinical manifestations of COVID-19 pneumonia, including gas exchange impairment, altered pulmonary mechanics and implications of abnormal chemical and mechanical stimuli. It also critically discusses the clinical implications for mechanical ventilation therapy.
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Affiliation(s)
- Luigi Camporota
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London
- Intensive Care Unit, Guy's and St Thomas' NHS Foundation Trust
| | - John N Cronin
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London
- Department of Anaesthetics, Royal Brompton and Harefield, part of Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center of Göttingen, Göttingen, Germany
| | - Federico Formenti
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK
- Department of Biomechanics, University of Nebraska Omaha, Omaha, Nebraska, USA
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Menga LS, Berardi C, Ruggiero E, Grieco DL, Antonelli M. Noninvasive respiratory support for acute respiratory failure due to COVID-19. Curr Opin Crit Care 2022; 28:25-50. [PMID: 34694240 PMCID: PMC8711305 DOI: 10.1097/mcc.0000000000000902] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Noninvasive respiratory support has been widely applied during the COVID-19 pandemic. We provide a narrative review on the benefits and possible harms of noninvasive respiratory support for COVID-19 respiratory failure. RECENT FINDINGS Maintenance of spontaneous breathing by means of noninvasive respiratory support in hypoxemic patients with vigorous spontaneous effort carries the risk of patient self-induced lung injury: the benefit of averting intubation in successful patients should be balanced with the harms of a worse outcome in patients who are intubated after failing a trial of noninvasive support.The risk of noninvasive treatment failure is greater in patients with the most severe oxygenation impairment (PaO2/FiO2 < 200 mmHg).High-flow nasal oxygen (HFNO) is the most widely applied intervention in COVID-19 patients with hypoxemic respiratory failure. Also, noninvasive ventilation (NIV) and continuous positive airway pressure delivered with different interfaces have been used with variable success rates. A single randomized trial showed lower need for intubation in patients receiving helmet NIV with specific settings, compared to HFNO alone.Prone positioning is recommended for moderate-to-severe acute respiratory distress syndrome patients on invasive ventilation. Awake prone position has been frequently applied in COVID-19 patients: one randomized trial showed improved oxygenation and lower intubation rate in patients receiving 6-h sessions of awake prone positioning, as compared to conventional management. SUMMARY Noninvasive respiratory support and awake prone position are tools possibly capable of averting endotracheal intubation in COVID-19 patients; carefully monitoring during any treatment is warranted to avoid delays in endotracheal intubation, especially in patients with PaO2/FiO2 < 200 mmHg.
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Affiliation(s)
- Luca S. Menga
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Cecilia Berardi
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ersilia Ruggiero
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico Luca Grieco
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Antonelli
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore
- Dipartimento di Scienze dell’Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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66
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Tu C, Wang Z, Xiang E, Zhang Q, Zhang Y, Wu P, Li C, Wu D. Human Umbilical Cord Mesenchymal Stem Cells Promote Macrophage PD-L1 Expression and Attenuate Acute Lung Injury in Mice. Curr Stem Cell Res Ther 2022; 17:564-575. [PMID: 35086457 DOI: 10.2174/1574888x17666220127110332] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/11/2021] [Accepted: 12/19/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) remains a serious clinical problem but has no approved pharmacotherapy. Mesenchymal stem cells (MSCs) represent an attractive therapeutic tool for tissue damage and inflammation owing to their unique immunomodulatory properties. The present study aims to explore the therapeutic effect and underlying mechanisms of human umbilical cord MSCs (UC-MSCs) in ALI mice. OBJECTIVE In this study, we identify a novel mechanism for human umbilical cord-derived MSCs (UC-MSCs)-mediated immunomodulation through PGE2-dependent reprogramming of host macrophages to promote their PD-L1 expression. Our study suggests that UC-MSCs or primed-UC-MSCs offer new therapeutic approaches for lung inflammatory diseases. METHODS Lipopolysaccharide (LPS)-induced ALI mice were injected with 5×105 UC-MSCs via the tail vein after 4 hours of LPS exposure. After 24 hours of UC-MSC administration, the total protein concentration and cell number in the bronchoalveolar lavage fluid (BALF), and cytokine levels in the lung tissue were measured. Lung pathological changes and macrophage infiltration after UC-MSC treatment were analyzed. Moreover, in vitro co-culture experiments were performed to analyze cytokine levels of RAW264.7 cells and Jurkat T cells. RESULTS UC-MSC treatment significantly improved LPS-induced ALI, as indicated by decreased total protein exudation concentration and cell number in BALF, and reduced pathological damage in ALI mice. UC-MSCs could inhibit pro-inflammatory cytokine levels (IL-1β, TNF-α, MCP-1, IL-2, and IFN-γ), whereas enhancing anti-inflammatory cytokine IL-10 expression, as well as reduced macrophage infiltration into the injured lung tissue. Importantly, UC-MSC administration increased programmed cell death protein ligand 1 (PD-L1) expression in the lung macrophages. Mechanistically, UC-MSCs upregulated cyclooxygenase-2 (COX2) expression and prostaglandin E2 (PGE2) secretion in response to LPS stimulation. UC-MSCs reduced the inflammatory cytokine levels in murine macrophage Raw264.7 through the COX2/PGE2 axis. Furthermore, UC-MSC-derived PGE2 enhanced PD-L1 expression in RAW264.7 cells, which in turn promoted programmed cell death protein 1 (PD-1) expression and reduced IL-2 and IFN-γ production in Jurkat T cells. CONCLUSION Our results suggest that UC-MSCs attenuate ALI via PGE2-dependent reprogramming of macrophages to promote their PD-L1 expression.
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Affiliation(s)
- Chengshu Tu
- Department of Pathophysiology, Tongji Medical College, Huazhong Science and Technology University, Wuhan, China
| | | | - E Xiang
- Wuhan Hamilton Biotechnology-Co., Ltd, Wuhan, China
- Department of Biochemistry and Molecular Biology, Wuhan University School of Basic Medical Sciences, Wuhan, China
| | - Quan Zhang
- Wuhan Hamilton Biotechnology-Co., Ltd, Wuhan, China
| | - Yaqi Zhang
- Wuhan Hamilton Biotechnology-Co., Ltd, Wuhan, China
- Department of Biochemistry and Molecular Biology, Wuhan University School of Basic Medical Sciences, Wuhan, China
| | - Ping Wu
- Department of Pathophysiology, Tongji Medical College, Huazhong Science and Technology University, Wuhan, China
| | - Changyong Li
- Department of Physiology, Wuhan University School of Basic Medical Sciences, Wuhan, China
| | - Dongcheng Wu
- Wuhan Hamilton Biotechnology-Co., Ltd, Wuhan, China
- Department of Biochemistry and Molecular Biology, Wuhan University School of Basic Medical Sciences, Wuhan, China
- Guangzhou Hamilton Biotechnology-Co., Ltd, Guangzhou, China
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67
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Flinspach AN, Booke H, Zacharowski K, Balaban Ü, Herrmann E, Adam EH. Associated Factors of High Sedative Requirements within Patients with Moderate to Severe COVID-19 ARDS. J Clin Med 2022; 11:588. [PMID: 35160040 PMCID: PMC8837042 DOI: 10.3390/jcm11030588] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/16/2022] [Accepted: 01/19/2022] [Indexed: 02/04/2023] Open
Abstract
The coronavirus pandemic continues to challenge global healthcare. Severely affected patients are often in need of high doses of analgesics and sedatives. The latter was studied in critically ill coronavirus disease 2019 (COVID-19) patients in this prospective monocentric analysis. COVID-19 acute respiratory distress syndrome (ARDS) patients admitted between 1 April and 1 December 2020 were enrolled in the study. A statistical analysis of impeded sedation using mixed-effect linear regression models was performed. Overall, 114 patients were enrolled, requiring unusual high levels of sedatives. During 67.9% of the observation period, a combination of sedatives was required in addition to continuous analgesia. During ARDS therapy, 85.1% (n = 97) underwent prone positioning. Veno-venous extracorporeal membrane oxygenation (vv-ECMO) was required in 20.2% (n = 23) of all patients. vv-ECMO patients showed significantly higher sedation needs (p < 0.001). Patients with hepatic (p = 0.01) or renal (p = 0.01) dysfunction showed significantly lower sedation requirements. Except for patient age (p = 0.01), we could not find any significant influence of pre-existing conditions. Age, vv-ECMO therapy and additional organ failure could be demonstrated as factors influencing sedation needs. Young patients and those receiving vv-ECMO usually require increased sedation for intensive care therapy. However, further studies are needed to elucidate the causes and mechanisms of impeded sedation.
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Affiliation(s)
- Armin N. Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe-University Frankfurt, 60590 Frankfurt/Main, Germany; (H.B.); (K.Z.); (E.H.A.)
| | - Hendrik Booke
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe-University Frankfurt, 60590 Frankfurt/Main, Germany; (H.B.); (K.Z.); (E.H.A.)
