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Sang L, Zhao Z, Yun PJ, Frerichs I, Möller K, Fu F, Liu X, Zhong N, Li Y. Qualitative and quantitative assessment of pendelluft: a simple method based on electrical impedance tomography. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1216. [PMID: 33178748 PMCID: PMC7607126 DOI: 10.21037/atm-20-4182] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Pendelluft, defined as asynchronous alveolar ventilation, is caused by different regional time constants or dynamic pleural pressure variations. The aim of the present study was to propose a simple method to evaluate pendelluft based on electrical impedance tomography (EIT). The efficacy of this method was demonstrated in well-known pendelluft scenarios in 6 patients. Methods Two patients with flail chest after accidents, two patients with acute respiratory distress syndrome (ARDS) and two patients with acutely exacerbated obstructive lung disease were prospectively included. EIT measurements were performed before and after surgery (in patients with flail chest, who had video-assisted thoracoscopic surgery with ribs fixation), or at two different levels of positive end-expiratory pressure (PEEP; ARDS patients), or two different time points (obstructive lung disease). Pendelluft was assessed by regional phase shift (defined as time difference between global and regional impedance-time curves) and amplitude differences (defined as the impedance difference between sum of all regional tidal variation and the global tidal variation). Results In patients with flail chest, pendelluft diminished several days after surgery (pendelluft amplitude normalized to tidal impedance variation reduced from 88% to 2% in one patient, 12% to 2% in the other). Increased PEEP reduced the amplitude of pendelluft (from 3% to 0% in one patient, 20% to 2% in the other) but not necessarily the phase shifts (average time differences were <0.1 second for both patients for both ins- and expiration) in ARDS patients. Pendelluft assessment in obstructive lung diseases reflected the change in airway resistance (from 5% to 1% in one patient after broncholytic medication administration, as airway resistance fell from 15 to 11 cmH2O/L/s; from 9% to 35% in the other patient with acute exacerbation, the corresponding airway resistance increased from 15 to 22 cmH2O/L/s). Conclusions The proposed EIT-based method can be used to evaluate the degree of pendelluft in dimension of phase shift and amplitude difference.
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Affiliation(s)
- Ling Sang
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Zhanqi Zhao
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China.,Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
| | - Po-Jen Yun
- Division of Thoracic Surgery, Department of Surgery, Tri-Service General Hospital, Taipei
| | - Inéz Frerichs
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center of Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Knut Möller
- Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
| | - Feng Fu
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China
| | - Xiaoqing Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Nanshan Zhong
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Guangzhou, China
| | - Yimin Li
- Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Guangzhou, China
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102
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Suffredini DA, Allison MG. A Rationale for Use of High Flow Nasal Cannula for Select Patients With Suspected or Confirmed Severe Acute Respiratory Syndrome Coronavirus-2 Infection. J Intensive Care Med 2020; 36:9-17. [PMID: 32912049 DOI: 10.1177/0885066620956630] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Infection with the novel 2019 coronavirus (SARS-CoV-2) is associated with the development of a viral pneumonia with severe hypoxemia and respiratory failure. In many cases these patients will require mechanical ventilation; but in others the severity of disease is significantly less and may not need invasive support. High flow nasal cannula (HFNC) is a widely used modality of delivering high concentrations of oxygen and airflow to patients with hypoxemic respiratory failure, but its use in patients with SARS-CoV-2 is poorly described. Concerns with use of HFNC have arisen including aerosolization of viral particles to healthcare workers (HCW) to delaying intubation and potentially worsening of outcomes. However, use of HFNC in other coronavirus pandemics and previous experimental evidence suggest HFNC is low risk and may be effective in select patients infected with SARS-CoV-2. With the significant increase in resource utilization in care of patients with SARS-CoV-2, identification of those that may benefit from HFNC allowing allocation of ventilators to those more critically ill is of significant importance. In this manuscript, we review pertinent literature regarding the use of HFNC in the current SARS-CoV-2 pandemic and address many concerns regarding its use.
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Affiliation(s)
- Dante A Suffredini
- Section of Critical Care Medicine, Department of Medicine, Ascension Saint Agnes Hospital Center, Baltimore MD, USA
| | - Michael G Allison
- Section of Critical Care Medicine, Department of Medicine, Ascension Saint Agnes Hospital Center, Baltimore MD, USA
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103
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Gonçalves-Ferri WA, Rossi FS, Costa ELV, Correa L, Iope D, Pacce PD, Martins-Celini F, Bernardes A, Ribeiro M, Amato MBP. Lung Recruitment and Pendelluft Resolution after Less Invasive Surfactant Administration in a Preterm Infant. Am J Respir Crit Care Med 2020; 202:766-769. [PMID: 32338994 DOI: 10.1164/rccm.201912-2439le] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | - Eduardo L V Costa
- Universidade de São Paulo São Paulo, Brazil.,Hospital Sírio Libanês São Paulo, Brazil and
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104
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Affiliation(s)
- Bhakti K Patel
- Pritzker School of Medicine, Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - John P Kress
- Pritzker School of Medicine, Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Jesse B Hall
- Pritzker School of Medicine, Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
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105
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Grieco DL, Menga LS, Conti G, Maggiore SM, Antonelli M. Reply to Spinelli and Mauri: Lung and Diaphragm Protection during Noninvasive Respiratory Support. Am J Respir Crit Care Med 2020; 201:876-878. [PMID: 31870169 PMCID: PMC7124726 DOI: 10.1164/rccm.201912-2321le] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Domenico Luca Grieco
- Fondazione Policlinico Universitario A. Gemelli IRCCSRome, Italy.,Catholic University of the Sacred HeartRome, Italyand
| | - Luca S Menga
- Fondazione Policlinico Universitario A. Gemelli IRCCSRome, Italy.,Catholic University of the Sacred HeartRome, Italyand
| | - Giorgio Conti
- Fondazione Policlinico Universitario A. Gemelli IRCCSRome, Italy.,Catholic University of the Sacred HeartRome, Italyand
| | | | - Massimo Antonelli
- Fondazione Policlinico Universitario A. Gemelli IRCCSRome, Italy.,Catholic University of the Sacred HeartRome, Italyand
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106
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Pérez J, Dorado JH, Papazian AC, Berastegui M, Gilgado DI, Cardoso GP, Cesio C, Accoce M. Titration and characteristics of pressure-support ventilation use in Argentina: an online cross-sectional survey study. Rev Bras Ter Intensiva 2020; 32:81-91. [PMID: 32401994 PMCID: PMC7206961 DOI: 10.5935/0103-507x.20200013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/04/2019] [Indexed: 11/28/2022] Open
Abstract
Objective To identify common practices related to the use and titration of pressure-support ventilation (PC-CSV - pressure control-continuous spontaneous ventilation) in patients under mechanical ventilation and to analyze diagnostic criteria for over-assistance and under-assistance. The secondary objective was to compare the responses provided by physician, physiotherapists and nurses related to diagnostic criteria for over-assistance and under-assistance. Methods An online survey was conducted using the Survey Monkey tool. Physicians, nurses and physiotherapists from Argentina with access to PC-CSV in their usual clinical practice were included. Results A total of 509 surveys were collected from October to December 2018. Of these, 74.1% were completed by physiotherapists. A total of 77.6% reported using PC-CSV to initiate the partial ventilatory support phase, and 43.8% of respondents select inspiratory pressure support level based on tidal volume. The main objective for selecting positive end-expiratory pressure (PEEP) level was to decrease the work of breathing. High tidal volume was the primary variable for detecting over-assistance, while the use of accessory respiratory muscles was the most commonly chosen for under-assistance. Discrepancies were observed between physicians and physiotherapists in relation to the diagnostic criteria for over-assistance. Conclusion The most commonly used mode to initiate the partial ventilatory support phase was PC-CSV. The most frequently selected variable to guide the titration of inspiratory pressure support level was tidal volume, and the main objective of PEEP was to decrease the work of breathing. Over-assistance was detected primarily by high tidal volume, while under-assistance by accessory respiratory muscles activation. Discrepancies were observed among professions in relation to the diagnostic criteria for over-assistance, but not for under-assistance.
