151
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Van Dessel ED, De Meyer GR, Morrison SG, Jorens PG, Schepens T. Flow-controlled ventilation in moderate acute respiratory distress syndrome due to COVID-19: an open-label repeated-measures controlled trial. Intensive Care Med Exp 2022; 10:19. [PMID: 35608696 PMCID: PMC9127816 DOI: 10.1186/s40635-022-00449-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/09/2022] [Indexed: 01/07/2023] Open
Abstract
Background Flow-controlled ventilation (FCV), a novel mode of mechanical ventilation characterised by constant flow during active expiration, may result in more efficient alveolar gas exchange, better lung recruitment and might be useful in limiting ventilator-induced lung injury. However, data regarding FCV in mechanically ventilated patients with acute lung injury or acute respiratory distress syndrome (ARDS) are scarce. Objectives We hypothesised that the use of FCV is feasible and would improve oxygenation in moderate COVID-19 ARDS compared to conventional ventilation. Design Open-label repeated-measures controlled trial. Setting From February to April 2021, patients with moderate COVID-19 ARDS were recruited in a tertiary referral intensive care unit. Patients Patients with moderate ARDS (PaO2/FIO2 ratio 100–200 mmHg, SpO2 88–94% and PaO2 60–80 mmHg) were considered eligible. Exclusion criteria were: extremes of age (< 18 years, > 80 years), obesity (body mass index > 40 kg/m2), prone positioning at the time of intervention, mechanical ventilation for more than 10 days and extracorporeal membrane oxygenation. Eleven patients were recruited. Intervention Participants were ventilated in FCV mode for 30 min, and subsequently in volume-control mode (VCV) for 30 min. Main outcome measures Feasibility of FCV to maintain oxygenation was assessed by the PaO2/FiO2 ratio (mmHg) as a primary outcome parameter. Secondary outcomes included ventilator parameters, PaCO2 and haemodynamic data. All adverse events were recorded. Results FCV was feasible in all patients and no adverse events were observed. There was no difference in the PaO2/FIO2 ratio after 30 min of ventilation in FCV mode (169 mmHg) compared to 30 min of ventilation in VCV mode subsequently (168 mmHg, 95% CI of pseudo-medians (− 10.5, 3.6), p = 0.56). The tidal volumes (p < 0.01) and minute ventilation were lower during FCV (p = 0.01) while PaCO2 was similar at the end of the 30-min ventilation periods (p = 0.31). Mean arterial pressure during FCV was comparable to baseline. Conclusions Thirty minutes of FCV in patients with moderate COVID-19 ARDS receiving neuromuscular blocking agents resulted in similar oxygenation, compared to VCV. FCV was feasible and did not result in adverse events. Trial registration: Clinicaltrials.gov identifier: NCT04894214.
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Affiliation(s)
- Eleni D Van Dessel
- Department of Critical Care Medicine, Antwerp University Hospital/University of Antwerp, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - Gregory R De Meyer
- Department of Critical Care Medicine, Antwerp University Hospital/University of Antwerp, Drie Eikenstraat 655, 2650, Edegem, Belgium.,Department of Anesthesiology, Antwerp University Hospital/University of Antwerp, Edegem, Belgium
| | - Stuart G Morrison
- Department of Anesthesiology, Antwerp University Hospital/University of Antwerp, Edegem, Belgium
| | - Philippe G Jorens
- Department of Critical Care Medicine, Antwerp University Hospital/University of Antwerp, Drie Eikenstraat 655, 2650, Edegem, Belgium
| | - Tom Schepens
- Department of Critical Care Medicine, Antwerp University Hospital/University of Antwerp, Drie Eikenstraat 655, 2650, Edegem, Belgium.
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152
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Abstract
OBJECTIVE To describe, through a narrative review, the physiologic principles underlying electrical impedance tomography, and its potential applications in managing acute respiratory distress syndrome (ARDS). To address the current evidence supporting its use in different clinical scenarios along the ARDS management continuum. DATA SOURCES We performed an online search in Pubmed to review articles. We searched MEDLINE, Cochrane Central Register, and clinicaltrials.gov for controlled trials databases. STUDY SELECTION Selected publications included case series, pilot-physiologic studies, observational cohorts, and randomized controlled trials. To describe the rationale underlying physiologic principles, we included experimental studies. DATA EXTRACTION Data from relevant publications were reviewed, analyzed, and its content summarized. DATA SYNTHESIS Electrical impedance tomography is an imaging technique that has aided in understanding the mechanisms underlying multiple interventions used in ARDS management. It has the potential to monitor and predict the response to prone positioning, aid in the dosage of flow rate in high-flow nasal cannula, and guide the titration of positive-end expiratory pressure during invasive mechanical ventilation. The latter has been demonstrated to improve physiologic and mechanical parameters correlating with lung recruitment. Similarly, its use in detecting pneumothorax and harmful patient-ventilator interactions such as pendelluft has been proven effective. Nonetheless, its impact on clinically meaningful outcomes remains to be determined. CONCLUSIONS Electrical impedance tomography is a potential tool for the individualized management of ARDS throughout its different stages. Clinical trials should aim to determine whether a specific approach can improve clinical outcomes in ARDS management.
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153
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Barbas CSV. Thoracic Computed Tomography to Assess ARDS and COVID-19 Lungs. Front Physiol 2022; 13:829534. [PMID: 35586712 PMCID: PMC9108486 DOI: 10.3389/fphys.2022.829534] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 03/28/2022] [Indexed: 12/16/2022] Open
Abstract
This review was designed to discuss the role of thoracic-computed tomography (CT) in the evaluation and treatment of patients with ARDS and COVID-19 lung disease. Non-aerated lungs characterize the ARDS lungs, compared to normal lungs in the lowermost lung regions, compressive atelectasis. Heterogenous ARDS lungs have a tomographic vertical gradient characterized by progressively more aerated lung tissues from the gravity-dependent to gravity-independent lungs levels. The application of positive pressure ventilation to these heterogeneous ARDS lungs provides some areas of high shear stress, others of tidal hyperdistension or tidal recruitment that increases the chances of appearance and perpetuation of ventilator-induced lung injury. Other than helping to the correct diagnosis of ARDS, thoracic-computed tomography can help to the adjustments of PEEP, ideal tidal volume, and a better choice of patient position during invasive mechanical ventilation. Thoracic tomography can also help detect possible intra-thoracic complications and in the follow-up of the ARDS patients’ evolution during their hospital stay. In COVID-19 patients, thoracic-computed tomography was the most sensitive imaging technique for diagnosing pulmonary involvement. The most common finding is diffuse pulmonary infiltrates, ranging from ground-glass opacities to parenchymal consolidations, especially in the lower portions of the lungs’ periphery. Tomographic lung volume loss was associated with an increased risk for oxygenation support and patient intubation and the use of invasive mechanical ventilation. Pulmonary dual-energy angio-tomography in COVID-19 patients showed a significant number of pulmonary ischemic areas even in the absence of visible pulmonary arterial thrombosis, which may reflect micro-thrombosis associated with COVID-19 pneumonia. A greater thoracic tomography severity score in ARDS was independently related to poor outcomes.
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Affiliation(s)
- Carmen Silvia Valente Barbas
- Associate Professor of Pneumology, University of São Paulo Medical School, Medical Staff Adult ICU Albert Einstein Hospital, São Paulo, Brazil
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154
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Abstract
This paper provides a review of a selection of papers published in the Journal of Clinical Monitoring and Computing in 2020 and 2021 highlighting what is new within the field of respiratory monitoring. Selected papers cover work in pulse oximetry monitoring, acoustic monitoring, respiratory system mechanics, monitoring during surgery, electrical impedance tomography, respiratory rate monitoring, lung ultrasound and detection of patient-ventilator asynchrony.
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155
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Botta M, Tsonas AM, Sinnige JS, De Bie AJR, Bindels AJGH, Ball L, Battaglini D, Brunetti I, Buiteman-Kruizinga LA, van der Heiden PLJ, de Jonge E, Mojoli F, Robba C, Schoe A, Paulus F, Pelosi P, Neto AS, Horn J, Schultz MJ. Effect of Automated Closed-loop ventilation versus convenTional VEntilation on duration and quality of ventilation in critically ill patients (ACTiVE) - study protocol of a randomized clinical trial. Trials 2022; 23:348. [PMID: 35461264 PMCID: PMC9034629 DOI: 10.1186/s13063-022-06286-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/07/2022] [Indexed: 12/16/2022] Open
Abstract
Background INTELLiVENT–Adaptive Support Ventilation (ASV) is a fully automated closed-loop mode of ventilation for use in critically ill patients. Evidence for benefit of INTELLiVENT–ASV in comparison to ventilation that is not fully automated with regard to duration of ventilation and quality of breathing is largely lacking. We test the hypothesis that INTELLiVENT–ASV shortens time spent on a ventilator and improves the quality of breathing. Methods The “Effects of Automated Closed–loop VenTilation versus Conventional Ventilation on Duration and Quality of Ventilation” (ACTiVE) study is an international, multicenter, two-group randomized clinical superiority trial. In total, 1200 intensive care unit (ICU) patients with an anticipated duration of ventilation of > 24 h will be randomly assigned to one of the two ventilation strategies. Investigators screen patients aged 18 years or older at start of invasive ventilation in the ICU. Patients either receive automated ventilation by means of INTELLiVENT–ASV, or ventilation that is not automated by means of a conventional ventilation mode. The primary endpoint is the number of days free from ventilation and alive at day 28; secondary endpoints are quality of breathing using granular breath-by-breath analysis of ventilation parameters and variables in a time frame of 24 h early after the start of invasive ventilation, duration of ventilation in survivors, ICU and hospital length of stay (LOS), and mortality rates in the ICU and hospital, and at 28 and 90 days. Discussion ACTiVE is one of the first randomized clinical trials that is adequately powered to compare the effects of automated closed-loop ventilation versus conventional ventilation on duration of ventilation and quality of breathing in invasively ventilated critically ill patients. The results of ACTiVE will support intensivist in their choices regarding the use of automated ventilation. Trial registration ACTiVE is registered in clinicaltrials.gov (study identifier: NCT04593810) on 20 October 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06286-w.
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Affiliation(s)
- Michela Botta
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.
| | - Anissa M Tsonas
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Jante S Sinnige
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands
| | - Ashley J R De Bie
- Department of Intensive Care, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | | | - Lorenzo Ball
- Department of Anesthesia and Intensive Care, San Martino Polyclinic Hospital, IRCCS for Oncology and Neurosciences, Genova, Italy
| | - Denise Battaglini
- Department of Anesthesia and Intensive Care, San Martino Polyclinic Hospital, IRCCS for Oncology and Neurosciences, Genova, Italy
| | - Iole Brunetti
- Department of Anesthesia and Intensive Care, San Martino Polyclinic Hospital, IRCCS for Oncology and Neurosciences, Genova, Italy
| | - Laura A Buiteman-Kruizinga
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Department of Intensive Care, Reinier de Graaf Hospital, Delft, The Netherlands
| | | | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Francesco Mojoli
- Department of Anesthesia and Intensive Care, San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | - Chiara Robba
- Department of Anesthesia and Intensive Care, San Martino Polyclinic Hospital, IRCCS for Oncology and Neurosciences, Genova, Italy
| | - Abraham Schoe
- Department of Intensive Care, Leiden University Medical Centre, Leiden, The Netherlands
| | - Frederique Paulus
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Faculty of Health, ACHIEVE, Centre of Applied Research, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
| | - Paolo Pelosi
- Department of Anesthesia and Intensive Care, San Martino Polyclinic Hospital, IRCCS for Oncology and Neurosciences, Genova, Italy.,Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genova, Genova, Italy
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Janneke Horn
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Amsterdam Neuroscience, Amsterdam UMC Research Institute, Amsterdam, The Netherlands
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam UMC location University of Amsterdam, Meibergdreef 9, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Department of Research and Development, Hamilton Medical AG, Bonaduz, Switzerland
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156
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Brioni M, Meli A, Grasselli G. Mechanical Ventilation for COVID-19 Patients. Semin Respir Crit Care Med 2022; 43:405-416. [PMID: 35439831 DOI: 10.1055/s-0042-1744305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Non-invasive ventilation (NIV) or invasive mechanical ventilation (MV) is frequently needed in patients with acute hypoxemic respiratory failure due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. While NIV can be delivered in hospital wards and nonintensive care environments, intubated patients require intensive care unit (ICU) admission and support. Thus, the lack of ICU beds generated by the pandemic has often forced the use of NIV in severely hypoxemic patients treated outside the ICU. In this context, awake prone positioning has been widely adopted to ameliorate oxygenation during noninvasive respiratory support. Still, the incidence of NIV failure and the role of patient self-induced lung injury on hospital outcomes of COVID-19 subjects need to be elucidated. On the other hand, endotracheal intubation is indicated when gas exchange deterioration, muscular exhaustion, and/or neurological impairment ensue. Yet, the best timing for intubation in COVID-19 is still widely debated, as it is the safest use of neuromuscular blocking agents. Not differently from other types of acute respiratory distress syndrome, the aim of MV during COVID-19 is to provide adequate gas exchange while avoiding ventilator-induced lung injury. At the same time, the use of rescue therapies is advocated when standard care is unable to guarantee sufficient organ support. Nevertheless, the general shortage of health care resources experienced during SARS-CoV-2 pandemic might affect the utilization of high-cost, highly specialized, and long-term supports. In this article, we describe the state-of-the-art of NIV and MV setting and their usage for acute hypoxemic respiratory failure of COVID-19 patients.