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe-University Frankfurt, 60590 Frankfurt/Main, Germany; (H.B.); (K.Z.); (E.H.A.)
| | - Ümniye Balaban
- Department of Biostatistics and Mathematical Modelling, Goethe-University Frankfurt, 60590 Frankfurt/Main, Germany; (Ü.B.); (E.H.)
| | - Eva Herrmann
- Department of Biostatistics and Mathematical Modelling, Goethe-University Frankfurt, 60590 Frankfurt/Main, Germany; (Ü.B.); (E.H.)
| | - Elisabeth H. Adam
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe-University Frankfurt, 60590 Frankfurt/Main, Germany; (H.B.); (K.Z.); (E.H.A.)
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Zanella A, Pesenti A, Busana M, De Falco S, Di Girolamo L, Scotti E, Protti I, Colombo SM, Scaravilli V, Biancolilli O, Carlin A, Gori F, Battistin M, Dondossola D, Pirrone F, Salerno D, Gatti S, Grasselli G. A Minimally Invasive and Highly Effective Extracorporeal CO2 Removal Device Combined With a Continuous Renal Replacement Therapy. Crit Care Med 2022; 50:e468-e476. [PMID: 35044966 DOI: 10.1097/ccm.0000000000005428] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Extracorporeal carbon dioxide removal is used to treat patients suffering from acute respiratory failure. However, the procedure is hampered by the high blood flow required to achieve a significant CO2 clearance. We aimed to develop an ultralow blood flow device to effectively remove CO2 combined with continuous renal replacement therapy (CRRT). DESIGN Preclinical, proof-of-concept study. SETTING An extracorporeal circuit where 200 mL/min of blood flowed through a hemofilter connected to a closed-loop dialysate circuit. An ion-exchange resin acidified the dialysate upstream, a membrane lung to increase Pco2 and promote CO2 removal. PATIENTS Six, 38.7 ± 2.0-kg female pigs. INTERVENTIONS Different levels of acidification were tested (from 0 to 5 mEq/min). Two l/hr of postdilution CRRT were performed continuously. The respiratory rate was modified at each step to maintain arterial Pco2 at 50 mm Hg. MEASUREMENTS AND MAIN RESULTS Increasing acidification enhanced CO2 removal efficiency of the membrane lung from 30 ± 5 (0 mEq/min) up to 145 ± 8 mL/min (5 mEq/min), with a 483% increase, representing the 73% ± 7% of the total body CO2 production. Minute ventilation decreased accordingly from 6.5 ± 0.7 to 1.7 ± 0.5 L/min. No major side effects occurred, except for transient tachycardia episodes. As expected from the alveolar gas equation, the natural lung Pao2 dropped at increasing acidification steps, given the high dissociation between the oxygenation and CO2 removal capability of the device, thus Pao2 decreased. CONCLUSIONS This new extracorporeal ion-exchange resin-based multiple-organ support device proved extremely high efficiency in CO2 removal and continuous renal support in a preclinical setting. Further studies are required before clinical implementation.
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69
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Itagaki T. Diaphragm-protective mechanical ventilation in acute respiratory failure. THE JOURNAL OF MEDICAL INVESTIGATION 2022; 69:165-172. [DOI: 10.2152/jmi.69.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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Bongiovanni F, Grieco DL, Anzellotti GM, Menga LS, Michi T, Cesarano M, Raggi V, De Bartolomeo C, Mura B, Mercurio G, D'Arrigo S, Bello G, Maviglia R, Pennisi MA, Antonelli M. Gas conditioning during helmet noninvasive ventilation: effect on comfort, gas exchange, inspiratory effort, transpulmonary pressure and patient-ventilator interaction. Ann Intensive Care 2021; 11:184. [PMID: 34952962 PMCID: PMC8708509 DOI: 10.1186/s13613-021-00972-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/12/2021] [Indexed: 01/21/2023] Open
Abstract
Background There is growing interest towards the use of helmet noninvasive ventilation (NIV) for the management of acute hypoxemic respiratory failure. Gas conditioning through heat and moisture exchangers (HME) or heated humidifiers (HHs) is needed during facemask NIV to provide a minimum level of humidity in the inspired gas (15 mg H2O/L). The optimal gas conditioning strategy during helmet NIV remains to be established. Methods Twenty patients with acute hypoxemic respiratory failure (PaO2/FiO2 < 300 mmHg) underwent consecutive 1-h periods of helmet NIV (PEEP 12 cmH2O, pressure support 12 cmH2O) with four humidification settings, applied in a random order: double-tube circuit with HHs and temperature set at 34 °C (HH34) and 37 °C (HH37); Y-piece circuit with HME; double-tube circuit with no humidification (NoH). Temperature and humidity of inhaled gas were measured through a capacitive hygrometer. Arterial blood gases, discomfort and dyspnea through visual analog scales (VAS), esophageal pressure swings (ΔPES) and simplified pressure–time product (PTPES), dynamic transpulmonary driving pressure (ΔPL) and asynchrony index were measured in each step. Results Median [IqR] absolute humidity, temperature and VAS discomfort were significantly lower during NoH vs. HME, HH34 and HH37: absolute humidity (mgH2O/L) 16 [12–19] vs. 28 [23–31] vs. 28 [24–31] vs. 33 [29–38], p < 0.001; temperature (°C) 29 [28–30] vs. 30 [29–31] vs. 31 [29–32] vs 32. [31–33], p < 0.001; VAS discomfort 4 [2–6] vs. 6 [2–7] vs. 7 [4–8] vs. 8 [4–10], p = 0.03. VAS discomfort increased with higher absolute humidity (p < 0.01) and temperature (p = 0.007). Higher VAS discomfort was associated with increased VAS dyspnea (p = 0.001). Arterial blood gases, respiratory rate, ΔPES, PTPES and ΔPL were similar in all conditions. Overall asynchrony index was similar in all steps, but autotriggering rate was lower during NoH and HME (p = 0.03). Conclusions During 1-h sessions of helmet NIV in patients with hypoxemic respiratory failure, a double-tube circuit with no humidification allowed adequate conditioning of inspired gas, optimized comfort and improved patient–ventilator interaction. Use of HHs or HME in this setting resulted in increased discomfort due to excessive heat and humidity in the interface, which was associated with more intense dyspnea. Trail Registration Registered on clinicaltrials.gov (NCT02875379) on August 23rd, 2016.
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Affiliation(s)
- Filippo Bongiovanni
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy. .,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy.
| | - Gian Marco Anzellotti
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Luca Salvatore Menga
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Teresa Michi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Melania Cesarano
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Valeria Raggi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Cecilia De Bartolomeo
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Benedetta Mura
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Giovanna Mercurio
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Sonia D'Arrigo
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Giuseppe Bello
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Riccardo Maviglia
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Mariano Alberto Pennisi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy.,Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, L.Go F. Vito, 00168, Rome, Italy
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71
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Takeshita Y, Terada J, Hirasawa Y, Kinoshita T, Tajima H, Koshikawa K, Kinouchi T, Isaka Y, Shionoya Y, Tada Y, Tsushima K. High-flow nasal cannula oxygen therapy in hypoxic patients with COVID-19 pneumonia: A retrospective cohort study confirming the utility of respiratory rate index. Respir Investig 2021; 60:146-153. [PMID: 34772644 PMCID: PMC8556581 DOI: 10.1016/j.resinv.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 09/30/2021] [Accepted: 10/10/2021] [Indexed: 12/13/2022]
Abstract
Background Although high-flow nasal cannula (HFNC) oxygen treatment has been frequently used in coronavirus disease 2019 (COVID-19) patients with acute respiratory failure after the 3rd wave of the pandemic in Japan, the usefulness of the indicators of ventilator avoidance, including respiratory rate-oxygenation (ROX) index and other parameters, namely oxygen saturation/fraction of inspired oxygen ratio and respiratory rate (RR), remain unclear. Methods Between January and May 2021, our institution treated 189 COVID-19 patients with respiratory failure requiring oxygen, among which 39 patients requiring HFNC treatment were retrospectively analyzed. The group that switched from HFNC treatment to conventional oxygen therapy (COT) was defined as the HFNC success group, and the group that switched from HFNC treatment to a ventilator was defined as the HFNC failure group. We followed the patients’ oxygenation parameters for a maximum of 30 days. Results HFNC treatment success occurred in 24 of 39 patients (62%) treated with HFNC therapy. Compared with the HFNC failure group, the HFNC success group had a significantly higher degree of RR improvement in the univariate analysis. Logistic regression analysis of HFNC treatment success adjusting for age, respiratory improvement, and a ROX index ≥5.55 demonstrated that an improved RR was associated with HFNC treatment success. The total COT duration was significantly shorter in the HFNC success group than in the HFNC failure group. Conclusions HFNC treatment can be useful for ventilator avoidance and allow the quick withdrawal of oxygen administration. RR improvement may be a convenient, useful, and simple indicator of HFNC treatment success.
