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Buiteman-Kruizinga LA, Mkadmi HE, Serpa Neto A, Kruizinga MD, Botta M, Schultz MJ, Paulus F, van der Heiden PL. Effect of INTELLiVENT-ASV versus Conventional Ventilation on Ventilation Intensity in Patients with COVID-19 ARDS-An Observational Study. J Clin Med 2021; 10:jcm10225409. [PMID: 34830691 PMCID: PMC8622732 DOI: 10.3390/jcm10225409] [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: 10/08/2021] [Revised: 11/01/2021] [Accepted: 11/15/2021] [Indexed: 11/16/2022] Open
Abstract
Driving pressure (ΔP) and mechanical power (MP) are associated with outcomes in critically ill patients, irrespective of the presence of Acute Respiratory Distress Syndrome (ARDS). INTELLiVENT-ASV, a fully automated ventilatory mode, controls the settings that affect ΔP and MP. This study compared the intensity of ventilation (ΔP and MP) with INTELLiVENT-ASV versus conventional ventilation in a cohort of COVID-19 ARDS patients in two intensive care units in the Netherlands. The coprimary endpoints were ΔP and MP before and after converting from conventional ventilation to INTELLiVENT-ASV. Compared to conventional ventilation, INTELLiVENT-ASV delivered ventilation with a lower ΔP and less MP. With conventional ventilation, ΔP was 13 cmH2O, and MP was 21.5 and 24.8 J/min, whereas with INTELLiVENT-ASV, ΔP was 11 and 10 cmH2O (mean difference –2 cm H2O (95 %CI –2.5 to –1.2 cm H2O), p < 0.001) and MP was 18.8 and 17.5 J/min (mean difference –7.3 J/Min (95% CI –8.8 to –5.8 J/min), p < 0.001). Conversion from conventional ventilation to INTELLiVENT-ASV resulted in a lower intensity of ventilation. These findings may favor the use of INTELLiVENT-ASV in COVID-19 ARDS patients, but future studies remain needed to see if the reduction in the intensity of ventilation translates into clinical benefits.
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Affiliation(s)
- Laura A. Buiteman-Kruizinga
- Department of Intensive Care, Reinier de Graaf Hospital, 2625 AD Delft, The Netherlands;
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands; (A.S.N.); (M.B.); (M.J.S.); (F.P.)
- Correspondence: ; Tel.: +31-152604040
| | - Hassan E. Mkadmi
- Department of Research, Reinier de Graaf Hospital, 2625 AD Delft, The Netherlands;
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands; (A.S.N.); (M.B.); (M.J.S.); (F.P.)
- Australian and New Zealand Intensive Care–Research Centre (ANZIC–RC), Monash University, Melbourne, VIC 3004, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
| | - Matthijs D. Kruizinga
- Department of Pediatrics, Juliana Children’s Hospital, 2545 AA The Hague, The Netherlands;
| | - Michela Botta
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands; (A.S.N.); (M.B.); (M.J.S.); (F.P.)
| | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands; (A.S.N.); (M.B.); (M.J.S.); (F.P.)
- Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok 10400, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford OX3 7FZ, UK
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, Location ‘AMC’, 1105 AZ Amsterdam, The Netherlands; (A.S.N.); (M.B.); (M.J.S.); (F.P.)
- ACHIEVE, Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, 1105 AZ Amsterdam, The Netherlands
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102
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Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: an Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists- Part II, Intraoperative Management and Troubleshooting. J Cardiothorac Vasc Anesth 2021; 35:3513-3527. [PMID: 34774253 DOI: 10.1053/j.jvca.2021.07.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Michael A Mazzeffi
- Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alton, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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103
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Zhu Y, Peng W, Zhen S, Jiang X. Mechanical power normalized to predicted body weight is associated with mortality in critically ill patients: a cohort study. BMC Anesthesiol 2021; 21:278. [PMID: 34753416 PMCID: PMC8578006 DOI: 10.1186/s12871-021-01497-1] [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: 06/20/2021] [Accepted: 10/31/2021] [Indexed: 11/28/2022] Open
Abstract
Background Mechanical power (MP), defined as the amount of energy produced by mechanical ventilation and released into the respiratory system, was reportedly a determining factor in the pathogenesis of ventilator-induced lung injury. However, previous studies suggest that the effects of MP were proportional to their involvement in the total lung function size. Therefore, MP normalized to the predicted body weight (norMP) should outperform the absolute MP value. The objective of this research is to determine the connection between norMP and mortality in critically ill patients who have been on invasive ventilation for at least 48 h. Methods This is a study of data stored in the databases of the MIMIC–III, which contains data of critically ill patients for over 50,000. The study involved critically ill patients who had been on invasive ventilation for at least 48 h. norMP was the relevant exposure. The major endpoint was ICU mortality, the secondary endpoints were 30-day, 90-day mortality; ICU length of stay, the number of ventilator-free days at day 28. Result The study involved a total of 1301 critically ill patients. This study revealed that norMP was correlated with ICU mortality [OR per quartile increase 1.33 (95% CI 1.16–1.52), p < 0.001]. Similarly, norMP was correlated with ventilator-free days at day 28, ICU length of stay. In the subgroup analysis, high norMP was associated with ICU mortality whether low or high Vt (OR 1.31, 95% CI 1.09–1.57, p = 0.004; OR 1.32, 95% CI 1.08–1.62, p = 0.008, respectively). But high norMP was associated with ICU mortality only in low PIP (OR 1.18, 95% CI 1.01–1.38, p = 0.034). Conclusion Our findings indicate that higher norMP is independently linked with elevated ICU mortality and various other clinical findings in critically ill patients with a minimum of 48 h of invasive ventilation. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01497-1.
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Affiliation(s)
- Yanhong Zhu
- Department of Anesthesiology, The First People's Hospital of Pinghu, Zhejiang, China
| | - Wenyong Peng
- Department of Anesthesiology, Jinhua Municipal Central Hospital, 365 Renmin East Road, Jinhua, Zhejiang, China
| | - Shuai Zhen
- Department of Anesthesiology, Jinhua Municipal Central Hospital, 365 Renmin East Road, Jinhua, Zhejiang, China
| | - Xiaofeng Jiang
- Department of Anesthesiology, Jinhua Municipal Central Hospital, 365 Renmin East Road, Jinhua, Zhejiang, China.
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104
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Yang X, An X, Wang C, Gao F, Lin Y, Chen W, Deng Q, Xu D, Li S, Zhang P, Sun B, Hou Y, Wu J. Protective Effect of Oxytocin on Ventilator-Induced Lung Injury Through NLRP3-Mediated Pathways. Front Pharmacol 2021; 12:722907. [PMID: 34733156 PMCID: PMC8558354 DOI: 10.3389/fphar.2021.722907] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
Mechanical ventilation is an indispensable life-support treatment for acute respiratory failure in critically ill patients, which is generally believed to involve uncontrolled inflammatory responses. Oxytocin (OT) has been reported to be effective in animal models of acute lung injury. However, it is not clear whether Oxytocin has a protective effect on ventilator-induced lung injury (VILI). Therefore, in this study, we aimed to determine whether OT can attenuate VILI and explore the possible mechanism of this protection. To this end, a mouse VILI model was employed. Mice were pretreated with OT 30 min before the intraperitoneal injection of saline or nigericin and ventilation for 4 h, after which they were euthanized. Pathological changes, lung wet/dry (W/D) weight ratio, myeloperoxidase (MPO) activity, the levels of inflammatory cytokines [i.e., interleukin (IL)-1β, IL-6, and IL-18] in lung tissues and bronchoalveolar lavage fluid (BALF), and expression of NLRP3, Toll-like receptor 4 (TLR4), caspase-1, nuclear factor (NF)-κB, and GSDMD in lung tissues were measured. OT treatment could reduce pathological injury, the W/D ratio, and MPO activity in VILI mice. Our data also indicated that OT administration alleviated the expression of TLR4/My-D88 and the activation of NF-κB, NLRP3, and caspase-1 in lung tissues from the VILI mice model. Furthermore, OT also decreased the levels of IL-1β, IL-6, and IL-18 in the bronchoalveolar lavage fluid. Moreover, the OT administration may alleviate the activation of GSDMD partially through its effects on the NLRP3-mediated pathway. Collectively, OT exerted a beneficial effect on VILI by downregulating TLR4-and NLRP3-mediated inflammatory pathways.
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Affiliation(s)
- Xiaomei Yang
- Department of Anesthesiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,School of Medicine, Cheeloo College of medicine, Shandong University, Jinan, China.,Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaona An
- Department of Anesthesiology, Zibo Central Hospital, Shandong University, Zibo, China
| | - Cheng Wang
- Department of Anesthesiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China.,School of Medicine, Cheeloo College of medicine, Shandong University, Jinan, China
| | - Feng Gao
- School of Medicine, Cheeloo College of medicine, Shandong University, Jinan, China
| | - Yicheng Lin
- Shandong Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wenjing Chen
- Department of Cardiology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, China
| | - Qiming Deng
- Department of Cardiology, The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Dongsheng Xu
- Department of Kidney Transplantation, The Second Hospital, Shandong University, Jinan, China
| | - Shengqiang Li
- Department of Anesthesiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Peng Zhang
- Department of Anesthesiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Baozhu Sun
- Department of Anesthesiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yuedong Hou
- Department of Anesthesiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jianbo Wu
- Department of Anesthesiology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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105
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Differential urine proteome analysis of a ventilator-induced lung injury rat model by label-free quantitative and parallel reaction monitoring proteomics. Sci Rep 2021; 11:21446. [PMID: 34728735 PMCID: PMC8563714 DOI: 10.1038/s41598-021-01007-w] [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: 06/28/2021] [Accepted: 10/18/2021] [Indexed: 12/17/2022] Open
Abstract
Urine is a promising resource for biomarker research. Therefore, the purpose of this study was to investigate potential urinary biomarkers to monitor the disease activity of ventilator-induced lung injury (VILI). In the discovery phase, a label-free data-dependent acquisition (DDA) quantitative proteomics method was used to profile the urinary proteomes of VILI rats. For further validation, the differential proteins were verified by parallel reaction monitoring (PRM)-targeted quantitative proteomics. In total, 727 high-confidence proteins were identified with at least 1 unique peptide (FDR ≤ 1%). Compared to the control group, 110 proteins (65 upregulated, 45 downregulated) were significantly changed in the VILI group (1.5-fold change, P < 0.05). The canonical pathways and protein-protein interaction analyses revealed that the differentially expressed proteins were enriched in multiple functions, including oxidative stress and inflammatory responses. Finally, thirteen proteins were identified as candidate biomarkers for VILI by PRM validation. Among these PRM-validated proteins, AMPN, MEP1B, LYSC1, DPP4 and CYC were previously reported as lung-associated disease biomarkers. SLC31, MEP1A, S15A2, NHRF1, XPP2, GGT1, HEXA, and ATPB were newly discovered in this study. Our results suggest that the urinary proteome might reflect the pathophysiological changes associated with VILI. These differential proteins are potential urinary biomarkers for the activity of VILI.
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106
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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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107
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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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108
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Park CG, Jung WS, Park HY, Kim HW, Kwak HJ, Jo YY. Comparison of the Effects of Normocapnia and Mild Hypercapnia on the Optic Nerve Sheath Diameter and Regional Cerebral Oxygen Saturation in Patients Undergoing Gynecological Laparoscopy with Total Intravenous Anesthesia. J Clin Med 2021; 10:jcm10204707. [PMID: 34682830 PMCID: PMC8540822 DOI: 10.3390/jcm10204707] [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: 09/10/2021] [Revised: 10/06/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
Cerebral hemodynamics may be altered by hypercapnia during a lung-protective ventilation (LPV), CO2 pneumoperitoneum, and Trendelenburg position during general anesthesia. The purpose of this study was to compare the effects of normocapnia and mild hypercapnia on the optic nerve sheath diameter (ONSD), regional cerebral oxygen saturation (rSO2), and intraoperative respiratory mechanics in patients undergoing gynecological laparoscopy under total intravenous anesthesia (TIVA). Sixty patients (aged between 19 and 65 years) scheduled for laparoscopic gynecological surgery in the Trendelenburg position. Patients under propofol/remifentanil total intravenous anesthesia were randomly assigned to either the normocapnia group (target PaCO2 = 35 mmHg, n = 30) or the hypercapnia group (target PaCO2 = 50 mmHg, n = 30). The ONSD, rSO2, and respiratory and hemodynamic parameters were measured at 5 min after anesthetic induction (Tind) in the supine position, and at 10 min and 40 min after pneumoperitoneum (Tpp10 and Tpp40, respectively) in the Trendelenburg position. There was no significant intergroup difference in change over time in the ONSD (p = 0.318). The ONSD increased significantly at Tpp40 when compared to Tind in both normocapnia and hypercapnia groups (p = 0.02 and 0.002, respectively). There was a significant intergroup difference in changes over time in the rSO2 (p < 0.001). The rSO2 decreased significantly in the normocapnia group (p = 0.01), whereas it increased significantly in the hypercapnia group at Tpp40 compared with Tind (p = 0.002). Alveolar dead space was significantly higher in the normocapnia group than in the hypercapnia group at Tpp40 (p = 0.001). In conclusion, mild hypercapnia during the LPV might not aggravate the increase in the ONSD during CO2 pneumoperitoneum in the Trendelenburg position and could improve rSO2 compared to normocapnia in patients undergoing gynecological laparoscopy with TIVA.
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Affiliation(s)
| | | | | | | | - Hyun-Jeong Kwak
- Correspondence: (H.-J.K.); (Y.-Y.J.); Tel.: +82-322-460-3637 (H.-J.K.); +82-322-460-3651 (Y.-Y.J.); Fax: 82-32-469-6319 (H.-J.K. & Y.-Y.J.)
| | - Youn-Yi Jo
- Correspondence: (H.-J.K.); (Y.-Y.J.); Tel.: +82-322-460-3637 (H.-J.K.); +82-322-460-3651 (Y.-Y.J.); Fax: 82-32-469-6319 (H.-J.K. & Y.-Y.J.)