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Affiliation(s)
- Matteo Brioni
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Meli
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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157
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Lung Recruitability and Positive End-Expiratory Pressure Setting in ARDS Caused by COVID-19. Chest 2022; 161:869-871. [PMID: 35396041 PMCID: PMC8980520 DOI: 10.1016/j.chest.2021.12.651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/29/2021] [Indexed: 12/16/2022] Open
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158
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A Ventilator Mode Cannot Set Itself, Nor Can It Be Solely Responsible for Outcomes. Crit Care Med 2022; 50:695-699. [PMID: 35311779 DOI: 10.1097/ccm.0000000000005403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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159
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Welker C, Huang J, Gil IJN, Ramakrishna H. 2021 Acute Respiratory Distress Syndrome Update, With Coronavirus Disease 2019 Focus. J Cardiothorac Vasc Anesth 2022; 36:1188-1195. [PMID: 33781671 PMCID: PMC7912364 DOI: 10.1053/j.jvca.2021.02.053] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 02/22/2021] [Indexed: 12/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a heterogeneous lung disease responsible for significant morbidity and mortality among critically ill patients, including those infected with severe acute respiratory syndrome coronavirus 2, the virus responsible for coronavirus disease 2019. Despite recent advances in pathophysiology, diagnostics, and therapeutics, ARDS is dangerously underdiagnosed, and supportive lung protective ventilation and prone positioning remain the mainstay interventions. Rescue therapies, including neuromuscular blockade and venovenous extracorporeal membrane oxygenation, remain a key component of clinical practice, although benefits are unclear. Even though coronavirus disease 2019 ARDS has some distinguishing features from traditional ARDS, including delayed onset, hyperinflammatory response, and pulmonary microthrombi, it clinically is similar to traditional ARDS and should be treated with established supportive therapies.
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Affiliation(s)
- Carson Welker
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Jeffrey Huang
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Iván J. Núñez Gil
- Department of Cardiology, Cardiovascular Institute, Hospital Clínico San Carlos, Madrid, Spain
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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160
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Karageorgos V, Proklou A, Vaporidi K. Lung and diaphragm protective ventilation: a synthesis of recent data. Expert Rev Respir Med 2022; 16:375-390. [PMID: 35354361 DOI: 10.1080/17476348.2022.2060824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
INTRODUCTION : To adhere to the Hippocratic Oath, to "first, do no harm", we need to make every effort to minimize the adverse effects of mechanical ventilation. Our understanding of the mechanisms of ventilator-induced lung injury (VILI) and ventilator-induced diaphragm dysfunction (VIDD) has increased in recent years. Research focuses now on methods to monitor lung stress and inhomogeneity and targets we should aim for when setting the ventilator. In parallel, efforts to promote early assisted ventilation to prevent VIDD have revealed new challenges, such as titrating inspiratory effort and synchronizing the mechanical with the patients' spontaneous breaths, while at the same time adhering to lung-protective targets. AREAS COVERED This is a narrative review of the key mechanisms contributing to VILI and VIDD and the methods currently available to evaluate and mitigate the risk of lung and diaphragm injury. EXPERT OPINION Implementing lung and diaphragm protective ventilation requires individualizing the ventilator settings, and this can only be accomplished by exploiting in everyday clinical practice the tools available to monitor lung stress and inhomogeneity, inspiratory effort, and patient-ventilator interaction.
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Affiliation(s)
- Vlasios Karageorgos
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Athanasia Proklou
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Katerina Vaporidi
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
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161
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Boesing C, Graf PT, Schmitt F, Thiel M, Pelosi P, Rocco PRM, Luecke T, Krebs J. Effects of different positive end-expiratory pressure titration strategies during prone positioning in patients with acute respiratory distress syndrome: a prospective interventional study. Crit Care 2022; 26:82. [PMID: 35346325 PMCID: PMC8962042 DOI: 10.1186/s13054-022-03956-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/19/2022] [Indexed: 01/01/2023] Open
Abstract
Background Prone positioning in combination with the application of low tidal volume and adequate positive end-expiratory pressure (PEEP) improves survival in patients with moderate to severe acute respiratory distress syndrome (ARDS). However, the effects of PEEP on end-expiratory transpulmonary pressure (Ptpexp) during prone positioning require clarification. For this purpose, the effects of three different PEEP titration strategies on Ptpexp, respiratory mechanics, mechanical power, gas exchange, and hemodynamics were evaluated comparing supine and prone positioning. Methods In forty consecutive patients with moderate to severe ARDS protective ventilation with PEEP titrated according to three different titration strategies was evaluated during supine and prone positioning: (A) ARDS Network recommendations (PEEPARDSNetwork), (B) the lowest static elastance of the respiratory system (PEEPEstat,RS), and (C) targeting a positive Ptpexp (PEEPPtpexp). The primary endpoint was to analyze whether Ptpexp differed significantly according to PEEP titration strategy during supine and prone positioning. Results Ptpexp increased progressively with prone positioning compared with supine positioning as well as with PEEPEstat,RS and PEEPPtpexp compared with PEEPARDSNetwork (positioning effect p < 0.001, PEEP strategy effect p < 0.001). PEEP was lower during prone positioning with PEEPEstat,RS and PEEPPtpexp (positioning effect p < 0.001, PEEP strategy effect p < 0.001). During supine positioning, mechanical power increased progressively with PEEPEstat,RS and PEEPPtpexp compared with PEEPARDSNetwork, and prone positioning attenuated this effect (positioning effect p < 0.001, PEEP strategy effect p < 0.001). Prone compared with supine positioning significantly improved oxygenation (positioning effect p < 0.001, PEEP strategy effect p < 0.001) while hemodynamics remained stable in both positions. Conclusions Prone positioning increased transpulmonary pressures while improving oxygenation and hemodynamics in patients with moderate to severe ARDS when PEEP was titrated according to the ARDS Network lower PEEP table. This PEEP titration strategy minimized parameters associated with ventilator-induced lung injury induction, such as transpulmonary driving pressure and mechanical power. We propose that a lower PEEP strategy (PEEPARDSNetwork) in combination with prone positioning may be part of a lung protective ventilation strategy in patients with moderate to severe ARDS. Trial registration German Clinical Trials Register (DRKS00017449). Registered June 27, 2019. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017449 Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03956-8.
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162
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Liang M, Chen X. Differential Prognostic Analysis of Higher and Lower PEEP in ARDS Patients: Systematic Review and Meta-Analysis. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:5399416. [PMID: 35356616 PMCID: PMC8959975 DOI: 10.1155/2022/5399416] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 02/25/2022] [Accepted: 03/02/2022] [Indexed: 12/30/2022]
Abstract
Background Positive end-expiratory pressure (PEEP) refers to the positive pressure in the respiratory tract at the end of the exhalation when we use a ventilator. The differences of higher PEEP and lower PEEP on clinical outcomes in acute respiratory distress syndrome (ARDS) patients are less well known. Methods A comprehensive literature search of all randomized control trials (RCTs) was conducted using PubMed, Embase, World Health Organization (WHO) Global Index Medicus, WHO clinical trial registry, and Clinicaltrials.gov. Inclusion criteria included RCTs comparing the clinical outcomes of higher and lower PEEP in ARDS patients. Results Eleven studies were included in the final analysis. In the higher PEEP group, the hospital mortality, 28-day mortality, and ICU mortality showed no significantly lower risk compared to the lower PEEP group (RR = 0.92, 95% CI 0.80-1.05, p = 0.22; RR = 0.88, 95% CI 0.73-1.05, p = 0.15; RR = 0.84, 95% CI 0.67-1.05, p = 0.12; respectively). High certainty could be obtained that there is no significant difference between the clinical outcomes of higher PEEP and lower PEEP in ARDS patients. Conclusions There is no significant difference of the hospital mortality, 28-day mortality, and ICU mortality between higher and lower PEEP in ARDS patients.
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Affiliation(s)
- Min Liang
- Department of Intensive Care Unit, Sir Run Run Shaw Hospital, Affiliated to School of Medicine, Zhejiang University, Hangzhou, China
| | - Xin Chen
- Department of Intensive Care Unit, Hangzhou Tumor Hospital, Affiliated to School of Medicine, Zhejiang University, Hangzhou, China
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163
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Sidebotham D, Barlow CJ. False-positive and false-negative risks for individual multicentre trials in critical care. BJA OPEN 2022; 1:100003. [PMID: 37588693 PMCID: PMC10430847 DOI: 10.1016/j.bjao.2022.100003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 01/27/2022] [Indexed: 08/18/2023]
Abstract
Background In medical research, null hypothesis significance testing (NHST) is the dominant framework for statistical inference. NHST involves calculating P-values and confidence intervals to quantify the evidence against the null hypothesis of no effect. However, P-values and confidence intervals cannot tell us the probability that the hypothesis is true. In contrast, false-positive risk (FPR) and false-negative risk (FNR) are post-test probabilities concerning the truth of the hypothesis, that is to say, the probability a real effect exists. Methods We calculated the FPR or FNR for 53 individual multicentre trials in critical care based on a pretest probability of 0.5 that the hypothesis was true. Results For trials reporting statistical significance, the FPR varied between 0.1% and 57.6%. For trials reporting non-significance, the FNR varied between 1.7% and 36.9%. Twenty-six of 47 trials (55.3%) reporting non-significance provided strong or very strong evidence in favour of the null hypothesis; the remaining trials provided limited evidence. There was no obvious relationship between the P-value and the FNR. Conclusions The FPR and FNR showed marked variability, indicating that the probability of a real or absent treatment effect differed substantially between trials. Only one trial reporting statistical significance provided convincing evidence of a real treatment effect, and nearly half of all trials reporting non-significance provided limited evidence for the absence of a treatment effect. Our findings suggest that the quality of evidence from multicentre trials in critical care is highly variable.
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Affiliation(s)
- David Sidebotham
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - C. Jake Barlow
- Department of Anaesthesia, Auckland City Hospital, Auckland, New Zealand
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
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164
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Zhuang S, Wu H, Lin H, Yan N, Zhang F, Wang W. Efficacy analysis of the lung recruitment maneuver in correcting pulmonary atelectasis in neurological intensive care unit-a retrospective study. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:315. [PMID: 35433997 PMCID: PMC9011305 DOI: 10.21037/atm-22-554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/15/2022] [Indexed: 12/16/2022]
Abstract
Background Atelectasis after supratentorial craniotomy is common. It can lead to the decrease of arterial partial pressure of oxygen (PaO2) in patients with neurosurgical intensive care units (NICU), and the recovery of neurological function is more and more difficult. However, due to the particularity of maintaining the stability of intracranial pressure (ICP), there are few reports on effective ways to alleviate atelectasis and improve oxygenation in patients with NICU effectively. Methods A retrospective analysis was conducted to analyze the clinical data of patients with atelectasis who received lung recruitment maneuver in the NICU. This study collected data on 33 patients. Of these, 17 patients had traumatic brain injury and 16 patients had spontaneous intracranial hemorrhage. PaO2, oxygenation index (OI), tidal volume, positive end-expiratory pressure (PEEP), respiratory system compliance, plateau pressure, respiratory rate, minute ventilation and chest computed tomography (CT) or portable chest X-ray images were compared before and after recruitment. As for safety evaluation indicators, we reviewed the invasive arterial blood pressure, heart rate, heart rhythm, and subcutaneous emphysema in all patients. Before and after lung recruitment, the data were compared using the paired t-test and the Wilcoxon test. Results Compared with tidal volume 8.1 [6.85-10.05] mL/kg, minute ventilation volume (9.3±1.3 L/min), respiratory system compliance 60 [39-80] mL/cmH2O, respiratory rate 17 [16-21.5] breaths/min, PEEP 4 [4-6] cmH2O, plateau pressure 19 [17-23] cmH2O, PaO2 (104.2±33.17 mmHg) and OI (250.6±87.65 mmHg) before lung recruitment, tidal volume 9 [8.05-10.65] mL/kg, minute ventilation (9.7±1.1 L/min), respiratory system compliance 69 [50-82.5] mL/cmH2O, respiratory rate 17 [14-18.5] breaths/min, PEEP 4 [4-5] cmH2O, plateau pressure 18 [16-19.5] cmH2O, PaO2 (127.3±34.95 mmHg) and OI (306.9±96.52 mmHg) of patients were significantly improved after recruitment after recruitment (all P<0.05). In all patients, chest CT showed a decrease in atelectasis area and bilateral pulmonary exudates in 25 patients after lung recruitment maneuver. X-ray after recruitment in 2 patients showed increased lung tissue transparency and decreased ground-glass shadowing, while improvements were not obvious in 6 patients. Conclusions For patients diagnosed with atelectasis in the NICU, lung recruitment maneuver can improve atelectasis, increase PaO2, and improve oxygenation.