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Affiliation(s)
- Joaquin Pérez
- Sanatorio Anchorena de San Martín, San Martín, Buenos Aires, Argentina
| | | | | | | | | | | | - Cristian Cesio
- Sanatorio Anchorena de San Martín, San Martín, Buenos Aires, Argentina
| | - Matías Accoce
- Sanatorio Anchorena de San Martín, San Martín, Buenos Aires, Argentina
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107
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Grieco DL, Menga LS, Raggi V, Bongiovanni F, Anzellotti GM, Tanzarella ES, Bocci MG, Mercurio G, Dell'Anna AM, Eleuteri D, Bello G, Maviglia R, Conti G, Maggiore SM, Antonelli M. Physiological Comparison of High-Flow Nasal Cannula and Helmet Noninvasive Ventilation in Acute Hypoxemic Respiratory Failure. Am J Respir Crit Care Med 2020; 201:303-312. [PMID: 31687831 DOI: 10.1164/rccm.201904-0841oc] [Citation(s) in RCA: 100] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Rationale: High-flow nasal cannula (HFNC) and helmet noninvasive ventilation (NIV) are used for the management of acute hypoxemic respiratory failure.Objectives: Physiological comparison of HFNC and helmet NIV in patients with hypoxemia.Methods: Fifteen patients with hypoxemia with PaO2/FiO2 < 200 mm Hg received helmet NIV (positive end-expiratory pressure ≥ 10 cm H2O, pressure support = 10-15 cm H2O) and HFNC (50 L/min) in randomized crossover order. Arterial blood gases, dyspnea, and comfort were recorded. Inspiratory effort was estimated by esophageal pressure (Pes) swings. Pes-simplified pressure-time product and transpulmonary pressure swings were measured.Measurements and Main Results: As compared with HFNC, helmet NIV increased PaO2/FiO2 (median [interquartile range]: 255 mm Hg [140-299] vs. 138 [101-172]; P = 0.001) and lowered inspiratory effort (7 cm H2O [4-11] vs. 15 [8-19]; P = 0.001) in all patients. Inspiratory effort reduction by NIV was linearly related to inspiratory effort during HFNC (r = 0.84; P < 0.001). Helmet NIV reduced respiratory rate (24 breaths/min [23-31] vs. 29 [26-32]; P = 0.027), Pes-simplified pressure-time product (93 cm H2O ⋅ s ⋅ min-1 [43-138] vs. 200 [168-335]; P = 0.001), and dyspnea (visual analog scale 3 [2-5] vs. 8 [6-9]; P = 0.002), without affecting PaCO2 (P = 0.80) and comfort (P = 0.50). In the overall cohort, transpulmonary pressure swings were not different between treatments (NIV = 18 cm H2O [14-21] vs. HFNC = 15 [8-19]; P = 0.11), but patients exhibiting lower inspiratory effort on HFNC experienced increases in transpulmonary pressure swings with helmet NIV. Higher transpulmonary pressure swings during NIV were associated with subsequent need for intubation.Conclusions: As compared with HFNC in hypoxemic respiratory failure, helmet NIV improves oxygenation, reduces dyspnea, inspiratory effort, and simplified pressure-time product, with similar transpulmonary pressure swings, PaCO2, and comfort.
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Affiliation(s)
- Domenico Luca Grieco
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; and
| | - Luca S Menga
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; and
| | - Valeria Raggi
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; and
| | - Filippo Bongiovanni
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; and
| | - Gian Marco Anzellotti
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; and
| | - Eloisa S Tanzarella
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; and
| | - Maria Grazia Bocci
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; and
| | - Giovanna Mercurio
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; and
| | - Antonio M Dell'Anna
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; and
| | - Davide Eleuteri
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; and
| | - Giuseppe Bello
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; and
| | - Riccardo Maviglia
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; and
| | - Giorgio Conti
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; and
| | - Salvatore Maurizio Maggiore
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia, Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; and
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108
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Pereira-Fantini PM, Pang B, Byars SG, Oakley RB, Perkins EJ, Dargaville PA, Davis PG, Nie S, Williamson NA, Ignjatovic V, Tingay DG. Preterm Lung Exhibits Distinct Spatiotemporal Proteome Expression at Initiation of Lung Injury. Am J Respir Cell Mol Biol 2020; 61:631-642. [PMID: 30995072 DOI: 10.1165/rcmb.2019-0084oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The development of regional lung injury in the preterm lung is not well understood. This study aimed to characterize time-dependent and regionally specific injury patterns associated with early ventilation of the preterm lung using a mass spectrometry-based proteomic approach. Preterm lambs delivered at 124-127 days gestation received 15 or 90 minutes of mechanical ventilation (positive end-expiratory pressure = 8 cm H2O, Vt = 6-8 ml/kg) and were compared with unventilated control lambs. At study completion, lung tissue was taken from standardized nondependent and dependent regions, and assessed for lung injury via histology, quantitative PCR, and proteomic analysis using Orbitrap-mass spectrometry. Ingenuity pathway analysis software was used to identify temporal and region-specific enrichments in pathways and functions. Apoptotic cell numbers were ninefold higher in nondependent lung at 15 and 90 minutes compared with controls, whereas proliferative cells were increased fourfold in the dependent lung at 90 minutes. The relative gene expression of lung injury markers was increased at 90 minutes in nondependent lung and unchanged in gravity-dependent lung. Within the proteome, the number of differentially expressed proteins was fourfold higher in the nondependent lung than the dependent lung. The number of differential proteins increased over time in both lung regions. A total of 95% of enriched canonical pathways and 94% of enriched cellular and molecular functions were identified only in nondependent lung tissue from the 90-minute ventilation group. In conclusion, complex injury pathways are initiated within the preterm lung after 15 minutes of ventilation and amplified by continuing ventilation. Injury development is region specific, with greater alterations within the proteome of nondependent lung.
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Affiliation(s)
| | | | - Sean G Byars
- Department of Clinical Pathology.,Melbourne Integrative Genomics
| | | | | | - Peter A Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Peter G Davis
- Neonatal Research, and.,Department of Obstetrics and Gynaecology, and.,The Royal Women's Hospital, Parkville, Victoria, Australia; and
| | - Shuai Nie
- Bio21 Institute, University of Melbourne, Parkville, Victoria, Australia
| | | | - Vera Ignjatovic
- Haematology Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics
| | - David G Tingay
- Neonatal Research, and.,Department of Paediatrics.,Department of Neonatology, Royal Children's Hospital, Parkville, Victoria, Australia
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109
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Rossi FS, Costa ELV, Iope DDM, Pacce PHD, Cestaro C, Braz LZ, Bousso A, Amato MBP. Pendelluft Detection Using Electrical Impedance Tomography in an Infant. Keep Those Images in Mind. Am J Respir Crit Care Med 2020; 200:1427-1429. [PMID: 31260637 DOI: 10.1164/rccm.201902-0461im] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Felipe S Rossi
- Materno-Infantil Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eduardo L V Costa
- Pulmonology Division, Cardiopulmonary Department, Heart Institute, University of Sao Paulo, São Paulo, Brazil; and
| | | | | | | | - Luisa Z Braz
- Materno-Infantil Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Albert Bousso
- Materno-Infantil Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcelo B P Amato
- Pulmonology Division, Cardiopulmonary Department, Heart Institute, University of Sao Paulo, São Paulo, Brazil; and
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110
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Lung- and Diaphragm-protective Ventilation in Acute Respiratory Distress Syndrome: Rationale and Challenges. Anesthesiology 2020; 130:620-633. [PMID: 30844950 DOI: 10.1097/aln.0000000000002605] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A novel approach to ventilation aims to be both lung- and diaphragm-protective. This strategy integrates concerns over excessive lung stress during spontaneous breathing while avoiding both insufficient and excessive inspiratory effort.
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111
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Nieman GF, Al-Khalisy H, Kollisch-Singule M, Satalin J, Blair S, Trikha G, Andrews P, Madden M, Gatto LA, Habashi NM. A Physiologically Informed Strategy to Effectively Open, Stabilize, and Protect the Acutely Injured Lung. Front Physiol 2020; 11:227. [PMID: 32265734 PMCID: PMC7096584 DOI: 10.3389/fphys.2020.00227] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 02/27/2020] [Indexed: 12/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) causes a heterogeneous lung injury and remains a serious medical problem, with one of the only treatments being supportive care in the form of mechanical ventilation. It is very difficult, however, to mechanically ventilate the heterogeneously damaged lung without causing secondary ventilator-induced lung injury (VILI). The acutely injured lung becomes time and pressure dependent, meaning that it takes more time and pressure to open the lung, and it recollapses more quickly and at higher pressure. Current protective ventilation strategies, ARDSnet low tidal volume (LVt) and the open lung approach (OLA), have been unsuccessful at further reducing ARDS mortality. We postulate that this is because the LVt strategy is constrained to ventilating a lung with a heterogeneous mix of normal and focalized injured tissue, and the OLA, although designed to fully open and stabilize the lung, is often unsuccessful at doing so. In this review we analyzed the pathophysiology of ARDS that renders the lung susceptible to VILI. We also analyzed the alterations in alveolar and alveolar duct mechanics that occur in the acutely injured lung and discussed how these alterations are a key mechanism driving VILI. Our analysis suggests that the time component of each mechanical breath, at both inspiration and expiration, is critical to normalize alveolar mechanics and protect the lung from VILI. Animal studies and a meta-analysis have suggested that the time-controlled adaptive ventilation (TCAV) method, using the airway pressure release ventilation mode, eliminates the constraints of ventilating a lung with heterogeneous injury, since it is highly effective at opening and stabilizing the time- and pressure-dependent lung. In animal studies it has been shown that by “casting open” the acutely injured lung with TCAV we can (1) reestablish normal expiratory lung volume as assessed by direct observation of subpleural alveoli; (2) return normal parenchymal microanatomical structural support, known as alveolar interdependence and parenchymal tethering, as assessed by morphometric analysis of lung histology; (3) facilitate regeneration of normal surfactant function measured as increases in surfactant proteins A and B; and (4) significantly increase lung compliance, which reduces the pathologic impact of driving pressure and mechanical power at any given tidal volume.