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109
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The Association between Mechanical Power and Mortality in Patients with Pneumonia Using Pressure-Targeted Ventilation. Diagnostics (Basel) 2021; 11:diagnostics11101862. [PMID: 34679560 PMCID: PMC8534721 DOI: 10.3390/diagnostics11101862] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/02/2021] [Accepted: 10/08/2021] [Indexed: 11/16/2022] Open
Abstract
Recent studies have reported that mechanical power (MP) is associated with increased mortality in patients with acute respiratory distress syndrome (ARDS). We aimed to investigate the association between 28-day mortality and MP in patients with severe pneumonia. In total, the data of 313 patients with severe pneumonia were used for analysis. Serial MP was calculated daily for either 21 days or until ventilator support was no longer required. Compared with the non-ARDS group, the ARDS group (106 patients) demonstrated lower age, a higher Acute Physiology and Chronic Health Evaluation II score, lower history of diabetes mellitus, elevated incidences of shock and jaundice, higher MP and driving pressure on Day 1, and more deaths within 28 days. Regression analysis revealed that MP was an independent factor associated with 28-day mortality (odds ratio, 1.048; 95% confidence interval, 1.020-1.077). MP was persistently high in non-survivors and low in survivors among the ARDS group, the non-ARDS group, and all patients. These findings indicate that MP is associated with the 28-day mortality in ventilated patients with severe pneumonia, both in the ARDS and non-ARDS groups. MP had a better predicted value for the 28-day mortality than the driving pressure.
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110
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Chiumello D, Coppola S, Formenti P, Ciabattoni A, Lucenteforte M, Liu G, Mao W, Pozzi T. A validation study of a continuous automatic measurement of the mechanical power in ARDS patients. J Crit Care 2021; 67:21-25. [PMID: 34624699 DOI: 10.1016/j.jcrc.2021.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 09/20/2021] [Accepted: 09/24/2021] [Indexed: 01/18/2023]
Abstract
The mechanical power (MP) is the energy delivered into the respiratory system over time. It can be computed as a direct measurement of the inspiratory area of the airway pressure and volume loop during the respiratory cycle or calculated by "power equations". The absence of a bedside computation limited its widespread use. Recently, it has been developed an automatic monitoring system inside of a mechanical ventilator. PURPOSE Our aim was to investigate the repeatability and the accuracy of the measured MP at different PEEP values and tidal volume compared with the calculated MP. MATERIAL AND METHODS MP was measured and calculated in sedated and paralyzed ARDS patients at low and high tidal volume, at 5-10-15 cmH2O of PEEP both in volume and pressure-controlled ventilation. The same measurements were performed twice. RESULTS Fifty ARDS patients were enrolled. MP was measured and calculated for a total of 300 measurements. The bias and limits of agreement were 0.38 from -1.31 to 2.0 J/min. The measured and calculated MP were similar in each ventilatory condition. CONCLUSIONS The mechanical power measured by a new automatic real time system implemented in a mechanical ventilator was repeatable and accurate compared with the computed one.
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Affiliation(s)
- D Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Via Di Rudini 9, Milan, Italy; Department of Health Sciences, University of Milan, Milano, Italy; Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy.
| | - S Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Via Di Rudini 9, Milan, Italy
| | - P Formenti
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Via Di Rudini 9, Milan, Italy
| | - A Ciabattoni
- Department of Health Sciences, University of Milan, Milano, Italy
| | - M Lucenteforte
- Department of Health Sciences, University of Milan, Milano, Italy
| | - G Liu
- Department of Emergency and Intensive Care, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - W Mao
- Department of Emergency and Intensive Care, University-Town Hospital of Chongqing Medical University, Chongqing, China
| | - T Pozzi
- Department of Health Sciences, University of Milan, Milano, Italy
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111
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Díaz F, González-Dambrauskas S, Cristiani F, Casanova DR, Cruces P. Driving Pressure and Normalized Energy Transmission Calculations in Mechanically Ventilated Children Without Lung Disease and Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2021; 22:870-878. [PMID: 34054120 DOI: 10.1097/pcc.0000000000002780] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To compare the new tools to evaluate the energy dissipated to the lung parenchyma in mechanically ventilated children with and without lung injury. We compared their discrimination capability between both groups when indexed by ideal body weight and driving pressure. DESIGN Post hoc analysis of individual patient data from two previously published studies describing pulmonary mechanics. SETTING Two academic hospitals in Latin-America. PATIENTS Mechanically ventilated patients younger than 15 years old were included. We analyzed two groups, 30 children under general anesthesia (ANESTH group) and 38 children with pediatric acute respiratory distress syndrome. INTERVENTIONS Respiratory mechanics were measured after intubation in all patients. MEASUREMENTS AND MAIN RESULTS Mechanical power and derived variables of the equation of motion (dynamic power, driving power, and mechanical energy) were computed and then indexed by ideal body weight. Driving pressure was higher in pediatric acute respiratory distress syndrome group compared with ANESTH group. Receiver operator curve analysis showed that driving pressure had the best discrimination capability compared with all derived variables of the equation of motion indexed by ideal body weight. The same results were observed when the subgroup of patients weighs less than 15 kg. There was no difference in unindexed mechanical power between groups. CONCLUSIONS Driving pressure is the variable that better discriminates pediatric acute respiratory distress syndrome from nonpediatric acute respiratory distress syndrome in children than the calculations derived from the equation of motion, even when indexed by ideal body weight. Unindexed mechanical power was useless to differentiate against both groups. Future studies should determine the threshold for variables of the energy dissipated by the lungs and their association with clinical outcomes.
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Affiliation(s)
- Franco Díaz
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
- Instituto de Ciencias e Innovación en Medicina (ICIM), Universidad del Desarrollo, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network)
- Unidad de Cuidados Intensivos Pediátricos Especializados, Casa de Galicia, Montevideo, Uruguay
- Unidad de Cuidados Intensivos de Niños, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
- Centro Hospitalario Pereira Rossell, Cátedra de Anestesiología, Facultad de Medicina. Universidad de la República, Montevideo, Uruguay
- Departamento de Post-Grado Pediatría, Escuela de Medicina, Facultad de Ciencias Médicas, Universidad de Santiago de Chile, Santiago, Chile
- Centro de Investigación de Medicina Veterinaria, Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Sebastián González-Dambrauskas
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network)
- Unidad de Cuidados Intensivos Pediátricos Especializados, Casa de Galicia, Montevideo, Uruguay
- Unidad de Cuidados Intensivos de Niños, Centro Hospitalario Pereira Rossell, Montevideo, Uruguay
| | - Federico Cristiani
- Centro Hospitalario Pereira Rossell, Cátedra de Anestesiología, Facultad de Medicina. Universidad de la República, Montevideo, Uruguay
| | - Daniel R Casanova
- Departamento de Post-Grado Pediatría, Escuela de Medicina, Facultad de Ciencias Médicas, Universidad de Santiago de Chile, Santiago, Chile
| | - Pablo Cruces
- Unidad de Paciente Crítico Pediátrico, Departamento de Pediatría, Hospital El Carmen de Maipú, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network)
- Centro Hospitalario Pereira Rossell, Cátedra de Anestesiología, Facultad de Medicina. Universidad de la República, Montevideo, Uruguay
- Centro de Investigación de Medicina Veterinaria, Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
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112
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Araos J, Alegria L, Garcia A, Cruces P, Soto D, Erranz B, Salomon T, Medina T, Garcia P, Dubó S, Bachmann MC, Basoalto R, Valenzuela ED, Rovegno M, Vera M, Retamal J, Cornejo R, Bugedo G, Bruhn A. Effect of positive end-expiratory pressure on lung injury and haemodynamics during experimental acute respiratory distress syndrome treated with extracorporeal membrane oxygenation and near-apnoeic ventilation. Br J Anaesth 2021; 127:807-814. [PMID: 34507822 PMCID: PMC8449633 DOI: 10.1016/j.bja.2021.07.031] [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: 04/06/2021] [Revised: 07/09/2021] [Accepted: 07/26/2021] [Indexed: 01/19/2023] Open
Abstract
Background Lung rest has been recommended during extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS). Whether positive end-expiratory pressure (PEEP) confers lung protection during ECMO for severe ARDS is unclear. We compared the effects of three different PEEP levels whilst applying near-apnoeic ventilation in a model of severe ARDS treated with ECMO. Methods Acute respiratory distress syndrome was induced in anaesthetised adult male pigs by repeated saline lavage and injurious ventilation for 1.5 h. After ECMO was commenced, the pigs received standardised near-apnoeic ventilation for 24 h to maintain similar driving pressures and were randomly assigned to PEEP of 0, 10, or 20 cm H2O (n=7 per group). Respiratory and haemodynamic data were collected throughout the study. Histological injury was assessed by a pathologist masked to PEEP allocation. Lung oedema was estimated by wet-to-dry-weight ratio. Results All pigs developed severe ARDS. Oxygenation on ECMO improved with PEEP of 10 or 20 cm H2O, but did not in pigs allocated to PEEP of 0 cm H2O. Haemodynamic collapse refractory to norepinephrine (n=4) and early death (n=3) occurred after PEEP 20 cm H2O. The severity of lung injury was lowest after PEEP of 10 cm H2O in both dependent and non-dependent lung regions, compared with PEEP of 0 or 20 cm H2O. A higher wet-to-dry-weight ratio, indicating worse lung injury, was observed with PEEP of 0 cm H2O. Histological assessment suggested that lung injury was minimised with PEEP of 10 cm H2O. Conclusions During near-apnoeic ventilation and ECMO in experimental severe ARDS, 10 cm H2O PEEP minimised lung injury and improved gas exchange without compromising haemodynamic stability.
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Affiliation(s)
- Joaquin Araos
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, USA
| | - Leyla Alegria
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Aline Garcia
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Pablo Cruces
- Center of Acute Respiratory Critical Illness, Santiago, Chile; Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile; Unidad de Pacientes Críticos Pediátrica, Hospital El Carmen Dr Luis Valentín Ferrada, Santiago, Chile
| | - Dagoberto Soto
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Benjamín Erranz
- Centro de Medicina Regenerativa, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Tatiana Salomon
- Unidad de Pacientes Críticos Pediátrica, Clínica Alemana, Santiago, Chile
| | - Tania Medina
- Unidad de Pacientes Críticos Pediátrica, Hospital El Carmen Dr Luis Valentín Ferrada, Santiago, Chile
| | - Patricio Garcia
- Departamento de Ciencias de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sebastián Dubó
- Departamento de Kinesiología, Facultad de Medicina, Universidad de Concepción, Concepción, Chile
| | - María C Bachmann
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Roque Basoalto
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Emilio D Valenzuela
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Maximiliano Rovegno
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Magdalena Vera
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Center of Acute Respiratory Critical Illness, Santiago, Chile
| | - Rodrigo Cornejo
- Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile; Center of Acute Respiratory Critical Illness, Santiago, Chile
| | - Guillermo Bugedo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Center of Acute Respiratory Critical Illness, Santiago, Chile
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Center of Acute Respiratory Critical Illness, Santiago, Chile.
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A Target for Increased Mortality Risk in Critically Ill Patients: The Concept of Perpetuity. J Clin Med 2021; 10:jcm10173971. [PMID: 34501419 PMCID: PMC8432225 DOI: 10.3390/jcm10173971] [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: 08/06/2021] [Revised: 08/24/2021] [Accepted: 08/25/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Emergency medicine is acuity-based and focuses on time-sensitive treatments for life-threatening diseases. Prolonged time in the emergency department, however, is associated with higher mortality in critically ill patients. Thus, we explored management after an acuity-based intervention, which we call perpetuity, as a potential mechanism for increased risk. To explore this concept, we evaluated the impact of each hour above a lung-protective tidal volume on risk of mortality. Methods: This cohort analysis includes all critically ill, non-trauma, adult patients admitted to two academic EDs between 1 November 2013 and 30 April 2017. Cox models with time-varying covariates were developed with time in perpetuity as a time-varying covariate, defined as hours above 8 mL/kg ideal body weight, adjusted for covariates. The primary outcome was the time to in-hospital death. Results: Our analysis included 2025 patients, 321 (16%) of whom had at least 1 h of perpetuity time. A partial likelihood-ratio test comparing models with and without hours in perpetuity was statistically significant (χ2(3) = 13.83, p = 0.0031). There was an interaction between age and perpetuity (Relative risk (RR) 0.9995; 95% Confidence interval (CI95): 0.9991–0.9998). For example, for each hour above 8 mL/kg ideal body weight, a 20-year-old with 90% oxygen saturation has a relative risk of death of 1.02, but a 40-year-old with 90% oxygen saturation has a relative risk of 1.01. Conclusions: Perpetuity, illustrated through the lens of mechanical ventilation, may represent a target for improving outcomes in critically ill patients, starting in the emergency department. Research is needed to evaluate the types of patients and interventions in which perpetuity plays a role.
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Retamal J, Damiani LF, Basoalto R, Benites MH, Bruhn A, Larsson A, Bugedo G. Physiological and inflammatory consequences of high and low respiratory rate in acute respiratory distress syndrome. Acta Anaesthesiol Scand 2021; 65:1013-1022. [PMID: 33844272 DOI: 10.1111/aas.13830] [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] [Received: 11/18/2020] [Revised: 03/17/2021] [Accepted: 03/29/2021] [Indexed: 12/18/2022]
Abstract
Using protective mechanical ventilation strategies with low tidal volume is usually accompanied by an increment of respiratory rate to maintain adequate alveolar ventilation. However, there is no robust data that support the safety of a high respiratory rate concerning ventilator-induced lung injury. Several experimental animal studies have explored the effects of respiratory rate over lung physiology, using a wide range of frequencies and different models. Clinical evidence is scarce and restricted to the physiological impact of increased respiratory rate. Undoubtedly, the respiratory rate can influence respiratory mechanics in various ways as a factor of multiplication of the power of ventilation, and gas exchange, and also on alveolar dynamics. In this narrative review, we present our point of view over the main experimental and clinical evidence available regarding the effect of respiratory rate on ventilator-induced lung injury development.
