151
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Beyoglu CA, Koksal GM. Perioperative management of a patient with deventilation syndrome. Obes Res Clin Pract 2020; 14:103-105. [PMID: 31974068 DOI: 10.1016/j.orcp.2020.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 10/24/2019] [Accepted: 01/06/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Cigdem Akyol Beyoglu
- Istanbul University- Cerrahpasa, Cerrahpasa School of Medicine, Department of Anesthesiology and Reanimation, Istanbul, Turkey.
| | - Guniz Meyanci Koksal
- Istanbul University- Cerrahpasa, Cerrahpasa School of Medicine, Department of Anesthesiology and Reanimation, Istanbul, Turkey
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152
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Predictors of asynchronies during assisted ventilation and its impact on clinical outcomes: The EPISYNC cohort study. J Crit Care 2020; 57:30-35. [PMID: 32032901 DOI: 10.1016/j.jcrc.2020.01.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/17/2020] [Accepted: 01/20/2020] [Indexed: 02/01/2023]
Abstract
PURPOSE To investigate if respiratory mechanics and other baseline characteristics are predictors of patient-ventilator asynchrony and to evaluate the relationship between asynchrony during assisted ventilation and clinical outcomes. METHODS We performed a prospective cohort study in patients under mechanical ventilation (MV). Baseline measurements included severity of illness and respiratory mechanics. The primary outcome was the Asynchrony Index (AI), defined as the number of asynchronous events divided by the number of ventilator cycles and wasted efforts. We recorded ventilator waveforms throughout the entire period of MV. RESULTS We analyzed 11,881 h of MV from 103 subjects. Median AI during the entire period of MV was 5.1% (IQR:2.6-8.7). Intrinsic PEEP was associated with AI (OR:1.72, 95%CI:1.1-2.68), but static compliance and airway resistance were not. Simplified Acute Physiology Score 3 (OR:1.03, 95%CI:1-1.06) was also associated with AI. Median AI was higher during assisted (5.4%, IQR:2.9-9.1) than controlled (2%, IQR:0.6-4.9) ventilation, and 22% of subjects had high incidence of asynchrony (AI≥10%). Subjects with AI≥10% had more extubation failure (33%) than patients with AI<10% (6%), p = .01. CONCLUSIONS Predictors of high incidence of asynchrony were severity of illness and intrinsic PEEP. High incidence of asynchrony was associated with extubation failure, but not mortality. TRIAL REGISTRATION ClinicalTrials.gov, NCT02687802.
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153
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Tuinman PR, Jonkman AH, Dres M, Shi ZH, Goligher EC, Goffi A, de Korte C, Demoule A, Heunks L. Respiratory muscle ultrasonography: methodology, basic and advanced principles and clinical applications in ICU and ED patients-a narrative review. Intensive Care Med 2020; 46:594-605. [PMID: 31938825 PMCID: PMC7103016 DOI: 10.1007/s00134-019-05892-8] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/02/2019] [Indexed: 02/06/2023]
Abstract
Respiratory muscle ultrasound is used to evaluate the anatomy and function of the respiratory muscle pump. It is a safe, repeatable, accurate, and non-invasive bedside technique that can be successfully applied in different settings, including general intensive care and the emergency department. Mastery of this technique allows the intensivist to rapidly diagnose and assess respiratory muscle dysfunction in critically ill patients and in patients with unexplained dyspnea. Furthermore, it can be used to assess patient-ventilator interaction and weaning failure in critically ill patients. This paper provides an overview of the basic and advanced principles underlying respiratory muscle ultrasound with an emphasis on the diaphragm. We review different ultrasound techniques useful for monitoring of the respiratory muscle pump and possible therapeutic consequences. Ideally, respiratory muscle ultrasound is used in conjunction with other components of critical care ultrasound to obtain a comprehensive evaluation of the critically ill patient. We propose the ABCDE-ultrasound approach, a systematic ultrasound evaluation of the heart, lungs and respiratory muscle pump, in patients with weaning failure.
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Affiliation(s)
- Pieter R Tuinman
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.,Amsterdam Leiden Intensive Care Focused Echography (ALIFE), Amsterdam, The Netherlands
| | - Annemijn H Jonkman
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
| | - Martin Dres
- Department of Pulmology and Medical Intensive Care, APHP Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Zhong-Hua Shi
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.,Department of Critical Care Medicine, Capital Medical University, Beijing Tiantan Hospital, Beijing, 100050, China
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, ON, Canada.,Critical Care Medicine, University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Alberto Goffi
- Interdepartmental Division of Critical Care Medicine and Department of Medicine, University of Toronto, Toronto, ON, Canada.,Division of Critical Care Medicine, Department of Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Chris de Korte
- Department of Radiology, Radboud UMC, Nijmegen, The Netherlands
| | - Alexandre Demoule
- Department of Pulmology and Medical Intensive Care, APHP Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.
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154
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Hunnekens B, Kamps S, Van De Wouw N. Variable-Gain Control for Respiratory Systems. IEEE TRANSACTIONS ON CONTROL SYSTEMS TECHNOLOGY : A PUBLICATION OF THE IEEE CONTROL SYSTEMS SOCIETY 2020; 28:163-171. [PMID: 32390782 PMCID: PMC7176038 DOI: 10.1109/tcst.2018.2871002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 08/22/2018] [Accepted: 09/04/2018] [Indexed: 06/09/2023]
Abstract
In this paper, we introduce a variable-gain control strategy for mechanical ventilators in the respiratory systems. Respiratory systems assist the patients who have difficulty breathing on their own. For the comfort of the patient, fast pressure buildup (and release) and a stable flow response are desired. However, linear controllers typically need to balance between these conflicting objectives. In order to balance this tradeoff in a more desirable manner, a variable-gain controller is proposed, which switches the controller gain based on the magnitude of the patient flow. The effectiveness of the control strategy is demonstrated in experiments on different test lungs.
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Affiliation(s)
- Bram Hunnekens
- DEMCON Macawi Respiratory Systems5692EnschedeThe Netherlands
| | - Sjors Kamps
- ASM Laser Separation International (ALSI) B.V.6641BeuningenThe Netherlands
| | - Nathan Van De Wouw
- Department of Mechanical EngineeringEindhoven University of Technology5600EindhovenThe Netherlands
- Department of Civil, Environmental, and Geo-EngineeringUniversity of MinnesotaMinneapolisMN55455USA
- Delft Center for Systems and ControlDelft University of Technology2628DelftThe Netherlands
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155
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Singh G, Chien C, Patel S. Pressure Regulated Volume Control (PRVC): Set it and forget it? Respir Med Case Rep 2020; 29:100822. [PMID: 32257782 PMCID: PMC7118406 DOI: 10.1016/j.rmcr.2019.03.001] [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: 11/29/2018] [Revised: 02/21/2019] [Accepted: 03/01/2019] [Indexed: 11/18/2022] Open
Abstract
Pressure-regulated volume control (PRVC) is a mode of ventilation in which the ventilator attempts to achieve set tidal volume at lowest possible airway pressure. This mode of ventilation is being commonly used as the initial mode of ventilation in many intensive care units. We describe two cases where this adaptive mode of ventilation became maladaptive leading to patient-ventilator dyssynchrony.