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Affiliation(s)
- Gary F Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Hassan Al-Khalisy
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States.,Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, United States
| | | | - Joshua Satalin
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Sarah Blair
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Girish Trikha
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States.,Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Penny Andrews
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Maria Madden
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Louis A Gatto
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States.,Department of Biological Sciences, SUNY Cortland, Cortland, NY, United States
| | - Nader M Habashi
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
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112
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Grassi A, Ferlicca D, Lupieri E, Calcinati S, Francesconi S, Sala V, Ormas V, Chiodaroli E, Abbruzzese C, Curto F, Sanna A, Zambon M, Fumagalli R, Foti G, Bellani G. Assisted mechanical ventilation promotes recovery of diaphragmatic thickness in critically ill patients: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:85. [PMID: 32164784 PMCID: PMC7068963 DOI: 10.1186/s13054-020-2761-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 02/05/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Diaphragm atrophy and dysfunction are consequences of mechanical ventilation and are determinants of clinical outcomes. We hypothesize that partial preservation of diaphragm function, such as during assisted modes of ventilation, will restore diaphragm thickness. We also aim to correlate the changes in diaphragm thickness and function to outcomes and clinical factors. METHODS This is a prospective, multicentre, observational study. Patients mechanically ventilated for more than 48 h in controlled mode and eventually switched to assisted ventilation were enrolled. Diaphragm ultrasound and clinical data collection were performed every 48 h until discharge or death. A threshold of 10% was used to define thinning during controlled and recovery of thickness during assisted ventilation. Patients were also classified based on the level of diaphragm activity during assisted ventilation. We evaluated the association between changes in diaphragm thickness and activity and clinical outcomes and data, such as ventilation parameters. RESULTS Sixty-two patients ventilated in controlled mode and then switched to the assisted mode of ventilation were enrolled. Diaphragm thickness significantly decreased during controlled ventilation (1.84 ± 0.44 to 1.49 ± 0.37 mm, p < 0.001) and was partially restored during assisted ventilation (1.49 ± 0.37 to 1.75 ± 0.43 mm, p < 0.001). A diaphragm thinning of more than 10% was associated with longer duration of controlled ventilation (10 [5, 15] versus 5 [4, 8.5] days, p = 0.004) and higher PEEP levels (12.6 ± 4 versus 10.4 ± 4 cmH2O, p = 0.034). An increase in diaphragm thickness of more than 10% during assisted ventilation was not associated with any clinical outcome but with lower respiratory rate (16.7 ± 3.2 versus 19.2 ± 4 bpm, p = 0.019) and Rapid Shallow Breathing Index (37 ± 11 versus 44 ± 13, p = 0.029) and with higher Pressure Muscle Index (2 [0.5, 3] versus 0.4 [0, 1.9], p = 0.024). Change in diaphragm thickness was not related to diaphragm function expressed as diaphragm thickening fraction. CONCLUSION Mode of ventilation affects diaphragm thickness, and preservation of diaphragmatic contraction, as during assisted modes, can partially reverse the muscle atrophy process. Avoiding a strenuous inspiratory work, as measured by Rapid Shallow Breathing Index and Pressure Muscle Index, may help diaphragm thickness restoration.
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Affiliation(s)
- Alice Grassi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Daniela Ferlicca
- Department of Anesthesia and Intensive Care Medicine, ASST Monza, Monza, Italy
| | - Ermes Lupieri
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Serena Calcinati
- Department of Anesthesia and Intensive Care Medicine, ASST Monza, Monza, Italy
| | - Silvia Francesconi
- Department of Anesthesia and Intensive Care Medicine, ASST Monza, Monza, Italy
| | - Vittoria Sala
- Department of Anesthesia and Intensive Care Medicine, ASST Monza, Monza, Italy
| | - Valentina Ormas
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Elena Chiodaroli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Chiara Abbruzzese
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCSS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Francesco Curto
- Neurocritical Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Andrea Sanna
- Neurocritical Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Massimo Zambon
- Department of Anesthesia and Intensive Care Medicine, Cernusco sul Naviglio Hospital, ASST Melegnano e Martesana, Milan, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Anesthesia and Intensive Care Medicine, ASST Monza, Monza, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy. .,Department of Anesthesia and Intensive Care Medicine, ASST Monza, Monza, Italy.
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113
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Impact of spontaneous breathing during mechanical ventilation in acute respiratory distress syndrome. Curr Opin Crit Care 2020; 25:192-198. [PMID: 30720482 DOI: 10.1097/mcc.0000000000000597] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Facilitating spontaneous breathing has been traditionally recommended during mechanical ventilation in acute respiratory distress syndrome (ARDS). However, early, short-term use of neuromuscular blockade appears to improve survival, and spontaneous effort has been shown to potentiate lung injury in animal and clinical studies. The purpose of this review is to describe the beneficial and deleterious effects of spontaneous breathing in ARDS, explain potential mechanisms for harm, and provide contemporary suggestions for clinical management. RECENT FINDINGS Gentle spontaneous effort can improve lung function and prevent diaphragm atrophy. However, accumulating evidence indicates that spontaneous effort may cause or worsen lung and diaphragm injury, especially if the ARDS is severe or spontaneous effort is vigorous. Recently, such effort-dependent lung injury has been termed patient self-inflicted lung injury (P-SILI). Finally, several approaches to minimize P-SILI while maintaining some diaphragm activity (e.g. partial neuromuscular blockade, high PEEP) appear promising. SUMMARY We update and summarize the role of spontaneous breathing during mechanical ventilation in ARDS, which can be beneficial or deleterious, depending on the strength of spontaneous activity and severity of lung injury. Future studies are needed to determine ventilator strategies that minimize injury but maintaining some diaphragm activity.
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114
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Borges JB, Cronin JN, Crockett DC, Hedenstierna G, Larsson A, Formenti F. Real-time effects of PEEP and tidal volume on regional ventilation and perfusion in experimental lung injury. Intensive Care Med Exp 2020; 8:10. [PMID: 32086632 PMCID: PMC7035410 DOI: 10.1186/s40635-020-0298-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 01/30/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Real-time bedside information on regional ventilation and perfusion during mechanical ventilation (MV) may help to elucidate the physiological and pathophysiological effects of MV settings in healthy and injured lungs. We aimed to study the effects of positive end-expiratory pressure (PEEP) and tidal volume (VT) on the distributions of regional ventilation and perfusion by electrical impedance tomography (EIT) in healthy and injured lungs. METHODS One-hit acute lung injury model was established in 6 piglets by repeated lung lavages (injured group). Four ventilated piglets served as the control group. A randomized sequence of any possible combination of three VT (7, 10, and 15 ml/kg) and four levels of PEEP (5, 8, 10, and 12 cmH2O) was performed in all animals. Ventilation and perfusion distributions were computed by EIT within three regions-of-interest (ROIs): nondependent, middle, dependent. A mixed design with one between-subjects factor (group: intervention or control), and two within-subjects factors (PEEP and VT) was used, with a three-way mixed analysis of variance (ANOVA). RESULTS Two-way interactions between PEEP and group, and VT and group, were observed for the dependent ROI (p = 0.035 and 0.012, respectively), indicating that the increase in the dependent ROI ventilation was greater at higher PEEP and VT in the injured group than in the control group. A two-way interaction between PEEP and VT was observed for perfusion distribution in each ROI: nondependent (p = 0.030), middle (p = 0.006), and dependent (p = 0.001); no interaction was observed between injured and control groups. CONCLUSIONS Large PEEP and VT levels were associated with greater pulmonary ventilation of the dependent lung region in experimental lung injury, whereas they affected pulmonary perfusion of all lung regions both in the control and in the experimental lung injury groups.