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Affiliation(s)
- Jaime Retamal
- Departamento de Medicina Intensiva Facultad de Medicina Pontificia Universidad Católica de Chile Santiago Chile
| | - Luis Felipe Damiani
- Departamento de Medicina Intensiva Facultad de Medicina Pontificia Universidad Católica de Chile Santiago Chile
- Departamento de Ciencias de la Salud Carrera de Kinesiología Facultad de Medicina Pontificia Universidad Católica de Chile Santiago Chile
| | - Roque Basoalto
- Departamento de Medicina Intensiva Facultad de Medicina Pontificia Universidad Católica de Chile Santiago Chile
| | - Martín H. Benites
- Departamento de Medicina Intensiva Clínica las Condes Santiago Chile
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva Facultad de Medicina Pontificia Universidad Católica de Chile Santiago Chile
| | - Anders Larsson
- Hedenstierna Laboratory Department of Surgical Sciences Section of Anaesthesiology and Critical Care Uppsala University Uppsala Sweden
| | - Guillermo Bugedo
- Departamento de Medicina Intensiva Facultad de Medicina Pontificia Universidad Católica de Chile Santiago Chile
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Abstract
Today's management of the ventilated patient still relies on the measurement of old parameters such as airway pressures and flow. Graphical presentations reveal the intricacies of patient-ventilator interactions in times of supporting the patient on the ventilator instead of fully ventilating the heavily sedated patient. This opens a new pathway for several bedside technologies based on basic physiologic knowledge; however, it may increase the complexity of measurements. The spread of the COVID-19 infection has confronted the anesthesiologist and intensivist with one of the most severe pulmonary pathologies of the last decades. Optimizing the patient at the bedside is an old and newly required skill for all physicians in the intensive care unit, supported by mobile technologies such as lung ultrasound and electrical impedance tomography. This review summarizes old knowledge and presents a brief insight into extended monitoring options.
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Affiliation(s)
- Ralph Gertler
- Department of Anaesthesiology and Intensive Care, HELIOS Klinikum München West, Teaching Hospital of the Ludwig-Maximilians-Universität, Steinerweg 5, München 85241, Germany.
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116
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Costa ELV, Slutsky AS, Brochard LJ, Brower R, Serpa-Neto A, Cavalcanti AB, Mercat A, Meade M, Morais CCA, Goligher E, Carvalho CRR, Amato MBP. Ventilatory Variables and Mechanical Power in Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2021; 204:303-311. [PMID: 33784486 DOI: 10.1164/rccm.202009-3467oc] [Citation(s) in RCA: 135] [Impact Index Per Article: 45.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Rationale: Mortality in acute respiratory distress syndrome (ARDS) has decreased after the adoption of lung-protective strategies. Lower Vt, lower driving pressure (ΔP), lower respiratory rates (RR), and higher end-expiratory pressure have all been suggested as key components of lung protection strategies. A unifying theoretical explanation has been proposed that attributes lung injury to the energy transfer rate (mechanical power) from the ventilator to the patient, calculated from a combination of several ventilator variables.Objectives: To assess the impact of mechanical power on mortality in patients with ARDS as compared with that of primary ventilator variables such as the ΔP, Vt, and RR.Methods: We obtained data on ventilatory variables and mechanical power from a pooled database of patients with ARDS who had participated in six randomized clinical trials of protective mechanical ventilation and one large observational cohort of patients with ARDS. The primary outcome was mortality at 28 days or 60 days.Measurements and Main Results: We included 4,549 patients (38% women; mean age, 55 ± 23 yr). The average mechanical power was 0.32 ± 0.14 J · min-1 · kg-1 of predicted body weight, the ΔP was 15.0 ± 5.8 cm H2O, and the RR was 25.7 ± 7.4 breaths/min. The driving pressure, RR, and mechanical power were significant predictors of mortality in adjusted analyses. The impact of the ΔP on mortality was four times as large as that of the RR.Conclusions: Mechanical power was associated with mortality during controlled mechanical ventilation in ARDS, but a simpler model using only the ΔP and RR was equivalent.
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Affiliation(s)
- Eduardo L V Costa
- Laboratório de Pneumologia, Laboratório de Investigação Médica 09, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil.,Instituto de Ensino e Pesquisa, Hospital Sírio-Libanes, São Paulo, São Paulo, Brazil
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Roy Brower
- Division of Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Ary Serpa-Neto
- Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
| | - Alexandre B Cavalcanti
- Instituto de Pesquisas Hospital do Coração-Hospital do Coração, São Paulo, São Paulo, Brazil
| | - Alain Mercat
- Département de Médecine Intensive-Réanimation, Centre Hospitalier Universitaire d'Angers, Université d'Angers, Angers, France
| | - Maureen Meade
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Caio C A Morais
- Laboratório de Pneumologia, Laboratório de Investigação Médica 09, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Ewan Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada; and.,Toronto General Hospital Research Institute, Toronto General Hospital, Toronto, Ontario, Canada
| | - Carlos R R Carvalho
- Laboratório de Pneumologia, Laboratório de Investigação Médica 09, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Marcelo B P Amato
- Laboratório de Pneumologia, Laboratório de Investigação Médica 09, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
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117
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Beitler JR, Walkey AJ. The Staying Power of Pressure- and Volume-limited Ventilation in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2021; 204:247-249. [PMID: 33891827 PMCID: PMC8513579 DOI: 10.1164/rccm.202104-0839ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Jeremy R Beitler
- Center for Acute Respiratory Failure and.,Division of Pulmonary and Critical Care Medicine Columbia University and New York-Presbyterian Hospital New York, New York
| | - Allan J Walkey
- Department of Medicine Boston University School of Medicine Boston, Massachusetts
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118
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Botta M, Wenstedt EFE, Tsonas AM, Buiteman-Kruizinga LA, van Meenen DMP, Korsten HHM, Horn J, Paulus F, Bindels AGJH, Schultz MJ, De Bie AJR. Effectiveness, safety and efficacy of INTELLiVENT-adaptive support ventilation, a closed-loop ventilation mode for use in ICU patients - a systematic review. Expert Rev Respir Med 2021; 15:1403-1413. [PMID: 34047244 DOI: 10.1080/17476348.2021.1933450] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Introduction: INTELLiVENT-Adaptive Support Ventilation (INTELLiVENT-ASV), an advanced closed-loop ventilation mode for use in intensive care unit (ICU) patients, is equipped with algorithms that automatically adjust settings on the basis of physiologic signals and patient's activity. Here we describe its effectiveness, safety, and efficacy in various types of ICU patients.Areas covered: A systematic search conducted in MEDLINE, EMBASE, the Cochrane Central register of Controlled Trials (CENTRAL), and in Google Scholar identified 10 randomized clinical trials.Expert opinion: Studies suggest INTELLiVENT-ASV to be an effective automated mode with regard to the titrations of tidal volume, airway pressure, and oxygen. INTELLiVENT-ASV is as safe as conventional modes. However, thus far studies have not shown INTELLiVENT-ASV to be superior to conventional modes with regard to duration of ventilation and other patient-centered outcomes. Future studies are needed to test its efficacy.
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Affiliation(s)
- M Botta
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands
| | - E F E Wenstedt
- Department of Intensive Care, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - A M Tsonas
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands
| | - L A Buiteman-Kruizinga
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands.,Department of Intensive Care, Reinier de Graaf Hospital, Delft, The Netherlands
| | - D M P van Meenen
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands
| | - H H M Korsten
- Department of Intensive Care, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.,Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - J Horn
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands.,Amsterdam Neuroscience, Amsterdam UMC Research Institute, Amsterdam, The Netherlands
| | - F Paulus
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands.,Faculty of Health, ACHIEVE, Centre of Applied Research, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - A G J H Bindels
- Department of Intensive Care, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - M J Schultz
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Research Unit, Mahidol University, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - A J R De Bie
- Department of Intensive Care, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.,Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
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Ball L, Volta CA, Saglietti F, Spadaro S, Di Lullo A, De Simone G, Guarnieri M, Della Corte F, Serpa Neto A, Gama de Abreu M, Schultz MJ, Zangrillo A, Pelosi P, Bignami E. Associations Between Expiratory Flow Limitation and Postoperative Pulmonary Complications in Patients Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:815-824. [PMID: 34404594 DOI: 10.1053/j.jvca.2021.07.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 07/13/2021] [Accepted: 07/19/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine whether driving pressure and expiratory flow limitation are associated with the development of postoperative pulmonary complications (PPCs) in cardiac surgery patients. DESIGN Prospective cohort study. SETTING University Hospital San Raffaele, Milan, Italy. PARTICIPANTS Patients undergoing elective cardiac surgery. MEASUREMENTS AND MAIN RESULTS The primary endpoint was the occurrence of a predefined composite of PPCs. The authors determined the association among PPCs and intraoperative ventilation parameters, mechanical power and energy load, and occurrence of expiratory flow limitation (EFL) assessed with the positive end-expiratory pressure test. Two hundred patients were enrolled, of whom 78 (39%) developed one or more PPCs. Patients with PPCs, compared with those without PPCs, had similar driving pressure (mean difference [MD] -0.1 [95% confidence interval (CI), -1.0 to 0.7] cmH2O, p = 0.561), mechanical power (MD 0.5 [95% CI, -0.3 to 1.1] J/m, p = 0.364), and total energy load (MD 95 [95% CI, -78 to 263] J, p = 0.293), but they had a higher incidence of EFL (51% v 38%, p = 0.005). Only EFL was associated independently with the development of PPCs (odds ratio 2.46 [95% CI, 1.28-4.80], p = 0.007). CONCLUSIONS PPCs occurred frequently in this patient population undergoing cardiac surgery. PPCs were associated independently with the presence of EFL but not with driving pressure, total energy load, or mechanical power.
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Affiliation(s)
- Lorenzo Ball
- Anesthesia and Intensive Care Unit, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands.
| | - Carlo Alberto Volta
- Department of Morphology, Surgery, and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Francesco Saglietti
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Savino Spadaro
- Department of Morphology, Surgery, and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Antonio Di Lullo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giulio De Simone
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marcello Guarnieri
- Department of Medicine and Surgery, University of Milan Bicocca, Milan, Italy
| | - Francesca Della Corte
- Department of Morphology, Surgery, and Experimental Medicine, Section of Anesthesia and Intensive Care, University of Ferrara, Ferrara, Italy
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, Australia
| | | | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care Unit, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Higher versus lower positive end-expiratory pressure in patients without acute respiratory distress syndrome: a meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:247. [PMID: 34266460 PMCID: PMC8280384 DOI: 10.1186/s13054-021-03669-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/04/2021] [Indexed: 12/29/2022]
Abstract
Background We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the association of higher positive end-expiratory pressure (PEEP), as opposed to lower PEEP, with hospital mortality in adult intensive care unit (ICU) patients undergoing invasive mechanical ventilation for reasons other than acute respiratory distress syndrome (ARDS). Methods We performed an electronic search of MEDLINE, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science from inception until June 16, 2021 with no language restrictions. In addition, a research-in-progress database and grey literature were searched. Results We identified 22 RCTs (2225 patients) comparing higher PEEP (1007 patients) with lower PEEP (991 patients). No statistically significant association between higher PEEP and hospital mortality was observed (risk ratio 1.02, 95% confidence interval 0.89–1.16; I2 = 0%, p = 0.62; low certainty of evidence). Among secondary outcomes, higher PEEP was associated with better oxygenation, higher respiratory system compliance, and lower risk of hypoxemia and ARDS occurrence. Furthermore, barotrauma, hypotension, duration of ventilation, lengths of stay, and ICU mortality were similar between the two groups. Conclusions In our meta-analysis of RCTs, higher PEEP, compared with lower PEEP, was not associated with mortality in patients without ARDS receiving invasive mechanical ventilation. Further large high-quality RCTs are required to confirm these findings. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03669-4.