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156
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Kim KT, Knopp J, Dixon B, Chase JG. Mechanically ventilated premature babies have sex differences in specific elastance: A pilot study. Pediatr Pulmonol 2020; 55:177-184. [PMID: 31596060 DOI: 10.1002/ppul.24538] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 09/18/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVES A pilot study to compare pulmonary mechanics in a neonatal intensive care unit (NICU) cohort, specifically, comparing lung elastance between male and female infants in the NICU. HYPOTHESIS Anecdotally, male infants are harder to ventilate than females. We hypothesize that males have higher model-based elastance (converse: lower specific compliance) compared to females, reflecting underlying stiffer lungs. STUDY DESIGN A clinically validated, single-compartment model is used to identify specific elastance (inverse of specific compliance) and resistance for each breath. Specific elastance accounts for weight differences when comparing male and female infants. Relative percent breath-to-breath variability (%ΔE) in specific elastance is also compared. Level of asynchrony was also determined. PATIENT-SUBJECT SELECTION Ten invasively mechanically ventilated patients from Christchurch Women's Hospital. METHODOLOGY Airway pressure and flow data from 10 invasive mechanical ventilation (MV) infants from Christchurch Women's Hospital Neonatal Intensive Care Unit, New Zealand was prospectively recorded under standard MV care. Model-based specific elastance and resistance are identified for each breath, as well as relative percent breath-to-breath variability (%ΔE) in specific elastance. RESULTS Male infants overall had higher specific elastance compared to females infants (P ≤ .01), with median (interquartile range) for males of 1.91 (1.33-2.48) cmH2 O·kg/mL compared to 1.31 (0.86-2.02) cmH2 O·kg/mL in females. Male infants had lower variability with %ΔE of -0.03 (-7.56 to 8.01)% vs female infants of -0.59 (12.56-12.86)%. Males had 14.75% asynchronous breaths whereas females had 17.54%. CONCLUSION Overall, males had higher specific elastance and correspondingly lower breath-to-breath variability. These results indicate male and female infants may require different MV settings, mode, and monitoring.
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Affiliation(s)
- Kyeong Tae Kim
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | - Jennifer Knopp
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
| | - Bronwyn Dixon
- Neonatal Intensive Care Unit, Christchurch Women's Hospital, Christchurch, New Zealand
| | - J Geoffrey Chase
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
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157
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Rodriguez PO, Tiribelli N, Gogniat E, Plotnikow GA, Fredes S, Fernandez Ceballos I, Pratto RA, Madorno M, Ilutovich S, San Roman E, Bonelli I, Guaymas M, Raimondi AC, Maskin LP, Setten M. Automatic detection of reverse-triggering related asynchronies during mechanical ventilation in ARDS patients using flow and pressure signals. J Clin Monit Comput 2019; 34:1239-1246. [DOI: 10.1007/s10877-019-00444-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 12/09/2019] [Indexed: 01/10/2023]
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158
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Chen Y, Yuan Y, Zhang H, Li F. Comparison of Inspiratory Effort, Workload and Cycling Synchronization Between Non-Invasive Proportional-Assist Ventilation and Pressure-Support Ventilation Using Different Models of Respiratory Mechanics. Med Sci Monit 2019; 25:9048-9057. [PMID: 31778366 PMCID: PMC6900923 DOI: 10.12659/msm.914629] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background This study assessed lung models for the influence of respiratory mechanics and inspiratory effort on breathing pattern and simulator-ventilator cycling synchronization in non-invasive ventilation. Material/Methods A Respironics V60 ventilator was connected to an active lung simulator modeling mildly restrictive, severely restrictive, obstructive and mixed obstructive/restrictive profiles. Pressure-support ventilation (PSV) and proportional-assist ventilation (PAV) were set to obtain similar tidal volume (VT). PAV was applied at flow assist (FA) 40–90% of resistance (Rrs) and volume assist (VA) 40–90% of elastance (Ers). Measurements were performed with system air leak of 25–28 L/minute. Ventilator performance and simulator-ventilator asynchrony were evaluated. Results At comparable VT, PAV had slightly lower peak inspiratory flow and higher driving pressure compared with PSV. Premature cycling occurred in the obstructive, severely restrictive and mildly restrictive models. During PAV, time for airway pressure to achieve 90% of maximum during inspiration (T90) in the severely restrictive model was shorter than those of the obstructive and mixed obstructive/restrictive models and close to that measured in the PSV mode. Increasing FA level reduced inspiratory trigger workload (PTP300) in obstructive and mixed obstructive/restrictive models. Increasing FA level decreased inspiratory time (TI) and tended to aggravate premature cycling, whereas increasing VA level attenuated this effect. Conclusions PAV with an appropriate combination of FA and VA decreases work of breathing during the inspiratory phase and improves simulator-ventilator cycling synchrony. FA has greater impact than VA in the adaptation to inspiratory effort demand. High VA level might help improve cycling synchrony.
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Affiliation(s)
- Yuqing Chen
- Department of Respiratory Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China (mainland)
| | - Yueyang Yuan
- School of Mechanical and Electrical Engineering, Hu Nan City University, Yi Yang, Hunan, China (mainland)
| | - Hai Zhang
- Department of Respiratory Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China (mainland)
| | - Feng Li
- Department of Respiratory Medicine, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China (mainland)
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159
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Akoumianaki E, Vaporidi K, Georgopoulos D. The Injurious Effects of Elevated or Nonelevated Respiratory Rate during Mechanical Ventilation. Am J Respir Crit Care Med 2019; 199:149-157. [PMID: 30199652 DOI: 10.1164/rccm.201804-0726ci] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Respiratory rate is one of the key variables that is set and monitored during mechanical ventilation. As part of increasing efforts to optimize mechanical ventilation, it is prudent to expand understanding of the potential harmful effects of not only volume and pressures but also respiratory rate. The mechanisms by which respiratory rate may become injurious during mechanical ventilation can be distinguished in two broad categories. In the first, well-recognized category, concerning both controlled and assisted ventilation, the respiratory rate per se may promote ventilator-induced lung injury, dynamic hyperinflation, ineffective efforts, and respiratory alkalosis. It may also be misinterpreted as distress delaying the weaning process. In the second category, which concerns only assisted ventilation, the respiratory rate may induce injury in a less apparent way by remaining relatively quiescent while being challenged by chemical feedback. By responding minimally to chemical feedback, respiratory rate leaves the control of V. e almost exclusively to inspiratory effort. In such cases, when assist is high, weak inspiratory efforts promote ineffective triggering, periodic breathing, and diaphragmatic atrophy. Conversely, when assist is low, diaphragmatic efforts are intense and increase the risk for respiratory distress, asynchronies, ventilator-induced lung injury, diaphragmatic injury, and cardiovascular complications. This review thoroughly presents the multiple mechanisms by which respiratory rate may induce injury during mechanical ventilation, drawing the attention of critical care physicians to the potential injurious effects of respiratory rate insensitivity to chemical feedback during assisted ventilation.
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Affiliation(s)
- Evangelia Akoumianaki
- 1 Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Katerina Vaporidi
- 1 Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Dimitris Georgopoulos
- 1 Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
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Tams C, Stephan PJ, Euliano NR, Martin AD, Patel R, Ataya A, Gabrielli A. Breathing variability predicts the suggested need for corrective intervention due to the perceived severity of patient-ventilator asynchrony during NIV. J Clin Monit Comput 2019; 34:1035-1042. [PMID: 31664660 DOI: 10.1007/s10877-019-00408-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
Abstract
Patient-ventilator asynchrony is associated with intolerance to noninvasive ventilation (NIV) and worsened outcomes. Our goal was to develop a tool to determine a patient needs for intervention by a practitioner due to the presence of patient-ventilator asynchrony. We postulated that a clinician can determine when a patient needs corrective intervention due to the perceived severity of patient-ventilator asynchrony. We hypothesized a new measure, patient breathing variability, would indicate when corrective intervention is suggested by a bedside practitioner due to the perceived severity of patient-ventilator asynchrony. With IRB approval data was collected on 78 NIV patients. A panel of experts reviewed retrospective data from a development set of 10 NIV patients to categorize them into one of the three categories. The three categories were; "No to mild asynchrony-no intervention needed", "moderate asynchrony-non-emergent corrective intervention required", and "severe asynchrony-immediate intervention required". A stepwise regression with a F-test forward selection criterion was used to develop a positive linear logic model predicting the expert panel's categorizations of the need for corrective intervention. The model was incorporated into a software tool for clinical implementation. The tool was implemented prospectively on 68 NIV patients simultaneous to a bedside practitioner scoring the need for corrective intervention due to the perceived severity of patient-ventilator asynchrony. The categories from the tool and the practitioner were compared with the rate of agreement, sensitivity, specificity, and receiver operator characteristic analyses. The rate of agreement in categorizing the suggested need for clinical intervention due to the perceived presence of patient-ventilator asynchrony between the tool and experienced bedside practitioners was 95% with a Kappa score of 0.85 (p < 0.001). Further analysis found a specificity of 84% and sensitivity of 99%. The tool appears to accurately match the suggested need for corrective intervention by a bedside practitioner. Application of the tool allows for continuous, real time, and non-invasive monitoring of patients receiving NIV, and may enable early corrective interventions to ameliorate potential patient-ventilator asynchrony.