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Affiliation(s)
- João Batista Borges
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK.
| | - John N Cronin
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | | | - Göran Hedenstierna
- Hedenstierna Laboratory, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Anders Larsson
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Federico Formenti
- Centre for Human and Applied Physiological Sciences, King's College London, London, UK. .,Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK.
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115
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Spinelli E, Mauri T, Beitler JR, Pesenti A, Brodie D. Respiratory drive in the acute respiratory distress syndrome: pathophysiology, monitoring, and therapeutic interventions. Intensive Care Med 2020; 46:606-618. [PMID: 32016537 PMCID: PMC7224136 DOI: 10.1007/s00134-020-05942-6] [Citation(s) in RCA: 144] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 01/16/2020] [Indexed: 12/18/2022]
Abstract
Neural respiratory drive, i.e., the activity of respiratory centres controlling breathing, is an overlooked physiologic variable which affects the pathophysiology and the clinical outcome of acute respiratory distress syndrome (ARDS). Spontaneous breathing may offer multiple physiologic benefits in these patients, including decreased need for sedation, preserved diaphragm activity and improved cardiovascular function. However, excessive effort to breathe due to high respiratory drive may lead to patient self-inflicted lung injury (P-SILI), even in the absence of mechanical ventilation. In the present review, we focus on the physiological and clinical implications of control of respiratory drive in ARDS patients. We summarize the main determinants of neural respiratory drive and the mechanisms involved in its potentiation, in health and ARDS. We also describe potential and pitfalls of the available bedside methods for drive assessment and explore classical and more “futuristic” interventions to control drive in ARDS patients.
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Affiliation(s)
- Elena Spinelli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano, Via F. Sforza 35, 20122, Milan, Italy
| | - Tommaso Mauri
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano, Via F. Sforza 35, 20122, Milan, Italy. .,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Università Degli Studi Di Milano, Via F. Sforza 35, 20122, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Daniel Brodie
- Center for Acute Respiratory Failure, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA
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116
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Patient self-inflicted lung injury and positive end-expiratory pressure for safe spontaneous breathing. Curr Opin Crit Care 2020; 26:59-65. [DOI: 10.1097/mcc.0000000000000691] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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117
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Wei XB, Wang ZH, Liao XL, Guo WX, Qin TH, Wang SH. Role of Neuromuscular Blocking Agents in Acute Respiratory Distress Syndrome: An Updated Meta-Analysis of Randomized Controlled Trials. Front Pharmacol 2020; 10:1637. [PMID: 32063852 PMCID: PMC7000374 DOI: 10.3389/fphar.2019.01637] [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: 08/28/2019] [Accepted: 12/16/2019] [Indexed: 12/16/2022] Open
Abstract
Background The therapeutic role of neuromuscular blocking agents (NMBA) in patients with acute respiratory distress syndrome (ARDS) remains controversial. Methods We systematically reviewed randomized controlled trials investigating the use of NMBA in ARDS patients from inception to July 2019. Relative risk (RR) was calculated for the incidence of barotrauma and mortality using the random-effect or fixed-effect model according to heterogeneity analysis. Results Data were combined from five randomized controlled trials that included 1,461 patients (724 in the NMBA group and 737 in the control group). Pooled analysis showed that NMBA infusion did not reduce 28-day mortality (RR = 0.72, 95% confidence interval (CI) 0.44 to 1.17, P=0.180, I-squared = 62.8%), but was associated with lower intensive care unit (ICU) mortality (RR = 0.60, 95% CI 0.41 to 0.88, P = 0.009, I-squared = 9.2%). In addition, the incidence of barotrauma was significantly lower in patients treated with NMBA (RR = 0.53, 95% CI 0.33 to 0.84, P = 0.007, I-squared = 0). However, infusion of NMBA might increase the risk of ICU-acquired weakness (RR = 1.34, 95% CI 0.97 to 1.84, P = 0.066, I-squared = 0). Conclusion Infusion of NMBA could reduce ICU mortality and the incidence of barotrauma. The risk of ICU-acquired weakness was higher in moderate-to-severe ARDS patients treated with NMBA. The real effects of NMBA need to be further evaluated and confirmed by a study with a stricter design.
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Affiliation(s)
- Xue-Biao Wei
- Department of Gerontological Critical Care Medicine, Guangdong Provincial Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhong-Hua Wang
- Department of Gerontological Critical Care Medicine, Guangdong Provincial Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xiao-Long Liao
- Department of Gerontological Critical Care Medicine, Guangdong Provincial Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wei-Xin Guo
- Department of Gerontological Critical Care Medicine, Guangdong Provincial Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Tie-He Qin
- Department of Gerontological Critical Care Medicine, Guangdong Provincial Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shou-Hong Wang
- Department of Gerontological Critical Care Medicine, Guangdong Provincial Geriatrics Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
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118
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Effects of Positive End-Expiratory Pressure and Spontaneous Breathing Activity on Regional Lung Inflammation in Experimental Acute Respiratory Distress Syndrome. Crit Care Med 2020; 47:e358-e365. [PMID: 30676338 DOI: 10.1097/ccm.0000000000003649] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To determine the impact of positive end-expiratory pressure during mechanical ventilation with and without spontaneous breathing activity on regional lung inflammation in experimental nonsevere acute respiratory distress syndrome. DESIGN Laboratory investigation. SETTING University hospital research facility. SUBJECTS Twenty-four pigs (28.1-58.2 kg). INTERVENTIONS In anesthetized animals, intrapleural pressure sensors were placed thoracoscopically in ventral, dorsal, and caudal regions of the left hemithorax. Lung injury was induced with saline lung lavage followed by injurious ventilation in supine position. During airway pressure release ventilation with low tidal volumes, positive end-expiratory pressure was set 4 cm H2O above the level to reach a positive transpulmonary pressure in caudal regions at end-expiration (best-positive end-expiratory pressure). Animals were randomly assigned to one of four groups (n = 6/group; 12 hr): 1) no spontaneous breathing activity and positive end-expiratory pressure = best-positive end-expiratory pressure - 4 cm H2O, 2) no spontaneous breathing activity and positive end-expiratory pressure = best-positive end-expiratory pressure + 4 cm H2O, 3) spontaneous breathing activity and positive end-expiratory pressure = best-positive end-expiratory pressure + 4 cm H2O, 4) spontaneous breathing activity and positive end-expiratory pressure = best-positive end-expiratory pressure - 4 cm H2O. MEASUREMENTS AND MAIN RESULTS Global lung inflammation assessed by specific [F]fluorodeoxyglucose uptake rate (median [25-75% percentiles], min) was decreased with higher compared with lower positive end-expiratory pressure both without spontaneous breathing activity (0.029 [0.027-0.030] vs 0.044 [0.041-0.065]; p = 0.004) and with spontaneous breathing activity (0.032 [0.028-0.043] vs 0.057 [0.042-0.075]; p = 0.016). Spontaneous breathing activity did not increase global lung inflammation. Lung inflammation in dorsal regions correlated with transpulmonary driving pressure from spontaneous breathing at lower (r = 0.850; p = 0.032) but not higher positive end-expiratory pressure (r = 0.018; p = 0.972). Higher positive end-expiratory pressure resulted in a more homogeneous distribution of aeration and regional transpulmonary pressures at end-expiration along the ventral-dorsal gradient, as well as a shift of the perfusion center toward dependent zones in the presence of spontaneous breathing activity. CONCLUSIONS In experimental mild-to-moderate acute respiratory distress syndrome, positive end-expiratory pressure levels that stabilize dependent lung regions reduce global lung inflammation during mechanical ventilation, independent from spontaneous breathing activity.
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119
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Mallory P, Cheifetz I. A comprehensive review of the use and understanding of airway pressure release ventilation. Expert Rev Respir Med 2020; 14:307-315. [PMID: 31869259 DOI: 10.1080/17476348.2020.1708719] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: Airway pressure release ventilation (APRV) is a mode of ventilation typically utilized as a rescue or alternative mode for patients with acute respiratory distress syndrome (ARDS) and hypoxemia that is refractory to conventional mechanical ventilation. APRV's indication and efficacy continue to remain unclear given lack of consensus amongst practitioners, inconsistent methodology for its use, and scarcity of convincing evidence.Areas covered: This review discusses the history of APRV, how APRV works, rationales for its use, and its theoretical advantages and disadvantages. This is followed by a review of current available literature examining APRV's use in the intensive care unit, with further focus on its use in the pediatric intensive care unit.Expert opinion: APRV is a ventilation mode with theoretical risks and benefits. Appropriate study of APRV's clinical efficacy is difficult given a heterogeneous patient population and widely variable use of APRV between centers. Despite a paucity of definitive evidence in support of either mode, it is possible that the use of APRV will begin to outpace the use of high-frequency oscillatory ventilation (HFOV) for the management of refractory hypoxemia as more attention is paid to benefits of spontaneous breathing and minimizing sedation. Furthermore, APRV's role during ECMO deserves further investigation.