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Affiliation(s)
- Yuichiro Takeshita
- Department of Pulmonary Medicine, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita, Chiba 286-8520, Japan
| | - Jiro Terada
- Department of Pulmonary Medicine, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita, Chiba 286-8520, Japan; Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan.
| | - Yasutaka Hirasawa
- Department of Pulmonary Medicine, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita, Chiba 286-8520, Japan
| | - Taku Kinoshita
- Department of Pulmonary Medicine, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita, Chiba 286-8520, Japan
| | - Hiroshi Tajima
- Department of Pulmonary Medicine, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita, Chiba 286-8520, Japan
| | - Ken Koshikawa
- Department of Pulmonary Medicine, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita, Chiba 286-8520, Japan; Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Toru Kinouchi
- Department of Pulmonary Medicine, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita, Chiba 286-8520, Japan; Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Yuri Isaka
- Department of Pulmonary Medicine, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita, Chiba 286-8520, Japan; Department of Respirology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Yu Shionoya
- Department of Pulmonary Medicine, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita, Chiba 286-8520, Japan
| | - Yuji Tada
- Department of Pulmonary Medicine, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita, Chiba 286-8520, Japan
| | - Kenji Tsushima
- Department of Pulmonary Medicine, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita, Chiba 286-8520, Japan
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72
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COVID-19 ARDS: Points to Be Considered in Mechanical Ventilation and Weaning. J Pers Med 2021; 11:jpm11111109. [PMID: 34834461 PMCID: PMC8618434 DOI: 10.3390/jpm11111109] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 12/21/2022] Open
Abstract
The COVID-19 disease can cause hypoxemic respiratory failure due to ARDS, requiring invasive mechanical ventilation. Although early studies reported that COVID-19-associated ARDS has distinctive features from ARDS of other causes, recent observational studies have demonstrated that ARDS related to COVID-19 shares common clinical characteristics and respiratory system mechanics with ARDS of other origins. Therefore, mechanical ventilation in these patients should be based on strategies aiming to mitigate ventilator-induced lung injury. Assisted mechanical ventilation should be applied early in the course of mechanical ventilation by considering evaluation and minimizing factors associated with patient-inflicted lung injury. Extracorporeal membrane oxygenation should be considered in selected patients with refractory hypoxia not responding to conventional ventilation strategies. This review highlights the current and evolving practice in managing mechanically ventilated patients with ARDS related to COVID-19.
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73
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Chiu LC, Kao KC. Mechanical Ventilation during Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome: A Narrative Review. J Clin Med 2021; 10:4953. [PMID: 34768478 PMCID: PMC8584351 DOI: 10.3390/jcm10214953] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/15/2021] [Accepted: 10/25/2021] [Indexed: 12/12/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threatening condition involving acute hypoxemic respiratory failure. Mechanical ventilation remains the cornerstone of management for ARDS; however, potentially injurious mechanical forces introduce the risk of ventilator-induced lung injury, multiple organ failure, and death. Extracorporeal membrane oxygenation (ECMO) is a salvage therapy aimed at ensuring adequate gas exchange for patients suffering from severe ARDS with profound hypoxemia where conventional mechanical ventilation has failed. ECMO allows for lower tidal volumes and airway pressures, which can reduce the risk of further lung injury, and allow the lungs to rest. However, the collateral effect of ECMO should be considered. Recent studies have reported correlations between mechanical ventilator settings during ECMO and mortality. In many cases, mechanical ventilation settings should be tailored to the individual; however, researchers have yet to establish optimal ventilator settings or determine the degree to which ventilation load can be decreased. This paper presents an overview of previous studies and clinical trials pertaining to the management of mechanical ventilation during ECMO for patients with severe ARDS, with a focus on clinical findings, suggestions, protocols, guidelines, and expert opinions. We also identified a number of issues that have yet to be adequately addressed.
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Affiliation(s)
- Li-Chung Chiu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan;
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Kuo-Chin Kao
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan;
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan 33302, Taiwan
- Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 33305, Taiwan
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Ziaka M, Exadaktylos A. Brain-lung interactions and mechanical ventilation in patients with isolated brain injury. Crit Care 2021; 25:358. [PMID: 34645485 PMCID: PMC8512596 DOI: 10.1186/s13054-021-03778-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/30/2021] [Indexed: 11/29/2022] Open
Abstract
During the last decade, experimental and clinical studies have demonstrated that isolated acute brain injury (ABI) may cause severe dysfunction of peripheral extracranial organs and systems. Of all potential target organs and systems, the lung appears to be the most vulnerable to damage after brain injury (BI). The pathophysiology of these brain–lung interactions are complex and involve neurogenic pulmonary oedema, inflammation, neurodegeneration, neurotransmitters, immune suppression and dysfunction of the autonomic system. The systemic effects of inflammatory mediators in patients with BI create a systemic inflammatory environment that makes extracranial organs vulnerable to secondary procedures that enhance inflammation, such as mechanical ventilation (MV), surgery and infections. Indeed, previous studies have shown that in the presence of a systemic inflammatory environment, specific neurointensive care interventions—such as MV—may significantly contribute to the development of lung injury, regardless of the underlying mechanisms. Although current knowledge supports protective ventilation in patients with BI, it must be born in mind that ABI-related lung injury has distinct mechanisms that involve complex interactions between the brain and lungs. In this context, the role of extracerebral pathophysiology, especially in the lungs, has often been overlooked, as most physicians focus on intracranial injury and cerebral dysfunction. The present review aims to fill this gap by describing the pathophysiology of complications due to lung injuries in patients with a single ABI, and discusses the possible impact of MV in neurocritical care patients with normal lungs.
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Affiliation(s)
- Mairi Ziaka
- Department of Internal Medicine, Thun General Hospital, Thun, Switzerland.
| | - Aristomenis Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital, University of Bern, Bern, Switzerland
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Agrawal DK, Smith BJ, Sottile PD, Albers DJ. A Damaged-Informed Lung Ventilator Model for Ventilator Waveforms. Front Physiol 2021; 12:724046. [PMID: 34658911 PMCID: PMC8517122 DOI: 10.3389/fphys.2021.724046] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 09/01/2021] [Indexed: 12/31/2022] Open
Abstract
Motivated by a desire to understand pulmonary physiology, scientists have developed physiological lung models of varying complexity. However, pathophysiology and interactions between human lungs and ventilators, e.g., ventilator-induced lung injury (VILI), present challenges for modeling efforts. This is because the real-world pressure and volume signals may be too complex for simple models to capture, and while complex models tend not to be estimable with clinical data, limiting clinical utility. To address this gap, in this manuscript we developed a new damaged-informed lung ventilator (DILV) model. This approach relies on mathematizing ventilator pressure and volume waveforms, including lung physiology, mechanical ventilation, and their interaction. The model begins with nominal waveforms and adds limited, clinically relevant, hypothesis-driven features to the waveform corresponding to pulmonary pathophysiology, patient-ventilator interaction, and ventilator settings. The DILV model parameters uniquely and reliably recapitulate these features while having enough flexibility to reproduce commonly observed variability in clinical (human) and laboratory (mouse) waveform data. We evaluate the proof-in-principle capabilities of our modeling approach by estimating 399 breaths collected for differently damaged lungs for tightly controlled measurements in mice and uncontrolled human intensive care unit data in the absence and presence of ventilator dyssynchrony. The cumulative value of mean squares error for the DILV model is, on average, ≈12 times less than the single compartment lung model for all the waveforms considered. Moreover, changes in the estimated parameters correctly correlate with known measures of lung physiology, including lung compliance as a baseline evaluation. Our long-term goal is to use the DILV model for clinical monitoring and research studies by providing high fidelity estimates of lung state and sources of VILI with an end goal of improving management of VILI and acute respiratory distress syndrome.
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Affiliation(s)
- Deepak K. Agrawal
- Department of Bioengineering, University of Colorado Denver|Anschutz Medical Campus, Aurora, CO, United States
- Section of Informatics and Data Science, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Bradford J. Smith
- Department of Bioengineering, University of Colorado Denver|Anschutz Medical Campus, Aurora, CO, United States
- Section of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
| | - Peter D. Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, United States
| | - David J. Albers
- Department of Bioengineering, University of Colorado Denver|Anschutz Medical Campus, Aurora, CO, United States
- Section of Informatics and Data Science, Department of Pediatrics, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
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Abstract
The pathophysiology of acute respiratory distress syndrome (ARDS) is marked by inflammation-mediated disruptions in alveolar-capillary permeability, edema formation, reduced alveolar clearance and collapse/derecruitment, reduced compliance, increased pulmonary vascular resistance, and resulting gas exchange abnormalities due to shunting and ventilation-perfusion mismatch. Mechanical ventilation, especially in the setting of regional disease heterogeneity, can propagate ventilator-associated injury patterns including barotrauma/volutrauma and atelectrauma. Lung injury due to the novel coronavirus SARS-CoV-2 resembles other causes of ARDS, though its initial clinical characteristics may include more profound hypoxemia and loss of dyspnea perception with less radiologically-evident lung injury, a pattern not described previously in ARDS.