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Affiliation(s)
- Shunfu Zhuang
- Department of Neurosurgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hong Wu
- Department of Neurosurgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hong Lin
- Department of Neurosurgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Ning Yan
- Department of Neurosurgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Feifei Zhang
- Department of Neurosurgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Weiwei Wang
- Department of Neurosurgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
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165
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Paternoster G, Bertini P, Belletti A, Landoni G, Gallotta S, Palumbo D, Isirdi A, Guarracino F. Veno-Venous Extracorporeal Membrane Oxygenation in Awake Non-Intubated Patients with COVID-19 ARDS at High Risk for Barotrauma. J Cardiothorac Vasc Anesth 2022; 36:2975-2982. [PMID: 35537972 PMCID: PMC8926433 DOI: 10.1053/j.jvca.2022.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 02/17/2022] [Accepted: 03/04/2022] [Indexed: 12/16/2022]
Abstract
Objectives: To assess the efficacy of an awake venovenous extracorporeal membrane oxygenation (VV-ECMO) management strategy in preventing clinically relevant barotrauma in patients with coronavirus disease 2019 (COVID-19) with severe acute respiratory distress syndrome (ARDS) at high risk for pneumothorax (PNX)/pneumomediastinum (PMD), defined as the detection of the Macklin-like effect on chest computed tomography (CT) scan. Design: A case series. Setting: At the intensive care unit of a tertiary-care institution. Participants: Seven patients with COVID-19-associated severe ARDS and Macklin-like radiologic sign on baseline chest CT. Interventions: Primary VV-ECMO under spontaneous breathing instead of invasive mechanical ventilation (IMV). All patients received noninvasive ventilation or oxygen through a high-flow nasal cannula before and during ECMO support. The study authors collected data on cannulation strategy, clinical management, and outcome. Failure of awake VV-ECMO strategy was defined as the need for IMV due to worsening respiratory failure or delirium/agitation. The primary outcome was the development of PNX/PMD. Measurements and Main Results: No patient developed PNX/PMD. The awake VV-ECMO strategy failed in 1 patient (14.3%). Severe complications were observed in 4 (57.1%) patients and were noted as the following: intracranial bleeding in 1 patient (14.3%), septic shock in 2 patients (28.6%), and secondary pulmonary infections in 3 patients (42.8%). Two patients died (28.6%), whereas 5 were successfully weaned off VV-ECMO and were discharged home. Conclusions: VV-ECMO in awake and spontaneously breathing patients with severe COVID-19 ARDS may be a feasible and safe strategy to prevent the development of PNX/PMD in patients at high risk for this complication.
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166
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Dianti J, Tisminetzky M, Ferreyro BL, Englesakis M, Del Sorbo L, Sud S, Talmor D, Ball L, Meade M, Hodgson C, Beitler JR, Sahetya S, Nichol A, Fan E, Rochwerg B, Brochard L, Slutsky AS, Ferguson ND, Serpa Neto A, Adhikari NK, Angriman F, Goligher EC. Association of PEEP and Lung Recruitment Selection Strategies with Mortality in Acute Respiratory Distress Syndrome: A Systematic Review and Network Meta-Analysis. Am J Respir Crit Care Med 2022; 205:1300-1310. [PMID: 35180042 DOI: 10.1164/rccm.202108-1972oc] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
RATIONALE The most beneficial positive end-expiratory pressure (PEEP) selection strategy in patients with acute respiratory distress syndrome (ARDS) is unknown and current practice is variable. OBJECTIVES To compare the relative effects of different PEEP selection strategies on mortality in adults with moderate to severe ARDS. METHODS We conducted a network meta-analysis using a Bayesian framework. Certainty of evidence was evaluated using GRADE methodology. RESULTS We included 18 randomized trials (4646 participants). In comparison to a lower PEEP strategy, the posterior probability of mortality benefit from a higher PEEP without lung recruitment maneuver (LRM) strategy was 99% (RR 0.77, 95% Crl 0.60-0.96, high certainty), the posterior probability of benefit of the Pes-guided strategy was 87% (RR 0.77, 95% CrI 0.48-1.22, moderate certainty), the posterior probability of benefit of a higher PEEP with brief LRM strategy was 96% (RR 0.83, 95% CrI 0.67-1.02, moderate certainty), and the posterior probability of increased mortality from a higher PEEP with prolonged LRM strategy was 77% (RR 1.06, 95% Crl 0.89-1.22, low certainty). In comparison to a higher PEEP without LRM strategy, the posterior probability of increased mortality from a higher PEEP with prolonged LRM strategy was 99% (RR 1.37, 95% CrI 1.04-1.81, moderate certainty). CONCLUSIONS AND RELEVANCE In patients with moderate to severe ARDS, higher PEEP without LRM is associated with a lower risk of death as compared to lower PEEP. A higher PEEP with prolonged LRM strategy is associated with increased risk of death when compared to higher PEEP without LRM.
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Affiliation(s)
- Jose Dianti
- Hospital Italiano de Buenos Aires, 37533, Intensive Care Unit, Buenos Aires, Argentina
| | - Manuel Tisminetzky
- University Health Network, 7989, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Bruno L Ferreyro
- University Health Network, 7989, Critical Care, Toronto, Ontario, Canada
| | - Marina Englesakis
- University Health Network, 7989, Library and Information Services, Toronto, Ontario, Canada
| | - Lorenzo Del Sorbo
- Toronto General Hospital, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Sachin Sud
- Trillium Health Center, Mississauga, Ontario, Canada
| | - Daniel Talmor
- Beth Israel Deaconess Medical Center, Department of Anesthesia and Critical Care, Boston, Massachusetts, United States
| | - Lorenzo Ball
- University of Genoa School of Medical and Pharmaceutical Sciences, 60225, Anaesthesia and Intensive Care Unit, Department of Surgical Science and Integrated Diagnostics (DISC), Genova, Italy
| | - Maureen Meade
- McMaster University, 3710, Clinical Epidemiology & Biostatistics, Hamilton, Ontario, Canada
| | - Carol Hodgson
- Monash University, ANZIC Research Centre, Melbourne, Victoria, Australia.,Alfred Health, 5392, Intensive Care, Melbourne, Victoria, Australia
| | - Jeremy R Beitler
- Columbia University College of Physicians and Surgeons, 12294, Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, New York, New York, United States.,NewYork-Presbyterian Hospital, 25065, New York, New York, United States
| | - Sarina Sahetya
- Johns Hopkins University, Pulmonary & Critical Care Medicine, Baltimore, Maryland, United States
| | - Alistair Nichol
- Monash University, Australian and New Zealand Intensive Care Research Centre, Melbourne, Victoria, Australia
| | - Eddy Fan
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Bram Rochwerg
- McMaster University, Medicine, Hamilton, Ontario, Canada
| | - Laurent Brochard
- St Michael's Hospital in Toronto, Li Ka Shing Knowledge Institute, Keenan Research Centre, Toronto, Ontario, Canada.,University of Toronto, 7938, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Arthur S Slutsky
- University of Toronto, 7938, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Niall D Ferguson
- University Health Network, Department of Medicine, Division of Respirology, Toronto, Ontario, Canada.,University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Ary Serpa Neto
- Hospital Israelita Albert Einstein, 37896, Intensive Care Unit, São Paulo, Brazil
| | | | - Federico Angriman
- University of Toronto, 7938, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Ewan C Goligher
- University Health Network, 7989, Department of Medicine, Division of Respirology, Critical Care Program, Toronto, Ontario, Canada.,University of Toronto, 7938, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada;
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167
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Roldán R, Rodriguez S, Barriga F, Tucci M, Victor M, Alcala G, Villamonte R, Suárez-Sipmann F, Amato M, Brochard L, Tusman G. Sequential lateral positioning as a new lung recruitment maneuver: an exploratory study in early mechanically ventilated Covid-19 ARDS patients. Ann Intensive Care 2022; 12:13. [PMID: 35150355 PMCID: PMC8840950 DOI: 10.1186/s13613-022-00988-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/21/2022] [Indexed: 12/16/2022] Open
Abstract
Background A sequential change in body position from supine-to-both lateral positions under constant ventilatory settings could be used as a postural recruitment maneuver in case of acute respiratory distress syndrome (ARDS), provided that sufficient positive end-expiratory pressure (PEEP) prevents derecruitment. This study aims to evaluate the feasibility and physiological effects of a sequential postural recruitment maneuver in early mechanically ventilated COVID-19 ARDS patients. Methods A cohort of 15 patients receiving lung-protective mechanical ventilation in volume-controlled with PEEP based on recruitability were prospectively enrolled and evaluated in five sequentially applied positions for 30 min each: Supine-baseline; Lateral-1st side; 2nd Supine; Lateral-2nd side; Supine-final. PEEP level was selected using the recruitment-to-inflation ratio (R/I ratio) based on which patients received PEEP 12 cmH2O for R/I ratio ≤ 0.5 or PEEP 15 cmH2O for R/I ratio > 0.5. At the end of each period, we measured respiratory mechanics, arterial blood gases, lung ultrasound aeration, end-expiratory lung impedance (EELI), and regional distribution of ventilation and perfusion using electric impedance tomography (EIT). Results Comparing supine baseline and final, respiratory compliance (29 ± 9 vs 32 ± 8 mL/cmH2O; p < 0.01) and PaO2/FIO2 ratio (138 ± 36 vs 164 ± 46 mmHg; p < 0.01) increased, while driving pressure (13 ± 2 vs 11 ± 2 cmH2O; p < 0.01) and lung ultrasound consolidation score decreased [5 (4–5) vs 2 (1–4); p < 0.01]. EELI decreased ventrally (218 ± 205 mL; p < 0.01) and increased dorsally (192 ± 475 mL; p = 0.02), while regional compliance increased in both ventral (11.5 ± 0.7 vs 12.9 ± 0.8 mL/cmH2O; p < 0.01) and dorsal regions (17.1 ± 1.8 vs 18.8 ± 1.8 mL/cmH2O; p < 0.01). Dorsal distribution of perfusion increased (64.8 ± 7.3% vs 66.3 ± 7.2%; p = 0.01). Conclusions Without increasing airway pressure, a sequential postural recruitment maneuver improves global and regional respiratory mechanics and gas exchange along with a redistribution of EELI from ventral to dorsal lung areas and less consolidation. Trial registration ClinicalTrials.gov, NCT04475068. Registered 17 July 2020, https://clinicaltrials.gov/ct2/show/NCT04475068 Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-00988-9.
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Affiliation(s)
- Rollin Roldán
- Laboratorio de Fisiología Experimental, Facultad de Medicina Humana, Universidad de Piura, Lima, Peru.,Intensive Care Unit, Hospital Rebagliati, Lima, Peru.,Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Shalim Rodriguez
- Laboratorio de Fisiología Experimental, Facultad de Medicina Humana, Universidad de Piura, Lima, Peru.,Intensive Care Unit, Hospital Rebagliati, Lima, Peru
| | - Fernando Barriga
- Laboratorio de Fisiología Experimental, Facultad de Medicina Humana, Universidad de Piura, Lima, Peru.,Intensive Care Unit, Hospital Rebagliati, Lima, Peru
| | - Mauro Tucci
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marcus Victor
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.,Electronics Engineering, Aeronautics Institute of Technology, São Paulo, Brazil
| | - Glasiele Alcala
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Renán Villamonte
- Laboratorio de Fisiología Experimental, Facultad de Medicina Humana, Universidad de Piura, Lima, Peru.,Intensive Care Unit, Hospital Rebagliati, Lima, Peru
| | - Fernando Suárez-Sipmann
- Intensive Care Unit, Hospital Universitario de La Princesa, Madrid, Spain.,Hedenstierna Laboratory, Surgical Sciences, Uppsala University, Uppsala, Sweden.,CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Marcelo Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
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168
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Assessment of respiratory support decision and the outcome of invasive mechanical ventilation in severe COVID-19 with ARDS. JOURNAL OF INTENSIVE MEDICINE 2022; 2:92-102. [PMID: 36785779 PMCID: PMC8810377 DOI: 10.1016/j.jointm.2021.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/12/2021] [Accepted: 12/10/2021] [Indexed: 01/15/2023]
Abstract
Background The coronavirus disease 2019 (COVID-19) is an ongoing pandemic. Invasive mechanical ventilation (IMV) is essential for the management of COVID-19 with acute respiratory distress syndrome (ARDS). We aimed to assess the impact of compliance with a respiratory decision support system on the outcomes of patients with COVID-19-associated ARDS who required IMV. Methods In this retrospective, single-center, case series study, patients with COVID-19-associated ARDS who required IMV at Zhongnan Hospital of Wuhan University, China, from January 8th, 2020, to March 24th, 2020, with the final follow-up date of April 20th, 2020, were included. Demographic, clinical, laboratory, imaging, and management information were collected and analyzed. Compliance with the respiratory support decision system was documented, and its relationship with 28-day mortality was evaluated. Results The study included 46 COVID-19-associated ARDS patients who required IMV. The median age of the 46 patients was 68.5 years, and 31 were men. The partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio at intensive care unit (ICU) admission was 104 mmHg. The median total length of IMV was 12.0 (interquartile range [IQR]: 6.0-27.3) days, and the median respiratory support decision score was 11.0 (IQR: 7.8-16.0). To 28 days after ICU admission, 18 (39.1%) patients died. Survivors had a significantly higher respiratory support decision score than non-survivors (15.0 [10.3-17.0] vs. 8.5 (6.0-10.3), P = 0.001). Using receiver operating characteristic (ROC) curve to assess the discrimination of respiratory support decision score to 28-day mortality, the area under the curve (AUC) was 0.796 (95% confidence interval [CI]: 0.657-0.934, P = 0.001) and the cut-off was 11.5 (sensitivity = 0.679, specificity = 0.889). Patients with a higher score (>11.5) were more likely to survive at 28 days after ICU admission (log-rank test, P < 0.001). Conclusions For severe COVID-19-associated ARDS with IMV, following the respiratory support decision and assessing completion would improve the progress of ventilation. With a decision score of >11.5, the mortality at 28 days after ICU admission showed an obvious decrease.