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Affiliation(s)
- Palen Mallory
- Division of Pediatric Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Ira Cheifetz
- Division of Pediatric Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
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120
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Borges JB, Morais CCA, Costa ELV. High PEEP may have reduced injurious transpulmonary pressure swings in the ROSE trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:404. [PMID: 31829216 PMCID: PMC6907242 DOI: 10.1186/s13054-019-2689-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 11/28/2019] [Indexed: 12/03/2022]
Affiliation(s)
- João B Borges
- Centre for Human & Applied Physiological Sciences (CHAPS), King's College London, London, UK.
| | - Caio C A Morais
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Eduardo L V Costa
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
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121
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Yehya N. Lessons learned in acute respiratory distress syndrome from the animal laboratory. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:503. [PMID: 31728356 DOI: 10.21037/atm.2019.09.33] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Since the description of the acute respiratory distress syndrome (ARDS) in 1967, investigators have struggled to reproduce the syndrome in the animal laboratory. While several different models of experimental acute lung injury (ALI) have been developed, none completely capture the inciting etiologies, initial inflammation, heterogeneity, and resolution of human ARDS. This potentially has contributed to the poor translation of potential therapeutics between animal ALI models and human ARDS. It was only recently that standardized criteria were suggested for what makes an ALI model comparable to human ARDS. Nevertheless, despite model heterogeneity, these models have contributed substantially to our understanding of the syndrome. From the initial studies identifying the risks of mechanical ventilation to the identification of potentially targetable inflammatory mediators, to modern studies focusing on regional heterogeneity and novel molecular pathways, animal models continue to inform our understanding of ARDS. This review will cover several major lessons learned from animal models of ALI, and provide some direction for future studies in this field.
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Affiliation(s)
- Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, PA, USA
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122
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Cereda M, Xin Y, Goffi A, Herrmann J, Kaczka DW, Kavanagh BP, Perchiazzi G, Yoshida T, Rizi RR. Imaging the Injured Lung: Mechanisms of Action and Clinical Use. Anesthesiology 2019; 131:716-749. [PMID: 30664057 PMCID: PMC6692186 DOI: 10.1097/aln.0000000000002583] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Acute respiratory distress syndrome (ARDS) consists of acute hypoxemic respiratory failure characterized by massive and heterogeneously distributed loss of lung aeration caused by diffuse inflammation and edema present in interstitial and alveolar spaces. It is defined by consensus criteria, which include diffuse infiltrates on chest imaging-either plain radiography or computed tomography. This review will summarize how imaging sciences can inform modern respiratory management of ARDS and continue to increase the understanding of the acutely injured lung. This review also describes newer imaging methodologies that are likely to inform future clinical decision-making and potentially improve outcome. For each imaging modality, this review systematically describes the underlying principles, technology involved, measurements obtained, insights gained by the technique, emerging approaches, limitations, and future developments. Finally, integrated approaches are considered whereby multimodal imaging may impact management of ARDS.
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Affiliation(s)
- Maurizio Cereda
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Yi Xin
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, ON, Canada
| | - Jacob Herrmann
- Departments of Anesthesia and Biomedical Engineering, University of Iowa, IA
| | - David W. Kaczka
- Departments of Anesthesia, Radiology, and Biomedical Engineering, University of Iowa, IA
| | | | - Gaetano Perchiazzi
- Hedenstierna Laboratory and Uppsala University Hospital, Uppsala University, Sweden
| | - Takeshi Yoshida
- Hospital for Sick Children, University of Toronto, ON, Canada
| | - Rahim R. Rizi
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
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123
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Coudroy R, Frat JP, Ehrmann S, Pène F, Terzi N, Decavèle M, Prat G, Garret C, Contou D, Bourenne J, Gacouin A, Girault C, Dellamonica J, Malacrino D, Labro G, Quenot JP, Herbland A, Jochmans S, Devaquet J, Benzekri D, Vivier E, Nseir S, Colin G, Thévenin D, Grasselli G, Assefi M, Guerin C, Bougon D, Lherm T, Kouatchet A, Ragot S, Thille AW. High-flow nasal oxygen therapy alone or with non-invasive ventilation in immunocompromised patients admitted to ICU for acute hypoxemic respiratory failure: the randomised multicentre controlled FLORALI-IM protocol. BMJ Open 2019; 9:e029798. [PMID: 31401603 PMCID: PMC6701687 DOI: 10.1136/bmjopen-2019-029798] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Non-invasive ventilation (NIV) is recommended as first-line therapy in respiratory failure of critically ill immunocompromised patients as it can decrease intubation and mortality rates as compared with standard oxygen. However, its recommendation is only conditional. Indeed, the use of NIV in this setting has been challenged recently based on results of trials finding similar outcomes with or without NIV or even deleterious effects of NIV. To date, NIV has been compared with standard oxygen but not to high-flow nasal oxygen therapy (HFOT) in immunocompromised patients. Several studies have found lower mortality rates using HFOT alone than when using HFOT with NIV sessions in patients with de novo respiratory failure, and even in immunocompromised patients. We are hypothesising that HFOT alone is more effective than HFOT with NIV sessions and reduces mortality of immunocompromised patients with acute hypoxemic respiratory failure. METHODS AND ANALYSIS This study is an investigator-initiated, multicentre randomised controlled trial comparing HFOT alone or with NIV in immunocompromised patients admitted to intensive care unit (ICU) for severe acute hypoxemic respiratory failure. Around 280 patients will be randomised with a 1:1 ratio in two groups. The primary outcome is the mortality rate at day 28 after inclusion. Secondary outcomes include the rate of intubation in each group, length of ICU and hospital stay and mortality up to day 180. ETHICS AND DISSEMINATION The study has been approved by the ethics committee and patients will be included after informed consent. The results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02978300.
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Affiliation(s)
- Rémi Coudroy
- Médecine Intensive et Réanimation, INSERM CIC 1402, groupe ALIVE, Université de Poitiers, CHU de Poitiers, Poitiers, France
| | - Jean-Pierre Frat
- Médecine Intensive et Réanimation, INSERM CIC 1402, groupe ALIVE, Université de Poitiers, CHU de Poitiers, Poitiers, France
| | - Stephan Ehrmann
- Médecine Intensive et Réanimation, CIC 1415, CRICS-TriggerSEP research network, Centre d'étude des pathologies respiratoires, INSERM U1100, Université de Tours, CHRU de Tours, Tours, France
| | - Frédéric Pène
- Médecine Intensive et Réanimation, Université Paris Descartes, Hôpital Cochin, APHP, Paris, France
| | - Nicolas Terzi
- Médecine Intensive et Réanimation, INSERM, Université Grenoble-Alpes, U1042, HP2, CHU Grenoble Alpes, Grenoble, France
| | - Maxens Decavèle
- Service de Pneumologie, Médecine Intensive et Réanimation, Département R3S, AP-HP, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France
| | - Gwenaël Prat
- Médecine Intensive et Réanimation, CHU de Brest, Brest, France
| | - Charlotte Garret
- Médecine Intensive et Réanimation, CHU de Nantes, Nantes, France
| | - Damien Contou
- Service de Réanimation Polyvalente, Centre Hospitalier Victor Dupouy, Argenteuil, France
| | - Jeremy Bourenne
- Médecine Intensive et Réanimation, Réanimation des Urgences, Aix-Marseille Université, CHU La Timone 2, Marseille, France
| | - Arnaud Gacouin
- Service des Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Hôpital Ponchaillou, Rennes, France
| | - Christophe Girault
- Service de Réanimation Médicale, Normandie Univ, Unirouen, UPRES EA-3830, Hôpital Charles Nicolle, CHU de Rouen, Rouen, France
| | | | | | - Guylaine Labro
- Medical Intensive Care Unit, Research Center EA3920, University of Franche-Comté, Hôpital Jean Minjoz, Besançon, France
| | - Jean-Pierre Quenot
- Service de Médecine Intensive-Réanimation, INSERM U1231, Equipe Lipness, Université Bourgogne-Franche-Comté, UMR1231 Lipides, Nutrition, Cancer, équipe Lipness, LipSTIC LabEx, Fondation de coopération scientifique Bourgogne-Franche-Comté, INSERM, CIC 1432, Module Epidémiologie Clinique, Centre d'Investigation Clinique, Module Epidémiologie Clinique/Essais Cliniques, CHU Dijon, Dijon, France
| | - Alexandre Herbland
- Service de Réanimation, Centre hospitalier Saint Louis, La Rochelle, France
| | - Sébastien Jochmans
- Service de Réanimation, Centre hospitalier Sud-Ile-de France, Melun, France
| | - Jérôme Devaquet
- Medical-Surgical Intensive Care Unit, Hôpital Foch, Suresnes, France
| | - Dalila Benzekri
- Médecine Intensive et Réanimation, Groupe Hospitalier Régional d'Orléans, Orléans, France
| | - Emmanuel Vivier
- Reanimation Polyvalente, Hôpital Saint Joseph Saint Luc, Lyon, France
| | - Saad Nseir
- Centre de Réanimation, Université de Lille, CHU de Lille, Lille, France
| | - Gwenhaël Colin
- Service de Médecine Intensive et Réanimation, Centre Hospitalier Départemental de Vendée, La Roche-sur-Yon, France
| | - Didier Thévenin
- Service de Réanimation Polyvalente, CH de Lens, Lens, France
| | - Giacomo Grasselli
- Department of Anesthesiology, Intensive Care and Emergency, Department of Pathophysiology and Transplantation, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mona Assefi
- Multidisciplinary Intensive Care Unit, Department of Anesthesia and Critical Care Medicine, School of Medicine, University Pierre and Marie Curie (UPMC), Pitié-Salpétrière Hospital, APHP, Paris, France
| | - Claude Guerin
- Service de Médecine Intensive-Réanimation, Université de Lyon, INSERM 955, Créteil, Hôpital de La Croix-Rousse, Hospices civils de Lyon, Lyon, France
| | - David Bougon
- Service de Réanimation, Centre Hospitalier Annecy Genevois, Annecy, France
| | | | | | - Stéphanie Ragot
- INSERM CIC 1402, Biostatistics, Université de Poitiers, Poitiers, France
| | - Arnaud W Thille
- Médecine Intensive et Réanimation, INSERM CIC 1402, groupe ALIVE, Université de Poitiers, CHU de Poitiers, Poitiers, France
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124
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Williams EC, Motta-Ribeiro GC, Vidal Melo MF. Driving Pressure and Transpulmonary Pressure: How Do We Guide Safe Mechanical Ventilation? Anesthesiology 2019; 131:155-163. [PMID: 31094753 PMCID: PMC6639048 DOI: 10.1097/aln.0000000000002731] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The physiological concept, pathophysiological implications and clinical relevance and application of driving pressure and transpulmonary pressure to prevent ventilator-induced lung injury are discussed.