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Affiliation(s)
- Carl Tams
- Convergent Engineering, 107 SW 140th Terrace, STE 1, Newberry, FL, 32669, USA
| | - Paul J Stephan
- Convergent Engineering, 107 SW 140th Terrace, STE 1, Newberry, FL, 32669, USA
| | - Neil R Euliano
- Convergent Engineering, 107 SW 140th Terrace, STE 1, Newberry, FL, 32669, USA.
| | - A Daniel Martin
- Department of Physical Therapy, College of Public Health & Health Professions, University of Florida, Gainesville, FL, 32610, USA
| | - Rohit Patel
- Department of Anesthesiology and Department of Emergency Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, PO Box 100254, Gainesville, FL, 32610, USA
| | - Ali Ataya
- Department of Pulmonary, Critical Care and Sleep Medicine, College of Medicine, University of Florida, 1600 SW Archer Road, Gainesville, FL, 32610, USA
| | - Andrea Gabrielli
- Department of Anesthesiology Perioperative Medicine and Pain Management, University of Miami Health System, 1611 NW 12th Ave (C-301), Miami, FL, 33136, USA
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161
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Identifying and managing patient-ventilator asynchrony: An international survey. Med Intensiva 2019; 45:138-146. [PMID: 31668560 DOI: 10.1016/j.medin.2019.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 08/01/2019] [Accepted: 09/01/2019] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To describe the main factors associated with proper recognition and management of patient-ventilator asynchrony (PVA). DESIGN An analytical cross-sectional study was carried out. SETTING An international study conducted in 20 countries through an online survey. PARTICIPANTS Physicians, respiratory therapists, nurses and physiotherapists currently working in the Intensive Care Unit (ICU). MAIN VARIABLES OF INTEREST Univariate and multivariate logistic regression models were used to establish associations between all variables (profession, training in mechanical ventilation, type of training program, years of experience and ICU characteristics) and the ability of HCPs to correctly identify and manage 6 PVA. RESULTS A total of 431 healthcare professionals answered a validated survey. The main factors associated to proper recognition of PVA were: specific training program in mechanical ventilation (MV) (OR 2.27; 95%CI 1.14-4.52; p=0.019), courses with more than 100h completed (OR 2.28; 95%CI 1.29-4.03; p=0.005), and the number of ICU beds (OR 1.037; 95%CI 1.01-1.06; p=0.005). The main factor influencing the management of PVA was the correct recognition of 6 PVAs (OR 118.98; 95%CI 35.25-401.58; p<0.001). CONCLUSION Identifying and managing PVA using ventilator waveform analysis is influenced by many factors, including specific training programs in MV, the number of ICU beds, and the number of recognized PVAs.
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162
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Double Cycling During Mechanical Ventilation: Frequency, Mechanisms, and Physiologic Implications. Crit Care Med 2019; 46:1385-1392. [PMID: 29985211 DOI: 10.1097/ccm.0000000000003256] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Double cycling generates larger than expected tidal volumes that contribute to lung injury. We analyzed the incidence, mechanisms, and physiologic implications of double cycling during volume- and pressure-targeted mechanical ventilation in critically ill patients. DESIGN Prospective, observational study. SETTING Three general ICUs in Spain. PATIENTS Sixty-seven continuously monitored adult patients undergoing volume control-continuous mandatory ventilation with constant flow, volume control-continuous mandatory ventilation with decelerated flow, or pressure control-continuous mandatory mechanical ventilation for longer than 24 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We analyzed 9,251 hours of mechanical ventilation corresponding to 9,694,573 breaths. Double cycling occurred in 0.6%. All patients had double cycling; however, the distribution of double cycling varied over time. The mean percentage (95% CI) of double cycling was higher in pressure control-continuous mandatory ventilation 0.54 (0.34-0.87) than in volume control-continuous mandatory ventilation with constant flow 0.27 (0.19-0.38) or volume control-continuous mandatory ventilation with decelerated flow 0.11 (0.06-0.20). Tidal volume in double-cycled breaths was higher in volume control-continuous mandatory ventilation with constant flow and volume control-continuous mandatory ventilation with decelerated flow than in pressure control-continuous mandatory ventilation. Double-cycled breaths were patient triggered in 65.4% and reverse triggered (diaphragmatic contraction stimulated by a previous passive ventilator breath) in 34.6% of cases; the difference was largest in volume control-continuous mandatory ventilation with decelerated flow (80.7% patient triggered and 19.3% reverse triggered). Peak pressure of the second stacked breath was highest in volume control-continuous mandatory ventilation with constant flow regardless of trigger type. Various physiologic factors, none mutually exclusive, were associated with double cycling. CONCLUSIONS Double cycling is uncommon but occurs in all patients. Periods without double cycling alternate with periods with clusters of double cycling. The volume of the stacked breaths can double the set tidal volume in volume control-continuous mandatory ventilation with constant flow. Gas delivery must be tailored to neuroventilatory demand because interdependent ventilator setting-related physiologic factors can contribute to double cycling. One third of double-cycled breaths were reverse triggered, suggesting that repeated respiratory muscle activation after time-initiated ventilator breaths occurs more often than expected.
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163
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Karikari S, Rausa J, Flores S, Loomba RS. Neurally adjusted ventilatory assist versus conventional ventilation in the pediatric population: Are there benefits? Pediatr Pulmonol 2019; 54:1374-1381. [PMID: 31231985 DOI: 10.1002/ppul.24413] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/09/2019] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Neurally-adjusted ventilator assist (NAVA) is a relatively new form of ventilation in which the electrical activity of the diaphragm is sensed by a catheter. The amplitude of this electrical signal is then used to deliver an appropriately proportioned pressure supported breath to the patient. Due to the synchronous nature of the breaths and the patient-adjusted nature of the support, NAVA has been shown to have benefits over conventional ventilation. Meta-analyses were conducted of published pediatric studies to compare ventilatory endpoints between NAVA and conventional ventilation. METHODS Studies comparing ventilatory parameters between NAVA and conventional ventilation in pediatric patients were identified. These studies were reviewed for appropriateness for inclusion and studies of only pediatric patients with data for similar endpoints between both arms were then pooled. RESULTS Statistically significant differences were noted in asynchrony, peak inspiratory pressure (PIP), and oxygen saturation by pulse oximetry. Asynchrony was 17% lower with NAVA, PIP was 1.74 cmH2 0 lower with NAVA, and oxygen saturation was 1.1% greater with NAVA. There was no statistically significant difference in peak expiratory pressure, mean airway pressure, electrical diaphragmatic activity, respiratory rate, hydrogen ion concentration, partial pressure of oxygen, or partial pressure of carbon dioxide. CONCLUSION Statistically significant differences were noted in percent asynchrony, PIP, and oxygen saturation when comparing NAVA to conventional ventilation. These all tended to favor NAVA. Other than percent asynchrony, however, the other statistically significant findings were not clinically significant.