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Affiliation(s)
- Kai Erik Swenson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, 55 Fruit Street, BUL 148, Boston, MA 02114, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
| | - Erik Richard Swenson
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA; Medical Service, Veterans Affairs Puget Sound Health Care System, 1660 South Columbian Way, Campus Box 358280 (S-111 Pulm), Seattle, WA 98108, USA
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De Oliveira B, Aljaberi N, Taha A, Abduljawad B, Hamed F, Rahman N, Mallat J. Patient-Ventilator Dyssynchrony in Critically Ill Patients. J Clin Med 2021; 10:jcm10194550. [PMID: 34640566 PMCID: PMC8509510 DOI: 10.3390/jcm10194550] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/20/2021] [Accepted: 09/27/2021] [Indexed: 11/16/2022] Open
Abstract
Patient–ventilator dyssynchrony is a mismatch between the patient’s respiratory efforts and mechanical ventilator delivery. Dyssynchrony can occur at any phase throughout the respiratory cycle. There are different types of dyssynchrony with different mechanisms and different potential management: trigger dyssynchrony (ineffective efforts, autotriggering, and double triggering); flow dyssynchrony, which happens during the inspiratory phase; and cycling dyssynchrony (premature cycling and delayed cycling). Dyssynchrony has been associated with patient outcomes. Thus, it is important to recognize and address these dyssynchronies at the bedside. Patient–ventilator dyssynchrony can be detected by carefully scrutinizing the airway pressure–time and flow–time waveforms displayed on the ventilator screens along with assessing the patient’s comfort. Clinicians need to know how to depict these dyssynchronies at the bedside. This review aims to define the different types of dyssynchrony and then discuss the evidence for their relationship with patient outcomes and address their potential management.
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Affiliation(s)
- Bruno De Oliveira
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Nahla Aljaberi
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Ahmed Taha
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Baraa Abduljawad
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Fadi Hamed
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Nadeem Rahman
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
| | - Jihad Mallat
- Critical Care Institute, Cleveland Clinic Abu Dhabi, Al Maryah Island, Abu Dhabi P.O. Box 112412, United Arab Emirates; (B.D.O.); (N.A.); (A.T.); (B.A.); (F.H.); (N.R.)
- Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH 44195, USA
- Faculty of Medicine, Normandy University, UNICAEN, ED 497, 1400 Caen, France
- Department of Anesthesiology and Critical Care Medicine, Centre Hospitalier de Lens, 62300 Lens, France
- Correspondence:
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Cronin JN, Camporota L, Formenti F. Mechanical ventilation in COVID-19: A physiological perspective. Exp Physiol 2021; 107:683-693. [PMID: 34541721 PMCID: PMC8667647 DOI: 10.1113/ep089400] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/24/2021] [Indexed: 12/13/2022]
Abstract
New Findings What is the topic of this review? This review presents the fundamental concepts of respiratory physiology and pathophysiology, with particular reference to lung mechanics and the pulmonary phenotype associated with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection and subsequent coronavirus disease 2019 (COVID‐19) pneumonia. What advances does it highlight? The review provides a critical summary of the main physiological aspects to be considered for safe and effective mechanical ventilation in patients with severe COVID‐19 in the intensive care unit.
Abstract Severe respiratory failure from coronavirus disease 2019 (COVID‐19) pneumonia not responding to non‐invasive respiratory support requires mechanical ventilation. Although ventilation can be a life‐saving therapy, it can cause further lung injury if airway pressure and flow and their timing are not tailored to the respiratory system mechanics of the individual patient. The pathophysiology of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection can lead to a pattern of lung injury in patients with severe COVID‐19 pneumonia typically associated with two distinct phenotypes, along a temporal and pathophysiological continuum, characterized by different levels of elastance, ventilation‐to‐perfusion ratio, right‐to‐left shunt, lung weight and recruitability. Understanding the underlying pathophysiology, duration of symptoms, radiological characteristics and lung mechanics at the individual patient level is crucial for the appropriate choice of mechanical ventilation settings to optimize gas exchange and prevent further lung injury. By critical analysis of the literature, we propose fundamental physiological and mechanical criteria for the selection of ventilation settings for COVID‐19 patients in intensive care units. In particular, the choice of tidal volume should be based on obtaining a driving pressure < 14 cmH2O, ensuring the avoidance of hypoventilation in patients with preserved compliance and of excessive strain in patients with smaller lung volumes and lower lung compliance. The level of positive end‐expiratory pressure (PEEP) should be informed by the measurement of the potential for lung recruitability, where patients with greater recruitability potential may benefit from higher PEEP levels. Prone positioning is often beneficial and should be considered early. The rationale for the proposed mechanical ventilation settings criteria is presented and discussed.
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Affiliation(s)
- John N Cronin
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK.,Department of Anaesthetics, Royal Brompton and Harefield, part of Guy's and St. Thomas' NHS Foundation Trust, London, UK
| | - Luigi Camporota
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK.,Intensive Care Unit, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Federico Formenti
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK.,Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK.,Department of Biomechanics, University of Nebraska Omaha, Omaha, Nebraska, USA
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Effect of Dihydropyridine Calcium Channel Blocker on Mortality of Hypertension Patients With Moderate-Severe Pulmonary Acute Respiratory Distress Syndrome: A Multicenter Retrospective Observational Cohort Study. Crit Care Explor 2021; 3:e0506. [PMID: 34514419 PMCID: PMC8425825 DOI: 10.1097/cce.0000000000000506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim was to evaluate the effect of dihydropyridine calcium channel blocker on the prognosis for moderate-severe pulmonary acute respiratory distress syndrome in hypertension patients. DESIGN A retrospective, observational, multicenter cohort study. SETTING A total of 307 patients without propensity score matching and 186 adult inpatients with propensity score matching diagnosed with hypertension and moderate-severe pulmonary acute respiratory distress syndrome in five teaching hospitals in Jiangsu province, China, from December 2015 to December 2020 were enrolled. PATIENTS A total of 307 patients without propensity score matching and 186 patients with propensity score matching diagnosed with hypertension and moderate-severe pulmonary acute respiratory distress syndrome were included in the final analysis. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic characteristics and clinical characteristics were recorded. The propensity score matching method was used to eliminate the difference between group with dihydropyridine calcium channel blocker and group without dihydropyridine calcium channel blocker. The primary outcome was in-hospital mortality. We used univariate and multivariate regression analyses for both patients with or without propensity score matching to assess the effect of these variables on mortality. In the subset of 186 patients with propensity score matching, in-hospital mortality was 53.2%. Inpatient mortality was significantly higher in patients treated with dihydropyridine calcium channel blocker than in those not treated with dihydropyridine calcium channel blocker of patients without propensity score matching (65.4% vs 40.4%; p < 0.01). Multivariate analysis for patients without propensity score matching showed that dihydropyridine calcium channel blocker (hazard ratio, 1.954; 95% CI, 1.415-2.699), lactate dehydrogenase greater than or equal to 600 U/L (hazard ratio, 3.809; 95% CI, 2.106-4.531), and lactate greater than or equal to 2 mmol/L (hazard ratio, 1.454; 95% CI, 1.041-2.029) were independently associated with in-hospital mortality. Based on univariate analysis for patients with propensity score matching, dihydropyridine calcium channel blocker (hazard ratio, 2.021; 95% CI, 1.333-3.064), lactate dehydrogenase greater than or equal to 600 U/L (hazard ratio, 4.379; 95% CI, 2.642-7.257), and lactate greater than or equal to 2 mmol/L (hazard ratio, 2.461; 95% CI, 1.534-3.951) were independently associated with in-hospital mortality. In contrast, patients not treated with dihydropyridine calcium channel blocker had a significant survival advantage over those treated with dihydropyridine calcium channel blocker in both patients without or with propensity score matching (p < 0.001; p = 0.001 by Kaplan-Meier analysis). CONCLUSIONS Dihydropyridine calcium channel blocker, lactate dehydrogenase greater than or equal to 600 U/L, and lactate greater than or equal to 2 mmol/L at admission were independent risk factors for patients with hypertension and moderate-severe pulmonary acute respiratory distress syndrome.
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81
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Biasucci DG, Buonsenso D, Piano A, Bonadia N, Vargas J, Settanni D, Bocci MG, Grieco DL, Carnicelli A, Scoppettuolo G, Eleuteri D, DE Pascale G, Pennisi MA, Franceschi F, Antonelli M. Lung ultrasound predicts non-invasive ventilation outcome in COVID-19 acute respiratory failure: a pilot study. Minerva Anestesiol 2021; 87:1006-1016. [PMID: 34263580 DOI: 10.23736/s0375-9393.21.15188-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The aim of this study is to determine relationships between lung aeration assessed by lung ultrasound (LUS) with non-invasive ventilation (NIMV) outcome, intensive care unit (ICU) admission and mechanical ventilation (MV) needs in COVID-19 respiratory failure. METHODS A cohort of adult patients with COVID-19 respiratory failure underwent LUS during initial assessment. A simplified LUS protocol consisting in scanning six areas, three for each side, was adopted. A score from 0 to 3 was assigned to each area. Comprehensive LUS score (LUSsc) was calculated as the sum of the score in all areas. LUSsc, the amount of involved sonographic lung areas (LUSq), the number of lung quadrants radiographically infiltrated and the degree of oxygenation impairment at admission (SpO<inf>2</inf>/FiO2 ratio) were compared to NIMV Outcome, MV needs and ICU admission. RESULTS Among 85 patients prospectively included in the analysis, 49 of 61 needed MV. LUSsc and LUSq were higher in patients who required MV (median 12 [IQR 8-14] and median 6 [IQR 4-6], respectively) than in those who did not (6 [IQR 2-9] and 3 [IQR 1-5], respectively), both P<0.001. NIMV trial failed in 26 patients out 36. LUSsc and LUSq were significantly higher in patients who failed NIMV than in those who did not. From ROC analysis, LUSsc ≥12 and LUSq ≥5 gave the best cut-off values for NIMV failure prediction (AUC=0.95, 95%CI 0.83-0.99 and AUC=0.81, 95% CI 0.65-0.91, respectively). CONCLUSIONS Our data suggest LUS as a possible tool for identifying patients who are likely to require MV and ICU admission or to fail a NIMV trial.