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Weaver L, Das A, Saffaran S, Yehya N, Scott TE, Chikhani M, Laffey JG, Hardman JG, Camporota L, Bates DG. High risk of patient self-inflicted lung injury in COVID-19 with frequently encountered spontaneous breathing patterns: a computational modelling study. Ann Intensive Care 2021; 11:109. [PMID: 34255207 PMCID: PMC8276227 DOI: 10.1186/s13613-021-00904-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 07/06/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND There is on-going controversy regarding the potential for increased respiratory effort to generate patient self-inflicted lung injury (P-SILI) in spontaneously breathing patients with COVID-19 acute hypoxaemic respiratory failure. However, direct clinical evidence linking increased inspiratory effort to lung injury is scarce. We adapted a computational simulator of cardiopulmonary pathophysiology to quantify the mechanical forces that could lead to P-SILI at different levels of respiratory effort. In accordance with recent data, the simulator parameters were manually adjusted to generate a population of 10 patients that recapitulate clinical features exhibited by certain COVID-19 patients, i.e., severe hypoxaemia combined with relatively well-preserved lung mechanics, being treated with supplemental oxygen. RESULTS Simulations were conducted at tidal volumes (VT) and respiratory rates (RR) of 7 ml/kg and 14 breaths/min (representing normal respiratory effort) and at VT/RR of 7/20, 7/30, 10/14, 10/20 and 10/30 ml/kg / breaths/min. While oxygenation improved with higher respiratory efforts, significant increases in multiple indicators of the potential for lung injury were observed at all higher VT/RR combinations tested. Pleural pressure swing increased from 12.0 ± 0.3 cmH2O at baseline to 33.8 ± 0.4 cmH2O at VT/RR of 7 ml/kg/30 breaths/min and to 46.2 ± 0.5 cmH2O at 10 ml/kg/30 breaths/min. Transpulmonary pressure swing increased from 4.7 ± 0.1 cmH2O at baseline to 17.9 ± 0.3 cmH2O at VT/RR of 7 ml/kg/30 breaths/min and to 24.2 ± 0.3 cmH2O at 10 ml/kg/30 breaths/min. Total lung strain increased from 0.29 ± 0.006 at baseline to 0.65 ± 0.016 at 10 ml/kg/30 breaths/min. Mechanical power increased from 1.6 ± 0.1 J/min at baseline to 12.9 ± 0.2 J/min at VT/RR of 7 ml/kg/30 breaths/min, and to 24.9 ± 0.3 J/min at 10 ml/kg/30 breaths/min. Driving pressure increased from 7.7 ± 0.2 cmH2O at baseline to 19.6 ± 0.2 cmH2O at VT/RR of 7 ml/kg/30 breaths/min, and to 26.9 ± 0.3 cmH2O at 10 ml/kg/30 breaths/min. CONCLUSIONS Our results suggest that the forces generated by increased inspiratory effort commonly seen in COVID-19 acute hypoxaemic respiratory failure are comparable with those that have been associated with ventilator-induced lung injury during mechanical ventilation. Respiratory efforts in these patients should be carefully monitored and controlled to minimise the risk of lung injury.
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Affiliation(s)
- Liam Weaver
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK
| | - Anup Das
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK
| | - Sina Saffaran
- Faculty of Engineering Science, University College London, London, WC1E 6BT, UK
| | - Nadir Yehya
- Department of Anaesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Timothy E Scott
- Academic Department of Military Anaesthesia and Critical Care, Royal Centre for Defence Medicine, ICT Centre, Birmingham, B15 2SQ, UK
| | - Marc Chikhani
- Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, NUI Galway, Galway, Ireland
| | - Jonathan G Hardman
- Anaesthesia & Critical Care, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
- Nottingham University Hospitals NHS Trust, Nottingham, NG7 2UH, UK
| | - Luigi Camporota
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK.
| | - Declan G Bates
- School of Engineering, University of Warwick, Coventry, CV4 7AL, UK.
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Zhang C, Xu F, Li W, Tong X, Xia R, Wang W, Du J, Shi X. Driving Pressure-Guided Individualized Positive End-Expiratory Pressure in Abdominal Surgery: A Randomized Controlled Trial. Anesth Analg 2021; 133:1197-1205. [PMID: 34125080 DOI: 10.1213/ane.0000000000005575] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The optimal positive end-expiratory pressure (PEEP) to prevent postoperative pulmonary complications (PPCs) remains unclear. Recent evidence showed that driving pressure was closely related to PPCs. In this study, we tested the hypothesis that an individualized PEEP guided by minimum driving pressure during abdominal surgery would reduce the incidence of PPCs. METHODS This single-centered, randomized controlled trial included a total of 148 patients scheduled for open upper abdominal surgery. Patients were randomly assigned to receive an individualized PEEP guided by minimum driving pressure or an empiric fixed PEEP of 6 cm H2O. The primary outcome was the incidence of clinically significant PPCs within the first 7 days after surgery, using a χ2 test. Secondary outcomes were the severity of PPCs, the area of atelectasis, and pleural effusion. Other outcomes, such as the incidence of different types of PPCs (including hypoxemia, atelectasis, pleural effusion, dyspnea, pneumonia, pneumothorax, and acute respiratory distress syndrome), intensive care unit (ICU) admission rate, length of hospital stay, and 30-day mortality were also explored. RESULTS The median value of PEEP in the individualized group was 10 cm H2O. The incidence of clinically significant PPCs was significantly lower in the individualized PEEP group compared with that in the fixed PEEP group (26 of 67 [38.8%] vs 42 of 67 [62.7%], relative risk = 0.619, 95% confidence intervals, 0.435-0.881; P = .006). The overall severity of PPCs and the area of atelectasis were also significantly diminished in the individualized PEEP group. Higher respiratory compliance during surgery and improved intra- and postoperative oxygenation was observed in the individualized group. No significant differences were found in other outcomes between the 2 groups, such as ICU admission rate or 30-day mortality. CONCLUSIONS The application of individualized PEEP based on minimum driving pressure may effectively decrease the severity of atelectasis, improve oxygenation, and reduce the incidence of clinically significant PPCs after open upper abdominal surgery.
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Affiliation(s)
- Chengmi Zhang
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Fengying Xu
- Department of Anesthesiology, No. 971 Hospital of People's Liberation Army Navy, Qingdao, China
| | - Weiwei Li
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xingyu Tong
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Ran Xia
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Wei Wang
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Jianer Du
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Xueyin Shi
- From the Department of Anesthesiology and Critical Care Medicine, Xinhua Hospital, affiliated with Shanghai Jiaotong University School of Medicine, Shanghai, China
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Modesto I Alapont V, Medina Villanueva A, Del Villar Guerra P, Camilo C, Fernández-Ureña S, Gordo-Vidal F, Khemani R. OLA strategy for ARDS: Its effect on mortality depends on achieved recruitment (PaO 2/FiO 2) and mechanical power. Systematic review and meta-analysis with meta-regression. Med Intensiva 2021; 45:S0210-5691(21)00075-9. [PMID: 34103170 DOI: 10.1016/j.medin.2021.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 02/26/2021] [Accepted: 03/26/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The "Open Lung Approach" (OLA), that includes high levels of positive end-expiratory pressure coupled with limited tidal volumes, is considered optimal for adult patients with ARDS. However, many previous meta-analyses have shown only marginal benefits of OLA on mortality but with statistical heterogeneity. It is crucial to identify the most likely moderators of this effect. To determine the effect of OLA strategy on mortality of ventilated ARDS patients. We hypothesized that the degree of recruitment achieved in the control group (PaO2/FiO2 ratio on day 3 of ventilation), and the difference in Mechanical Power (MP) or Driving Pressure (DP) between experimental and control groups will be the most likely sources of heterogeneity. DESIGN A Systematic Review and Meta-analysis was performed according to PRISMA statement and registered in PROSPERO database. We searched only for randomized controlled trials (RCTs). GRADE guidelines were used for rating the quality of evidence. Publication bias was assessed. For the Meta-analysis, we used a Random Effects Model. Sources of heterogeneity were explored with Meta-Regression, using a priori proposed set of possible moderators. For model comparison, Akaike's Information Criterion with the finite sample correction (AICc) was used. SETTING Not applicable. PATIENTS Fourteen RCTs were included in the study. INTERVENTIONS Not applicable. MAIN VARIABLES OF INTEREST Not applicable. RESULTS Evidence of publication bias was detected, and quality of evidence was downgraded. Pooled analysis did not show a significant difference in the 28-day mortality between OLA strategy and control groups. Overall risk of bias was low. The analysis detected statistical heterogeneity. The two "best" explicative meta-regression models were those that used control PaO2/FiO2 on day 3 and difference in MP between experimental and control groups. The DP and MP models were highly correlated. CONCLUSIONS There is no clear benefit of OLA strategy on mortality of ARDS patients, with significant heterogeneity among RCTs. Mortality effect of OLA is mediated by lung recruitment and mechanical power.
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Affiliation(s)
| | | | - P Del Villar Guerra
- Department of Pediatrics, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - C Camilo
- PICU, Hospital de Santa Maria-Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - S Fernández-Ureña
- Urgencias Pediátricas, Complejo Hospitalario Universitario Materno Insular Las Palmas, Universidad de Las Palmas, Las Palmas de Gran Canaria, Spain
| | - F Gordo-Vidal
- ICU, Hospital del Henares, Grupo de Investigación en Patología Crítica de la Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - R Khemani
- PICU, Children's Hospital Los Angeles, California, USA
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Hong Y, Chen L, Pan Q, Ge H, Xing L, Zhang Z. Individualized Mechanical power-based ventilation strategy for acute respiratory failure formalized by finite mixture modeling and dynamic treatment regimen. EClinicalMedicine 2021; 36:100898. [PMID: 34041461 PMCID: PMC8144670 DOI: 10.1016/j.eclinm.2021.100898] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Mechanical ventilation (MV) is the key to the successful treatment of acute respiratory failure (ARF) in the intensive care unit (ICU). The study aims to formalize the concept of individualized MV strategy with finite mixture modeling (FMM) and dynamic treatment regime (DTR). METHODS ARF patients requiring MV for over 48 h from 2008 to 2019 were included. FMM was conducted to identify classes of ARF. Static and dynamic mechanical power (MP_static and MP_dynamic) and relevant clinical variables were calculated/collected from hours 0 to 48 at an interval of 8 h. Δ M P was calculated as the difference between actual and optimal MP. FINDINGS A total of 8768 patients were included for analysis with a mortality rate of 27%. FFM identified three classes of ARF, namely, the class 1 (baseline), class 2 (critical) and class 3 (refractory respiratory failure). The effect size of MP_static on mortality is the smallest in class 1 (HR for every 5 Joules/min increase: 1.29; 95% CI: 1.15 to 1.45; p < 0.001) and the largest in class 3 (HR for every 5 Joules/min increase: 1.83; 95% CI: 1.52 to 2.20; p < 0.001). INTERPRETATION MP has differing therapeutic effects for subtypes of ARF. Optimal MP estimated by DTR model may help to improve survival outcome. FUNDING The study was funded by Health Science and Technology Plan of Zhejiang Province (2021KY745), Key Research & Development project of Zhejiang Province (2021C03071) and Yilu "Gexin" - Fluid Therapy Research Fund Project (YLGX-ZZ-2,020,005).
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Affiliation(s)
- Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Lin Chen
- Department of Critical Care Medicine, Affiliated Jinhua Hospital, Zhejiang University School of Medicine, Jinhua, China
| | - Qing Pan
- College of Information Engineering, Zhejiang University of Technology, 310023, Hangzhou, China
| | - Huiqing Ge
- Department of Respiratory Care, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Lifeng Xing
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
| | - Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, 310016, China
- Corresponding author at: Address: No 3, East Qingchun Road, Hangzhou 310016, Zhejiang Province, China.
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Mechanical Ventilation Strategy Guided by Transpulmonary Pressure in Severe Acute Respiratory Distress Syndrome Treated With Venovenous Extracorporeal Membrane Oxygenation. Crit Care Med 2021; 48:1280-1288. [PMID: 32590385 DOI: 10.1097/ccm.0000000000004445] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Previous studies have suggested that adjusting ventilator settings based on transpulmonary pressure measurements may minimize ventilator-induced lung injury, but this has never been investigated in patients with severe acute respiratory distress syndrome supported with venovenous extracorporeal membrane oxygenation. We aimed to evaluate whether a transpulmonary pressure-guided ventilation strategy would increase the proportion of patients successfully weaned from venovenous extracorporeal membrane oxygenation support in patients with severe acute respiratory distress syndrome. DESIGN Single-center, prospective, randomized controlled trial. SETTING Sixteen-bed, respiratory ICU at a tertiary academic medical center. PATIENTS Severe acute respiratory distress syndrome patients receiving venovenous extracorporeal membrane oxygenation. INTERVENTIONS One-hundred four patients were randomized to transpulmonary pressure-guided ventilation group (n = 52) or lung rest strategy group (n = 52) groups. Two patients had cardiac arrest during establishment of venovenous extracorporeal membrane oxygenation in the lung rest group did not receive the assigned intervention. Thus, 102 patients were included in the analysis. MEASUREMENTS AND MAIN RESULTS The proportion of patients successfully weaned from venovenous extracorporeal membrane oxygenation in the transpulmonary pressure-guided group was significantly higher than that in the lung rest group (71.2% vs 48.0%; p = 0.017). Compared with the lung rest group, driving pressure, tidal volumes, and mechanical power were significantly lower, and positive end-expiratory pressure was significantly higher, in the transpulmonary pressure-guided group during venovenous extracorporeal membrane oxygenation support. In the transpulmonary pressure-guided group, levels of interleukin-1β, interleukin-6, and interleukin-8 were significantly lower, and interleukin-10 was significantly higher, than those of the lung rest group over time. Lung density was significantly lower in the transpulmonary pressure-guided group after venovenous extracorporeal membrane oxygenation support than in the lung rest group. CONCLUSIONS A transpulmonary pressure-guided ventilation strategy could increase the proportion of patients with severe acute respiratory distress syndrome successfully weaned from venovenous extracorporeal membrane oxygenation.
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Quantification of Volatile Aldehydes Deriving from In Vitro Lipid Peroxidation in the Breath of Ventilated Patients. Molecules 2021; 26:molecules26113089. [PMID: 34064214 PMCID: PMC8196825 DOI: 10.3390/molecules26113089] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 05/14/2021] [Accepted: 05/19/2021] [Indexed: 01/18/2023] Open
Abstract
Exhaled aliphatic aldehydes were proposed as non-invasive biomarkers to detect increased lipid peroxidation in various diseases. As a prelude to clinical application of the multicapillary column–ion mobility spectrometry for the evaluation of aldehyde exhalation, we, therefore: (1) identified the most abundant volatile aliphatic aldehydes originating from in vitro oxidation of various polyunsaturated fatty acids; (2) evaluated emittance of aldehydes from plastic parts of the breathing circuit; (3) conducted a pilot study for in vivo quantification of exhaled aldehydes in mechanically ventilated patients. Pentanal, hexanal, heptanal, and nonanal were quantifiable in the headspace of oxidizing polyunsaturated fatty acids, with pentanal and hexanal predominating. Plastic parts of the breathing circuit emitted hexanal, octanal, nonanal, and decanal, whereby nonanal and decanal were ubiquitous and pentanal or heptanal not being detected. Only pentanal was quantifiable in breath of mechanically ventilated surgical patients with a mean exhaled concentration of 13 ± 5 ppb. An explorative analysis suggested that pentanal exhalation is associated with mechanical power—a measure for the invasiveness of mechanical ventilation. In conclusion, exhaled pentanal is a promising non-invasive biomarker for lipid peroxidation inducing pathologies, and should be evaluated in future clinical studies, particularly for detection of lung injury.