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Affiliation(s)
- Serwaa Karikari
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School/ Rosalind Franklin University of Medicine and Science, Chicago, Illinois
| | - Jacqueline Rausa
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School/ Rosalind Franklin University of Medicine and Science, Chicago, Illinois
| | - Saul Flores
- Division of Critical Care, Texas Children's Hospital, Houston, Texas
| | - Rohit S Loomba
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School/ Rosalind Franklin University of Medicine and Science, Chicago, Illinois
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164
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Vetrugno L, Guadagnin GM, Barbariol F, Langiano N, Zangrillo A, Bove T. Ultrasound Imaging for Diaphragm Dysfunction: A Narrative Literature Review. J Cardiothorac Vasc Anesth 2019; 33:2525-2536. [DOI: 10.1053/j.jvca.2019.01.003] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Indexed: 12/15/2022]
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165
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González-Seguel F, Camus-Molina A, Jasmén Sepúlveda A, Pérez Araos R, Molina Blamey J, Graf Santos J. Settings and monitoring of mechanical ventilation during physical therapy in adult critically ill patients: protocol for a scoping review. BMJ Open 2019; 9:e030692. [PMID: 31455713 PMCID: PMC6720146 DOI: 10.1136/bmjopen-2019-030692] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Early mobilisation has been extensively advocated to improve functional outcomes in critically ill patients, even though consistent evidence of its benefits has remained elusive. These conflicting results could be explained by a lack of knowledge on the optimal dosage of physical therapy and a mismatch between ventilatory support and exercise-induced patient ventilatory demand. Modern mechanical ventilators provide real-time monitoring of respiratory/metabolic variables and ventilatory setting that could be used for physical therapy dosage or ventilatory support titration, allowing individualised interventions in these patients. The aim of this review is to comprehensively map and summarise current knowledge on adjustments of respiratory support and respiratory or metabolic monitoring during physical therapy in adult critically ill mechanically ventilated patients. METHODS AND ANALYSIS This is a scoping review protocol based on the methodology of the Joanna-Briggs-Institute. The search strategy will be conducted from inception to 30 June 2019 as a cut-off date in PubMed, CINAHL, Rehabilitation & Sport Medicine, Scielo Citation Index, Epistemónikos, Clinical Trials, PEDro and Cochrane Library, performed by a biomedical librarian and two critical care physiotherapists. All types of articles will be selected, including conference abstracts, clinical practice guidelines and expert recommendations. Bibliometric variables, patient characteristics, physical therapy interventions, ventilator settings and respiratory or metabolic monitoring will be extracted. The identified literature will be analysed by four critical care physiotherapists and reviewed by a senior critical care physician. ETHICS AND DISSEMINATION Ethical approval is not required. The knowledge-translation of the results will be carried out based on the End-of-Grant strategies: diffusion, dissemination and application. The results will be published in a peer-review journal, presentations will be disseminated in relevant congresses, and recommendations based on the results will be developed through training for mechanical ventilation and physical therapy stakeholders.
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Affiliation(s)
- Felipe González-Seguel
- Servicio de Medicina Física y Rehabilitación, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
- School of Physical Therapy, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Agustín Camus-Molina
- School of Physical Therapy, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Anita Jasmén Sepúlveda
- Bibliotecas Biomédicas, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Rodrigo Pérez Araos
- Departamento de Paciente Crítico, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Jorge Molina Blamey
- School of Physical Therapy, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
| | - Jerónimo Graf Santos
- Departamento de Paciente Crítico, Facultad de Medicina, Clínica Alemana Universidad del Desarrollo, Santiago, Chile
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Piquilloud L, Beloncle F, Richard JCM, Mancebo J, Mercat A, Brochard L. Information conveyed by electrical diaphragmatic activity during unstressed, stressed and assisted spontaneous breathing: a physiological study. Ann Intensive Care 2019; 9:89. [PMID: 31414251 PMCID: PMC6692797 DOI: 10.1186/s13613-019-0564-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 07/31/2019] [Indexed: 11/13/2022] Open
Abstract
Background The electrical activity of the crural diaphragm (Eadi), a surrogate of respiratory drive, can now be measured at the bedside in mechanically ventilated patients with a specific catheter. The expected range of Eadi values under stressed or assisted spontaneous breathing is unknown. This study explored Eadi values in healthy subjects during unstressed (baseline), stressed (with a resistance) and assisted spontaneous breathing. The relation between Eadi and inspiratory effort was analyzed. Methods Thirteen healthy male volunteers were included in this randomized crossover study. Eadi and esophageal pressure (Peso) were recorded during unstressed and stressed spontaneous breathing and under assisted ventilation delivered in pressure support (PS) at low and high assist levels and in neurally adjusted ventilatory assist (NAVA). Overall eight different situations were assessed in each participant (randomized order). Peak, mean and integral of Eadi, breathing pattern, esophageal pressure–time product (PTPeso) and work of breathing (WOB) were calculated offline. Results Median [interquartile range] peak Eadi at baseline was 17 [13–22] μV and was above 10 μV in 92% of the cases. Eadimax defined as Eadi measured at maximal inspiratory capacity reached 90 [63 to 99] μV. Median peak Eadi/Eadimax ratio was 16.8 [15.6–27.9]%. Compared to baseline, respiratory rate and minute ventilation were decreased during stressed non-assisted breathing, whereas peak Eadi and PTPeso were increased. During unstressed assisted breathing, peak Eadi decreased during high-level PS compared to unstressed non-assisted breathing and to NAVA (p = 0.047). During stressed breathing, peak Eadi was lower during all assisted ventilation modalities compared to stressed non-assisted breathing. During assisted ventilation, across the different conditions, peak Eadi changed significantly, whereas PTPeso and WOB/min were not significantly modified. Finally, Eadi signal was still present even when Peso signal was suppressed due to high assist levels. Conclusion Eadi analysis provides complementary information compared to respiratory pattern and to Peso monitoring, particularly in the presence of high assist levels. Trial registration The study was registered as NCT01818219 in clinicaltrial.gov. Registered 28 February 2013 Electronic supplementary material The online version of this article (10.1186/s13613-019-0564-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lise Piquilloud
- Medical Intensive Care Department, University Hospital of Angers, University of Angers, 4, Rue Larrey, 49100, Angers, France. .,Adult Intensive Care and Burn Unit, University Hospital and University of Lausanne, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - François Beloncle
- Medical Intensive Care Department, University Hospital of Angers, University of Angers, 4, Rue Larrey, 49100, Angers, France
| | - Jean-Christophe M Richard
- SAMU74, Emergency Department, General Hospital of Annecy, 1, Av de l'hôpital, 74370, Epagny Metz-Tessy, France.,INSERM, UMR 955, Créteil, France
| | - Jordi Mancebo
- Intensive Care Department, Sant Pau Hospital, Carrer de Sant Quinti 89, 08041, Barcelona, Spain
| | - Alain Mercat
- Medical Intensive Care Department, University Hospital of Angers, University of Angers, 4, Rue Larrey, 49100, Angers, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
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Chen C, Wen T, Liao W. Neurally adjusted ventilatory assist versus pressure support ventilation in patient-ventilator interaction and clinical outcomes: a meta-analysis of clinical trials. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:382. [PMID: 31555696 DOI: 10.21037/atm.2019.07.60] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background The objective of this study was to conduct a meta-analysis comparing neurally adjusted ventilatory assist (NAVA) with pressure support ventilation (PSV) in adult ventilated patients with patient-ventilator interaction and clinical outcomes. Methods The PubMed, the Web of Science, Scopus, and Medline were searched for appropriate clinical trials (CTs) comparing NAVA with PSV for the adult ventilated patients. RevMan 5.3 was performed for comparing NAVA with PSV in asynchrony index (AI), ineffective efforts, auto-triggering, double asynchrony, premature asynchrony, breathing pattern (Peak airway pressure (Pawpeek), mean airway pressure (Pawmean), tidal volume (VT, mL/kg), minute volume (MV), respiratory muscle unloading (peak electricity of diaphragm (EAdipeak), P 0.1, VT/EAdi), clinical outcomes (ICU mortality, duration of ventilation days, ICU stay time, hospital stay time). Results Our meta-analysis included 12 studies involving a total of 331 adult ventilated patients, AI was significantly lower in NAVA group [mean difference (MD) -12.82, 95% confidence interval (CI): -21.20 to -4.44, I2=88%], and using subgroup analysis, grouped by mechanical ventilation, the results showed that NAVA also had lower AI than PSV (Mechanical ventilation, MD -9.52, 95% CI: -17.85 to -1.20, I2=87%), (Non-invasive ventilation (NIV), MD -24.55, 95% CI: -35.40 to -13.70, I2=0%). NAVA was significantly lower than the PSV in auto-triggering (MD -0.28, 95% CI: -0.51 to -0.05, I2=10%), and premature triggering (MD -2.49, 95% CI: -3.77 to -1.21, I2=29%). There were no significant differences in double triggering, ineffective efforts, breathing pattern (Pawmean, Pawpeak, VT, MV), and respiratory muscle unloading (EAdipeak, P 0.1, VT/EAdi). For clinical outcomes, NAVA was significantly lower than the PSV (MD -2.82, 95% CI: -5.55 to -0.08, I2=0%) in the duration of ventilation, but two groups did not show significant differences in ICU mortality, ICU stay time, and hospital stay time. Conclusions NAVA is more beneficial in patient-ventilator interaction than PSV, and could decrease the duration of ventilation.