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Affiliation(s)
- Daniele G Biasucci
- Intensive Care Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy -
| | - Danilo Buonsenso
- Department of Woman and Child Health and Public Health, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Alfonso Piano
- Emergency Room, "A. Gemelli" University Hospital Foundation IRCCS, Rome, Italy
| | - Nicola Bonadia
- Emergency Medicine, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Joel Vargas
- Intensive Care Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Donatella Settanni
- Intensive Care Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Maria G Bocci
- Intensive Care Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Domenico L Grieco
- Intensive Care Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Annamaria Carnicelli
- Emergency Medicine, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Giancarlo Scoppettuolo
- Infectious Diseases Unit, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Davide Eleuteri
- Intensive Care Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Gennaro DE Pascale
- Intensive Care Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Mariano A Pennisi
- Shock and Trauma Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Francesco Franceschi
- Emergency Medicine, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Massimo Antonelli
- Intensive Care Unit, Department of Emergency, Anesthesiology and Intensive Care Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
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Abstract
Acute respiratory distress syndrome (ARDS) is one of the most common severe diseases seen in the clinical setting. With the continuous exploration of ARDS in recent decades, the understanding of ARDS has improved. ARDS is not a simple lung disease but a clinical syndrome with various etiologies and pathophysiological changes. However, in the intensive care unit, ARDS often occurs a few days after primary lung injury or after a few days of treatment for other severe extrapulmonary diseases. Under such conditions, ARDS often progresses rapidly to severe ARDS and is difficult to treat. The occurrence and development of ARDS in these circumstances are thus not related to primary lung injury; the real cause of ARDS may be the “second hit” caused by inappropriate treatment. In view of the limited effective treatments for ARDS, the strategic focus has shifted to identifying potential or high-risk ARDS patients during the early stages of the disease and implementing treatment strategies aimed at reducing ARDS and related organ failure. Future research should focus on the prevention of ARDS.
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Abstract
Acute respiratory distress syndrome (ARDS) is an acute respiratory illness characterised by bilateral chest radiographical opacities with severe hypoxaemia due to non-cardiogenic pulmonary oedema. The COVID-19 pandemic has caused an increase in ARDS and highlighted challenges associated with this syndrome, including its unacceptably high mortality and the lack of effective pharmacotherapy. In this Seminar, we summarise current knowledge regarding ARDS epidemiology and risk factors, differential diagnosis, and evidence-based clinical management of both mechanical ventilation and supportive care, and discuss areas of controversy and ongoing research. Although the Seminar focuses on ARDS due to any cause, we also consider commonalities and distinctions of COVID-19-associated ARDS compared with ARDS from other causes.
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Affiliation(s)
- Nuala J Meyer
- Pulmonary, Allergy and Critical Care Division, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
| | - Luciano Gattinoni
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA, USA
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Waters J, Spiegel R, Hockstein M. Helmets Save Lives, or At Least Ventilator-Free Days: August 2021 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2021; 78:310-312. [PMID: 34325865 PMCID: PMC8313428 DOI: 10.1016/j.annemergmed.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Jessica Waters
- Department of Emergency Medicine, MedStar Washington Hospital Center
| | - Rory Spiegel
- Department of Emergency Medicine, MedStar Washington Hospital Center
| | - Max Hockstein
- Department of Emergency Medicine, MedStar Washington Hospital Center
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Alladina J, Levy SD, Cho JL, Brait KL, Rao SR, Camacho A, Hibbert KA, Harris RS, Medoff BD, Januzzi JL, Thompson BT, Bajwa EK. Plasma Soluble Suppression of Tumorigenicity-2 Associates with Ventilator Liberation in Acute Hypoxemic Respiratory Failure. Am J Respir Crit Care Med 2021; 203:1257-1265. [PMID: 33400890 DOI: 10.1164/rccm.202005-1951oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Rationale: Standard physiologic assessments of extubation readiness in patients with acute hypoxemic respiratory failure (AHRF) may not reflect lung injury resolution and could adversely affect clinical decision-making and patient outcomes. Objectives: We hypothesized that elevations in inflammatory plasma biomarkers sST2 (soluble suppression of tumorigenicity-2) and IL-6 indicate ongoing lung injury in AHRF and better inform patient outcomes compared with standard clinical assessments. Methods: We measured daily plasma biomarkers and physiologic variables in 200 patients with AHRF for up to 9 days after intubation. We tested the associations of baseline values with the primary outcome of unassisted breathing at Day 29. We analyzed the ability of serial biomarker measurements to inform successful ventilator liberation. Measurements and Main Results: Baseline sST2 concentrations were higher in patients dead or mechanically ventilated versus breathing unassisted at Day 29 (491.7 ng/ml [interquartile range (IQR), 294.5-670.1 ng/ml] vs. 314.4 ng/ml [IQR, 127.5-550.1 ng/ml]; P = 0.0003). Higher sST2 concentrations over time were associated with a decreased probability of ventilator liberation (hazard ratio, 0.80 per log-unit increase; 95% confidence interval [CI], 0.75-0.83; P = 0.03). Patients with higher sST2 concentrations on the day of liberation were more likely to fail liberation compared with patients who remained successfully liberated (320.9 ng/ml [IQR, 181.1- 495.6 ng/ml] vs. 161.6 ng/ml [IQR, 95.8-292.5 ng/ml]; P = 0.002). Elevated sST2 concentrations on the day of liberation decreased the odds of successful liberation when adjusted for standard physiologic parameters (odds ratio, 0.325; 95% CI, 0.119-0.885; P = 0.03). IL-6 concentrations did not associate with outcomes. Conclusions: Using sST2 concentrations to guide ventilator management may more accurately reflect underlying lung injury and outperform traditional measures of readiness for ventilator liberation.
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Affiliation(s)
| | - Sean D Levy
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Josalyn L Cho
- Division of Pulmonary, Critical Care, and Occupational Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | - Sowmya R Rao
- Boston University School of Public Health, Boston, Massachusetts; and
| | - Alexander Camacho
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | | | - R Scott Harris
- Division of Pulmonary and Critical Care Medicine and.,Vertex Pharmaceuticals, Boston, Massachusetts
| | | | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Ednan K Bajwa
- Division of Pulmonary and Critical Care Medicine and
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Flinspach AN, Booke H, Zacharowski K, Balaban Ü, Herrmann E, Adam EH. High sedation needs of critically ill COVID-19 ARDS patients-A monocentric observational study. PLoS One 2021; 16:e0253778. [PMID: 34314422 PMCID: PMC8315516 DOI: 10.1371/journal.pone.0253778] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Accepted: 06/13/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Therapy of severely affected coronavirus patient, requiring intubation and sedation is still challenging. Recently, difficulties in sedating these patients have been discussed. This study aims to describe sedation practices in patients with 2019 coronavirus disease (COVID-19)-induced acute respiratory distress syndrome (ARDS). METHODS We performed a retrospective monocentric analysis of sedation regimens in critically ill intubated patients with respiratory failure who required sedation in our mixed 32-bed university intensive care unit. All mechanically ventilated adults with COVID-19-induced ARDS requiring continuously infused sedative therapy admitted between April 4, 2020, and June 30, 2020 were included. We recorded demographic data, sedative dosages, prone positioning, sedation levels and duration. Descriptive data analysis was performed; for additional analysis, a logistic regression with mixed effect was used. RESULTS In total, 56 patients (mean age 67 (±14) years) were included. The mean observed sedation period was 224 (±139) hours. To achieve the prescribed sedation level, we observed the need for two or three sedatives in 48.7% and 12.8% of the cases, respectively. In cases with a triple sedation regimen, the combination of clonidine, esketamine and midazolam was observed in most cases (75.7%). Analgesia was achieved using sufentanil in 98.6% of the cases. The analysis showed that the majority of COVID-19 patients required an unusually high sedation dose compared to those available in the literature. CONCLUSION The global pandemic continues to affect patients severely requiring ventilation and sedation, but optimal sedation strategies are still lacking. The findings of our observation suggest unusual high dosages of sedatives in mechanically ventilated patients with COVID-19. Prescribed sedation levels appear to be achievable only with several combinations of sedatives in most critically ill patients suffering from COVID-19-induced ARDS and a potential association to the often required sophisticated critical care including prone positioning and ECMO treatment seems conceivable.