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Gong J, Zhang B, Huang X, Li B, Huang J. Product of driving pressure and respiratory rate for predicting weaning outcomes. J Int Med Res 2021; 49:3000605211010045. [PMID: 33969736 PMCID: PMC8113923 DOI: 10.1177/03000605211010045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective Clinicians cannot precisely determine the time for withdrawal of ventilation.
We aimed to evaluate the performance of driving pressure (DP)×respiratory
rate (RR) to predict the outcome of weaning. Methods Plateau pressure (Pplat) and total positive end-expiratory pressure (PEEPtot)
were measured during mechanical ventilation with brief deep sedation and on
volume-controlled mechanical ventilation with a tidal volume of 6 mL/kg and
a PEEP of 0 cmH2O. Pplat and PEEPtot were measured by patients
holding their breath for 2 s after inhalation and exhalation, respectively.
DP was determined as Pplat minus PEEPtot. The rapid shallow breathing index
was measured from the ventilator. The highest RR was recorded within 3
minutes during a spontaneous breathing trial. Patients who tolerated a
spontaneous breathing trial for 1 hour were extubated. Results Among the 105 patients studied, 44 failed weaning. During ventilation
withdrawal, DP×RR was 136.7±35.2 cmH2O breaths/minute in the
success group and 230.2±52.2 cmH2O breaths/minute in the failure
group. A DP×RR index >170.8 cmH2O breaths/minute had a
sensitivity of 93.2% and specificity of 88.5% to predict failure of
weaning. Conclusions Measurement of DP×RR during withdrawal of ventilation may help predict the
weaning outcome. A high DP×RR increases the likelihood of weaning
failure. Statement: This manuscript was previously posted as a preprint
on Research Square with the following link: https://www.researchsquare.com/article/rs-15065/v3 and DOI:
10.21203/rs.2.24506/v3
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Affiliation(s)
- Ju Gong
- Department of Emergency Medicine, The First affiliated Hospital of Soochow University, Suzhou, China
| | - Bibo Zhang
- Department of Emergency Medicine, The Affiliated Changshu Hospital of Xuzhou Medical University, Changshu, China
| | - Xiaowen Huang
- Department of Acupuncture and Tuina, Changshu Hospital of Traditional Chinese Medicine, Changshu, China
| | - Bin Li
- Department of Critical Care Medicine, The Affiliated Changshu Hospital of Xuzhou Medical University, Changshu, China
| | - Jian Huang
- Department of Emergency Medicine, The First affiliated Hospital of Soochow University, Suzhou, China
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Abstract
Mechanical power of ventilation, currently defined as the energy delivered from the ventilator to the respiratory system over a period of time, has been recognized as a promising indicator to evaluate ventilator-induced lung injury and predict the prognosis of ventilated critically ill patients. Mechanical power can be accurately measured by the geometric method, while simplified equations allow an easy estimation of mechanical power at the bedside. There may exist a safety threshold of mechanical power above which lung injury is inevitable, and the assessment of mechanical power might be helpful to determine whether the extracorporeal respiratory support is needed in patients with acute respiratory distress syndrome. It should be noted that relatively low mechanical power does not exclude the possibility of lung injury. Lung size and inhomogeneity should also be taken into consideration. Problems regarding the safety limits of mechanical power and contribution of each component to lung injury have not been determined yet. Whether mechanical power-directed lung-protective ventilation strategy could improve clinical outcomes also needs further investigation. Therefore, this review discusses the algorithms, clinical relevance, optimization, and future directions of mechanical power in critically ill patients.
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Wu Z, Liu Y, Xu J, Xie J, Zhang S, Huang L, Huang Y, Yang Y, Qiu H. A Ventilator-associated Pneumonia Prediction Model in Patients With Acute Respiratory Distress Syndrome. Clin Infect Dis 2021; 71:S400-S408. [PMID: 33367575 DOI: 10.1093/cid/ciaa1518] [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] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Mechanical ventilation is crucial for acute respiratory distress syndrome (ARDS) patients and diagnosis of ventilator-associated pneumonia (VAP) in ARDS patients is challenging. Hence, an effective model to predict VAP in ARDS is urgently needed. METHODS We performed a secondary analysis of patient-level data from the Early versus Delayed Enteral Nutrition (EDEN) of ARDSNet randomized controlled trials. Multivariate binary logistic regression analysis established a predictive model, incorporating characteristics selected by systematic review and univariate analyses. The model's discrimination, calibration, and clinical usefulness were assessed using the C-index, calibration plot, and decision curve analysis (DCA). RESULTS Of the 1000 unique patients enrolled in the EDEN trials, 70 (7%) had ARDS complicated with VAP. Mechanical ventilation duration and intensive care unit (ICU) stay were significantly longer in the VAP group than non-VAP group (P < .001 for both) but the 60-day mortality was comparable. Use of neuromuscular blocking agents, severe ARDS, admission for unscheduled surgery, and trauma as primary ARDS causes were independent risk factors for VAP. The area under the curve of the model was .744, and model fit was acceptable (Hosmer-Lemeshow P = .185). The calibration curve indicated that the model had proper discrimination and good calibration. DCA showed that the VAP prediction nomogram was clinically useful when an intervention was decided at a VAP probability threshold between 1% and 61%. CONCLUSIONS The prediction nomogram for VAP development in ARDS patients can be applied after ICU admission, using available variables. Potential clinical benefits of using this model deserve further assessment.
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Affiliation(s)
- Zongsheng Wu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yao Liu
- Department of Emergency, Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
| | - Jingyuan Xu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Shi Zhang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Lili Huang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yingzi Huang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
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Clusters of Double Triggering Impact Clinical Outcomes: Insights From the EPIdemiology of Patient-Ventilator aSYNChrony (EPISYNC) Cohort Study. Crit Care Med 2021; 49:1460-1469. [PMID: 33883458 DOI: 10.1097/ccm.0000000000005029] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To measure the impact of clusters of double triggering on clinical outcomes. DESIGN Prospective cohort study. SETTING Respiratory ICU in Brazil. PATIENTS Adult patients under recent mechanical ventilation and with expectation of mechanical ventilation for more than 24 hours after enrollment. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We used a dedicated software to analyze ventilator waveforms throughout the entire period of mechanical ventilation and detect double triggering. We defined a cluster of double triggering as a period of time containing at least six double triggering events in a 3-minute period. Patients were followed until hospital discharge. We addressed the association between the presence and the duration of clusters with clinical outcomes. A total of 103 patients were enrolled in the study and 90 (87%) had at least one cluster of double triggering. The median number of clusters per patient was 19 (interquartile range, 6-41), with a median duration of 8 minutes (6-12 min). Compared with patients who had no clusters, patients with at least one cluster had longer duration of mechanical ventilation (7 d [4-11 d] vs 2 d [2-3 d]) and ICU length of stay (9 d [7-16 d] vs 13 d [2-8 d]). Thirty-three patients had high cumulative duration of clusters of double triggering (≥ 12 hr), and it was associated with longer duration of mechanical ventilation, fewer ventilator-free days, and longer ICU length of stay. Adjusted by duration of mechanical ventilation and severity of illness, high cumulative duration of clusters was associated with shorter survival at 28 days (hazard ratio, 2.09 d; 95% CI, 1.04-4.19 d). CONCLUSIONS Clusters of double triggering are common and were associated with worse clinical outcomes. Patients who had a high cumulative duration of clusters had fewer ventilator-free days, longer duration of mechanical ventilation, longer ICU length of stay, and shorter survival than patients with low cumulative duration of cluster.
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Hong W, Zhi FX, Kun TH, Hua FJ, Huan Ling L, Fang F, Wen C, Jie W, Yang LC. 6-Gingerol attenuates ventilator-induced lung injury via anti-inflammation and antioxidative stress by modulating the PPARγ/NF-κBsignalling pathway in rats. Int Immunopharmacol 2021; 92:107367. [PMID: 33461160 DOI: 10.1016/j.intimp.2021.107367] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 12/08/2020] [Accepted: 01/04/2021] [Indexed: 02/05/2023]
Abstract
Although mechanical ventilation (MV) is indispensable to life-support therapy in critically ill patients, it may promote or aggravatelunginjury known asventilator-inducedlunginjury(VILI). 6-Gingerol is the principal ingredient of ginger with potential anti-inflammatory and antioxidant properties in various diseases. Nevertheless, the role and mechanism of 6-gingerol in the process of VILI has not been explicitly investigated. In the study, we found that pre-treatment with 6-gingerol significantly improved the histological changes and pulmonary oedema, inhibited neutrophil accumulation and the release of early pro-inflammatory cytokines and MPO, and reduced oxidative stress reactions after high MV. Moreover, 6-gingerol treatment also increased PPARγ expression and decreased NF-κB activation in rats subjected to high MV. Furthermore, GW9662, a specific PPARγ inhibitor, was demonstrated to activatethe NF-κB pathway and cancele the protective role of 6-gingerol in VILI. This indicates that 6-gingerol exerted anti-inflammatory and antioxidative stress effects in VILI by activating PPARγ and inhibiting the NF-κBsignalling pathway.
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Affiliation(s)
- Wei Hong
- Department of Anesthesiology, Huazhong University of Science and Technology Union ShenZhen Hospital, ShenZhen, China; Department of Anesthesiology, The 6th Affiliated Hospital of Shenzhen University Health Science Center, ShenZhen, China
| | - Fang Xiang Zhi
- Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Department of Anesthesiology, Subei People's Hospital, YangZhou 225001, China
| | - Tu Han Kun
- Department of Anesthesiology, Huazhong University of Science and Technology Union ShenZhen Hospital, ShenZhen, China; Department of Anesthesiology, The 6th Affiliated Hospital of Shenzhen University Health Science Center, ShenZhen, China
| | - Feng Jie Hua
- Department of Anesthesiology, Huazhong University of Science and Technology Union ShenZhen Hospital, ShenZhen, China; Department of Anesthesiology, The 6th Affiliated Hospital of Shenzhen University Health Science Center, ShenZhen, China
| | - Li Huan Ling
- Department of Anesthesiology, Huazhong University of Science and Technology Union ShenZhen Hospital, ShenZhen, China; Department of Anesthesiology, The 6th Affiliated Hospital of Shenzhen University Health Science Center, ShenZhen, China
| | - Fang Fang
- Department of General Medicine, Huazhong University of Science and Technology Union ShenZhen Hospital and The 6th Affiliated Hospital of Shenzhen University Health Science Center, ShenZhen, China
| | - Chen Wen
- Department of Anesthesiology, Yuebei People's Hospital, Shantou University Medical College, Shaoguan, Guangdong Province, China
| | - Wang Jie
- Institute of Anesthesiology and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
| | - Li Chao Yang
- Department of Anesthesiology, Huazhong University of Science and Technology Union ShenZhen Hospital, ShenZhen, China; Department of Anesthesiology, The 6th Affiliated Hospital of Shenzhen University Health Science Center, ShenZhen, China.
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Comparison of Mechanical Power During Adaptive Support Ventilation Versus Nonautomated Pressure-Controlled Ventilation-A Pilot Study. Crit Care Explor 2021; 3:e0335. [PMID: 33604578 PMCID: PMC7886404 DOI: 10.1097/cce.0000000000000335] [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] [Indexed: 11/26/2022] Open
Abstract
Supplemental Digital Content is available in the text. The aim of this pilot study was to compare the amount of “mechanical power of ventilation” under adaptive support ventilation with nonautomated pressure-controlled ventilation.
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He K, Han S, An L, Zhang J. Inhibition of MicroRNA-214 Alleviates Lung Injury and Inflammation via Increasing FGFR1 Expression in Ventilator-Induced Lung Injury. Lung 2021; 199:63-72. [PMID: 33389067 DOI: 10.1007/s00408-020-00415-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 12/11/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Ventilator-induced lung injury (VILI) is an additional inflammatory injury caused by mechanical ventilation (MV). This study aimed to determine the effects of microRNA-214 (miR-214) on VILI and its underlying mechanism of action. METHODS To develop a VILI mouse model, mice were subjected to MV. The expression of miR-214 was detected by qRT-PCR. The macrophages, fibroblasts, epithelial cells, and endothelial cells were isolated from lung tissues by fluorescence-activated cell sorting. The histopathological changes of lung, lung wet/dry weight (W/D) ratio, and myeloperoxidase (MPO) activity were used to evaluate the degree of lung injury. The levels of pro-inflammatory cytokines in bronchoalveolar lavage fluid (BALF) were measured by enzyme-linked immunosorbent assay (ELISA). Dual-luciferase reporter assay was performed to determine the interactions between miR-214 and FGFR1. Western blot was used to detect the protein expression of FGFR1, p-AKT, and p-PI3K. RESULTS The expression of miR-214 was increased in lung tissues and macrophages, fibroblasts, epithelial cells, and endothelial cells isolated from lung tissues in VILI mice. MiR-214 inhibition decreased the histopathological changes of lung, lung W/D ratio, MPO activity, and pro-inflammatory cytokines levels in BALF in VILI mice. FGFR1 was targeted by miR-214. The protein expression of FGFR1 was decreased in VILI mice. Ponatinib (FGFR1 inhibitor) reversed the suppressive effects of miR-214 inhibition on lung injury and inflammation of VILI mice. MiR-214 increased the activity of PI3K/AKT pathway by regulating FGFR1. CONCLUSIONS Inhibition of miR-214 attenuated lung injury and inflammation in VILI mice by increasing FGFR1 expression, providing a novel therapeutic target for VILI.