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169
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Prediction and estimation of pulmonary response and elastance evolution for volume-controlled and pressure-controlled ventilation. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2021.103367] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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170
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Mega C, Cavalli I, Ranieri VM, Tonetti T. Protective ventilation in patients with acute respiratory distress syndrome related to COVID-19: always, sometimes or never? Curr Opin Crit Care 2022; 28:51-56. [PMID: 34813522 PMCID: PMC8711310 DOI: 10.1097/mcc.0000000000000904] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW To review current evidence on the pathophysiology of COVID-19-related acute respiratory distress syndrome (ARDS) and on the implementation of lung protective ventilation. RECENT FINDINGS Although multiple observations and physiological studies seem to show a different pathophysiological behaviour in COVID-19-ARDS compared with 'classical' ARDS, numerous studies on thousands of patients do not confirm these findings and COVID-19-ARDS indeed shares similar characteristics and interindividual heterogeneity with ARDS from other causes. Although still scarce, present evidence on the application of lung protective ventilation in COVID-19-ARDS shows that it is indeed consistently applied in ICUs worldwide with a possible signal towards better survival at least in one study. The levels of positive end-expiratory pressure (PEEP) usually applied in these patients are higher than in 'classical' ARDS, proposing once again the issue of PEEP personalization in hypoxemic patients. In the absence of robust evidence, careful evaluation of the patient is needed, and empiric settings should be oriented towards lower levels of PEEP. SUMMARY According to the present evidence, a lung protective strategy based on low tidal volume and plateau pressures is indicated in COVID-19-ARDS as in ARDS from other causes; however, there are still uncertainties on the appropriate levels of PEEP.
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Affiliation(s)
- Chiara Mega
- Alma Mater Studiorum - Università di Bologna, Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, IRCCS Policlinico di Sant'Orsola, Bologna, Italy
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171
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Gallifant J, Zhang J, del Pilar Arias Lopez M, Zhu T, Camporota L, Celi LA, Formenti F. Artificial intelligence for mechanical ventilation: systematic review of design, reporting standards, and bias. Br J Anaesth 2022; 128:343-351. [PMID: 34772497 PMCID: PMC8792831 DOI: 10.1016/j.bja.2021.09.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 09/09/2021] [Accepted: 09/27/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Artificial intelligence (AI) has the potential to personalise mechanical ventilation strategies for patients with respiratory failure. However, current methodological deficiencies could limit clinical impact. We identified common limitations and propose potential solutions to facilitate translation of AI to mechanical ventilation of patients. METHODS A systematic review was conducted in MEDLINE, Embase, and PubMed Central to February 2021. Studies investigating the application of AI to patients undergoing mechanical ventilation were included. Algorithm design and adherence to reporting standards were assessed with a rubric combining published guidelines, satisfying the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis [TRIPOD] statement. Risk of bias was assessed by using the Prediction model Risk Of Bias ASsessment Tool (PROBAST), and correspondence with authors to assess data and code availability. RESULTS Our search identified 1,342 studies, of which 95 were included: 84 had single-centre, retrospective study design, with only one randomised controlled trial. Access to data sets and code was severely limited (unavailable in 85% and 87% of studies, respectively). On request, data and code were made available from 12 and 10 authors, respectively, from a list of 54 studies published in the last 5 yr. Ethnicity was frequently under-reported 18/95 (19%), as was model calibration 17/95 (18%). The risk of bias was high in 89% (85/95) of the studies, especially because of analysis bias. CONCLUSIONS Development of algorithms should involve prospective and external validation, with greater code and data availability to improve confidence in and translation of this promising approach. TRIAL REGISTRATION NUMBER PROSPERO - CRD42021225918.
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Affiliation(s)
- Jack Gallifant
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK,Corresponding authors.
| | - Joe Zhang
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, London, UK,Institute of Global Health Innovation, Imperial College London, London, UK
| | | | - Tingting Zhu
- Institute of Biomedical Engineering, Department of Engineering Science, University of Oxford, Oxford, UK
| | - Luigi Camporota
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK,Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, London, UK
| | - Leo A. Celi
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA, USA,Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Harvard University, Boston, MA, USA,Corresponding authors.
| | - Federico Formenti
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK,Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK,Department of Biomechanics, University of Nebraska Omaha, Omaha, NE, USA
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172
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Individualized positive end-expiratory pressure guided by end-expiratory lung volume in early acute respiratory distress syndrome: study protocol for the multicenter, randomized IPERPEEP trial. Trials 2022; 23:63. [PMID: 35057852 PMCID: PMC8772175 DOI: 10.1186/s13063-021-05993-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 12/30/2021] [Indexed: 12/16/2022] Open
Abstract
Background In acute respiratory distress syndrome (ARDS), response to positive end-expiratory pressure (PEEP) is variable according to different degrees of lung recruitability. The search for a tool to individualize PEEP based on patients’ individual response is warranted. End-expiratory lung volume (EELV) assessment by nitrogen washing-washout aids bedside estimation of PEEP-induced alveolar recruitment and may therefore help titrate PEEP on patient’s individual recruitability. We designed a randomized trial to test whether an individualized PEEP setting protocol driven by EELV measurement may improve a composite clinical outcome in patients with moderate-to-severe ARDS (IPERPEEP trial). Methods IPERPEEP is an open-label, multicenter, randomized trial that will be conducted in 10 intensive care units in Italy and will enroll 132 ARDS patients showing PaO2/FiO2 ratio ≤ 150 mmHg within 24 h from endotracheal intubation while on mechanical ventilation with PEEP 5 cmH2O. To standardize lung volumes at study initiation, all patients will undergo mechanical ventilation with tidal volume of 6 ml/kg of predicted body weight and PEEP set to obtain a plateau pressure within 28 and 30 cmH2O for 30 min (EXPRESS PEEP). Afterwards, a 5-step decremental PEEP trial will be conducted (EXPRESS PEEP to PEEP 5 cmH2O), and EELV will be measured at each step. Recruitment-to-inflation ratio will be calculated for each PEEP range from EELV difference. Patients will be then randomized to receive mechanical ventilation with PEEP set according to the optimal recruitment observed in the PEEP trial (IPERPEEP arm) trial or to achieve a plateau pressure of 28–30 cmH2O (control arm, EXPRESS strategy). In both groups, tidal volume size, use of prone positioning and neuromuscular blocking agents, and weaning from PEEP and from mechanical ventilation will be standardized. The primary endpoint of the study is a composite clinical outcome incorporating in-ICU mortality, 60-day ventilator-free days, and serum interleukin-6 concentration over the course of the initial 72 h of treatment. Discussion The IPERPEEP study is a randomized trial powered to elucidate whether an individualized PEEP setting protocol based on bedside assessment of lung recruitability can improve a composite clinical outcome during moderate-to-severe ARDS. Trial registration ClinicalTrials.govNCT04012073. Registered 9 July 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05993-0.
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173
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Tipre DN, Cidon M, Moats RA. Imaging Pulmonary Blood Vessels and Ventilation-Perfusion Mismatch in COVID-19. Mol Imaging Biol 2022; 24:526-536. [PMID: 35041149 PMCID: PMC8764889 DOI: 10.1007/s11307-021-01700-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/22/2021] [Accepted: 12/27/2021] [Indexed: 12/16/2022]
Abstract
COVID-19 hypoxemic patients although sharing a same etiology (SARS-CoV-2 infection) present themselves quite differently from one another. Patients also respond differently to prescribed medicine and to prone Vs supine bed positions. A severe pulmonary ventilation-perfusion mismatch usually triggers moderate to severe COVID-19 cases. Imaging can aid the physician in assessing severity of COVID-19. Although useful for their portability X-ray and ultrasound serving on the frontline to evaluate lung parenchymal abnormalities are unable to provide information about pulmonary vasculature and blood flow redistribution which is a consequence of hypoxemia in COVID-19. Advanced imaging modalities such as computed tomography, single-photon emission tomography, and electrical impedance tomography use a sharp algorithm visualizing pulmonary ventilation-perfusion mismatch in the abnormal and in the apparently normal parenchyma. Imaging helps to access the severity of infection, lung performance, ventilation-perfusion mismatch, and informs strategies for medical treatment. This review summarizes the capacity of these imaging modalities to assess ventilation-perfusion mismatch in COVID-19. Despite having limitations, these modalities provide vital information on blood volume distribution, pulmonary embolism, pulmonary vasculature and are useful to assess severity of lung disease and effectiveness of treatment in COVID-19 patients.
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Affiliation(s)
- Dnyanesh N Tipre
- Translational Biomedical Imaging Laboratory, Department of Radiology, Children's Hospital Los Angeles, The Saban Research Institute, 4650 Sunset Blvd Rm 305, Los Angeles, CA, USA.
| | - Michal Cidon
- Department of Rheumatology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Rex A Moats
- Translational Biomedical Imaging Laboratory, Department of Radiology, Children's Hospital Los Angeles, The Saban Research Institute, 4650 Sunset Blvd Rm 305, Los Angeles, CA, USA
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174
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Patel B, Mumby S, Johnson N, Falaschetti E, Hansen J, Adcock I, McAuley D, Takata M, Karbing DS, Jabaudon M, Schellengowski P, Rees SE. Decision support system to evaluate ventilation in the acute respiratory distress syndrome (DeVENT study)-trial protocol. Trials 2022; 23:47. [PMID: 35039050 PMCID: PMC8762446 DOI: 10.1186/s13063-021-05967-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/23/2021] [Indexed: 12/16/2022] Open
Abstract
Background The acute respiratory distress syndrome (ARDS) occurs in response to a variety of insults, and mechanical ventilation is life-saving in this setting, but ventilator-induced lung injury can also contribute to the morbidity and mortality in the condition. The Beacon Caresystem is a model-based bedside decision support system using mathematical models tuned to the individual patient’s physiology to advise on appropriate ventilator settings. Personalised approaches using individual patient description may be particularly advantageous in complex patients, including those who are difficult to mechanically ventilate and wean, in particular ARDS. Methods We will conduct a multi-centre international randomised, controlled, allocation concealed, open, pragmatic clinical trial to compare mechanical ventilation in ARDS patients following application of the Beacon Caresystem to that of standard routine care to investigate whether use of the system results in a reduction in driving pressure across all severities and phases of ARDS. Discussion Despite 20 years of clinical trial data showing significant improvements in ARDS mortality through mitigation of ventilator-induced lung injury, there remains a gap in its personalised application at the bedside. Importantly, the protective effects of higher positive end-expiratory pressure (PEEP) were noted only when there were associated decreases in driving pressure. Hence, the pressures set on the ventilator should be determined by the diseased lungs’ pressure-volume relationship which is often unknown or difficult to determine. Knowledge of extent of recruitable lung could improve the ventilator driving pressure. Hence, personalised management demands the application of mechanical ventilation according to the physiological state of the diseased lung at that time. Hence, there is significant rationale for the development of point-of-care clinical decision support systems which help personalise ventilatory strategy according to the current physiology. Furthermore, the potential for the application of the Beacon Caresystem to facilitate local and remote management of large numbers of ventilated patients (as seen during this COVID-19 pandemic) could change the outcome of mechanically ventilated patients during the course of this and future pandemics. Trial registration ClinicalTrials.gov identifier NCT04115709. Registered on 4 October 2019, version 4.0 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05967-2.