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Affiliation(s)
- Armin Niklas Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Hessen, Germany
| | - Hendrik Booke
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Hessen, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Hessen, Germany
| | - Ümniye Balaban
- Department of Biostatistics and Mathematical Modelling, Goethe-University Frankfurt, Hessen, Germany
| | - Eva Herrmann
- Department of Biostatistics and Mathematical Modelling, Goethe-University Frankfurt, Hessen, Germany
| | - Elisabeth Hannah Adam
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Hessen, Germany
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Grieco DL, Maggiore SM, Roca O, Spinelli E, Patel BK, Thille AW, Barbas CSV, de Acilu MG, Cutuli SL, Bongiovanni F, Amato M, Frat JP, Mauri T, Kress JP, Mancebo J, Antonelli M. Non-invasive ventilatory support and high-flow nasal oxygen as first-line treatment of acute hypoxemic respiratory failure and ARDS. Intensive Care Med 2021; 47:851-866. [PMID: 34232336 PMCID: PMC8261815 DOI: 10.1007/s00134-021-06459-2] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/09/2021] [Indexed: 12/21/2022]
Abstract
The role of non-invasive respiratory support (high-flow nasal oxygen and noninvasive ventilation) in the management of acute hypoxemic respiratory failure and acute respiratory distress syndrome is debated. The oxygenation improvement coupled with lung and diaphragm protection produced by non-invasive support may help to avoid endotracheal intubation, which prevents the complications of sedation and invasive mechanical ventilation. However, spontaneous breathing in patients with lung injury carries the risk that vigorous inspiratory effort, combined or not with mechanical increases in inspiratory airway pressure, produces high transpulmonary pressure swings and local lung overstretch. This ultimately results in additional lung damage (patient self-inflicted lung injury), so that patients intubated after a trial of noninvasive support are burdened by increased mortality. Reducing inspiratory effort by high-flow nasal oxygen or delivery of sustained positive end-expiratory pressure through the helmet interface may reduce these risks. In this physiology-to-bedside review, we provide an updated overview about the role of noninvasive respiratory support strategies as early treatment of hypoxemic respiratory failure in the intensive care unit. Noninvasive strategies appear safe and effective in mild-to-moderate hypoxemia (PaO2/FiO2 > 150 mmHg), while they can yield delayed intubation with increased mortality in a significant proportion of moderate-to-severe (PaO2/FiO2 ≤ 150 mmHg) cases. High-flow nasal oxygen and helmet noninvasive ventilation represent the most promising techniques for first-line treatment of severe patients. However, no conclusive evidence allows to recommend a single approach over the others in case of moderate-to-severe hypoxemia. During any treatment, strict physiological monitoring remains of paramount importance to promptly detect the need for endotracheal intubation and not delay protective ventilation.
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Affiliation(s)
- Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. .,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy.
| | - Salvatore Maurizio Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy.,University Department of Innovative Technologies in Medicine and Dentistry, Gabriele D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Oriol Roca
- Servei de Medicina Intensiva, Hospital Universitari Vall D'Hebron, Institut de Recerca Vall D'Hebron, Barcelona, Spain.,Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Maggiore Policlinico Hospital, Milan, Italy
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Arnaud W Thille
- Centre Hospitalier Universitaire (CHU) de Poitiers, Médecine Intensive Réanimation, Poitiers, France.,Centre D'Investigation Clinique 1402, ALIVE, INSERM, Université de Poitiers, Poitiers, France
| | - Carmen Sílvia V Barbas
- Division of Pulmonary and Critical Care, University of São Paulo, São Paulo, Brazil.,Intensive Care Unit, Albert Einstein Hospital, São Paulo, Brazil
| | - Marina Garcia de Acilu
- Servei de Medicina Intensiva, Hospital Universitari Vall D'Hebron, Institut de Recerca Vall D'Hebron, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Salvatore Lucio Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Filippo Bongiovanni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Marcelo Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jean-Pierre Frat
- Centre Hospitalier Universitaire (CHU) de Poitiers, Médecine Intensive Réanimation, Poitiers, France.,Centre D'Investigation Clinique 1402, ALIVE, INSERM, Université de Poitiers, Poitiers, France
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Maggiore Policlinico Hospital, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - John P Kress
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Maggiore Policlinico Hospital, Milan, Italy
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
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88
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Yu X, Gu S, Li M, Zhan Q. Awake Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome: Which Clinical Issues Should Be Taken Into Consideration. Front Med (Lausanne) 2021; 8:682526. [PMID: 34277659 PMCID: PMC8282255 DOI: 10.3389/fmed.2021.682526] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/01/2021] [Indexed: 01/18/2023] Open
Abstract
With the goal of protecting injured lungs and extrapulmonary organs, venovenous extracorporeal membrane oxygenation (VV-ECMO) has been increasingly adopted as a rescue therapy for patients with severe acute respiratory distress syndrome (ARDS) when conventional mechanical ventilation failed to provide effective oxygenation and decarbonation. In recent years, it has become a promising approach to respiratory support for awake, non-intubated, spontaneously breathing patients with respiratory failure, referred to as awake ECMO, to avoid possible detrimental effects associated with intubation, mechanical ventilation, and the adjunctive therapies. However, several complex clinical issues should be taken into consideration when initiating and implementing awake ECMO, such as selecting potential patients who appeared to benefit most; techniques to facilitating cannulation and maintain stable ECMO blood flow; approaches to manage pain, agitation, and delirium; and approaches to monitor and modulate respiratory drive. It is worth mentioning that there had also been some inherent disadvantages and limitations of awake ECMO compared to the conventional combination of ECMO and invasive mechanical ventilation. Here, we review the use of ECMO in awake, spontaneously breathing patients with severe ARDS, highlighting the issues involving bedside clinical practice, detailing some of the technical aspects, and summarizing the initial clinical experience gained over the past years.
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Affiliation(s)
- Xin Yu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Sichao Gu
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Min Li
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
| | - Qingyuan Zhan
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, National Clinical Research Center for Respiratory Diseases, Institute of Respiratory Medicine, China-Japan Friendship Hospital, Beijing, China
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89
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Battaglini D, Sottano M, Ball L, Robba C, Rocco PR, Pelosi P. Ten golden rules for individualized mechanical ventilation in acute respiratory distress syndrome. JOURNAL OF INTENSIVE MEDICINE 2021; 1:42-51. [PMID: 36943812 PMCID: PMC7919509 DOI: 10.1016/j.jointm.2021.01.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/21/2021] [Accepted: 01/23/2021] [Indexed: 12/22/2022]
Abstract
Considerable progress has been made over the last decades in the management of acute respiratory distress syndrome (ARDS). Mechanical ventilation(MV) remains the cornerstone of supportive therapy for ARDS. Lung-protective MV minimizes the risk of ventilator-induced lung injury (VILI) and improves survival. Several parameters contribute to the risk of VILI and require careful setting including tidal volume (VT), plateau pressure (Pplat), driving pressure (ΔP), positive end-expiratory pressure (PEEP), and respiratory rate. Measurement of energy and mechanical power allows quantification of the relative contributions of various parameters (VT, Pplat, ΔP, PEEP, respiratory rate, and airflow) for the individualization of MV settings. The use of neuromuscular blocking agents mainly in cases of severe ARDS can improve oxygenation and reduce asynchrony, although they are not known to confer a survival benefit. Rescue respiratory therapies such as prone positioning, inhaled nitric oxide, and extracorporeal support techniques may be adopted in specific situations. Furthermore, respiratory weaning protocols should also be considered. Based on a review of recent clinical trials, we present 10 golden rules for individualized MV in ARDS management.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa 16132, Italy
- Department of Medicine, University of Barcelona, Barcelona 08007, Spain
| | - Marco Sottano
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa 16132, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa 16126, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa 16132, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa 16126, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa 16132, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa 16126, Italy
| | - Patricia R.M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro 21941-901, Brazil
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa 16132, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa 16126, Italy
- Corresponding author: Paolo Pelosi, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa 16132, Italy.
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90
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Nakayama R, Iwamoto Y, Bunya N, Sawada A, Takahashi K, Goto Y, Kasai T, Kakizaki R, Uemura S, Narimatsu E. Bilateral phrenic nerve block as an effective means of controlling inspiratory efforts in a COVID-19 patient. Respir Med Case Rep 2021; 33:101455. [PMID: 34189030 PMCID: PMC8222048 DOI: 10.1016/j.rmcr.2021.101455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 05/31/2021] [Accepted: 06/15/2021] [Indexed: 11/25/2022] Open
Abstract
Bilateral continuous phrenic nerve block effectively regulates refractory persistent, strong inspiratory effort in a patient with coronavirus disease (COVID-19). A 73-year-old man with acute respiratory distress syndrome (ARDS) due to COVID-19 was admitted to the intensive care unit (ICU). Use of neuromuscular blocking agents (NMBAs) was stopped due to uncontrollable strong inspiratory efforts and worsened lung injury. We performed bilateral continuous phrenic nerve block, which suppressed inspiratory efforts, resulting in lung injury improvement. A bilateral continuous phrenic nerve block is a viable alternative to control refractory strong inspiratory effort leading to lung injury in cases with prolonged NMBA use.