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Affiliation(s)
- Kun He
- Department of Anesthesiology, The Fourth Hospital of Shijiazhuang, No. 206, Zhongshan East Road, Shijiazhuang, 050011, Hebei, China
| | - Shuang Han
- Department of Anesthesiology, Hebei General Hospital, No. 348, Heping West Road, Shijiazhuang, 050051, Hebei, China
| | - Li An
- Department of Anesthesiology, The Fourth Hospital of Shijiazhuang, No. 206, Zhongshan East Road, Shijiazhuang, 050011, Hebei, China.
| | - Jin Zhang
- Department of Anesthesiology, The Fourth Hospital of Shijiazhuang, No. 206, Zhongshan East Road, Shijiazhuang, 050011, Hebei, China
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Chiu LC, Lin SW, Chuang LP, Li HH, Liu PH, Tsai FC, Chang CH, Hung CY, Lee CS, Leu SW, Hu HC, Huang CC, Wu HP, Kao KC. Mechanical power during extracorporeal membrane oxygenation and hospital mortality in patients with acute respiratory distress syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:13. [PMID: 33407733 PMCID: PMC7787230 DOI: 10.1186/s13054-020-03428-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/07/2020] [Indexed: 12/20/2022]
Abstract
Background Mechanical power (MP) refers to the energy delivered by a ventilator to the respiratory system per unit of time. MP referenced to predicted body weight (PBW) or respiratory system compliance have better predictive value for mortality than MP alone in acute respiratory distress syndrome (ARDS). Our objective was to assess the potential impact of consecutive changes of MP on hospital mortality among ARDS patients receiving extracorporeal membrane oxygenation (ECMO).
Methods We performed a retrospective analysis of patients with severe ARDS receiving ECMO in a tertiary care referral center in Taiwan between May 2006 and October 2015. Serial changes of MP during ECMO were recorded. Results A total of 152 patients with severe ARDS rescued with ECMO were analyzed. Overall hospital mortality was 53.3%. There were no significant differences between survivors and nonsurvivors in terms of baseline values of MP or other ventilator settings. Cox regression models demonstrated that mean MP alone, MP referenced to PBW, and MP referenced to compliance during the first 3 days of ECMO were all independently associated with hospital mortality. Higher MP referenced to compliance (HR 2.289 [95% CI 1.214–4.314], p = 0.010) was associated with a higher risk of death than MP itself (HR 1.060 [95% CI 1.018–1.104], p = 0.005) or MP referenced to PBW (HR 1.004 [95% CI 1.002–1.007], p < 0.001). The 90-day hospital mortality of patients with high MP (> 14.4 J/min) during the first 3 days of ECMO was significantly higher than that of patients with low MP (≦ 14.4 J/min) (70.7% vs. 46.8%, p = 0.004), and the 90-day hospital mortality of patients with high MP referenced to compliance (> 0.53 J/min/ml/cm H2O) during the first 3 days of ECMO was significantly higher than that of patients with low MP referenced to compliance (≦ 0.53 J/min/ml/cm H2O) (63.6% vs. 29.7%, p < 0.001). Conclusions MP during the first 3 days of ECMO was the only ventilatory variable independently associated with 90-day hospital mortality, and MP referenced to compliance during ECMO was more predictive for mortality than was MP alone.
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Affiliation(s)
- Li-Chung Chiu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan.,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Department of Thoracic Medicine, New Taipei Municipal TuCheng Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Shih-Wei Lin
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan
| | - Li-Pang Chuang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan
| | - Hsin-Hsien Li
- Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan, Taiwan.,Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Pi-Hua Liu
- Clinical Informatics and Medical Statistics Research Center, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Feng-Chun Tsai
- Division of Cardiovascular Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chih-Hao Chang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan.,Department of Thoracic Medicine, New Taipei Municipal TuCheng Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Chen-Yiu Hung
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan.,Department of Thoracic Medicine, New Taipei Municipal TuCheng Hospital and Chang Gung University, Taoyuan, Taiwan
| | - Chung-Shu Lee
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan
| | - Shaw-Woei Leu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan
| | - Han-Chung Hu
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan.,Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan, Taiwan.,Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Chung-Chi Huang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan.,Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan, Taiwan.,Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Huang-Pin Wu
- Division of Pulmonary, Critical Care and Sleep Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Kuo-Chin Kao
- Department of Thoracic Medicine, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Linkou, No. 5, Fu-Shing St., GuiShan, Taoyuan, Taiwan. .,Department of Respiratory Therapy, Chang Gung University College of Medicine, Taoyuan, Taiwan. .,Department of Respiratory Therapy, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan. .,Department of Intensive Care, Xiamen Chang Gung Hospital, Xiamen, China.
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Belliato M, Epis F, Cremascoli L, Ferrari F, Quattrone MG, Fisser C, Malfertheiner MV, Taccone FS, Di Nardo M, Broman LM, Lorusso R. Mechanical Power during Veno-Venous Extracorporeal Membrane Oxygenation Initiation: A Pilot-Study. MEMBRANES 2021; 11:membranes11010030. [PMID: 33401668 PMCID: PMC7824596 DOI: 10.3390/membranes11010030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 12/27/2020] [Accepted: 12/29/2020] [Indexed: 12/27/2022]
Abstract
Mechanical power (MP) represents a useful parameter to describe and quantify the forces applied to the lungs during mechanical ventilation (MV). In this multi-center, prospective, observational study, we analyzed MP variations following MV adjustments after veno-venous extra-corporeal membrane oxygenation (VV ECMO) initiation. We also investigated whether the MV parameters (including MP) in the early phases of VV ECMO run may be related to the intensive care unit (ICU) mortality. Thirty-five patients with severe acute respiratory distress syndrome were prospectively enrolled and analyzed. After VV ECMO initiation, we observed a significant decrease in median MP (32.4 vs. 8.2 J/min, p < 0.001), plateau pressure (27 vs. 21 cmH2O, p = 0.012), driving pressure (11 vs. 8 cmH2O, p = 0.014), respiratory rate (RR, 22 vs. 14 breaths/min, p < 0.001), and tidal volume adjusted to patient ideal body weight (VT/IBW, 5.5 vs. 4.0 mL/kg, p = 0.001) values. During the early phase of ECMO run, RR (17 vs. 13 breaths/min, p = 0.003) was significantly higher, while positive end-expiratory pressure (10 vs. 14 cmH2O, p = 0.048) and VT/IBW (3.0 vs. 4.0 mL/kg, p = 0.028) were lower in ICU non-survivors, when compared to the survivors. The observed decrease in MP after ECMO initiation did not influence ICU outcome. Waiting for large studies assessing the role of these parameters in VV ECMO patients, RR and MP monitoring should not be underrated during ECMO.
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Affiliation(s)
- Mirko Belliato
- 2nd Intensive Care Unit, UOC Anestesia e Rianimazione II Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
| | - Francesco Epis
- 2nd Intensive Care Unit, UOC Anestesia e Rianimazione II Cardiopolmonare, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
- Correspondence: ; Tel.: +39-0382-503524
| | - Luca Cremascoli
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, 27100 Pavia, Italy; (L.C.); (M.G.Q.)
| | - Fiorenza Ferrari
- 1st Intensive Care Unit, UOC Anestesia e Rianimazione I, Fondazione IRCCS Policlinico San Matteo, 27100 Pavia, Italy;
- International Renal Research Institute of Vicenza (IRRIV) and Department of Nephrology, Dialysis and Transplantation, 36100 Vicenza, Italy
| | - Maria Giovanna Quattrone
- Department of Clinical-Surgical, Diagnostic and Paediatric Sciences, Unit of Anaesthesia and Intensive Care, University of Pavia, 27100 Pavia, Italy; (L.C.); (M.G.Q.)
| | - Christoph Fisser
- Department of Internal Medicine II, Cardiology and Pneumology, Intensive Care, University Hospital Regensburg, 93053 Regensburg, Germany; (C.F.); (M.V.M.)
| | - Maximilian Valentin Malfertheiner
- Department of Internal Medicine II, Cardiology and Pneumology, Intensive Care, University Hospital Regensburg, 93053 Regensburg, Germany; (C.F.); (M.V.M.)
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Cliniques Universitaires de Brussels, 1070 Brussels, Belgium;
| | - Matteo Di Nardo
- Pediatric Intensive Care, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, and Department of Physiology and Pharmacology, Karolinska Institutet, 171 64 Solna (Stockholm), Sweden;
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), 6229 HX Maastricht, The Netherlands;
- Cardiovascular Research Institute Maastricht (CARIM), 6229 ER Maastricht, The Netherlands
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Viola L, Russo E, Benni M, Gamberini E, Circelli A, Bissoni L, Santonastaso DP, Scognamiglio G, Bolondi G, Mezzatesta L, Agnoletti V. Lung mechanics in type L CoVID-19 pneumonia: a pseudo-normal ARDS. TRANSLATIONAL MEDICINE COMMUNICATIONS 2020; 5:27. [PMID: 33363256 PMCID: PMC7750393 DOI: 10.1186/s41231-020-00076-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 11/11/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND This study was conceived to provide systematic data about lung mechanics during early phases of CoVID-19 pneumonia, as long as to explore its variations during prone positioning. METHODS We enrolled four patients hospitalized in the Intensive Care Unit of "M. Bufalini" hospital, Cesena (Italy); after the positioning of an esophageal balloon, we measured mechanical power, respiratory system and transpulmonary parameters and arterial blood gases every 6 hours, just before decubitus change and 1 hour after prono-supination. RESULTS Both respiratory system and transpulmonary compliance and driving pressure confirmed the pseudo-normal respiratory mechanics of early CoVID-19 pneumonia (respectively, CRS 40.8 ml/cmH2O and DPRS 9.7 cmH2O; CL 53.1 ml/cmH2O and DPL 7.9 cmH2O). Interestingly, prone positioning involved a worsening in respiratory mechanical properties throughout time (CRS,SUP 56.3 ml/cmH2O and CRS,PR 41.5 ml/cmH2O - P 0.37; CL,SUP 80.8 ml/cmH2O and CL,PR 53.2 ml/cmH2O - P 0.23). CONCLUSIONS Despite the severe ARDS pattern, respiratory system and lung mechanical properties during CoVID-19 pneumonia are pseudo-normal and tend to worsen during pronation. TRIAL REGISTRATION Restrospectively registered.
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Affiliation(s)
- Lorenzo Viola
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
| | - Emanuele Russo
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
| | - Marco Benni
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
| | - Emiliano Gamberini
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
| | - Alessandro Circelli
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
| | - Luca Bissoni
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
| | | | - Giovanni Scognamiglio
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
| | - Giuliano Bolondi
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
| | - Luca Mezzatesta
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
- University of Messina, Messina, Italy
| | - Vanni Agnoletti
- U.O. Anestesia e Rianimazione, Ospedale “M. Bufalini” Hospital, 286, Viale Ghirotti, Cesena, Italy
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137
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The predictive validity for mortality of the driving pressure and the mechanical power of ventilation. Intensive Care Med Exp 2020; 8:60. [PMID: 33336298 PMCID: PMC7746416 DOI: 10.1186/s40635-020-00346-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 09/17/2020] [Indexed: 12/22/2022] Open
Abstract
Background Outcome prediction in critically ill patients under invasive ventilation remains extremely challenging. The driving pressure (ΔP) and the mechanical power of ventilation (MP) are associated with patient-centered outcomes like mortality and duration of ventilation. The objective of this study was to assess the predictive validity for mortality of the ΔP and the MP at 24 h after start of invasive ventilation. Methods This is a post hoc analysis of an observational study in intensive care unit patients, restricted to critically ill patients receiving invasive ventilation for at least 24 h. The two exposures of interest were the modified ΔP and the MP at 24 h after start of invasive ventilation. The primary outcome was 90-day mortality; secondary outcomes were ICU and hospital mortality. The predictive validity was measured as incremental 90-day mortality beyond that predicted by the Acute Physiology, Age and Chronic Health Evaluation (APACHE) IV score and the Simplified Acute Physiology Score (SAPS) II. Results The analysis included 839 patients with a 90-day mortality of 42%. The median modified ΔP at 24 h was 15 [interquartile range 12 to 19] cm H2O; the median MP at 24 h was 206 [interquartile range 145 to 298] 10−3 J/min/kg predicted body weight (PBW). Both parameters were associated with 90-day mortality (odds ratio (OR) for 1 cm H2O increase in the modified ΔP, 1.05 [95% confidence interval (CI) 1.03 to 1.08]; P < 0.001; OR for 100 10−3 J/min/kg PBW increase in the MP, 1.20 [95% CI 1.09 to 1.33]; P < 0.001). Area under the ROC for 90-day mortality of the modified ΔP and the MP were 0.70 [95% CI 0.66 to 0.74] and 0.69 [95% CI 0.65 to 0.73], which was neither different from that of the APACHE IV score nor that of the SAPS II. Conclusions In adult patients under invasive ventilation, the modified ΔP and the MP at 24 h are associated with 90 day mortality. Neither the modified ΔP nor the MP at 24 h has predictive validity beyond the APACHE IV score and the SAPS II.