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Affiliation(s)
- Brijesh Patel
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College, London, UK.
| | - Sharon Mumby
- Airway Disease, National, Heart & Lung Institute, Imperial College, London, UK
| | - Nicholas Johnson
- Imperial Clinical Trials Unit, Stadium House, 68 Wood Lane, London, W12 7RH, UK
| | | | | | - Ian Adcock
- Airway Disease, National, Heart & Lung Institute, Imperial College, London, UK
| | - Danny McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | - Masao Takata
- Division of Anaesthetics, Pain Medicine, and Intensive Care, Department of Surgery and Cancer, Imperial College, London, UK
| | - Dan S Karbing
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, University Hospital of Clermont-Ferrand, GReD, Université Clermont Auvergne, CNRS, INSERM, Clermont-Ferrand, France
| | - Peter Schellengowski
- Medical University of Vienna, Department of Medicine I, Waehringer Guertel 18-20, A-1090, Vienna, Austria
| | - Stephen E Rees
- Respiratory and Critical Care Group, Department of Health Science and Technology, Aalborg University, Aalborg, Denmark
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175
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Petit M, Jullien E, Vieillard-Baron A. Right Ventricular Function in Acute Respiratory Distress Syndrome: Impact on Outcome, Respiratory Strategy and Use of Veno-Venous Extracorporeal Membrane Oxygenation. Front Physiol 2022; 12:797252. [PMID: 35095561 PMCID: PMC8795709 DOI: 10.3389/fphys.2021.797252] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 12/21/2021] [Indexed: 12/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by protein-rich alveolar edema, reduced lung compliance and severe hypoxemia. Despite some evidence of improvements in mortality over recent decades, ARDS remains a major public health problem with 30% 28-day mortality in recent cohorts. Pulmonary vascular dysfunction is one of the pivot points of the pathophysiology of ARDS, resulting in a certain degree of pulmonary hypertension, higher levels of which are associated with morbidity and mortality. Pulmonary hypertension develops as a result of endothelial dysfunction, pulmonary vascular occlusion, increased vascular tone, extrinsic vessel occlusion, and vascular remodeling. This increase in right ventricular (RV) afterload causes uncoupling between the pulmonary circulation and RV function. Without any contractile reserve, the right ventricle has no adaptive reserve mechanism other than dilatation, which is responsible for left ventricular compression, leading to circulatory failure and worsening of oxygen delivery. This state, also called severe acute cor pulmonale (ACP), is responsible for excess mortality. Strategies designed to protect the pulmonary circulation and the right ventricle in ARDS should be the cornerstones of the care and support of patients with the severest disease, in order to improve prognosis, pending stronger evidence. Acute cor pulmonale is associated with higher driving pressure (≥18 cmH2O), hypercapnia (PaCO2 ≥ 48 mmHg), and hypoxemia (PaO2/FiO2 < 150 mmHg). RV protection should focus on these three preventable factors identified in the last decade. Prone positioning, the setting of positive end-expiratory pressure, and inhaled nitric oxide (INO) can also unload the right ventricle, restore better coupling between the right ventricle and the pulmonary circulation, and correct circulatory failure. When all these strategies are insufficient, extracorporeal membrane oxygenation (ECMO), which improves decarboxylation and oxygenation and enables ultra-protective ventilation by decreasing driving pressure, should be discussed in seeking better control of RV afterload. This review reports the pathophysiology of pulmonary hypertension in ARDS, describes right heart function, and proposes an RV protective approach, ranging from ventilatory settings and prone positioning to INO and selection of patients potentially eligible for veno-venous extracorporeal membrane oxygenation (VV ECMO).
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Affiliation(s)
- Matthieu Petit
- Medical Intensive Care Unit, University Hospital Ambroise Paré, APHP, Boulogne-Billancourt, France
- UFR des Sciences de la Santé Simone Veil, Université Paris-Saclay, Montigny-le-Bretonneux, France
| | - Edouard Jullien
- Medical Intensive Care Unit, University Hospital Ambroise Paré, APHP, Boulogne-Billancourt, France
- UFR des Sciences de la Santé Simone Veil, Université Paris-Saclay, Montigny-le-Bretonneux, France
| | - Antoine Vieillard-Baron
- Medical Intensive Care Unit, University Hospital Ambroise Paré, APHP, Boulogne-Billancourt, France
- UFR des Sciences de la Santé Simone Veil, Université Paris-Saclay, Montigny-le-Bretonneux, France
- *Correspondence: Antoine Vieillard-Baron,
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176
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Abstract
Acute respiratory distress syndrome (ARDS) is a clinical syndrome characterized by several clinical features and pathological responses involving the respiratory system primarily. Infections (viral), sepsis, and massive transfusion are the commonest causes of ARDS during pregnancy. The majority of them recover with noninvasive ventilatory (NIV) support. NIV is safe in pregnancy provided the center is experienced and has a protocolized patient care pathway. Parturients requiring invasive mechanical ventilation are best managed in experienced centers. PaO2/FiO2 targets are higher in parturients compared to nonpregnant patients. Permissive hypercapnia is not a safe option in pregnancy. In severe ARDS with refractory hypoxemia, prone ventilation is a safe option. However, it has to be done in experienced centers. Venovenous ECMO is a safe alternative option in pregnant women with refractory hypoxemia, and delivery has been prolonged to a safe viable age on ECMO. The decision to deliver and the mode of delivery have to be a multidisciplinary decision; primary criterion is maternal survival. Postdelivery, establishing maternal bonding while in ventilatory support facilitates early weaning and minimizes lactation failure.
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Affiliation(s)
- Sunil T Pandya
- Department of Anaesthesia, Peri-operative Medicine and Critical Care, AIG Hospitals, Hyderabad, Telangana, India
- Sunil T Pandya, Department of Anaesthesia, Peri-operative Medicine and Critical Care, AIG Hospitals, Hyderabad, Telangana, India, e-mail:
| | - Sai J Krishna
- Department of Anaesthesia, Peri-operative Medicine and Critical Care, AIG Hospitals, Hyderabad, Telangana, India
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177
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Evidence-Based Mechanical Ventilatory Strategies in ARDS. J Clin Med 2022; 11:jcm11020319. [PMID: 35054013 PMCID: PMC8780427 DOI: 10.3390/jcm11020319] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 02/01/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) remains one of the leading causes of morbidity and mortality in critically ill patients despite advancements in the field. Mechanical ventilatory strategies are a vital component of ARDS management to prevent secondary lung injury and improve patient outcomes. Multiple strategies including utilization of low tidal volumes, targeting low plateau pressures to minimize barotrauma, using low FiO2 (fraction of inspired oxygen) to prevent injury related to oxygen free radicals, optimization of positive end expiratory pressure (PEEP) to maintain or improve lung recruitment, and utilization of prone ventilation have been shown to decrease morbidity and mortality. The role of other mechanical ventilatory strategies like non-invasive ventilation, recruitment maneuvers, esophageal pressure monitoring, determination of optimal PEEP, and appropriate patient selection for extracorporeal support is not clear. In this article, we review evidence-based mechanical ventilatory strategies and ventilatory adjuncts for ARDS.
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178
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Duggal A, Kast R, Van Ark E, Bulgarelli L, Siuba MT, Osborn J, Rey DA, Zampieri FG, Cavalcanti AB, Maia I, Paisani DM, Laranjeira LN, Serpa Neto A, Deliberato RO. Identification of acute respiratory distress syndrome subphenotypes de novo using routine clinical data: a retrospective analysis of ARDS clinical trials. BMJ Open 2022; 12:e053297. [PMID: 34992112 PMCID: PMC8739395 DOI: 10.1136/bmjopen-2021-053297] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES The acute respiratory distress syndrome (ARDS) is a heterogeneous condition, and identification of subphenotypes may help in better risk stratification. Our study objective is to identify ARDS subphenotypes using new simpler methodology and readily available clinical variables. SETTING This is a retrospective Cohort Study of ARDS trials. Data from the US ARDSNet trials and from the international ART trial. PARTICIPANTS 3763 patients from ARDSNet data sets and 1010 patients from the ART data set. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was 60-day or 28-day mortality, depending on what was reported in the original trial. K-means cluster analysis was performed to identify subgroups. Sets of candidate variables were tested to assess their ability to produce different probabilities for mortality in each cluster. Clusters were compared with biomarker data, allowing identification of subphenotypes. RESULTS Data from 4773 patients were analysed. Two subphenotypes (A and B) resulted in optimal separation in the final model, which included nine routinely collected clinical variables, namely heart rate, mean arterial pressure, respiratory rate, bilirubin, bicarbonate, creatinine, PaO2, arterial pH and FiO2. Participants in subphenotype B showed increased levels of proinflammatory markers, had consistently higher mortality, lower number of ventilator-free days at day 28 and longer duration of ventilation compared with patients in the subphenotype A. CONCLUSIONS Routinely available clinical data can successfully identify two distinct subphenotypes in adult ARDS patients. This work may facilitate implementation of precision therapy in ARDS clinical trials.
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Affiliation(s)
- Abhijit Duggal
- Department of Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Rachel Kast
- Department of Clinical Data Science, Endpoint Health, Palo Alto, California, USA
| | - Emily Van Ark
- Department of Clinical Data Science, Endpoint Health, Palo Alto, California, USA
| | - Lucas Bulgarelli
- Department of Clinical Data Science, Endpoint Health, Palo Alto, California, USA
| | - Matthew T Siuba
- Department of Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jeff Osborn
- Department of Clinical Data Science, Endpoint Health, Palo Alto, California, USA
| | - Diego Ariel Rey
- Department of Clinical Data Science, Endpoint Health, Palo Alto, California, USA
| | | | | | - Israel Maia
- Hospital do Coracao, Sao Paulo, São Paulo, Brazil
| | | | | | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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Zerbib Y, Lambour A, Maizel J, Kontar L, De Cagny B, Soupison T, Bradier T, Slama M, Brault C. Respiratory effects of lung recruitment maneuvers depend on the recruitment-to-inflation ratio in patients with COVID-19-related acute respiratory distress syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2022; 26:12. [PMID: 34983597 PMCID: PMC8727044 DOI: 10.1186/s13054-021-03876-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 12/20/2021] [Indexed: 12/28/2022]
Abstract
Background In the context of acute respiratory distress syndrome (ARDS), the response to lung recruitment maneuvers (LRMs) varies considerably from one patient to another and so is difficult to predict. The aim of the study was to determine whether or not the recruitment-to-inflation (R/I) ratio could differentiate between patients according to the change in lung mechanics during the LRM. Methods We evaluated the changes in gas exchange and respiratory mechanics induced by a stepwise LRM at a constant driving pressure of 15 cmH2O during pressure-controlled ventilation. We assessed lung recruitability by measuring the R/I ratio. Patients were dichotomized with regard to the median R/I ratio. Results We included 30 patients with moderate-to-severe ARDS and a median [interquartile range] R/I ratio of 0.62 [0.42–0.83]. After the LRM, patients with high recruitability (R/I ratio ≥ 0.62) presented an improvement in the PaO2/FiO2 ratio, due to significant increase in respiratory system compliance (33 [27–42] vs. 42 [35–60] mL/cmH2O; p < 0.001). In low recruitability patients (R/I < 0.62), the increase in PaO2/FiO2 ratio was associated with a significant decrease in pulse pressure as a surrogate of cardiac output (70 [55–85] vs. 50 [51–67] mmHg; p = 0.01) but not with a significant change in respiratory system compliance (33 [24–47] vs. 35 [25–47] mL/cmH2O; p = 0.74). Conclusion After the LRM, patients with high recruitability presented a significant increase in respiratory system compliance (indicating a gain in ventilated area), while those with low recruitability presented a decrease in pulse pressure suggesting a drop in cardiac output and therefore in intrapulmonary shunt. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03876-z.
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Affiliation(s)
- Yoann Zerbib
- Intensive Care Department, CHU Amiens-Picardie, 1 Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Alexis Lambour
- Intensive Care Department, CHU Amiens-Picardie, 1 Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Julien Maizel
- Intensive Care Department, CHU Amiens-Picardie, 1 Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Loay Kontar
- Intensive Care Department, CHU Amiens-Picardie, 1 Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Bertrand De Cagny
- Intensive Care Department, CHU Amiens-Picardie, 1 Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Thierry Soupison
- Intensive Care Department, CHU Amiens-Picardie, 1 Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Thomas Bradier
- Intensive Care Department, CHU Amiens-Picardie, 1 Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Michel Slama
- Intensive Care Department, CHU Amiens-Picardie, 1 Rue du Professeur Christian Cabrol, 80000, Amiens, France
| | - Clément Brault
- Intensive Care Department, CHU Amiens-Picardie, 1 Rue du Professeur Christian Cabrol, 80000, Amiens, France.
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180
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von Knethen A, Heinicke U, Laux V, Parnham MJ, Steinbicker AU, Zacharowski K. Antioxidants as Therapeutic Agents in Acute Respiratory Distress Syndrome (ARDS) Treatment-From Mice to Men. Biomedicines 2022; 10:98. [PMID: 35052778 PMCID: PMC8773193 DOI: 10.3390/biomedicines10010098] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 12/26/2021] [Accepted: 12/31/2021] [Indexed: 12/16/2022] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a major cause of patient mortality in intensive care units (ICUs) worldwide. Considering that no causative treatment but only symptomatic care is available, it is obvious that there is a high unmet medical need for a new therapeutic concept. One reason for a missing etiologic therapy strategy is the multifactorial origin of ARDS, which leads to a large heterogeneity of patients. This review summarizes the various kinds of ARDS onset with a special focus on the role of reactive oxygen species (ROS), which are generally linked to ARDS development and progression. Taking a closer look at the data which already have been established in mouse models, this review finally proposes the translation of these results on successful antioxidant use in a personalized approach to the ICU patient as a potential adjuvant to standard ARDS treatment.