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Affiliation(s)
- Elizabeth C Williams
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts. Current Affiliation: Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland (E.C.W.)
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125
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Tomicic V, Cornejo R. Lung monitoring with electrical impedance tomography: technical considerations and clinical applications. J Thorac Dis 2019; 11:3122-3135. [PMID: 31463141 DOI: 10.21037/jtd.2019.06.27] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
In recent years there has been substantial progress in the imaging evaluation of patients with lung disease requiring mechanical ventilatory assistance. This has been demonstrated by the inclusion of pulmonary ultrasound, positron emission tomography, electrical impedance tomography (EIT), and magnetic resonance imaging (MRI). The EIT uses electric current to evaluate the distribution of alternating current conductivity within the thoracic cavity. The advantage of the latter is that it is non-invasive, bedside radiation-free functional imaging modality for continuous monitoring of lung ventilation and perfusion. EIT can detect recruitment or derecruitment, overdistension, variation of poorly ventilated lung units (silent spaces), and pendelluft phenomenon in spontaneously breathing patients. In addition, the regional expiratory time constants have been recently explored.
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Affiliation(s)
- Vinko Tomicic
- Jefe Unidad de Cuidados Intensivos Respiratorios, Clínica Indisa, Universidad Andres Bello, Santiago, Chile
| | - Rodrigo Cornejo
- Jefe Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Chile
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126
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Douglas IS, Bednash JS, Fein DG, Mallampalli RK, Mansoori JN, Gershengorn HB. Update in Critical Care and Acute Respiratory Distress Syndrome 2018. Am J Respir Crit Care Med 2019; 199:1335-1343. [PMID: 30958975 DOI: 10.1164/rccm.201903-0550up] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Affiliation(s)
- Ivor S Douglas
- 1 Pulmonary, Sleep and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver, Colorado
| | - Joseph S Bednash
- 2 Acute Lung Injury Center of Excellence, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Rama K Mallampalli
- 4 Department of Medicine, The Ohio State University, Columbus, Ohio; and
| | - Jason N Mansoori
- 1 Pulmonary, Sleep and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver, Colorado
| | - Hayley B Gershengorn
- 5 Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Miller School of Medicine, University of Miami, Miami, Florida
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127
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Affiliation(s)
- Jean-Michel Arnal
- Service of Reanimation, Sainte Musse Hospital, Toulon, France - .,Department of Medical Research, Hamilton Medical, Bonaduz, Switzerland -
| | - Robert Chatburn
- Department of Medicine, Lerner College of Medicine and Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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128
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Kollisch-Singule M, Andrews P, Satalin J, Gatto LA, Nieman GF, Habashi NM. The time-controlled adaptive ventilation protocol: mechanistic approach to reducing ventilator-induced lung injury. Eur Respir Rev 2019; 28:28/152/180126. [PMID: 30996041 DOI: 10.1183/16000617.0126-2018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/16/2019] [Indexed: 11/05/2022] Open
Abstract
Airway pressure release ventilation (APRV) is a ventilator mode that has previously been considered a rescue mode, but has gained acceptance as a primary mode of ventilation. In clinical series and experimental animal models of extrapulmonary acute respiratory distress syndrome (ARDS), the early application of APRV was able to prevent the development of ARDS. Recent experimental evidence has suggested mechanisms by which APRV, using the time-controlled adaptive ventilation (TCAV) protocol, may reduce lung injury, including: 1) an improvement in alveolar recruitment and homogeneity; 2) reduction in alveolar and alveolar duct micro-strain and stress-risers; 3) reduction in alveolar tidal volumes; and 4) recruitment of the chest wall by combating increased intra-abdominal pressure. This review examines these studies and discusses our current understanding of the pleiotropic mechanisms by which TCAV protects the lung. APRV set according to the TCAV protocol has been misunderstood and this review serves to highlight the various protective physiological and mechanical effects it has on the lung, so that its clinical application may be broadened.
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Affiliation(s)
| | - Penny Andrews
- Dept of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Joshua Satalin
- Dept of Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Louis A Gatto
- Dept of Surgery, SUNY Upstate Medical University, Syracuse, NY, USA.,Dept of Biological Sciences, SUNY Cortland, Cortland, NY, USA
| | - Gary F Nieman
- Dept of Surgery, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Nader M Habashi
- Dept of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
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129
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Grieco DL, Menga LS, Eleuteri D, Antonelli M. Patient self-inflicted lung injury: implications for acute hypoxemic respiratory failure and ARDS patients on non-invasive support. Minerva Anestesiol 2019; 85:1014-1023. [PMID: 30871304 DOI: 10.23736/s0375-9393.19.13418-9] [Citation(s) in RCA: 136] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
The role of spontaneous breathing among patients with acute hypoxemic respiratory failure and ARDS is debated: while avoidance of intubation with noninvasive ventilation (NIV) or high-flow nasal cannula improves clinical outcome, treatment failure worsens mortality. Recent data suggest patient self-inflicted lung injury (P-SILI) as a possible mechanism aggravating lung damage in these patients. P-SILI is generated by intense inspiratory effort yielding: (A) swings in transpulmonary pressure (i.e. lung stress) causing the inflation of big volumes in an aerated compartment markedly reduced by the disease-induced aeration loss; (B) abnormal increases in transvascular pressure, favouring negative-pressure pulmonary edema; (C) an intra-tidal shift of gas between different lung zones, generated by different transmission of muscular force (i.e. pendelluft); (D) diaphragm injury. Experimental data suggest that not all subjects are exposed to the development of P-SILI: patients with a PaO2/FiO2 ratio below 200 mmHg may represent the most at risk population. For them, current evidence indicates that high-flow nasal cannula alone may be superior to intermittent sessions of low-PEEP NIV delivered through face mask, while continuous high-PEEP helmet NIV likely promotes treatment success and may mitigate lung injury. The optimal initial noninvasive treatment of hypoxemic respiratory failure/ARDS remains however uncertain; high-flow nasal cannula and high-PEEP helmet NIV are promising tools to enhance success of the approach, but the best balance between these techniques has yet to be identified. During noninvasive support, careful clinical monitoring remains mandatory for prompt detection of treatment failure, in order not to delay intubation and protective ventilation.