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Wittenstein J, Scharffenberg M, Ran X, Keller D, Michler P, Tauer S, Theilen R, Kiss T, Bluth T, Koch T, Gama de Abreu M, Huhle R. Comparative effects of flow vs. volume-controlled one-lung ventilation on gas exchange and respiratory system mechanics in pigs. Intensive Care Med Exp 2020; 8:24. [PMID: 33336305 PMCID: PMC7746431 DOI: 10.1186/s40635-020-00308-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 01/23/2023] Open
Abstract
Background Flow-controlled ventilation (FCV) allows expiratory flow control, reducing the collapse of the airways during expiration. The performance of FCV during one-lung ventilation (OLV) under intravascular normo- and hypovolaemia is currently unknown. In this explorative study, we hypothesised that OLV with FCV improves PaO2 and reduces mechanical power compared to volume-controlled ventilation (VCV). Sixteen juvenile pigs were randomly assigned to one of two groups: (1) intravascular normovolaemia (n = 8) and (2) intravascular hypovolaemia (n = 8). To mimic inflammation due to major thoracic surgery, a thoracotomy was performed, and 0.5 μg/kg/h lipopolysaccharides from Escherichia coli continuously administered intravenously. Animals were randomly assigned to OLV with one of two sequences (60 min per mode): (1) VCV–FCV or (2) FCV–VCV. Variables of gas exchange, haemodynamics and respiratory signals were collected 20, 40 and 60 min after initiation of OLV with each mechanical ventilation mode. The distribution of ventilation was determined using electrical impedance tomography (EIT). Results Oxygenation did not differ significantly between modes (P = 0.881). In the normovolaemia group, the corrected expired minute volume (P = 0.022) and positive end-expiratory pressure (PEEP) were lower during FCV than VCV. The minute volume (P ≤ 0.001), respiratory rate (P ≤ 0.001), total PEEP (P ≤ 0.001), resistance of the respiratory system (P ≤ 0.001), mechanical power (P ≤ 0.001) and resistive mechanical power (P ≤ 0.001) were lower during FCV than VCV irrespective of the volaemia status. The distribution of ventilation did not differ between both ventilation modes (P = 0.103). Conclusions In a model of OLV in normo- and hypovolemic pigs, mechanical power was lower during FCV compared to VCV, without significant differences in oxygenation. Furthermore, the efficacy of ventilation was higher during FCV compared to VCV during normovolaemia.
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Affiliation(s)
- Jakob Wittenstein
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Martin Scharffenberg
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Xi Ran
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Diana Keller
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Pia Michler
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Sebastian Tauer
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Raphael Theilen
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Thomas Kiss
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Thomas Bluth
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Thea Koch
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany.
| | - Robert Huhle
- Pulmonary Engineering Group, Dept. of Anaesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus at Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany
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Ordies S, Orlitova M, Heigl T, Sacreas A, Van Herck A, Kaes J, Saez B, Vanstapel A, Ceulemans L, Vanaudenaerde BM, Vos R, Verschakelen J, Verleden GM, Verleden SE, Van Raemdonck DE, Neyrinck AP. Flow-controlled ventilation during EVLP improves oxygenation and preserves alveolar recruitment. Intensive Care Med Exp 2020; 8:70. [PMID: 33237343 PMCID: PMC7686942 DOI: 10.1186/s40635-020-00360-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 11/17/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Ex vivo lung perfusion (EVLP) is a widespread accepted platform for preservation and evaluation of donor lungs prior to lung transplantation (LTx). Standard lungs are ventilated using volume-controlled ventilation (VCV). We investigated the effects of flow-controlled ventilation (FCV) in a large animal EVLP model. Fourteen porcine lungs were mounted on EVLP after a warm ischemic interval of 2 h and randomized in two groups (n = 7/group). In VCV, 7 grafts were conventionally ventilated and in FCV, 7 grafts were ventilated by flow-controlled ventilation. EVLP physiologic parameters (compliance, pulmonary vascular resistance and oxygenation) were recorded hourly. After 6 h of EVLP, broncho-alveolar lavage (BAL) was performed and biopsies for wet-to-dry weight (W/D) ratio and histology were taken. The left lung was inflated, frozen in liquid nitrogen vapors and scanned with computed tomography (CT) to assess regional distribution of Hounsfield units (HU). RESULTS All lungs endured 6 h of EVLP. Oxygenation was better in FCV compared to VCV (p = 0.01) and the decrease in lung compliance was less in FCV (p = 0.03). W/D ratio, pathology and BAL samples did not differ between both groups (p = 0.16, p = 0.55 and p = 0.62). Overall, CT densities tended to be less pronounced in FCV (p = 0.05). Distribution of CT densities revealed a higher proportion of well-aerated lung parts in FCV compared to VCV (p = 0.01). CONCLUSIONS FCV in pulmonary grafts mounted on EVLP is feasible and leads to improved oxygenation and alveolar recruitment. This ventilation strategy might prolong EVLP over time, with less risk for volutrauma and atelectrauma.
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Affiliation(s)
- Sofie Ordies
- Unit of Anesthesiology and Algology, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Anesthesiology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.,Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Michaela Orlitova
- Unit of Anesthesiology and Algology, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium.,Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Tobias Heigl
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Annelore Sacreas
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Anke Van Herck
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Janne Kaes
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Berta Saez
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Arno Vanstapel
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Laurens Ceulemans
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Bart M Vanaudenaerde
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Robin Vos
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | | | - Geert M Verleden
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Pneumology, University Hospitals Leuven, Leuven, Belgium
| | - Stijn E Verleden
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Dirk E Van Raemdonck
- Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.,Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium.,Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases, Metabolism and Ageing (CHROMETA), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Arne P Neyrinck
- Unit of Anesthesiology and Algology, Department of Cardiovascular Sciences, Katholieke Universiteit Leuven, Leuven, Belgium. .,Department of Anesthesiology, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Leuven Lung Transplant Group, Katholieke Universiteit Leuven, Leuven, Belgium.
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140
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Abstract
Despite substantial advances in anesthesia safety within the past decades, perioperative mortality remains a prevalent problem and can be considered among the top causes of death worldwide. Acute organ failure is a major risk factor of morbidity and mortality in surgical patients and develops primarily as a consequence of a dysregulated inflammatory response and insufficient tissue perfusion. Neurological dysfunction, myocardial ischemia, acute kidney injury, respiratory failure, intestinal dysfunction, and hepatic impairment are among the most serious complications impacting patient outcome and recovery. Pre-, intra-, and postoperative arrangements, such as enhanced recovery after surgery programs, can contribute to lowering the occurrence of organ dysfunction, and mortality rates have improved with the advent of specialized intensive care units and advances in procedures relating to extracorporeal organ support. However, no specific pharmacological therapies have proven effective in the prevention or reversal of perioperative organ injury. Therefore, understanding the underlying mechanisms of organ dysfunction is essential to identify novel treatment strategies to improve perioperative care and outcomes for surgical patients. This review focuses on recent knowledge of pathophysiological and molecular pathways leading to perioperative organ injury. Additionally, we highlight potential therapeutic targets relevant to the network of events that occur in clinical settings with organ failure.
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Affiliation(s)
- Catharina Conrad
- From the Department of Anesthesiology, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas.,Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Holger K Eltzschig
- From the Department of Anesthesiology, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas
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141
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Kneyber MCJ, Ilia S, Koopman AA, van Schelven P, van Dijk J, Burgerhof JGM, Markhorst DG, Blokpoel RGT. Energy transmission in mechanically ventilated children: a translational study. Crit Care 2020; 24:601. [PMID: 33028370 PMCID: PMC7539278 DOI: 10.1186/s13054-020-03313-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Accepted: 09/28/2020] [Indexed: 11/30/2022] Open
Abstract
Background Recurrent delivery of tidal mechanical energy (ME) inflicts ventilator-induced lung injury (VILI) when stress and strain exceed the limits of tissue tolerance. Mechanical power (MP) is the mathematical description of the ME delivered to the respiratory system over time. It is unknown how ME relates to underlying lung pathology and outcome in mechanically ventilated children. We therefore tested the hypothesis that ME per breath with tidal volume (Vt) normalized to bodyweight correlates with underlying lung pathology and to study the effect of resistance on the ME dissipated to the lung. Methods We analyzed routinely collected demographic, physiological, and laboratory data from deeply sedated and/or paralyzed children < 18 years with and without lung injury. Patients were stratified into respiratory system mechanic subgroups according to the Pediatric Mechanical Ventilation Consensus Conference (PEMVECC) definition. The association between MP, ME, lung pathology, and duration of mechanical ventilation as a primary outcome measure was analyzed adjusting for confounding variables and effect modifiers. The effect of endotracheal tube diameter (ETT) and airway resistance on energy dissipation to the lung was analyzed in a bench model with different lung compliance settings. Results Data of 312 patients with a median age of 7.8 (1.7–44.2) months was analyzed. Age (p < 0.001), RR p < 0.001), and Vt < 0.001) were independently associated with MPrs. ME but not MP correlated significantly (p < 0.001) better with lung pathology. Competing risk regression analysis adjusting for PRISM III 24 h score and PEMVECC stratification showed that ME on day 1 or day 2 of MV but not MP was independently associated with the duration of mechanical ventilation. About 33% of all energy generated by the ventilator was transferred to the lung and highly dependent on lung compliance and airway resistance but not on endotracheal tube size (ETT) during pressure control (PC) ventilation. Conclusions ME better related to underlying lung pathology and patient outcome than MP. The delivery of generated energy to the lung was not dependent on ETT size during PC ventilation. Further studies are needed to identify injurious MErs thresholds in ventilated children.
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Affiliation(s)
- Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, The University of Groningen, Internal Postal Code CA 80, P.O. Box 30.001, 9700, RB, Groningen, the Netherlands. .,Critical Care, Anesthesia, Peri-operative Medicine & Emergency Medicine (CAPE), The University of Groningen, Groningen, the Netherlands.
| | - Stavroula Ilia
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, The University of Groningen, Internal Postal Code CA 80, P.O. Box 30.001, 9700, RB, Groningen, the Netherlands.,Pediatric Intensive Care Unit, University Hospital Heraklion, University of Crete, Crete, Greece
| | - Alette A Koopman
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, The University of Groningen, Internal Postal Code CA 80, P.O. Box 30.001, 9700, RB, Groningen, the Netherlands
| | - Patrick van Schelven
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, The University of Groningen, Internal Postal Code CA 80, P.O. Box 30.001, 9700, RB, Groningen, the Netherlands
| | - Jefta van Dijk
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, The University of Groningen, Internal Postal Code CA 80, P.O. Box 30.001, 9700, RB, Groningen, the Netherlands
| | - Johannes G M Burgerhof
- Department of Epidemiology, University Medical Center Groningen, The University of Groningen, Groningen, the Netherlands
| | - Dick G Markhorst
- Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
| | - Robert G T Blokpoel
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, The University of Groningen, Internal Postal Code CA 80, P.O. Box 30.001, 9700, RB, Groningen, the Netherlands
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142
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Petsiuk A, Tanikella NG, Dertinger S, Pringle A, Oberloier S, Pearce JM. Partially RepRapable automated open source bag valve mask-based ventilator. HARDWAREX 2020; 8:e00131. [PMID: 32835141 PMCID: PMC7417990 DOI: 10.1016/j.ohx.2020.e00131] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 07/23/2020] [Accepted: 07/30/2020] [Indexed: 05/18/2023]
Abstract
This study describes the development of a simple and easy-to-build portable automated bag valve mask (BVM) compression system, which, during acute shortages and supply chain disruptions can serve as a temporary emergency ventilator. The resuscitation system is based on the Arduino controller with a real-time operating system installed on a largely RepRap 3-D printable parametric component-based structure. The cost of the materials for the system is under $170, which makes it affordable for replication by makers around the world. The device provides a controlled breathing mode with tidal volumes from 100 to 800 mL, breathing rates from 5 to 40 breaths/minute, and inspiratory-to-expiratory ratio from 1:1 to 1:4. The system is designed for reliability and scalability of measurement circuits through the use of the serial peripheral interface and has the ability to connect additional hardware due to the object-oriented algorithmic approach. Experimental results after testing on an artificial lung for peak inspiratory pressure (PIP), respiratory rate (RR), positive end-expiratory pressure (PEEP), tidal volume, proximal pressure, and lung pressure demonstrate repeatability and accuracy exceeding human capabilities in BVM-based manual ventilation. Future work is necessary to further develop and test the system to make it acceptable for deployment outside of emergencies such as with COVID-19 pandemic in clinical environments, however, the nature of the design is such that desired features are relatively easy to add using protocols and parametric design files provided.
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Affiliation(s)
- Aliaksei Petsiuk
- Department of Electrical & Computer Engineering, Michigan Technological University, USA
| | - Nagendra G. Tanikella
- Department of Materials Science & Engineering, Michigan Technological University, USA
| | | | - Adam Pringle
- Department of Materials Science & Engineering, Michigan Technological University, USA
| | - Shane Oberloier
- Department of Electrical & Computer Engineering, Michigan Technological University, USA
| | - Joshua M. Pearce
- Department of Electrical & Computer Engineering, Michigan Technological University, USA
- Department of Materials Science & Engineering, Michigan Technological University, USA
- Équipe de Recherche sur les Processus Innovatifs (ERPI) , Université de Lorraine, France
- School of Electrical Engineering, Aalto University, Finland
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143
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Epidemiology, Mechanical Power, and 3-Year Outcomes in Acute Respiratory Distress Syndrome Patients Using Standardized Screening. An Observational Cohort Study. Ann Am Thorac Soc 2020; 16:1263-1272. [PMID: 31247145 PMCID: PMC6812172 DOI: 10.1513/annalsats.201812-910oc] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Rationale: Limited data on the epidemiology of acute respiratory distress syndrome (ARDS) using a standardized screening program exist. Objectives: To describe the population-based incidence of hypoxemic respiratory failure and ARDS using a prospective standardized screening protocol; and to describe the mechanical ventilation practice and the mechanical power and examine their association with 28-day and 3-year survival outcomes. Methods: A prospective standardized screening program for ARDS, as a quality improvement initiative, was initiated at four adult intensive care units over a 27-month period. An ancillary analysis of this observational cohort was performed. Patients requiring mechanical ventilation for ≥24 hours underwent prospective and consecutive screening using standardized ventilator settings. Patient physiological data and outcomes were collected prospectively through an electronic clinical-information system and retrospectively analyzed to apply Berlin criteria. Results: Screened were 7,944 patients, among which 986 (12.4%) had hypoxemic respiratory failure (arterial oxygen tension to inspired fraction of oxygen ratio ≤300), and 731 (9.2%) met criteria for ARDS. Age-adjusted incidence of hypoxemic respiratory failure and ARDS were 37.7 and 27.6 cases per 100,000 person-years, respectively. Patients sustaining the diagnosis of ARDS had a hospital mortality of 26.5% for mild, 31.8% for moderate, and 60.0% for severe ARDS and a 3-year mortality of 43.5% for mild, 46.9% for moderate, and 71.1% for severe ARDS. Mechanical power >22 J/min was associated with increased 28-day hospital and 3-year mortality. Determinants of mechanical power associated with lower 28-day hospital and 3-year survival included plateau pressure >30 cm H2O and driving pressure >15 cm H2O, but not tidal volumes >8 ml/kg of predicted body weight. Conclusions: Using standardized screening, a large proportion of patients with hypoxemic respiratory failure met criteria for ARDS. Increasing ARDS severity was associated with increased 28-day hospital and 3-year mortality. Increased mechanical power was associated with increased mortality. Potentially modifiable determinants of mechanical power associated with lower survival included plateau pressure and driving pressure.