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Affiliation(s)
- Andreas von Knethen
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Ulrike Heinicke
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Volker Laux
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Michael J Parnham
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Theodor-Stern-Kai 7, 60596 Frankfurt, Germany
| | - Andrea U Steinbicker
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
| | - Kai Zacharowski
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
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181
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Adams CE, McAuley DF. Acute Respiratory Distress Syndrome. ENCYCLOPEDIA OF RESPIRATORY MEDICINE 2022. [PMCID: PMC8106506 DOI: 10.1016/b978-0-08-102723-3.00233-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a prevalent and important cause of respiratory failure. Underlying causes include pulmonary and non-pulmonary aetiologies. ARDS is acute hypoxaemic respiratory failure associated with non-cardiogenic pulmonary oedema, reduced pulmonary compliance, and can lead to lung fibrosis. In addition to treating the underlying cause, often the mainstay of the management of ARDS is invasive mechanical ventilation. This can perpetuate lung injury—ventilator-associated lung injury (VALI). Despite recent advances in our understanding of this, ARDS-associated morbidity and mortality remains high. This chapter discusses the pathophysiology of ARDS and its management, including mechanical ventilation, adjunctive therapies, and some recently trialed pharmacotherapies.
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182
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Focused Management of Patients With Severe Acute Brain Injury and ARDS. Chest 2022; 161:140-151. [PMID: 34506794 PMCID: PMC8423666 DOI: 10.1016/j.chest.2021.08.066] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 08/04/2021] [Accepted: 08/25/2021] [Indexed: 02/04/2023] Open
Abstract
Considering the COVID-19 pandemic where concomitant occurrence of ARDS and severe acute brain injury (sABI) has increasingly coemerged, we synthesize existing data regarding the simultaneous management of both conditions. Our aim is to provide readers with fundamental principles and concepts for the management of sABI and ARDS, and highlight challenges and conflicts encountered while managing concurrent disease. Up to 40% of patients with sABI can develop ARDS. Although there are trials and guidelines to support the mainstays of treatment for ARDS and sABI independently, guidance on concomitant management is limited. Treatment strategies aimed at managing severe ARDS may at times conflict with the management of sABI. In this narrative review, we discuss the physiological basis and risks involved during simultaneous management of ARDS and sABI, summarize evidence for treatment decisions, and demonstrate these principles using hypothetical case scenarios. Use of invasive or noninvasive monitoring to assess brain and lung physiology may facilitate goal-directed treatment strategies with the potential to improve outcome. Understanding the pathophysiology and key treatment concepts for comanagement of these conditions is critical to optimizing care in this high-acuity patient population.
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183
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Terzi N, Guérin C. Optimizing Mechanical Ventilation in Refractory ARDS. ENCYCLOPEDIA OF RESPIRATORY MEDICINE 2022. [PMCID: PMC8740657 DOI: 10.1016/b978-0-12-801238-3.11480-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Mechanical ventilation in patients with refractory acute respiratory distress syndrome (ARDS) must provide lung protection. This is achieved by limiting tidal volume (VT) and plateau pressure (Pplat). With the current evidence available VT should be initially set around 6 mL per kg predicted body weight and PPlat maintained below 30 cmH2O and monitored. Positive end-expiratory pressure (PEEP), which also contributes to lung protection, should be set > 12 cmH2O, provided oxygenation gets improved, with same Pplat target. Recruitment maneuvers should be used with caution avoiding higher PEEP. Neuromuscular blockade should be started and prone position performed for sessions longer than 16 h. High frequency oscillation ventilation should be used in expert centers only if previous management failed to improve oxygenation.
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Lagier D, Zeng C, Fernandez-Bustamante A, Melo MFV. Perioperative Pulmonary Atelectasis: Part II. Clinical Implications. Anesthesiology 2022; 136:206-236. [PMID: 34710217 PMCID: PMC9885487 DOI: 10.1097/aln.0000000000004009] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The development of pulmonary atelectasis is common in the surgical patient. Pulmonary atelectasis can cause various degrees of gas exchange and respiratory mechanics impairment during and after surgery. In its most serious presentations, lung collapse could contribute to postoperative respiratory insufficiency, pneumonia, and worse overall clinical outcomes. A specific risk assessment is critical to allow clinicians to optimally choose the anesthetic technique, prepare appropriate monitoring, adapt the perioperative plan, and ensure the patient's safety. Bedside diagnosis and management have benefited from recent imaging advancements such as lung ultrasound and electrical impedance tomography, and monitoring such as esophageal manometry. Therapeutic management includes a broad range of interventions aimed at promoting lung recruitment. During general anesthesia, these strategies have consistently demonstrated their effectiveness in improving intraoperative oxygenation and respiratory compliance. Yet these same intraoperative strategies may fail to affect additional postoperative pulmonary outcomes. Specific attention to the postoperative period may be key for such outcome impact of lung expansion. Interventions such as noninvasive positive pressure ventilatory support may be beneficial in specific patients at high risk for pulmonary atelectasis (e.g., obese) or those with clinical presentations consistent with lung collapse (e.g., postoperative hypoxemia after abdominal and cardiothoracic surgeries). Preoperative interventions may open new opportunities to minimize perioperative lung collapse and prevent pulmonary complications. Knowledge of pathophysiologic mechanisms of atelectasis and their consequences in the healthy and diseased lung should provide the basis for current practice and help to stratify and match the intensity of selected interventions to clinical conditions.
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Affiliation(s)
- David Lagier
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Congli Zeng
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Marcos F. Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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185
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Garfield B, Handslip R, Patel BV. Ventilator-Associated Lung Injury. ENCYCLOPEDIA OF RESPIRATORY MEDICINE 2022. [PMCID: PMC8128668 DOI: 10.1016/b978-0-08-102723-3.00237-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ventilatory support, while life saving, can also cause or aggravate lung injury through several mechanisms which are encompassed within ventilator-associated lung injury (VALI). The important realizationin the acute respiratory distress syndrome that the “baby” lung resided in non-dependent areas led to the conceptualization of “lung rest” to reduce stress and strain to exposed alveolar units. We discuss concepts and mechanisms within VALI that ultimately induce maladaptive lung responses, as well as, current and future management strategies to detect and mitigate VALI at the bedside.
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186
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Wijnberge M, Jansen JRC, Pinsky MR, Klanderman RB, Terwindt LE, Bosboom JJ, Lemmers N, Vlaar AP, Veelo DP, Geerts BF. Feasibility to estimate mean systemic filling pressure with inspiratory holds at the bedside. Front Physiol 2022; 13:1041730. [PMID: 36523553 PMCID: PMC9745184 DOI: 10.3389/fphys.2022.1041730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 10/25/2022] [Indexed: 11/30/2022] Open
Abstract
Background: A decade ago, it became possible to derive mean systemic filling pressure (MSFP) at the bedside using the inspiratory hold maneuver. MSFP has the potential to help guide hemodynamic care, but the estimation is not yet implemented in common clinical practice. In this study, we assessed the ability of MSFP, vascular compliance (Csys), and stressed volume (Vs) to track fluid boluses. Second, we assessed the feasibility of implementation of MSFP in the intensive care unit (ICU). Exploratory, a potential difference in MSFP response between colloids and crystalloids was assessed. Methods: This was a prospective cohort study in adult patients admitted to the ICU after cardiac surgery. The MSFP was determined using 3-4 inspiratory holds with incremental pressures (maximum 35 cm H2O) to construct a venous return curve. Two fluid boluses were administered: 100 and 500 ml, enabling to calculate Vs and Csys. Patients were randomized to crystalloid or colloid fluid administration. Trained ICU consultants acted as study supervisors, and protocol deviations were recorded. Results: A total of 20 patients completed the trial. MSFP was able to track the 500 ml bolus (p < 0.001). In 16 patients (80%), Vs and Csys could be determined. Vs had a median of 2029 ml (IQR 1605-3164), and Csys had a median of 73 ml mmHg-1 (IQR 56-133). A difference in response between crystalloids and colloids was present for the 100 ml fluid bolus (p = 0.019) and in a post hoc analysis, also for the 500 ml bolus (p = 0.010). Conclusion: MSFP can be measured at the bedside and provides insights into the hemodynamic status of a patient that are currently missing. The clinical feasibility of Vs and Csys was judged ambiguously based on the lack of required hemodynamic stability. Future studies should address the clinical obstacles found in this study, and less-invasive alternatives to determine MSFP should be further explored. Clinical Trial Registration: ClinicalTrials.gov Identifier NCT03139929.
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Affiliation(s)
- Marije Wijnberge
- Amsterdam UMC Location Academic Medical Center, Department of Anesthesiology, Amsterdam, Netherlands
- Amsterdam UMC Location Academic Medical Center, Department of Intensive Care Medicine, Amsterdam, Netherlands
- *Correspondence: Marije Wijnberge, Alexander P. Vlaar,
| | - Jos R. C. Jansen
- Leiden University Medical Center, Department of Intensive Care Medicine, Leiden, Netherlands
| | - Michael R. Pinsky
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Robert B. Klanderman
- Amsterdam UMC Location Academic Medical Center, Department of Anesthesiology, Amsterdam, Netherlands
- Amsterdam UMC Location Academic Medical Center, Department of Intensive Care Medicine, Amsterdam, Netherlands
| | - Lotte E. Terwindt
- Amsterdam UMC Location Academic Medical Center, Department of Anesthesiology, Amsterdam, Netherlands
| | - Joachim J. Bosboom
- Amsterdam UMC Location Academic Medical Center, Department of Anesthesiology, Amsterdam, Netherlands
- Amsterdam UMC Location Academic Medical Center, Department of Intensive Care Medicine, Amsterdam, Netherlands
| | - Nikki Lemmers
- Amsterdam UMC Location Academic Medical Center, Department of Anesthesiology, Amsterdam, Netherlands
| | - Alexander P. Vlaar
- Amsterdam UMC Location Academic Medical Center, Department of Intensive Care Medicine, Amsterdam, Netherlands
- *Correspondence: Marije Wijnberge, Alexander P. Vlaar,
| | - Denise P. Veelo
- Amsterdam UMC Location Academic Medical Center, Department of Anesthesiology, Amsterdam, Netherlands
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187
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Taran S, McCredie VA, Goligher EC. Noninvasive and invasive mechanical ventilation for neurologic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2022; 189:361-386. [PMID: 36031314 DOI: 10.1016/b978-0-323-91532-8.00015-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Patients with acute neurologic injuries frequently require mechanical ventilation due to diminished airway protective reflexes, cardiopulmonary failure secondary to neurologic insults, or to facilitate gas exchange to precise targets. Mechanical ventilation enables tight control of oxygenation and carbon dioxide levels, enabling clinicians to modulate cerebral hemodynamics and intracranial pressure with the goal of minimizing secondary brain injury. In patients with acute spinal cord injuries, neuromuscular conditions, or diseases of the peripheral nerve, mechanical ventilation enables respiratory support under conditions of impending or established respiratory failure. Noninvasive ventilatory approaches may be carefully considered for certain disease conditions, including myasthenia gravis and amyotrophic lateral sclerosis, but may be inappropriate in patients with Guillain-Barré syndrome or when relevant contra-indications exist. With regard to discontinuing mechanical ventilation, considerable uncertainty persists about the best approach to wean patients, how to identify patients ready for extubation, and when to consider primary tracheostomy. Recent consensus guidelines highlight these and other knowledge gaps that are the focus of active research efforts. This chapter outlines important general principles to consider when initiating, titrating, and discontinuing mechanical ventilation in patients with acute neurologic injuries. Important disease-specific considerations are also reviewed where appropriate.
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Affiliation(s)
- Shaurya Taran
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada.
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188
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Sepsis and Septic Shock. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00038-1] [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
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189
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Gattinoni L, Marini JJ. In search of the Holy Grail: identifying the best PEEP in ventilated patients. Intensive Care Med 2022; 48:728-731. [PMID: 35513707 PMCID: PMC9205826 DOI: 10.1007/s00134-022-06698-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/06/2022] [Indexed: 01/04/2023]
Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Göttingen, Germany
| | - John J. Marini
- Pulmonary and Critical Care Medicine, Regions Hospital and University of Minnesota, St. Paul, MN USA
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190
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Beretta E, Romanò F, Sancini G, Grotberg JB, Nieman GF, Miserocchi G. Pulmonary Interstitial Matrix and Lung Fluid Balance From Normal to the Acutely Injured Lung. Front Physiol 2021; 12:781874. [PMID: 34987415 PMCID: PMC8720972 DOI: 10.3389/fphys.2021.781874] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/02/2021] [Indexed: 01/17/2023] Open
Abstract
This review analyses the mechanisms by which lung fluid balance is strictly controlled in the air-blood barrier (ABB). Relatively large trans-endothelial and trans-epithelial Starling pressure gradients result in a minimal flow across the ABB thanks to low microvascular permeability aided by the macromolecular structure of the interstitial matrix. These edema safety factors are lost when the integrity of the interstitial matrix is damaged. The result is that small Starling pressure gradients, acting on a progressively expanding alveolar barrier with high permeability, generate a high transvascular flow that causes alveolar flooding in minutes. We modeled the trans-endothelial and trans-epithelial Starling pressure gradients under control conditions, as well as under increasing alveolar pressure (Palv) conditions of up to 25 cmH2O. We referred to the wet-to-dry weight (W/D) ratio, a specific index of lung water balance, to be correlated with the functional state of the interstitial structure. W/D averages ∼5 in control and might increase by up to ∼9 in severe edema, corresponding to ∼70% loss in the integrity of the native matrix. Factors buffering edemagenic conditions include: (i) an interstitial capacity for fluid accumulation located in the thick portion of ABB, (ii) the increase in interstitial pressure due to water binding by hyaluronan (the "safety factor" opposing the filtration gradient), and (iii) increased lymphatic flow. Inflammatory factors causing lung tissue damage include those of bacterial/viral and those of sterile nature. Production of reactive oxygen species (ROS) during hypoxia or hyperoxia, or excessive parenchymal stress/strain [lung overdistension caused by patient self-induced lung injury (P-SILI)] can all cause excessive inflammation. We discuss the heterogeneity of intrapulmonary distribution of W/D ratios. A W/D ∼6.5 has been identified as being critical for the transition to severe edema formation. Increasing Palv for W/D > 6.5, both trans-endothelial and trans-epithelial gradients favor filtration leading to alveolar flooding. Neither CT scan nor ultrasound can identify this initial level of lung fluid balance perturbation. A suggestion is put forward to identify a non-invasive tool to detect the earliest stages of perturbation of lung fluid balance before the condition becomes life-threatening.