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Key Words
- ARDS, acute respiratory distress syndrome
- Acute respiratory distress syndrome
- COVID-19
- COVID-19, coronavirus disease
- CT, computed tomography
- Case report
- Edi, electrical activity of the diaphragm
- ICU, intensive care unit
- ICU-AW, intensive care unit-acquired weakness
- NMBAs, neuromuscular blocking agents
- Neuromuscular blocking agents
- P-SILI, patient self-inflicted lung injury
- PEEP, positive end-expiratory pressure
- Patient self-inflicted lung injury
- Pes, oesophageal pressure
- Phrenic nerve block
- ⊿Pes, change in oesophageal pressure
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Affiliation(s)
- Ryuichi Nakayama
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Japan
| | - Yusuke Iwamoto
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Japan
| | - Naofumi Bunya
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Japan
| | - Atsushi Sawada
- Department of Anesthesiology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Japan
| | - Kazunobu Takahashi
- Department of Anesthesiology, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Japan
| | - Yuya Goto
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Japan
| | - Takehiko Kasai
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Japan
| | - Ryuichiro Kakizaki
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Japan
| | - Shuji Uemura
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Japan
| | - Eichi Narimatsu
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, South 1, West 16, Chuo-ku, Sapporo, Japan
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91
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Etiology, incidence, and outcomes of patient-ventilator asynchrony in critically-ill patients undergoing invasive mechanical ventilation. Sci Rep 2021; 11:12390. [PMID: 34117278 PMCID: PMC8196026 DOI: 10.1038/s41598-021-90013-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/30/2021] [Indexed: 02/05/2023] Open
Abstract
Patient-ventilator asynchrony (PVA) is commonly encountered during mechanical ventilation of critically ill patients. Estimates of PVA incidence vary widely. Type, risk factors, and consequences of PVA remain unclear. We aimed to measure the incidence and identify types of PVA, characterize risk factors for development, and explore the relationship between PVA and outcome among critically ill, mechanically ventilated adult patients admitted to medical, surgical, and medical-surgical intensive care units in a large academic institution staffed with varying provider training background. A single center, retrospective cohort study of all adult critically ill patients undergoing invasive mechanical ventilation for ≥ 12 h. A total of 676 patients who underwent 696 episodes of mechanical ventilation were included. Overall PVA occurred in 170 (24%) episodes. Double triggering 92(13%) was most common, followed by flow starvation 73(10%). A history of smoking, and pneumonia, sepsis, or ARDS were risk factors for overall PVA and double triggering (all P < 0.05). Compared with volume targeted ventilation, pressure targeted ventilation decreased the occurrence of events (all P < 0.01). During volume controlled synchronized intermittent mandatory ventilation and pressure targeted ventilation, ventilator settings were associated with the incidence of overall PVA. The number of overall PVA, as well as double triggering and flow starvation specifically, were associated with worse outcomes and fewer hospital-free days (all P < 0.01). Double triggering and flow starvation are the most common PVA among critically ill, mechanically ventilated patients. Overall incidence as well as double triggering and flow starvation PVA specifically, portend worse outcome.
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92
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Nguyen J, Kesper K, Kräling G, Birk C, Mross P, Hofeditz N, Höchst J, Lampe P, Penning A, Leutenecker-Twelsiek B, Schindler C, Buchenauer H, Geisel D, Sommer C, Henning R, Wallot P, Wiesmann T, Beutel B, Schneider G, Castro-Camus E, Koch M. Repurposing CPAP machines as stripped-down ventilators. Sci Rep 2021; 11:12204. [PMID: 34108549 PMCID: PMC8190155 DOI: 10.1038/s41598-021-91673-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 05/28/2021] [Indexed: 01/15/2023] Open
Abstract
The worldwide shortage of medical-grade ventilators is a well-known issue, that has become one of the central topics during the COVID-19 pandemic. Given that these machines are expensive and have long lead times, one approach is to vacate them for patients in critical conditions while patients with mild to moderate symptoms are treated with stripped-down ventilators. We propose a mass-producible solution that can create such ventilators with minimum effort. The central part is a module that can be attached to CPAP machines and repurpose them as low-pressure ventilators. Here, we describe the concept and first measurements which underline the potential of our solution. Our approach may serve as a starting point for open-access ventilator technologies.
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Affiliation(s)
- J Nguyen
- Faculty of Physics and Material Sciences Centre, Philipps-Universität Marburg, Marburg, Germany.
| | - K Kesper
- Department of Pneumology, Philipps-Universität Marburg, Marburg, Germany
| | - G Kräling
- Department of Medical Technology, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - C Birk
- Faculty of Physics and Material Sciences Centre, Philipps-Universität Marburg, Marburg, Germany
| | - P Mross
- Department of Neurology, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - N Hofeditz
- Faculty of Physics and Material Sciences Centre, Philipps-Universität Marburg, Marburg, Germany
| | - J Höchst
- Faculty of Mathematics and Computer Science, Philipps-Universität Marburg, Marburg, Germany
| | - P Lampe
- Faculty of Mathematics and Computer Science, Philipps-Universität Marburg, Marburg, Germany
| | - A Penning
- Faculty of Mathematics and Computer Science, Philipps-Universität Marburg, Marburg, Germany
| | | | - C Schindler
- Faculty of Physics and Material Sciences Centre, Philipps-Universität Marburg, Marburg, Germany
| | | | - D Geisel
- Faculty of Physics and Material Sciences Centre, Philipps-Universität Marburg, Marburg, Germany
| | - C Sommer
- Faculty of Physics and Material Sciences Centre, Philipps-Universität Marburg, Marburg, Germany
| | - R Henning
- Department of Anaesthesiology & Intensive Care Medicine, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - P Wallot
- Department of Anaesthesiology & Intensive Care Medicine, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - T Wiesmann
- Department of Anaesthesiology & Intensive Care Medicine, Universitätsklinikum Gießen und Marburg, Marburg, Germany
| | - B Beutel
- Department of Medicine, Pulmonary and Critical Care Medicine, Universitätsklinikum Gießen und Marburg, Member of the German Centre for Lung Research (DZL), Marburg, Germany
| | | | - E Castro-Camus
- Centro de Investigaciones en Optica, A.C., Loma del Bosque 115, Lomas del Campestre, 37150, Leon, Guanajuato, Mexico
| | - M Koch
- Faculty of Physics and Material Sciences Centre, Philipps-Universität Marburg, Marburg, Germany
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93
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Rezoagli E, Villa S, Gatti S, Russotto V, Borgo A, Lucchini A, Foti G, Bellani G. Helmet and face mask for non-invasive respiratory support in patients with acute hypoxemic respiratory failure: A retrospective study. J Crit Care 2021; 65:56-61. [PMID: 34091270 DOI: 10.1016/j.jcrc.2021.05.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 05/20/2021] [Accepted: 05/22/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Non-invasive respiratory support could reduce the incidence of intubation in patients with Acute Hypoxemic Respiratory Failure (AHRF). The optimal interface or modality of non-invasive respiratory support is debated. We sought to evaluate the differences between patients who succeeded or failed non-invasive respiratory support, with a specific focus on the type of non-invasive respiratory support (i.e. helmet CPAP versus face mask NIV). MATERIALS AND METHODS In a single-center observational retrospective study, we investigated baseline, clinical characteristics and AHRF management by non-invasive respiratory support between January 2015 to December 2016. Data on gas exchange and respiratory mechanics, non-invasive respiratory support duration, ICU length of stay and mortality were collected. RESULTS 110 patients with AHRF were included of which 41 patients (37%) were intubated. The use of helmet CPAP (p = 0.016) and a lower fluid balance (p = 0.038) were independently associated with a decreased rate of intubation after adjustment for confounders. Face mask NIV patients trended to a higher respiratory frequency at 1 h after treatment [28 (22-36) versus 24 (18-29) hours, p = 0.067], and showed a longer ICU stay (p = 0.009) compared to patients treated with helmet CPAP. CONCLUSIONS Helmet CPAP and a lower fluid balance were independent predictors of a lower intubation rate in AHRF patients in ICU. Prospective studies aimed at identifying the optimal interface and modality of non-invasive respiratory support in AHRF patients are needed.