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144
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SARS-CoV-2-induced Acute Respiratory Distress Syndrome: Pulmonary Mechanics and Gas-Exchange Abnormalities. Ann Am Thorac Soc 2020; 17:1164-1168. [PMID: 32579033 PMCID: PMC7462332 DOI: 10.1513/annalsats.202005-462rl] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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145
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The effects of pressure- versus volume-controlled ventilation on ventilator work of breathing. Biomed Eng Online 2020; 19:72. [PMID: 32933529 PMCID: PMC7491025 DOI: 10.1186/s12938-020-00815-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 09/04/2020] [Indexed: 12/03/2022] Open
Abstract
Background Measurement of work of breathing (WOB) during mechanical ventilation is essential to assess the status and progress of intensive care patients. Increasing ventilator WOB is known as a risk factor for ventilator-induced lung injury (VILI). In addition, the minimization of WOB is crucial to facilitate the weaning process. Several studies have assessed the effects of varying inspiratory flow waveforms on the patient’s WOB during assisted ventilation, but there are few studies on the different effect of inspiratory flow waveforms on ventilator WOB during controlled ventilation. Methods In this paper, we analyze the ventilator WOB, termed mechanical work (MW) for three common inspiratory flow waveforms both in normal subjects and COPD patients. We use Rohrer’s equation for the resistance of the endotracheal tube (ETT) and lung airways. The resistance of pulmonary and chest wall tissue are also considered. Then, the resistive MW required to overcome each component of the respiratory resistance is computed for square and sinusoidal waveforms in volume-controlled ventilation (VCV), and decelerating waveform of flow in pressure-controlled ventilation (PCV). Results The results indicate that under the constant I:E ratio, a square flow profile best minimizes the MW both in normal subjects and COPD patients. Furthermore, the large I:E ratio may be used to lower MW. The comparison of results shows that ETT and lung airways have the main contribution to resistive MW in normals and COPDs, respectively. Conclusion These findings support that for lowering the MW especially in patients with obstructive lung diseases, flow with square waveforms in VCV, are more favorable than decelerating waveform of flow in PCV. Our analysis suggests the square profile is the best choice from the viewpoint of less MW.
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146
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Belhouideg S. Impact of 3D printed medical equipment on the management of the Covid19 pandemic. Int J Health Plann Manage 2020; 35:1014-1022. [PMID: 32567722 PMCID: PMC7361600 DOI: 10.1002/hpm.3009] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/09/2020] [Accepted: 05/22/2020] [Indexed: 12/24/2022] Open
Abstract
Very high mortality rates of coronavirus pandemic (COVID-19) are observed around the world due to lack of medical equipment. The increased need for medical devices and personal protective equipment (PPE) has kept several healthcare professionals at risk. Fortunately, 3D printing technology allows to overcome the lack of medical supplies. This study highlights the impact of 3D printing on the combat against COVID19, and its importance in the medical product supply chain. Indeed, the existing medical equipment fabricated by 3D printing technology and its role in the management of Covid19 pandemic is presented. Moreover, the last works are examined to know whether the models of the medical equipment are free of use and whether useful informations are presented (eg, available design data and setup guidelines).
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Affiliation(s)
- Soufiane Belhouideg
- Team of Applied Physics and New Technologies, Department of Physics, Polydisciplinary Faculty Beni MellalSultan Moulay Slimane UniversityBeni MellalMorocco
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147
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Spadaro S, Grasso S, Karbing DS, Santoro G, Cavallesco G, Maniscalco P, Murgolo F, Di Mussi R, Ragazzi R, Rees SE, Volta CA, Fogagnolo A. Physiological effects of two driving pressure-based methods to set positive end-expiratory pressure during one lung ventilation. J Clin Monit Comput 2020; 35:1149-1157. [PMID: 32816177 PMCID: PMC7439797 DOI: 10.1007/s10877-020-00582-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/17/2020] [Indexed: 12/14/2022]
Abstract
During one-lung ventilation (OLV), titrating the positive end-expiratory pressure (PEEP) to target a low driving pressure (∆P) could reduce postoperative pulmonary complications. However, it is unclear how to conduct PEEP titration: by stepwise increase starting from zero PEEP (PEEPINCREMENTAL) or by stepwise decrease after a lung recruiting manoeuvre (PEEPDECREMENTAL). In this randomized trial, we compared the physiological effects of these two PEEP titration strategies on respiratory mechanics, ventilation/perfusion mismatch and gas exchange. Patients undergoing video-assisted thoracoscopic surgery in OLV were randomly assigned to a PEEPINCREMENTAL or PEEPDECREMENTAL strategy to match the lowest ∆P. In the PEEPINCREMENTAL group, PEEP was stepwise titrated from ZEEP up to 16 cm H2O, whereas in the PEEPDECREMENTAL group PEEP was decrementally titrated, starting from 16 cm H2O, immediately after a lung recruiting manoeuvre. Respiratory mechanics, ventilation/perfusion mismatch and blood gas analyses were recorded at baseline, after PEEP titration and at the end of surgery. Sixty patients were included in the study. After PEEP titration, shunt decreased similarly in both groups, from 50 [39-55]% to 35 [28-42]% in the PEEPINCREMENTAL and from 45 [37-58]% to 33 [25-45]% in the PEEPDECREMENTAL group (both p < 0.001 vs baseline). The resulting ∆P, however, was lower in the PEEPDECREMENTAL than in the PEEPINCREMENTAL group (8 [7-11] vs 10 [9-11] cm H2O; p = 0.03). In the PEEPDECREMENTAL group the PaO2/ FIO2 ratio increased significantly after intervention (from 140 [99-176] to 186 [152-243], p < 0.001). Both the PEEPINCREMENTAL and the PEEPDECREMENTAL strategies were able to decrease intraoperative shunt, but only PEEPDECREMENTAL improved oxygenation and lowered intraoperative ΔP.Clinical trial number NCT03635281; August 2018; "retrospectively registered".
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Affiliation(s)
- Savino Spadaro
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy.
| | - Salvatore Grasso
- Department of Emergency and Organ Transplant (DETO), "Aldo Moro" University of Bari, Bari, Italy
| | - Dan Stieper Karbing
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Giuseppe Santoro
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
| | - Giorgio Cavallesco
- Department of Morphology, Experimental Medicine and Surgery, Thoracic Surgery, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, Ferrara, Italy
| | - Pio Maniscalco
- Department of Morphology, Experimental Medicine and Surgery, Thoracic Surgery, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, Ferrara, Italy
| | - Francesca Murgolo
- Department of Emergency and Organ Transplant (DETO), "Aldo Moro" University of Bari, Bari, Italy
| | - Rosa Di Mussi
- Department of Emergency and Organ Transplant (DETO), "Aldo Moro" University of Bari, Bari, Italy
| | - Riccardo Ragazzi
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
| | - Stephen Edward Rees
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Carlo Alberto Volta
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
| | - Alberto Fogagnolo
- Department of Morphology, Experimental Medicine and Surgery, Section of Anaesthesia and Intensive Care, Azienda Ospedaliera-Universitaria Sant' Anna, University of Ferrara, Via Aldo Moro, 8, 44124, Ferrara, Italy
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148
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Chi Y, He H, Long Y. A simple method of mechanical power calculation: using mean airway pressure to replace plateau pressure. J Clin Monit Comput 2020; 35:1139-1147. [PMID: 32780353 DOI: 10.1007/s10877-020-00575-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 08/04/2020] [Indexed: 12/30/2022]
Abstract
The reference method for mechanical power (MP) calculation proposed by Gattinoni et al. is based on plateau pressure (Pplat) which needs an inspiratory hold. This study aims to introduce and validate a simple surrogate for MP calculation without any intervention in ventilated patients with or without acute respiratory distress syndrome (ARDS). The introduced equation is as:[Formula: see text]where Pmean is mean airway pressure, VE is minute ventilation, PEEP is positive end-expiratory pressure, and Te/Ti is expiratory-to-inspiratory ratio. 50 patients with ARDS and 50 post-operative patients without ARDS were enrolled. Pmean-derived MP and reference MP were obtained at the inspiratory plateau time (Tplat) of 0 and 0.5 s (s). When Tplat was adjusted from 0 to 0.5 s, higher Pmean [non-ARDS cases: 9.3 (8.8-9.9) cmH2O versus 8.2 (7.9-8.8) cmH2O, P < 0.001; ARDS cases: 14 (13-16) cmH2O versus 13 (11-14) cmH2O, P < 0.001] and shorter Te/Ti [non-ARDS cases: 1.4 (1.2-1.7) versus 2.4 (2.0-3.0), P < 0.001; ARDS cases: 1.3 (1.2-1.5) versus 2.5 (2.3-2.9), P < 0.001] were found. At both Tplat levels, the Pmean-derived MP correlated well with the reference MP both in patients with or without ARDS (non-ARDS: slopes = 1.05, 0.94, R2 = 0.95, 0.93, bias + 0.76, + 0.51; ARDS: slopes = 1.03, 0.95, R2 = 0.96, 0.96, bias + 0.97, + 0.78. P < 0.0001 for all). In patients with or without ARDS, Pmean-derived MP allows rapid and dynamic estimation of mechanical power without any intervention at the bedside.
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Affiliation(s)
- Yi Chi
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Huaiwu He
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Yun Long
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, 1 Shuaifuyuan, Dongcheng District, Beijing, China.
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149
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Abstract
OBJECTIVES To examine the potentially modifiable drivers that injure and heal the "baby lung" of acute respiratory distress syndrome and describe a rational clinical approach to favor benefit. DATA SOURCES Published experimental studies and clinical papers that address varied aspects of ventilator-induced lung injury pathogenesis and its consequences. STUDY SELECTION Published information relevant to the novel hypothesis of progressive lung vulnerability and to the biophysical responses of lung injury and repair. DATA EXTRACTION None. DATA SYNTHESIS In acute respiratory distress syndrome, the reduced size and capacity for gas exchange of the functioning "baby lung" imply loss of ventilatory capability that dwindles in proportion to severity of lung injury. Concentrating the entire ventilation workload and increasing perfusion to these already overtaxed units accentuates their potential for progressive injury. Unlike static airspace pressures, which, in theory, apply universally to aerated structures of all dimensions, the components of tidal inflation that relate to power (which include frequency and flow) progressively intensify their tissue-stressing effects on parenchyma and microvasculature as the ventilated compartment shrinks further, especially during the first phase of the evolving injury. This "ventilator-induced lung injury vortex" of the shrinking baby lung is opposed by reactive, adaptive, and reparative processes. In this context, relatively little attention has been paid to the evolving interactions between lung injury and response and to the timing of interventions that worsen, limit or reverse a potentially accelerating ventilator-induced lung injury process. Although universal and modifiable drivers hold the potential to progressively injure the functional lung units of acute respiratory distress syndrome in a positive feedback cycle, measures can be taken to interrupt that process and encourage growth and healing of the "baby lung" of severe acute respiratory distress syndrome.
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Affiliation(s)
- John J Marini
- University of Minnesota and Regions Hospital, Minneapolis/St. Paul, MN
| | - Luciano Gattinoni
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Medical University of Göttingen, Göttingen, Germany
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150
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Abstract
This review focuses on the use of veno-venous extracorporeal membrane oxygenation for respiratory failure across all blood flow ranges. Starting with a short overview of historical development, aspects of the physiology of gas exchange (i.e., oxygenation and decarboxylation) during extracorporeal circulation are discussed. The mechanisms of phenomena such as recirculation and shunt playing an important role in daily clinical practice are explained.Treatment of refractory and symptomatic hypoxemic respiratory failure (e.g., acute respiratory distress syndrome [ARDS]) currently represents the main indication for high-flow veno-venous-extracorporeal membrane oxygenation. On the other hand, lower-flow extracorporeal carbon dioxide removal might potentially help to avoid or attenuate ventilator-induced lung injury by allowing reduction of the energy load (i.e., driving pressure, mechanical power) transmitted to the lungs during mechanical ventilation or spontaneous ventilation. In the latter context, extracorporeal carbon dioxide removal plays an emerging role in the treatment of chronic obstructive pulmonary disease patients during acute exacerbations. Both applications of extracorporeal lung support raise important ethical considerations, such as likelihood of ultimate futility and end-of-life decision-making. The review concludes with a brief overview of potential technical developments and persistent challenges.
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