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Affiliation(s)
- Chongxiang Chen
- Department of Intensive Care Unit, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China.,Guangzhou Institute of Respiratory Diseases, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, Guangzhou 510120, China
| | - Tianmeng Wen
- School of Public Health, Sun Yat-sen University, Guangzhou 510000, China
| | - Wei Liao
- Department of Intensive Care Unit, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
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de Haro C, Ochagavia A, López-Aguilar J, Fernandez-Gonzalo S, Navarra-Ventura G, Magrans R, Montanyà J, Blanch L. Patient-ventilator asynchronies during mechanical ventilation: current knowledge and research priorities. Intensive Care Med Exp 2019; 7:43. [PMID: 31346799 PMCID: PMC6658621 DOI: 10.1186/s40635-019-0234-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/07/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mechanical ventilation is common in critically ill patients. This life-saving treatment can cause complications and is also associated with long-term sequelae. Patient-ventilator asynchronies are frequent but underdiagnosed, and they have been associated with worse outcomes. MAIN BODY Asynchronies occur when ventilator assistance does not match the patient's demand. Ventilatory overassistance or underassistance translates to different types of asynchronies with different effects on patients. Underassistance can result in an excessive load on respiratory muscles, air hunger, or lung injury due to excessive tidal volumes. Overassistance can result in lower patient inspiratory drive and can lead to reverse triggering, which can also worsen lung injury. Identifying the type of asynchrony and its causes is crucial for effective treatment. Mechanical ventilation and asynchronies can affect hemodynamics. An increase in intrathoracic pressure during ventilation modifies ventricular preload and afterload of ventricles, thereby affecting cardiac output and hemodynamic status. Ineffective efforts can decrease intrathoracic pressure, but double cycling can increase it. Thus, asynchronies can lower the predictive accuracy of some hemodynamic parameters of fluid responsiveness. New research is also exploring the psychological effects of asynchronies. Anxiety and depression are common in survivors of critical illness long after discharge. Patients on mechanical ventilation feel anxiety, fear, agony, and insecurity, which can worsen in the presence of asynchronies. Asynchronies have been associated with worse overall prognosis, but the direct causal relation between poor patient-ventilator interaction and worse outcomes has yet to be clearly demonstrated. Critical care patients generate huge volumes of data that are vastly underexploited. New monitoring systems can analyze waveforms together with other inputs, helping us to detect, analyze, and even predict asynchronies. Big data approaches promise to help us understand asynchronies better and improve their diagnosis and management. CONCLUSIONS Although our understanding of asynchronies has increased in recent years, many questions remain to be answered. Evolving concepts in asynchronies, lung crosstalk with other organs, and the difficulties of data management make more efforts necessary in this field.
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Affiliation(s)
- Candelaria de Haro
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain. .,CIBERES, Instituto de Salud Carlos III, Madrid, Spain.
| | - Ana Ochagavia
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Josefina López-Aguilar
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Sol Fernandez-Gonzalo
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain.,CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain
| | - Guillem Navarra-Ventura
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain
| | - Rudys Magrans
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Lluís Blanch
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
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The Association Between Ventilator Dyssynchrony, Delivered Tidal Volume, and Sedation Using a Novel Automated Ventilator Dyssynchrony Detection Algorithm. Crit Care Med 2019; 46:e151-e157. [PMID: 29337804 DOI: 10.1097/ccm.0000000000002849] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE Ventilator dyssynchrony is potentially harmful to patients with or at risk for the acute respiratory distress syndrome. Automated detection of ventilator dyssynchrony from ventilator waveforms has been difficult. It is unclear if certain types of ventilator dyssynchrony deliver large tidal volumes and whether levels of sedation alter the frequency of ventilator dyssynchrony. DESIGN A prospective observational study. SETTING A university medical ICU. PATIENTS Patients with or at risk for acute respiratory distress syndrome. INTERVENTIONS Continuous pressure-time, flow-time, and volume-time data were directly obtained from the ventilator. The level of sedation and the use of neuromuscular blockade was extracted from the medical record. Machine learning algorithms that incorporate clinical insight were developed and trained to detect four previously described and clinically relevant forms of ventilator dyssynchrony. The association between normalized tidal volume and ventilator dyssynchrony and the association between sedation and the frequency of ventilator dyssynchrony were determined. MEASUREMENTS AND MAIN RESULTS A total of 4.26 million breaths were recorded from 62 ventilated patients. Our algorithm detected three types of ventilator dyssynchrony with an area under the receiver operator curve of greater than 0.89. Ventilator dyssynchrony occurred in 34.4% (95% CI, 34.41-34.49%) of breaths. When compared with synchronous breaths, double-triggered and flow-limited breaths were more likely to deliver tidal volumes greater than 10 mL/kg (40% and 11% compared with 0.2%; p < 0.001 for both comparisons). Deep sedation reduced but did not eliminate the frequency of all ventilator dyssynchrony breaths (p < 0.05). Ventilator dyssynchrony was eliminated with neuromuscular blockade (p < 0.001). CONCLUSION We developed a computerized algorithm that accurately detects three types of ventilator dyssynchrony. Double-triggered and flow-limited breaths are associated with the frequent delivery of tidal volumes of greater than 10 mL/kg. Although ventilator dyssynchrony is reduced by deep sedation, potentially deleterious tidal volumes may still be delivered. However, neuromuscular blockade effectively eliminates ventilator dyssynchrony.