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Affiliation(s)
- Egidio Beretta
- Department of Medicine and Surgery, School of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Francesco Romanò
- Univ. Lille, CNRS, ONERA, Arts et Métiers, Centrale Lille, FRE 2017-LMFL-Laboratoire de Mécanique des Fluides de Lille – Kampé de Fériet, Lille, France
| | - Giulio Sancini
- Department of Medicine and Surgery, School of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - James B. Grotberg
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Gary F. Nieman
- Department of Surgery, State University of New York Upstate Medical University, Syracuse, NY, United States
| | - Giuseppe Miserocchi
- Department of Medicine and Surgery, School of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Monza, Italy
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191
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Villar J, Ferrando C, Tusman G, Berra L, Rodríguez-Suárez P, Suárez-Sipmann F. Unsuccessful and Successful Clinical Trials in Acute Respiratory Distress Syndrome: Addressing Physiology-Based Gaps. Front Physiol 2021; 12:774025. [PMID: 34916959 PMCID: PMC8669801 DOI: 10.3389/fphys.2021.774025] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/08/2021] [Indexed: 12/29/2022] Open
Abstract
The acute respiratory distress syndrome (ARDS) is a severe form of acute hypoxemic respiratory failure caused by an insult to the alveolar-capillary membrane, resulting in a marked reduction of aerated alveoli, increased vascular permeability and subsequent interstitial and alveolar pulmonary edema, reduced lung compliance, increase of physiological dead space, and hypoxemia. Most ARDS patients improve their systemic oxygenation, as assessed by the ratio between arterial partial pressure of oxygen and inspired oxygen fraction, with conventional intensive care and the application of moderate-to-high levels of positive end-expiratory pressure. However, in some patients hypoxemia persisted because the lungs are markedly injured, remaining unresponsive to increasing the inspiratory fraction of oxygen and positive end-expiratory pressure. For decades, mechanical ventilation was the only standard support technique to provide acceptable oxygenation and carbon dioxide removal. Mechanical ventilation provides time for the specific therapy to reverse the disease-causing lung injury and for the recovery of the respiratory function. The adverse effects of mechanical ventilation are direct consequences of the changes in pulmonary airway pressures and intrathoracic volume changes induced by the repetitive mechanical cycles in a diseased lung. In this article, we review 14 major successful and unsuccessful randomized controlled trials conducted in patients with ARDS on a series of techniques to improve oxygenation and ventilation published since 2010. Those trials tested the effects of adjunctive therapies (neuromuscular blocking agents, prone positioning), methods for selecting the optimum positive end-expiratory pressure (after recruitment maneuvers, or guided by esophageal pressure), high-frequency oscillatory ventilation, extracorporeal oxygenation, and pharmacologic immune modulators of the pulmonary and systemic inflammatory responses in patients affected by ARDS. We will briefly comment physiology-based gaps of negative trials and highlight the possible needs to address in future clinical trials in ARDS.
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Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Multidisciplinary Organ Dysfunction Evaluation Research Network (MODERN), Research Unit, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain.,Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Carlos Ferrando
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Department of Anesthesiology and Critical Care, Hospital Clinic, Barcelona, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clinic, Barcelona, Spain
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Lorenzo Berra
- Harvard Medical School, Boston, MA, United States.,Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Pedro Rodríguez-Suárez
- Department of Thoracic Surgery, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
| | - Fernando Suárez-Sipmann
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Intensive Care Unit, Hospital Universitario La Princesa, Madrid, Spain.,Hedenstierna Laboratory, Department of Surgical Sciences, Anesthesiology and Critical Care, Uppsala University Hospital, Uppsala, Sweden
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Abstract
Influenza infection causes severe illness in 3 to 5 million people annually, with up to an estimated 650,000 deaths per annum. As such, it represents an ongoing burden to health care systems and human health. Severe acute respiratory infection can occur, resulting in respiratory failure requiring intensive care support. Herein we discuss diagnostic approaches, including development of CLIA-waived point of care tests that allow rapid diagnosis and treatment of influenza. Bacterial and fungal coinfections in severe influenza pneumonia are associated with worse outcomes, and we summarize the approach and treatment options for diagnosis and treatment of bacterial and Aspergillus coinfection. We discuss the available drug options for the treatment of severe influenza, and treatments which are no longer supported by the evidence base. Finally, we describe the supportive management and ventilatory approach to patients with respiratory failure as a result of severe influenza in the intensive care unit.
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Affiliation(s)
- Liam S O'Driscoll
- Department of Intensive Care Medicine, St. James's University Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland
| | - Ignacio Martin-Loeches
- Department of Intensive Care Medicine, St. James's University Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland.,Respiratory Medicine, Hospital Clinic, IDIBAPS, Universidad de Barcelona, CIBERes, Barcelona, Spain
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193
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Positive End-Expiratory Pressure and Respiratory Rate Modify the Association of Mechanical Power and Driving Pressure With Mortality Among Patients With Acute Respiratory Distress Syndrome. Crit Care Explor 2021; 3:e0583. [PMID: 34909696 PMCID: PMC8663805 DOI: 10.1097/cce.0000000000000583] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Supplemental Digital Content is available in the text. IMPORTANCE: Mechanical power and driving pressure have known associations with survival for patients with acute respiratory distress syndrome. OBJECTIVES: To further understand the relative importance of mechanical power and driving pressure as clinical targets for ventilator management. DESIGN: Secondary observational analysis of randomized clinical trial data. SETTING AND PARTICIPANTS: Patients with the acute respiratory distress syndrome from three Acute Respiratory Distress Syndrome Network trials. MAIN OUTCOMES AND MEASURES: After adjusting for patient severity in a multivariate Cox proportional hazards model, we examined the relative association of driving pressure and mechanical power with hospital mortality. Among 2,410 patients, the relationship between driving pressure and mechanical power with mortality was modified by respiratory rate, positive end-expiratory pressure, and flow. RESULTS: Among patients with low respiratory rate (< 26), only power was significantly associated with mortality (power [hazard ratio, 1.82; 95% CI, 1.41–2.35; p < 0.001] vs driving pressure [hazard ratio, 1.01; 95% CI, 0.84–1.21; p = 0.95]), while among patients with high respiratory rate, neither was associated with mortality. Both power and driving pressure were associated with mortality at high airway flow (power [hazard ratio, 1.28; 95% CI, 1.15–1.43; p < 0.001] vs driving pressure [hazard ratio, 1.15; 95% CI, 1.01–1.30; p = 0.041]) and neither at low flow. At low positive end-expiratory pressure, neither was associated with mortality, whereas at high positive end-expiratory pressure (≥ 10 cm H2O), only power was significantly associated with mortality (power [hazard ratio, 1.22; 95% CI, 1.09–1.37; p < 0.001] vs driving pressure [hazard ratio, 1.16; 95% CI, 0.99–1.35; p = 0.059]). CONCLUSIONS AND RELEVANCE: The relationship between mechanical power and driving pressure with mortality differed within severity subgroups defined by positive end-expiratory pressure, respiratory rate, and airway flow.
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194
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Watanabe R, Suehiro K, Mukai A, Tanaka K, Yamada T, Mori T, Nishikawa K. Changes in stroke volume induced by lung recruitment maneuver can predict fluid responsiveness during intraoperative lung-protective ventilation in prone position. BMC Anesthesiol 2021; 21:303. [PMID: 34856928 PMCID: PMC8638171 DOI: 10.1186/s12871-021-01527-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 11/18/2021] [Indexed: 12/16/2022] Open
Abstract
Background The present study aimed to evaluate the reliability of hemodynamic changes induced by lung recruitment maneuver (LRM) in predicting stroke volume (SV) increase after fluid loading (FL) in prone position. Methods Thirty patients undergoing spine surgery in prone position were enrolled. Lung-protective ventilation (tidal volume, 6–7 mL/kg; positive end-expiratory pressure, 5 cmH2O) was provided to all patients. LRM (30 cmH2O for 30 s) was performed. Hemodynamic variables including mean arterial pressure (MAP), heart rate, SV, SV variation (SVV), and pulse pressure variation (PPV) were simultaneously recorded before, during, and at 5 min after LRM and after FL (250 mL in 10 min). Receiver operating characteristic curves were generated to evaluate the predictability of SVV, PPV, and SV decrease by LRM (ΔSVLRM) for SV responders (SV increase after FL > 10%). The gray zone approach was applied for ΔSVLRM. Results Areas under the curve (AUCs) for ΔSVLRM, SVV, and PPV to predict SV responders were 0.778 (95% confidence interval: 0.590–0.909), 0.563 (0.371–0.743), and 0.502 (0.315–0.689), respectively. The optimal threshold for ΔSVLRM was 30% (sensitivity, 92.3%; specificity, 70.6%). With the gray zone approach, the inconclusive values ranged 25 to 75% for ΔSVLRM (including 50% of enrolled patients). Conclusion In prone position, LRM-induced SV decrease predicted SV increase after FL with higher reliability than traditional dynamic indices. On the other hand, considering the relatively large gray zone in this study, future research is needed to further improve the clinical significance. Trial registration UMIN Clinical Trial Registry UMIN000027966. Registered 28th June 2017.
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Affiliation(s)
- Ryota Watanabe
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, 1-5-7 Asahimachi, Abeno-ku, Osaka, 545-8586, Japan
| | - Koichi Suehiro
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, 1-5-7 Asahimachi, Abeno-ku, Osaka, 545-8586, Japan.
| | - Akira Mukai
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, 1-5-7 Asahimachi, Abeno-ku, Osaka, 545-8586, Japan
| | - Katsuaki Tanaka
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, 1-5-7 Asahimachi, Abeno-ku, Osaka, 545-8586, Japan
| | - Tokuhiro Yamada
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, 1-5-7 Asahimachi, Abeno-ku, Osaka, 545-8586, Japan
| | - Takashi Mori
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, 1-5-7 Asahimachi, Abeno-ku, Osaka, 545-8586, Japan
| | - Kiyonobu Nishikawa
- Department of Anesthesiology, Osaka City University Graduate School of Medicine, 1-5-7 Asahimachi, Abeno-ku, Osaka, 545-8586, Japan
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195
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Valk CMA, Tsonas AM, Botta M, Bos LDJ, Pillay J, Serpa Neto A, Schultz MJ, Paulus F. Association of early positive end-expiratory pressure settings with ventilator-free days in patients with coronavirus disease 2019 acute respiratory distress syndrome: A secondary analysis of the Practice of VENTilation in COVID-19 study. Eur J Anaesthesiol 2021; 38:1274-1283. [PMID: 34238782 PMCID: PMC8630930 DOI: 10.1097/eja.0000000000001565] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND There is uncertainty about how much positive end-expiratory pressure (PEEP) should be used in patients with acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19). OBJECTIVE To investigate whether a higher PEEP strategy is superior to a lower PEEP strategy regarding the number of ventilator-free days (VFDs). DESIGN Multicentre observational study conducted from 1 March to 1 June 2020. SETTING AND PATIENTS Twenty-two ICUs in The Netherlands and 933 invasively ventilated COVID-19 ARDS patients. INTERVENTIONS Patients were categorised retrospectively as having received invasive ventilation with higher (n=259) or lower PEEP (n=674), based on the high and low PEEP/FiO2 tables of the ARDS Network, and using ventilator settings and parameters in the first hour of invasive ventilation, and every 8 h thereafter at fixed time points during the first four calendar days. We also used propensity score matching to control for observed confounding factors that might influence outcomes. MAIN OUTCOMES AND MEASURES The primary outcome was the number of VFDs. Secondary outcomes included distant organ failures including acute kidney injury (AKI) and use of renal replacement therapy (RRT), and mortality. RESULTS In the unmatched cohort, the higher PEEP strategy had no association with the median [IQR] number of VFDs (2.0 [0.0 to 15.0] vs. 0.0 [0.0 to 16.0] days). The median (95% confidence interval) difference was 0.21 (-3.34 to 3.78) days, P = 0.905. In the matched cohort, the higher PEEP group had an association with a lower median number of VFDs (0.0 [0.0 to 14.0] vs. 6.0 [0.0 to 17.0] days) a median difference of -4.65 (-8.92 to -0.39) days, P = 0.032. The higher PEEP strategy had associations with higher incidence of AKI (in the matched cohort) and more use of RRT (in the unmatched and matched cohorts). The higher PEEP strategy had no association with mortality. CONCLUSION In COVID-19 ARDS, use of higher PEEP may be associated with a lower number of VFDs, and may increase the incidence of AKI and need for RRT. TRIAL REGISTRATION Practice of VENTilation in COVID-19 is registered at ClinicalTrials.gov, NCT04346342.