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Affiliation(s)
- Domenico L Grieco
- Institute of Anesthesiology and Resuscitation, Sacred Heart Catholic University, Rome, Italy - .,Department of Emergency, Anesthesiology and Resuscitation Sciences, A. Gemelli University Polyclinic, IRCCS and Foundation, Rome, Italy -
| | - Luca S Menga
- Institute of Anesthesiology and Resuscitation, Sacred Heart Catholic University, Rome, Italy.,Department of Emergency, Anesthesiology and Resuscitation Sciences, A. Gemelli University Polyclinic, IRCCS and Foundation, Rome, Italy
| | - Davide Eleuteri
- Institute of Anesthesiology and Resuscitation, Sacred Heart Catholic University, Rome, Italy.,Department of Emergency, Anesthesiology and Resuscitation Sciences, A. Gemelli University Polyclinic, IRCCS and Foundation, Rome, Italy
| | - Massimo Antonelli
- Institute of Anesthesiology and Resuscitation, Sacred Heart Catholic University, Rome, Italy.,Department of Emergency, Anesthesiology and Resuscitation Sciences, A. Gemelli University Polyclinic, IRCCS and Foundation, Rome, Italy
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130
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Araos J, Alegria L, Garcia P, Cruces P, Soto D, Erranz B, Amthauer M, Salomon T, Medina T, Rodriguez F, Ayala P, Borzone GR, Meneses M, Damiani F, Retamal J, Cornejo R, Bugedo G, Bruhn A. Near-Apneic Ventilation Decreases Lung Injury and Fibroproliferation in an Acute Respiratory Distress Syndrome Model with Extracorporeal Membrane Oxygenation. Am J Respir Crit Care Med 2019; 199:603-612. [DOI: 10.1164/rccm.201805-0869oc] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
| | | | | | - Pablo Cruces
- Center of Acute Respiratory Critical Illness, Santiago, Chile
- Centro de Investigación de Medicina Veterinaria, Escuela de Medicina Veterinaria, Facultad de Ecología y Recursos Naturales, Universidad Andrés Bello, 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
- Escuela de Enfermería, Facultad de Medicina, Universidad Finis Terrae, Santiago, Chile
| | | | - Pedro Ayala
- Departamento de Enfermedades Respiratorias, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gisella R. Borzone
- Departamento de Enfermedades Respiratorias, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Manuel Meneses
- Departamento de Anatomía Patológica, Instituto Nacional del Tórax, Santiago, Chile
| | - Felipe Damiani
- Departamento de Medicina Intensiva
- Escuela de Kinesiología, Facultad de Ciencias, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile; and
| | - Jaime Retamal
- Departamento de Medicina Intensiva
- Center of Acute Respiratory Critical Illness, Santiago, Chile
| | - Rodrigo Cornejo
- Center of Acute Respiratory Critical Illness, Santiago, Chile
- Unidad de Pacientes Críticos, Departamento de Medicina, Hospital Clínico Universidad de Chile, Santiago, Chile
| | - Guillermo Bugedo
- Departamento de Medicina Intensiva
- Center of Acute Respiratory Critical Illness, Santiago, Chile
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva
- Center of Acute Respiratory Critical Illness, Santiago, Chile
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131
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Goligher EC. Myotrauma in mechanically ventilated patients. Intensive Care Med 2019; 45:881-884. [PMID: 30741329 DOI: 10.1007/s00134-019-05557-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 02/02/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. .,Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada. .,Toronto General Hospital Research Institute, 585 University Ave., 11-PMB Room 192, Toronto, ON, M5G 2N2, Canada.
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132
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Increased 90-Day Mortality in Spontaneously Breathing Patients With Paraquat Poisoning. Crit Care Med 2019; 47:219-228. [DOI: 10.1097/ccm.0000000000003518] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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133
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Kyo M, Ohshimo S, Shime N. Should We Abandon Airway Pressure Release Ventilation in Pediatric Acute Respiratory Distress Syndrome? Am J Respir Crit Care Med 2018; 198:1459-1460. [DOI: 10.1164/rccm.201807-1274le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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134
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Daxon B. Concerns over Airway Pressure Release Ventilation Management in Children with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2018; 198:1458-1459. [DOI: 10.1164/rccm.201806-1164le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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135
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136
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Guiding ventilation with transpulmonary pressure. Intensive Care Med 2018; 45:535-538. [PMID: 30506355 DOI: 10.1007/s00134-018-5483-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 11/26/2018] [Indexed: 10/27/2022]
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137
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Bachmann MC, Morais C, Bugedo G, Bruhn A, Morales A, Borges JB, Costa E, Retamal J. Electrical impedance tomography in acute respiratory distress syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:263. [PMID: 30360753 PMCID: PMC6203288 DOI: 10.1186/s13054-018-2195-6] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 09/14/2018] [Indexed: 12/29/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a clinical entity that acutely affects the lung parenchyma, and is characterized by diffuse alveolar damage and increased pulmonary vascular permeability. Currently, computed tomography (CT) is commonly used for classifying and prognosticating ARDS. However, performing this examination in critically ill patients is complex, due to the need to transfer these patients to the CT room. Fortunately, new technologies have been developed that allow the monitoring of patients at the bedside. Electrical impedance tomography (EIT) is a monitoring tool that allows one to evaluate at the bedside the distribution of pulmonary ventilation continuously, in real time, and which has proven to be useful in optimizing mechanical ventilation parameters in critically ill patients. Several clinical applications of EIT have been developed during the last years and the technique has been generating increasing interest among researchers. However, among clinicians, there is still a lack of knowledge regarding the technical principles of EIT and potential applications in ARDS patients. The aim of this review is to present the characteristics, technical concepts, and clinical applications of EIT, which may allow better monitoring of lung function during ARDS.
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Affiliation(s)
- M Consuelo Bachmann
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.,Acute Respiratory and Critical Illness Center (ARCI), Santiago, Chile
| | - Caio Morais
- Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Guillermo Bugedo
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.,Acute Respiratory and Critical Illness Center (ARCI), Santiago, Chile
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.,Acute Respiratory and Critical Illness Center (ARCI), Santiago, Chile
| | - Arturo Morales
- Departamento Enfermedades Respiratorias, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - João B Borges
- Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil.,Hedenstierna Laboratory, Department of Surgical Sciences, Section of Anaesthesiology and Critical Care, Uppsala University, Uppsala, Sweden
| | - Eduardo Costa
- Divisao de Pneumologia, Instituto do Coracao (Incor), Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile. .,Acute Respiratory and Critical Illness Center (ARCI), Santiago, Chile.
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138
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Yoshida T, Nakamura MAM, Morais CCA, Amato MBP, Kavanagh BP. Reverse Triggering Causes an Injurious Inflation Pattern during Mechanical Ventilation. Am J Respir Crit Care Med 2018; 198:1096-1099. [DOI: 10.1164/rccm.201804-0649le] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Takeshi Yoshida
- St. Michael's HospitalToronto, Ontario, Canadaand
- University of TorontoToronto, Ontario, Canada
| | | | | | | | - Brian P. Kavanagh
- University of TorontoToronto, Ontario, Canada
- Hospital for Sick ChildrenToronto, Ontario, Canada
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139
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Karagiannidis C, Waldmann AD, Róka PL, Schreiber T, Strassmann S, Windisch W, Böhm SH. Regional expiratory time constants in severe respiratory failure estimated by electrical impedance tomography: a feasibility study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:221. [PMID: 30236123 PMCID: PMC6148957 DOI: 10.1186/s13054-018-2137-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 07/27/2018] [Indexed: 01/17/2023]
Abstract
Background Electrical impedance tomography (EIT) has been used to guide mechanical ventilation in ICU patients with lung collapse. Its use in patients with obstructive pulmonary diseases has been rare since obstructions could not be monitored on a regional level at the bedside. The current study therefore determines breath-by-breath regional expiratory time constants in intubated patients with chronic obstructive pulmonary disease (COPD) and acute respiratory distress syndrome (ARDS). Methods Expiratory time constants calculated from the global impedance EIT signal were compared to the pneumatic volume signals measured with an electronic pneumotachograph. EIT-derived expiratory time constants were additionally determined on a regional and pixelwise level. However, regional EIT signals on a single pixel level could in principle not be compared with similar pneumatic changes since these measurements cannot be obtained in patients. For this study, EIT measurements were conducted in 14 intubated patients (mean Simplified Acute Physiology Score II (SAPS II) 35 ± 10, mean time on invasive mechanical ventilation 36 ± 26 days) under four different positive end-expiratory pressure (PEEP) levels ranging from 10 to 17 cmH2O. Only patients with moderate-severe ARDS or COPD exacerbation were included into the study, preferentally within the first days following intubation. Results Spearman’s correlation coefficient for comparison between EIT-derived time constants and those from flow/volume curves was between 0.78 for tau (τ) calculated from the global impedance signal up to 0.83 for the mean of all pixelwise calculated regional impedance changes over the entire PEEP range. Furthermore, Bland-Altman analysis revealed a corresponding bias of 0.02 and 0.14 s within the limits of agreement ranging from − 0.50 to 0.65 s for the aforementioned calculation methods. In addition, exemplarily in patients with moderate-severe ARDS or COPD exacerbation, different PEEP levels were shown to have an influence on the distribution pattern of regional time constants. Conclusions EIT-based determination of breath-by-breath regional expiratory time constants is technically feasible, reliable and valid in invasively ventilated patients with severe respiratory failure and provides a promising tool to individually adjust mechanical ventilation in response to the patterns of regional airflow obstruction. Trial registration German Trial Register DRKS 00011650, registered 01/31/17. Electronic supplementary material The online version of this article (10.1186/s13054-018-2137-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.