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de Haro C, Magrans R, López-Aguilar J, Montanyà J, Lena E, Subirà C, Fernandez-Gonzalo S, Gomà G, Fernández R, Albaiceta GM, Skrobik Y, Lucangelo U, Murias G, Ochagavia A, Kacmarek RM, Rue M, Blanch L. Effects of sedatives and opioids on trigger and cycling asynchronies throughout mechanical ventilation: an observational study in a large dataset from critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:245. [PMID: 31277722 PMCID: PMC6612107 DOI: 10.1186/s13054-019-2531-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 06/26/2019] [Indexed: 12/23/2022]
Abstract
Background In critically ill patients, poor patient-ventilator interaction may worsen outcomes. Although sedatives are often administered to improve comfort and facilitate ventilation, they can be deleterious. Whether opioids improve asynchronies with fewer negative effects is unknown. We hypothesized that opioids alone would improve asynchronies and result in more wakeful patients than sedatives alone or sedatives-plus-opioids. Methods This prospective multicenter observational trial enrolled critically ill adults mechanically ventilated (MV) > 24 h. We compared asynchronies and sedation depth in patients receiving sedatives, opioids, or both. We recorded sedation level and doses of sedatives and opioids. BetterCare™ software continuously registered ineffective inspiratory efforts during expiration (IEE), double cycling (DC), and asynchrony index (AI) as well as MV modes. All variables were averaged per day. We used linear mixed-effects models to analyze the relationships between asynchronies, sedation level, and sedative and opioid doses. Results In 79 patients, 14,166,469 breaths were recorded during 579 days of MV. Overall asynchronies were not significantly different in days classified as sedatives-only, opioids-only, and sedatives-plus-opioids and were more prevalent in days classified as no-drugs than in those classified as sedatives-plus-opioids, irrespective of the ventilatory mode. Sedative doses were associated with sedation level and with reduced DC (p < 0.0001) in sedatives-only days. However, on days classified as sedatives-plus-opioids, higher sedative doses and deeper sedation had more IEE (p < 0.0001) and higher AI (p = 0.0004). Opioid dosing was inversely associated with overall asynchronies (p < 0.001) without worsening sedation levels into morbid ranges. Conclusions Sedatives, whether alone or combined with opioids, do not result in better patient-ventilator interaction than opioids alone, in any ventilatory mode. Higher opioid dose (alone or with sedatives) was associated with lower AI without depressing consciousness. Higher sedative doses administered alone were associated only with less DC. Trial registration ClinicalTrial.gov, NCT03451461 Electronic supplementary material The online version of this article (10.1186/s13054-019-2531-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Candelaria de Haro
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain. .,Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain. .,CIBERES, Instituto de Salud Carlos III, Madrid, Spain.
| | - Rudys Magrans
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Josefina López-Aguilar
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Enrico Lena
- Department of Perioperative Medicine, Intensive Care and Emergency, Cattinara Hospital, Trieste University, Trieste, Italy
| | - Carles Subirà
- ICU, Fundació Althaia, Universitat Internacional de Catalunya, Manresa, Spain
| | - Sol Fernandez-Gonzalo
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain
| | - Gemma Gomà
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Rafael Fernández
- CIBERES, Instituto de Salud Carlos III, Madrid, Spain.,ICU, Fundació Althaia, Universitat Internacional de Catalunya, Manresa, Spain
| | - Guillermo M Albaiceta
- CIBERES, Instituto de Salud Carlos III, Madrid, Spain.,Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Oviedo, Spain.,Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain
| | - Yoanna Skrobik
- Department of Medicine, McGill University, Montréal, Québec, Canada.,Regroupement des Soins Critiques Respiratoires, Réseau de Santé Respiratoire, Fonds de Recherche du Québec en Santé, Montréal, Québec, Canada
| | - Umberto Lucangelo
- Department of Perioperative Medicine, Intensive Care and Emergency, Cattinara Hospital, Trieste University, Trieste, Italy
| | - Gastón Murias
- Critical Care Department, Hospital Británico, Buenos Aires, Argentina
| | - Ana Ochagavia
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Robert M Kacmarek
- Department of Respiratory Care, Department of Anesthesiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Montserrat Rue
- Department of Basic Medical Sciences, Universitat de Lleida-IRB Lleida, Lleida, Spain.,Health Services Research Network in Chronic Diseases (REDISSEC), Madrid, Spain
| | - Lluís Blanch
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
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Kim KT, Knopp J, Dixon B, Chase G. Quantifying neonatal pulmonary mechanics in mechanical ventilation. Biomed Signal Process Control 2019. [DOI: 10.1016/j.bspc.2019.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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173
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Bonacina D, Bronco A, Nacoti M, Ferrari F, Fazzi F, Bonanomi E, Bellani G. Pressure support ventilation, sigh adjunct to pressure support ventilation, and neurally adjusted ventilatory assist in infants after cardiac surgery: A physiologic crossover randomized study. Pediatr Pulmonol 2019; 54:1078-1086. [PMID: 31004420 DOI: 10.1002/ppul.24335] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 03/25/2019] [Accepted: 03/25/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVES We sought to compare gas exchange, respiratory mechanics, and asynchronies during pressure support ventilation (PSV), sigh adjunct to PSV (PSV SIGH), and neurally adjusted ventilatory assist (NAVA) in hypoxemic infants after cardiac surgery. DESIGN Prospective, single-center, crossover, randomized physiologic study. SETTING Tertiary-care pediatric intensive care unit. PATIENTS Fourteen hypoxemic infants (median age 11.5 days [8.7-74]). INTERVENTIONS The protocol begins with a 1 hour step of PSV, followed by two consecutive steps in PSV SIGH and NAVA in random order, with a washout period of 30 minutes (PSV) between them. MAIN RESULTS Three infants presented an irregular Eadi signal because of diaphragmatic paralysis and were excluded from analysis. For the remaining 11 infants, PaO2 /FiO 2 and oxygenation index improved in PSV SIGH compared with PSV (P < 0.05) but not in NAVA compared with PSV. PSV SIGH showed increased tidal volumes and lower respiratory rate than PSV (P < 0.05), as well as a significant improvement in compliance with respiratory system indexed to body weight when compared with both PSV and NAVA (P < 0.01). No changes in mean airway pressure was registered among steps. Inspiratory time resulted prolonged for both PSV SIGH and NAVA than PSV (P < 0.05). NAVA showed the higher coefficient of variability in respiratory parameters and a significative decrease in asynchrony index when compared with both PSV and PSV SIGH (P < 0.01). CONCLUSIONS The adjunct of one SIGH per minute to PSV improved oxygenation and lung mechanics while NAVA provided the best patient-ventilator synchrony in infants after cardiac surgery.
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Affiliation(s)
- Daniele Bonacina
- Pediatric Intensive Care Unit, A.S.S.T. Papa Giovanni XXIII, Bergamo, Italy
| | - Alfio Bronco
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Mirco Nacoti
- Pediatric Intensive Care Unit, A.S.S.T. Papa Giovanni XXIII, Bergamo, Italy
| | - Floriana Ferrari
- Pediatric Intensive Care Unit, A.S.S.T. Papa Giovanni XXIII, Bergamo, Italy
| | - Francesco Fazzi
- Pediatric Intensive Care Unit, A.S.S.T. Papa Giovanni XXIII, Bergamo, Italy
| | - Ezio Bonanomi
- Pediatric Intensive Care Unit, A.S.S.T. Papa Giovanni XXIII, Bergamo, Italy
| | - Giacomo Bellani
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy.,Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
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Papazian L, Aubron C, Brochard L, Chiche JD, Combes A, Dreyfuss D, Forel JM, Guérin C, Jaber S, Mekontso-Dessap A, Mercat A, Richard JC, Roux D, Vieillard-Baron A, Faure H. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care 2019. [PMID: 31197492 DOI: 10.1186/s13613-019-0540-9.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Fifteen recommendations and a therapeutic algorithm regarding the management of acute respiratory distress syndrome (ARDS) at the early phase in adults are proposed. The Grade of Recommendation Assessment, Development and Evaluation (GRADE) methodology has been followed. Four recommendations (low tidal volume, plateau pressure limitation, no oscillatory ventilation, and prone position) had a high level of proof (GRADE 1 + or 1 -); four (high positive end-expiratory pressure [PEEP] in moderate and severe ARDS, muscle relaxants, recruitment maneuvers, and venovenous extracorporeal membrane oxygenation [ECMO]) a low level of proof (GRADE 2 + or 2 -); seven (surveillance, tidal volume for non ARDS mechanically ventilated patients, tidal volume limitation in the presence of low plateau pressure, PEEP > 5 cmH2O, high PEEP in the absence of deleterious effect, pressure mode allowing spontaneous ventilation after the acute phase, and nitric oxide) corresponded to a level of proof that did not allow use of the GRADE classification and were expert opinions. Lastly, for three aspects of ARDS management (driving pressure, early spontaneous ventilation, and extracorporeal carbon dioxide removal), the experts concluded that no sound recommendation was possible given current knowledge. The recommendations and the therapeutic algorithm were approved by the experts with strong agreement.