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Affiliation(s)
- Christel M A Valk
- From the Department of Intensive Care & Laboratory of Experimental Intensive Care and Anaesthesiology (LEICA), Amsterdam UMC, Location AMC, Amsterdam (CMAV, AMT, MB, LDJB, ASN, MJS, FP), Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands (JP), Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil (ASN), Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University (ASN), Data Analytics Research & Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Melbourne, Victoria, Australia (ASN), Nuffield Department of Medicine, Oxford University, Oxford, UK (MJS), Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand (MJS) and ACHIEVE Centre of Expertise, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands (FP)
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196
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Wendel-Garcia PD, Roche-Campo F, Mancebo J. Positive end-expiratory pressure, or the perennial conundrum surrounding lung recruitment. Med Intensiva 2021; 45:513-515. [PMID: 34839882 DOI: 10.1016/j.medine.2021.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 08/22/2021] [Indexed: 12/16/2022]
Affiliation(s)
- P D Wendel-Garcia
- Institute of Intensive Care Medicine, University Hospital of Zurich, Zurich, Switzerland
| | - F Roche-Campo
- Intensive Care Dept, Hospital de Tortosa Verge de la Cinta, Tortosa, Tarragona, Spain
| | - J Mancebo
- Intensive Care Dept, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
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197
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Modesto I Alapont V, Medina Villanueva A, Del Villar Guerra P, Camilo C, Fernández-Ureña S, Gordo-Vidal F, Khemani R. OLA strategy for ARDS: Its effect on mortality depends on achieved recruitment (PaO 2/FiO 2) and mechanical power. Systematic review and meta-analysis with meta-regression. Med Intensiva 2021; 45:516-531. [PMID: 34839883 DOI: 10.1016/j.medine.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 03/26/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The "Open Lung Approach" (OLA), that includes high levels of positive end-expiratory pressure coupled with limited tidal volumes, is considered optimal for adult patients with ARDS. However, many previous meta-analyses have shown only marginal benefits of OLA on mortality but with statistical heterogeneity. It is crucial to identify the most likely moderators of this effect. To determine the effect of OLA strategy on mortality of ventilated ARDS patients. We hypothesized that the degree of recruitment achieved in the control group (PaO2/FiO2 ratio on day 3 of ventilation), and the difference in Mechanical Power (MP) or Driving Pressure (DP) between experimental and control groups will be the most likely sources of heterogeneity. DESIGN A Systematic Review and Meta-analysis was performed according to PRISMA statement and registered in PROSPERO database. We searched only for randomized controlled trials (RCTs). GRADE guidelines were used for rating the quality of evidence. Publication bias was assessed. For the Meta-analysis, we used a Random Effects Model. Sources of heterogeneity were explored with Meta-Regression, using a priori proposed set of possible moderators. For model comparison, Akaike's Information Criterion with the finite sample correction (AICc) was used. SETTING Not applicable. PATIENTS Fourteen RCTs were included in the study. INTERVENTIONS Not applicable. MAIN VARIABLES OF INTEREST Not applicable. RESULTS Evidence of publication bias was detected, and quality of evidence was downgraded. Pooled analysis did not show a significant difference in the 28-day mortality between OLA strategy and control groups. Overall risk of bias was low. The analysis detected statistical heterogeneity. The two "best" explicative meta-regression models were those that used control PaO2/FiO2 on day 3 and difference in MP between experimental and control groups. The DP and MP models were highly correlated. CONCLUSIONS There is no clear benefit of OLA strategy on mortality of ARDS patients, with significant heterogeneity among RCTs. Mortality effect of OLA is mediated by lung recruitment and mechanical power.
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Affiliation(s)
| | | | - P Del Villar Guerra
- Department of Pediatrics, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - C Camilo
- PICU, Hospital de Santa Maria-Centro Hospitalar Lisboa Norte, Lisboa, Portugal
| | - S Fernández-Ureña
- Urgencias Pediátricas, Complejo Hospitalario Universitario Materno Insular Las Palmas, Universidad de Las Palmas, Las Palmas de Gran Canaria, Spain
| | - F Gordo-Vidal
- ICU, Hospital del Henares, Grupo de Investigación en Patología Crítica de la Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
| | - R Khemani
- PICU, Children's Hospital Los Angeles, California, USA
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198
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Wick KD, McAuley DF, Levitt JE, Beitler JR, Annane D, Riviello ED, Calfee CS, Matthay MA. Promises and challenges of personalized medicine to guide ARDS therapy. Crit Care 2021; 25:404. [PMID: 34814925 PMCID: PMC8609268 DOI: 10.1186/s13054-021-03822-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/09/2021] [Indexed: 02/08/2023] Open
Abstract
Identifying new effective treatments for the acute respiratory distress syndrome (ARDS), including COVID-19 ARDS, remains a challenge. The field of ARDS investigation is moving increasingly toward innovative approaches such as the personalization of therapy to biological and clinical sub-phenotypes. Additionally, there is growing recognition of the importance of the global context to identify effective ARDS treatments. This review highlights emerging opportunities and continued challenges for personalizing therapy for ARDS, from identifying treatable traits to innovative clinical trial design and recognition of patient-level factors as the field of critical care investigation moves forward into the twenty-first century.
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Affiliation(s)
- Katherine D Wick
- Cardiovascular Research Institute, University of California San Francisco, 513 Parnassus Avenue, HSE 760, San Francisco, CA, 94143, USA.
| | - Daniel F McAuley
- Belfast Health and Social Care Trust, Royal Victoria Hospital and Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Joseph E Levitt
- Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, Stanford, CA, USA
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University, New York, NY, USA
| | - Djillali Annane
- Department of Intensive Care, FHU SEPSIS, and RHU RECORDS, Hôpital Raymond Poincaré (APHP), Garches, France
- Laboratory of Infection & Inflammation, School of Medicine Simone Veil, INSERM, University Versailles Saint Quentin, University Paris Saclay, Garches, France
| | - Elisabeth D Riviello
- Harvard Medical School and Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Carolyn S Calfee
- Cardiovascular Research Institute, University of California San Francisco, 513 Parnassus Avenue, HSE 760, San Francisco, CA, 94143, USA
- Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Michael A Matthay
- Cardiovascular Research Institute, University of California San Francisco, 513 Parnassus Avenue, HSE 760, San Francisco, CA, 94143, USA
- Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco, CA, USA
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Scharffenberg M, Wittenstein J, Ran X, Zhang Y, Braune A, Theilen R, Maiello L, Benzi G, Bluth T, Kiss T, Pelosi P, Rocco PRM, Schultz MJ, Kotzerke J, Gama de Abreu M, Huhle R. Mechanical Power Correlates With Lung Inflammation Assessed by Positron-Emission Tomography in Experimental Acute Lung Injury in Pigs. Front Physiol 2021; 12:717266. [PMID: 34880770 PMCID: PMC8645956 DOI: 10.3389/fphys.2021.717266] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 10/20/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Mechanical ventilation (MV) may initiate or worsen lung injury, so-called ventilator-induced lung injury (VILI). Although different mechanisms of VILI have been identified, research mainly focused on single ventilator parameters. The mechanical power (MP) summarizes the potentially damaging effects of different parameters in one single variable and has been shown to be associated with lung damage. However, to date, the association of MP with pulmonary neutrophilic inflammation, as assessed by positron-emission tomography (PET), has not been prospectively investigated in a model of clinically relevant ventilation settings yet. We hypothesized that the degree of neutrophilic inflammation correlates with MP. Methods: Eight female juvenile pigs were anesthetized and mechanically ventilated. Lung injury was induced by repetitive lung lavages followed by initial PET and computed tomography (CT) scans. Animals were then ventilated according to the acute respiratory distress syndrome (ARDS) network recommendations, using the lowest combinations of positive end-expiratory pressure and inspiratory oxygen fraction that allowed adequate oxygenation. Ventilator settings were checked and adjusted hourly. Physiological measurements were conducted every 6 h. Lung imaging was repeated 24 h after first PET/CT before animals were killed. Pulmonary neutrophilic inflammation was assessed by normalized uptake rate of 2-deoxy-2-[18F]fluoro-D-glucose (KiS), and its difference between the two PET/CT was calculated (ΔKiS). Lung aeration was assessed by lung CT scan. MP was calculated from the recorded pressure-volume curve. Statistics included the Wilcoxon tests and non-parametric Spearman correlation. Results: Normalized 18F-FDG uptake rate increased significantly from first to second PET/CT (p = 0.012). ΔKiS significantly correlated with median MP (ρ = 0.738, p = 0.037) and its elastic and resistive components, but neither with median peak, plateau, end-expiratory, driving, and transpulmonary driving pressures, nor respiratory rate (RR), elastance, or resistance. Lung mass and volume significantly decreased, whereas relative mass of hyper-aerated lung compartment increased after 24 h (p = 0.012, p = 0.036, and p = 0.025, respectively). Resistance and PaCO2 were significantly higher (p = 0.012 and p = 0.017, respectively), whereas RR, end-expiratory pressure, and MP were lower at 18 h compared to start of intervention. Conclusions: In this model of experimental acute lung injury in pigs, pulmonary neutrophilic inflammation evaluated by PET/CT increased after 24 h of MV, and correlated with MP.
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Affiliation(s)
- Martin Scharffenberg
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Jakob Wittenstein
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Xi Ran
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Intensive Care, Chongqing General Hospital, University of Chinese Academy of Sciences, Chongqing, China
| | - Yingying Zhang
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Anesthesiology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Anja Braune
- Department of Nuclear Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Raphael Theilen
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Lorenzo Maiello
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Giulia Benzi
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Clinical and Biological Sciences, Service of Anesthesia and Intensive Care, Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Thomas Bluth
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Thomas Kiss
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Anaesthesiology, Intensive-, Pain- and Palliative Care Medicine, Radebeul Hospital, Academic Hospital of the Technische Universität Dresden, Radebeul, Germany
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcus J. Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Jörg Kotzerke
- Department of Nuclear Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Robert Huhle
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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200
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Su PL, Lin WC, Ko YF, Cheng KS, Chen CW. Electrical Impedance Tomography Analysis Between Two Similar Respiratory System Compliance During Decremetal PEEP Titration in ARDS Patients. J Med Biol Eng 2021; 41:888-894. [PMID: 34803552 PMCID: PMC8593398 DOI: 10.1007/s40846-021-00668-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 10/21/2021] [Indexed: 12/16/2022]
Abstract
Purpose The positive end-expiratory pressure (PEEP) level with best respiratory system compliance (Crs) is frequently used for PEEP selection in acute respiratory distress syndrome (ARDS) patients. On occasion, two similar best Crs (where the difference between the Crs of two PEEP levels is < 1 ml/cm H2O) may be identified during decremental PEEP titration. Selecting PEEP under such conditions is challenging. The aim of this study was to provide supplementary rationale for PEEP selection by assessing the global and regional ventilation distributions between two PEEP levels in this situation. Methods Eight ARDS cases with similar best Crs at two different PEEP levels were analyzed using examination-specific electrical impedance tomography (EIT) measures and airway stress index (SIaw). Five Crs were measured at PEEP values of 25 cm H2O (PEEP25), 20 cm H2O (PEEP20), 15 cm H2O (PEEPH), 11 cm H2O (PEEPI), and 7 cm H2O (PEEPL). The higher PEEP value of the two PEEPs with similar best Crs was designated as PEEPupper, while the lower designated as PEEPlower. Results PEEPH and PEEPI shared the best Crs in two cases, while similar Crs was found at PEEPI and PEEPL in the remaining six cases. SIaw was higher with PEEPupper as compared to PEEPlower (1.06 ± 0.10 versus 0.99 ± 0.09, p = 0.05). Proportion of lung hyperdistension was significantly higher with PEEPupper than PEEPlower (7.0 ± 5.1% versus 0.3 ± 0.5%, p = 0.0002). In contrast, proportion of recruitable lung collapse was higher with PEEPlower than PEEPupper (18.6 ± 4.4% versus 5.9 ± 3.7%, p < 0.0001). Cyclic alveolar collapse and reopening during tidal breathing was higher at PEEPlower than PEEPupper (34.4 ± 19.3% versus 16.0 ± 9.1%, p = 0.046). The intratidal gas distribution (ITV) index was also significantly higher at PEEPlower than PEEPupper (2.6 ± 1.3 versus 1.8 ± 0.7, p = 0.042). Conclusions PEEPupper is a rational selection in ARDS cases with two similar best Crs. EIT provides additional information for the selection of PEEP in such circumstances. Supplementary Information The online version contains supplementary material available at 10.1007/s40846-021-00668-2.
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Affiliation(s)
- Po-Lan Su
- Institute of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan, 70403 Taiwan
| | - Wei-Chieh Lin
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan, 70403 Taiwan
| | - Yen-Fen Ko
- Institute of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Kuo-Sung Cheng
- Institute of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Chang-Wen Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan, 70403 Taiwan.,Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
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