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Affiliation(s)
- Emanuele Rezoagli
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore, 48, Monza 20900, MB, Italy.; Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital, ASST Monza, Monza e Brianza, Via G. B. Pergolesi, 33, Monza 20900, MB, Italy
| | - Silvia Villa
- Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital, ASST Monza, Monza e Brianza, Via G. B. Pergolesi, 33, Monza 20900, MB, Italy
| | - Stefano Gatti
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore, 48, Monza 20900, MB, Italy
| | - Vincenzo Russotto
- Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital, ASST Monza, Monza e Brianza, Via G. B. Pergolesi, 33, Monza 20900, MB, Italy
| | - Asia Borgo
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore, 48, Monza 20900, MB, Italy
| | - Alberto Lucchini
- Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital, ASST Monza, Monza e Brianza, Via G. B. Pergolesi, 33, Monza 20900, MB, Italy
| | - Giuseppe Foti
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore, 48, Monza 20900, MB, Italy.; Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital, ASST Monza, Monza e Brianza, Via G. B. Pergolesi, 33, Monza 20900, MB, Italy
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milano-Bicocca, Via Cadore, 48, Monza 20900, MB, Italy.; Department of Anesthesia and Intensive Care Medicine, San Gerardo Hospital, ASST Monza, Monza e Brianza, Via G. B. Pergolesi, 33, Monza 20900, MB, Italy.
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94
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Coppola S, Pozzi T, Chiumello D. Reverse trigger in COVID-19 ARDS. Minerva Anestesiol 2021; 87:1271-1272. [PMID: 34036772 DOI: 10.23736/s0375-9393.21.15798-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy
| | - Tommaso Pozzi
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Davide Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy - .,Department of Health Sciences, University of Milan, Milan, Italy.,Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy
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95
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Grieco DL, Menga LS, Cesarano M, Rosà T, Spadaro S, Bitondo MM, Montomoli J, Falò G, Tonetti T, Cutuli SL, Pintaudi G, Tanzarella ES, Piervincenzi E, Bongiovanni F, Dell'Anna AM, Delle Cese L, Berardi C, Carelli S, Bocci MG, Montini L, Bello G, Natalini D, De Pascale G, Velardo M, Volta CA, Ranieri VM, Conti G, Maggiore SM, Antonelli M. Effect of Helmet Noninvasive Ventilation vs High-Flow Nasal Oxygen on Days Free of Respiratory Support in Patients With COVID-19 and Moderate to Severe Hypoxemic Respiratory Failure: The HENIVOT Randomized Clinical Trial. JAMA 2021; 325:1731-1743. [PMID: 33764378 PMCID: PMC7995134 DOI: 10.1001/jama.2021.4682] [Citation(s) in RCA: 256] [Impact Index Per Article: 85.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE High-flow nasal oxygen is recommended as initial treatment for acute hypoxemic respiratory failure and is widely applied in patients with COVID-19. OBJECTIVE To assess whether helmet noninvasive ventilation can increase the days free of respiratory support in patients with COVID-19 compared with high-flow nasal oxygen alone. DESIGN, SETTING, AND PARTICIPANTS Multicenter randomized clinical trial in 4 intensive care units (ICUs) in Italy between October and December 2020, end of follow-up February 11, 2021, including 109 patients with COVID-19 and moderate to severe hypoxemic respiratory failure (ratio of partial pressure of arterial oxygen to fraction of inspired oxygen ≤200). INTERVENTIONS Participants were randomly assigned to receive continuous treatment with helmet noninvasive ventilation (positive end-expiratory pressure, 10-12 cm H2O; pressure support, 10-12 cm H2O) for at least 48 hours eventually followed by high-flow nasal oxygen (n = 54) or high-flow oxygen alone (60 L/min) (n = 55). MAIN OUTCOMES AND MEASURES The primary outcome was the number of days free of respiratory support within 28 days after enrollment. Secondary outcomes included the proportion of patients who required endotracheal intubation within 28 days from study enrollment, the number of days free of invasive mechanical ventilation at day 28, the number of days free of invasive mechanical ventilation at day 60, in-ICU mortality, in-hospital mortality, 28-day mortality, 60-day mortality, ICU length of stay, and hospital length of stay. RESULTS Among 110 patients who were randomized, 109 (99%) completed the trial (median age, 65 years [interquartile range {IQR}, 55-70]; 21 women [19%]). The median days free of respiratory support within 28 days after randomization were 20 (IQR, 0-25) in the helmet group and 18 (IQR, 0-22) in the high-flow nasal oxygen group, a difference that was not statistically significant (mean difference, 2 days [95% CI, -2 to 6]; P = .26). Of 9 prespecified secondary outcomes reported, 7 showed no significant difference. The rate of endotracheal intubation was significantly lower in the helmet group than in the high-flow nasal oxygen group (30% vs 51%; difference, -21% [95% CI, -38% to -3%]; P = .03). The median number of days free of invasive mechanical ventilation within 28 days was significantly higher in the helmet group than in the high-flow nasal oxygen group (28 [IQR, 13-28] vs 25 [IQR 4-28]; mean difference, 3 days [95% CI, 0-7]; P = .04). The rate of in-hospital mortality was 24% in the helmet group and 25% in the high-flow nasal oxygen group (absolute difference, -1% [95% CI, -17% to 15%]; P > .99). CONCLUSIONS AND RELEVANCE Among patients with COVID-19 and moderate to severe hypoxemia, treatment with helmet noninvasive ventilation, compared with high-flow nasal oxygen, resulted in no significant difference in the number of days free of respiratory support within 28 days. Further research is warranted to determine effects on other outcomes, including the need for endotracheal intubation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04502576.
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Affiliation(s)
- Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca S Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Melania Cesarano
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Tommaso Rosà
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Savino Spadaro
- Department of Morphology, Surgery, and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Ferrara, Italy
| | | | - Jonathan Montomoli
- Department of Anaesthesia and Intensive Care, Infermi Hospital, Rimini, Italy
| | - Giulia Falò
- Department of Morphology, Surgery, and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Ferrara, Italy
| | - Tommaso Tonetti
- Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Alma Mater Studiorum-Università di Bologna, Bologna, Italy
| | - Salvatore L Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gabriele Pintaudi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Eloisa S Tanzarella
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Edoardo Piervincenzi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Filippo Bongiovanni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio M Dell'Anna
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Delle Cese
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cecilia Berardi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Simone Carelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Maria Grazia Bocci
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Montini
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe Bello
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Daniele Natalini
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Matteo Velardo
- European School of Obstetric Anesthesia, EESOA Simulation Center, Rome, Italy
| | - Carlo Alberto Volta
- Department of Morphology, Surgery, and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Ferrara, Italy
| | - V Marco Ranieri
- Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Alma Mater Studiorum-Università di Bologna, Bologna, Italy
| | - Giorgio Conti
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Salvatore Maurizio Maggiore
- University Department of Innovative Technologies in Medicine and Dentistry, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine, and Emergency, SS Annunziata Hospital, Chieti, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario AGemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
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96
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Oto B, Annesi J, Foley RJ. Patient-ventilator dyssynchrony in the intensive care unit: A practical approach to diagnosis and management. Anaesth Intensive Care 2021; 49:86-97. [PMID: 33906464 DOI: 10.1177/0310057x20978981] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient-ventilator dyssynchrony or asynchrony occurs when, for any parameter of respiration, discordance exists between the patient's spontaneous effort and the ventilator's provided support. If not recognised, it may promote oversedation, prolong the duration of mechanical ventilation, create risk for lung injury, and generally confuse the clinical picture. Seven forms of dyssynchrony are common: (a) ineffective triggering; (b) autotriggering; (c) inadequate flow; (d) too much flow; (e) premature cycling; (f) delayed cycling; and (g) peak pressure apnoea. 'Reverse triggering' also occurs and may mimic premature cycling. Correct diagnosis of these phenomena often permits management by simple ventilator optimisation rather than by less desirable measures.
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Affiliation(s)
- Brandon Oto
- Adult Critical Care, UConn Health, Farmington, USA
| | - Janet Annesi
- Respiratory Therapy Department, UConn Health, Farmington, USA
| | - Raymond J Foley
- Division of Pulmonary, Critical Care, and Sleep Medicine, UConn Health, Farmington, USA
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97
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Abstract
Purpose of Review This paper will evaluate the recent literature and best practices in airway management in critically ill patients. Recent Findings Cardiac arrest remains a common complication of intubation in these high-risk patients. Patients with desaturation or peri-intubation hypotension are at high risk of cardiac arrest, and each of these complications have been reported in up to half of all intubations in critically ill patient populations. Summary There have been significant advances in preoxygenation and devices available for performing laryngoscopy and rescue oxygenation. However, the risk of cardiovascular collapse remains concerningly high with few studies to guide therapeutic maneuvers to reduce this risk.
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98
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Affiliation(s)
- Neil MacIntyre
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Craig Rackley
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Felix Khusid
- Department of Respiratory Therapy, NewYork-Presbyterian Brooklyn Methodist Hospital, Brooklyn, NY
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99
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Can We Always Trust the Wisdom of the Body? Crit Care Med 2021; 50:1268-1271. [PMID: 33779582 DOI: 10.1097/ccm.0000000000005022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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100
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Welhengama C, Hall A, Hunter JM. Neuromuscular blocking drugs in the critically ill. BJA Educ 2021; 21:258-263. [PMID: 34178382 DOI: 10.1016/j.bjae.2021.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2021] [Indexed: 12/17/2022] Open
Affiliation(s)
- C Welhengama
- St. Helen's and Knowsley Teaching Hospitals, Prescot, UK
| | - A Hall
- Liverpool University Foundation Trust, Liverpool, UK
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