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Affiliation(s)
- Laurent Papazian
- Service de Médecine Intensive - Réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France.
| | - Cécile Aubron
- Medical Intensive Care Unit, Centre Hospitalier Régional et Universitaire de Brest, site La Cavale Blanche, Bvd Tanguy Prigent, 29609, Brest Cedex, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Jean-Daniel Chiche
- Service de Médecine Intensive - Réanimation, Hôpital Cochin, Hôpitaux Universitaires Paris-Centre, Assistance Publique - Hôpitaux de Paris, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Alain Combes
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié- Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Didier Dreyfuss
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 Rue des Renouillers, 92700, Colombes, France
| | - Jean-Marie Forel
- Service de Médecine Intensive - Réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France
| | - Claude Guérin
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Samir Jaber
- Department of Anesthesiology and Intensive Care (DAR B), Saint Eloi University Hospital, Montpellier, France
| | - Armand Mekontso-Dessap
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri-Mondor, AP-HP, DHU A-TVB, 94010, Créteil, France
| | - Alain Mercat
- Medical Intensive Care Department, Angers University Hospital, 4, rue Larrey, 49933, Angers Cedex, France
| | | | - Damien Roux
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 Rue des Renouillers, 92700, Colombes, France
| | | | - Henri Faure
- Service de Médecine Intensive - Réanimation, Centre Hospitalier Intercommunal Robert Ballanger, 93602, Aulnay-sous-Bois, France
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Papazian L, Aubron C, Brochard L, Chiche JD, Combes A, Dreyfuss D, Forel JM, Guérin C, Jaber S, Mekontso-Dessap A, Mercat A, Richard JC, Roux D, Vieillard-Baron A, Faure H. Formal guidelines: management of acute respiratory distress syndrome. Ann Intensive Care 2019; 9:69. [PMID: 31197492 PMCID: PMC6565761 DOI: 10.1186/s13613-019-0540-9] [Citation(s) in RCA: 410] [Impact Index Per Article: 82.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/27/2019] [Indexed: 12/16/2022] Open
Abstract
Fifteen recommendations and a therapeutic algorithm regarding the management of acute respiratory distress syndrome (ARDS) at the early phase in adults are proposed. The Grade of Recommendation Assessment, Development and Evaluation (GRADE) methodology has been followed. Four recommendations (low tidal volume, plateau pressure limitation, no oscillatory ventilation, and prone position) had a high level of proof (GRADE 1 + or 1 −); four (high positive end-expiratory pressure [PEEP] in moderate and severe ARDS, muscle relaxants, recruitment maneuvers, and venovenous extracorporeal membrane oxygenation [ECMO]) a low level of proof (GRADE 2 + or 2 −); seven (surveillance, tidal volume for non ARDS mechanically ventilated patients, tidal volume limitation in the presence of low plateau pressure, PEEP > 5 cmH2O, high PEEP in the absence of deleterious effect, pressure mode allowing spontaneous ventilation after the acute phase, and nitric oxide) corresponded to a level of proof that did not allow use of the GRADE classification and were expert opinions. Lastly, for three aspects of ARDS management (driving pressure, early spontaneous ventilation, and extracorporeal carbon dioxide removal), the experts concluded that no sound recommendation was possible given current knowledge. The recommendations and the therapeutic algorithm were approved by the experts with strong agreement.
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Affiliation(s)
- Laurent Papazian
- Service de Médecine Intensive - Réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France.
| | - Cécile Aubron
- Medical Intensive Care Unit, Centre Hospitalier Régional et Universitaire de Brest, site La Cavale Blanche, Bvd Tanguy Prigent, 29609, Brest Cedex, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Jean-Daniel Chiche
- Service de Médecine Intensive - Réanimation, Hôpital Cochin, Hôpitaux Universitaires Paris-Centre, Assistance Publique - Hôpitaux de Paris, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - Alain Combes
- Service de Réanimation, Institut de Cardiologie, Groupe Hospitalier Pitié- Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, boulevard de l'Hôpital, 75013, Paris, France
| | - Didier Dreyfuss
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 Rue des Renouillers, 92700, Colombes, France
| | - Jean-Marie Forel
- Service de Médecine Intensive - Réanimation, Hôpital Nord, Chemin des Bourrely, 13015, Marseille, France
| | - Claude Guérin
- Service de Réanimation Médicale, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France
| | - Samir Jaber
- Department of Anesthesiology and Intensive Care (DAR B), Saint Eloi University Hospital, Montpellier, France
| | - Armand Mekontso-Dessap
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri-Mondor, AP-HP, DHU A-TVB, 94010, Créteil, France
| | - Alain Mercat
- Medical Intensive Care Department, Angers University Hospital, 4, rue Larrey, 49933, Angers Cedex, France
| | | | - Damien Roux
- Intensive Care Unit, Louis Mourier Hospital, AP-HP, 178 Rue des Renouillers, 92700, Colombes, France
| | | | - Henri Faure
- Service de Médecine Intensive - Réanimation, Centre Hospitalier Intercommunal Robert Ballanger, 93602, Aulnay-sous-Bois, France
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Alonso-Iñigo JM, Fas MJ, Albert A, Dolz A, Carratalá JM, Díaz-Lobato S. Effects on Humidification and Ventilatory Parameters of Three Single-limb Heated-wired Circuits for Non-invasive Ventilation: A Bench Study. Arch Bronconeumol 2019; 56:28-34. [PMID: 31164282 DOI: 10.1016/j.arbres.2019.04.011] [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: 11/26/2018] [Revised: 04/12/2019] [Accepted: 04/16/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The objective of this study was to evaluate the effects of three single-limb heated wired circuits (SLHWC) for NIV, on ventilatory parameters and humidification performance in a simulation lung model. METHODS Three SLHWC compatible with the MR-850 Heated Humidifier (HH) (Fisher & Paykel, Auckland, New Zealand) were tested: RT-319 (FP) (Fisher & Paykel, Auckland, New Zealand), Respironics 1045770 (RP) (DEAS, Castel Bolognese, Italy) and Intersurgical B/SYS 5809001 (IT) (Intersurgical, Wokingham, UK). A Bipap Vision ventilator (Philips Respironics, Murrysville, PA, USA) in pressure control ventilation (PCV) connected to a test lung was used for simulation. Each SHWC performance was evaluated in four ventilatory conditions: IPAP of 15cmH2O with FiO2 0.3 and 1, respectively; and, IPAP of 25cmH2O with FiO2 0.3 and 1, respectively. EPAP was set at 5cmH2O. Hygrometric and ventilatory measurements including: relative humidity (RH), temperature (T), Pplat, PIP, PEEP, peak inspiratory flow (PIF), and tidal volume (Vt) were measured. RESULTS In each FiO2 group absolute humidity (AH) was similar with FP regardless of the IPAP level employed compared to IT and RP (P<.001). Except for RP at FiO2 0.3, AH increased significantly in IT and RP groups as IPAP increased (P<.001). PIP, Pplat, PEEP, PIF, and Vt values were significantly higher with FP and RP in each FiO2 group compared to IT (P<.001). CONCLUSIONS Humidification performance varied significantly among the three circuits, being FP the only one able to maintain stable AH values during the study with no influence on ventilatory parameters.