| | - Andreas D Waldmann
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.,Swisstom AG, Schulstrasse 1, 7302, Landquart, Switzerland
| | - Péter L Róka
- Budapest University of Technology and Economics, Budapest, Hungary
| | - Tina Schreiber
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Stephan Strassmann
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Wolfram Windisch
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Stephan H Böhm
- Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsmedizin Rostock, Schillingallee 35, D-18057, Rostock, Germany
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140
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Mauri T, Foti G, Fornari C, Constantin JM, Guerin C, Pelosi P, Ranieri M, Conti S, Tubiolo D, Rondelli E, Lovisari F, Fossali T, Spadaro S, Grieco DL, Navalesi P, Calamai I, Becher T, Roca O, Wang YM, Knafelj R, Cortegiani A, Mancebo J, Brochard L, Pesenti A. Pressure support ventilation + sigh in acute hypoxemic respiratory failure patients: study protocol for a pilot randomized controlled trial, the PROTECTION trial. Trials 2018; 19:460. [PMID: 30157955 PMCID: PMC6114230 DOI: 10.1186/s13063-018-2828-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 07/28/2018] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Adding cyclic short sustained inflations (sigh) to assisted ventilation yields optimizes lung recruitment, decreases heterogeneity and reduces inspiratory effort in patients with acute hypoxemic respiratory failure (AHRF). These findings suggest that adding sigh to pressure support ventilation (PSV) might decrease the risk of lung injury, shorten weaning and improve clinical outcomes. Thus, we conceived a pilot trial to test the feasibility of adding sigh to PSV (the PROTECTION study). METHODS PROTECTION is an international randomized controlled trial that will be conducted in 23 intensive care units (ICUs). Patients with AHRF who have been intubated from 24 h to 7 days and undergoing PSV from 4 to 24 h will be enrolled. All patients will first undergo a 30-min sigh test by adding sigh to clinical PSV for 30 min to identify early oxygenation responders. Then, patients will be randomized to PSV or PSV + sigh until extubation, ICU discharge, death or day 28. Sigh will be delivered as a 3-s pressure control breath delivered once per minute at 30 cmH2O. Standardized protocols will guide ventilation settings, switch back to controlled ventilation, use of rescue treatments, performance of spontaneous breathing trial, extubation and reintubation. The primary endpoint of the study will be to verify the feasibility of PSV + sigh evaluated through reduction of failure to remain on assisted ventilation during the first 28 days in the PSV + sigh group versus standard PSV (15 vs. 22%). Failure will be defined by switch back to controlled ventilation for more than 24 h or use of rescue treatments or reintubation within 48 h from elective extubation. Setting the power to 80% and first-risk order to 5%, the computed size of the trial is 129 patients per arm. DISCUSSION PROTECTION is a pilot randomized controlled trial testing the feasibility of adding sigh to PSV. If positive, it will provide physicians with an effective addition to standard PSV for lung protection, able to reduce failure of assisted ventilation. PROTECTION will provide the basis for a future larger trial aimed at verifying the impact of PSV + sigh on 28-day survival and ventilator-free days. TRIAL REGISTRATION ClinicalTrials.gov, NCT03201263 . Registered on 28 June 2017.
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Affiliation(s)
- Tommaso Mauri
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Giuseppe Foti
- ASST Monza, University of Milan-Bicocca, Monza, Italy
| | - Carla Fornari
- Research Centre on Public Health, School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Jean-Michel Constantin
- Department of Preoperative Medicine, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
| | - Claude Guerin
- Service de Réanimation Médicale, Hôpital de la Croix Rousse, Lyon, France
| | - Paolo Pelosi
- Department of Surgical and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Marco Ranieri
- Department of Anesthesia and Intensive Care Medicine, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Sara Conti
- Research Centre on Public Health, School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
| | - Daniela Tubiolo
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
| | - Egle Rondelli
- ASST Monza, University of Milan-Bicocca, Monza, Italy
| | - Federica Lovisari
- Department of Anesthesia and Critical Care, Niguarda Hospital, University of Milan-Bicocca, Milan, Italy
| | - Tommaso Fossali
- Department of Anesthesiology and Intensive Care, ASST Fatebenefratelli Sacco - Luigi Sacco Hospital, Milan, Italy
| | - Savino Spadaro
- Department of morphology, surgery and experimental medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, Ferrara, Italy
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, IRCCS Fondazione Policlinico A. Gemelli, Rome, Italy
| | - Paolo Navalesi
- Dipartimento di Scienze Mediche e Chirurgiche, Università Magna Graecia di Catanzaro, Azienda Ospedaliera Universitaria Mater Domini, Catanzaro, Italy
| | - Italo Calamai
- AUSL Toscana Centro, Unit of Anesthesia and Resuscitation, San Giuseppe Hospital, Empoli, Italy
| | - Tobias Becher
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Oriol Roca
- Critical Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Yu-Mei Wang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Rihard Knafelj
- Center for Internal Intensive medicine (MICU), University Medical Center Ljubljana, Ljubljana, Slovenia
| | - Andrea Cortegiani
- Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anesthesia, Analgesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo, Italy
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Antonio Pesenti
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy. .,Anesthesia and Critical Care, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy. .,Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.
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141
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Marini JJ. Conditional Value of Raising Positive End-Expiratory Pressure to Counter Vigorous Breathing Efforts in Injured Lungs. Am J Respir Crit Care Med 2018; 197:1239-1240. [DOI: 10.1164/rccm.201712-2615ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- John J. Marini
- Regions HospitalUniversity of MinnesotaSt. Paul, Minnesota
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142
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Mireles-Cabodevila E, Dugar S, Chatburn RL. APRV for ARDS: the complexities of a mode and how it affects even the best trials. J Thorac Dis 2018; 10:S1058-S1063. [PMID: 29850185 DOI: 10.21037/jtd.2018.03.156] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Eduardo Mireles-Cabodevila
- Respiratory Institute, Cleveland Clinic, Ohio, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Ohio, USA
| | - Siddharth Dugar
- Respiratory Institute, Cleveland Clinic, Ohio, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Ohio, USA
| | - Robert L Chatburn
- Respiratory Institute, Cleveland Clinic, Ohio, USA.,Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Ohio, USA
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143
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Yoshida T, Amato MBP, Kavanagh BP. Understanding spontaneous vs. ventilator breaths: impact and monitoring. Intensive Care Med 2018; 44:2235-2238. [PMID: 29574574 DOI: 10.1007/s00134-018-5145-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 03/19/2018] [Indexed: 11/26/2022]
Affiliation(s)
- Takeshi Yoshida
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
- Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
| | - Marcelo B P Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Instituto do Coração (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Brian P Kavanagh
- Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
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144
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Roshdy A, Katira BH, Kuebler WM, Kavanagh BP. Vascular-induced lung injury: another advocate for personalized ARDS management : Discussion on "Inspiratory preload obliteration may injure lungs via cyclical 'on-off' vascular flow". Intensive Care Med 2018; 44:540-541. [PMID: 29450595 DOI: 10.1007/s00134-018-5077-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2018] [Indexed: 10/18/2022]
Affiliation(s)
- Ashraf Roshdy
- Critical Care Unit, Queen Elizabeth Hospital, Lewisham and Greenwich NHS Trust, Stadium Road, Woolwich, London, SE18 4QH, UK. .,Critical Care Medicine, Alexandria University, Alexandria, Egypt.
| | - B H Katira
- Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - W M Kuebler
- Institute of Physiology, Charité-Universitätsmedizin, Berlin, Germany
| | - B P Kavanagh
- Department of Critical Care Medicine, Hospital for Sick Children, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.,Research Institute, Hospital for Sick Children, University of Toronto, Toronto, Canada.,Department of Anesthesia, Hospital for Sick Children, University of Toronto, Toronto, Canada
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