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Affiliation(s)
- Jose M Alonso-Iñigo
- Department of Anesthesiology, Critical Care and Pain Medicine, Hospital Universitari i Politècnic La Fe, Valencia, Spain.
| | - María J Fas
- Department of Hospital Managing, Hospital de Manises, Manises, Valencia, Spain
| | - Alejandro Albert
- Emergency Department, Hospital General Universitario de Alicante, Alicante, Spain
| | - Abel Dolz
- Emergency Department, Hospital de Sagunto, Sagunto, Valencia, Spain
| | - José M Carratalá
- Short-stay Medical Unit, Emergency Department, Hospital General Universitario de Alicante, Alicante, Spain
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178
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Sousa MLDA, Magrans R, Hayashi FK, Blanch L, Kacmarek RM, Ferreira JC. EPISYNC study: predictors of patient-ventilator asynchrony in a prospective cohort of patients under invasive mechanical ventilation - study protocol. BMJ Open 2019; 9:e028601. [PMID: 31123002 PMCID: PMC6537972 DOI: 10.1136/bmjopen-2018-028601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Patient-ventilator asynchrony is common during the entire period of invasive mechanical ventilation (MV) and is associated with worse clinical outcomes. However, risk factors associated with asynchrony are not completely understood. The main objectives of this study are to estimate the incidence of asynchrony during invasive MV and its association with respiratory mechanics and other baseline patient characteristics. METHODS AND ANALYSIS We designed a prospective cohort study of patients admitted to the intensive care unit (ICU) of a university hospital. Inclusion criteria are adult patients under invasive MV initiated for less than 72 hours, and with expectation of remaining under MV for more than 24 hours. Exclusion criteria are high flow bronchopleural fistula, inability to measure respiratory mechanics and previous tracheostomy. Baseline assessment includes clinical characteristics of patients at ICU admission, including severity of illness, reason for initiation of MV, and measurement of static mechanics of the respiratory system. We will capture ventilator waveforms during the entire MV period that will be analysed with dedicated software (Better Care, Barcelona, Spain), which automatically identifies several types of asynchrony and calculates the asynchrony index (AI). We will use a linear regression model to identify risk factors associated with AI. To assess the relationship between survival and AI we will use Kaplan-Meier curves, log rank tests and Cox regression. The calculated sample size is 103 patients. The statistical analysis will be performed by the software R Programming (www.R-project.org) and will be considered statistically significant if the p value is less than 0.05. ETHICS AND DISSEMINATION The study was approved by the Ethics Committee of Instituto do Coração, School of Medicine, University of São Paulo, Brazil, and informed consent was waived due to the observational nature of the study. We aim to disseminate the study findings through peer-reviewed publications and national and international conference presentations. TRIAL REGISTRATION NUMBER NCT02687802; Pre-results.
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Affiliation(s)
- Mayson Laercio de Araujo Sousa
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina Universidade de Sao Paulo, Sao Paulo, Brazil
- Serviço de Fisioterapia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina Universidade de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Rudys Magrans
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Sabadell, Spain
| | - Fátima K Hayashi
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina Universidade de Sao Paulo, Sao Paulo, Brazil
- Serviço de Fisioterapia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina Universidade de Sao Paulo, Sao Paulo, Sao Paulo, Brazil
| | - Lluis Blanch
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Sabadell, Spain
| | - R M Kacmarek
- Department of Respiratory Care, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Anesthesiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Juliana C Ferreira
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina Universidade de Sao Paulo, Sao Paulo, Brazil
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Costamagna A, Fanelli V. Assisted mode of mechanical ventilation: choose wisely. Minerva Anestesiol 2019; 85:814-815. [PMID: 31064172 DOI: 10.23736/s0375-9393.19.13706-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Andrea Costamagna
- Department of Anesthesia and Critical Care, Città della Salute e della Scienza, Turin, Italy
| | - Vito Fanelli
- Department of Anesthesia and Critical Care, Città della Salute e della Scienza, Turin, Italy - .,Department of Surgical Science, University of Turin, Turin, Italy
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180
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Ruiz Ferrón F, Serrano Simón J. La monitorización convencional no es suficiente para valorar el esfuerzo respiratorio durante la ventilación asistida. Med Intensiva 2019; 43:197-206. [DOI: 10.1016/j.medin.2018.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 01/25/2018] [Accepted: 02/14/2018] [Indexed: 12/28/2022]
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Abstract
PURPOSE OF REVIEW Esophageal manometry has shown its usefulness to estimate transpulmonary pressure, that is lung stress, and the intensity of spontaneous effort in patients with acute respiratory distress syndrome. However, clinical uptake of esophageal manometry in ICU is still low. Thus, the purpose of review is to describe technical tips to adequately measure esophageal pressure at the bedside, and then update the most important clinical applications of esophageal manometry in ICU. RECENT FINDINGS Each esophageal balloon has its own nonstressed volume and it should be calibrated properly to measure pleural pressure accurately: transpulmonary pressure calculated on absolute esophageal pressure reflects values in the lung regions adjacent to the esophageal balloon (i.e. dependent to middle lung). Inspiratory transpulmonary pressure calculated from airway plateau pressure and the chest wall to respiratory system elastance ratio reasonably reflects lung stress in the nondependent 'baby' lung, at highest risk of hyperinflation. Also esophageal pressure can be used to detect and minimize patient self-inflicted lung injury. SUMMARY Esophageal manometry is not a complicated technique. There is a large potential to improve clinical outcome in patients with acute respiratory distress syndrome, acting as an early detector of risk of lung injury from mechanical ventilation and vigorous spontaneous effort.
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182
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Redmond DP, Chiew YS, Major V, Chase JG. Evaluation of model-based methods in estimating respiratory mechanics in the presence of variable patient effort. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 171:67-79. [PMID: 27697371 DOI: 10.1016/j.cmpb.2016.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 08/11/2016] [Accepted: 09/14/2016] [Indexed: 06/06/2023]
Abstract
Monitoring of respiratory mechanics is required for guiding patient-specific mechanical ventilation settings in critical care. Many models of respiratory mechanics perform poorly in the presence of variable patient effort. Typical modelling approaches either attempt to mitigate the effect of the patient effort on the airway pressure waveforms, or attempt to capture the size and shape of the patient effort. This work analyses a range of methods to identify respiratory mechanics in volume controlled ventilation modes when there is patient effort. The models are compared using 4 Datasets, each with a sample of 30 breaths before, and 2-3 minutes after sedation has been administered. The sedation will reduce patient efforts, but the underlying pulmonary mechanical properties are unlikely to change during this short time. Model identified parameters from breathing cycles with patient effort are compared to breathing cycles that do not have patient effort. All models have advantages and disadvantages, so model selection may be specific to the respiratory mechanics application. However, in general, the combined method of iterative interpolative pressure reconstruction, and stacking multiple consecutive breaths together has the best performance over the Dataset. The variability of identified elastance when there is patient effort is the lowest with this method, and there is little systematic offset in identified mechanics when sedation is administered.
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Affiliation(s)
- Daniel P Redmond
- Centre for Bioengineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand.
| | - Yeong Shiong Chiew
- Centre for Bioengineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand; School of Engineering, Monash University Malaysia, Jalan Lagoon Selatan, Bandar Sunway, Subang Jaya, Selangor 47500, Malaysia.
| | - Vincent Major
- Centre for Bioengineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand.
| | - J Geoffrey Chase
- Centre for Bioengineering, University of Canterbury, Private Bag 4800, Christchurch, New Zealand.
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183
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Hannan LM, Rautela L, Berlowitz DJ, McDonald C, Cori JM, Sheers N, Chao C, O'Donoghue FJ, Howard ME. Randomised controlled trial of polysomnographic titration of noninvasive ventilation. Eur Respir J 2019; 53:13993003.02118-2018. [DOI: 10.1183/13993003.02118-2018] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 03/03/2019] [Indexed: 12/23/2022]
Abstract
Noninvasive ventilation (NIV) settings determined during wakefulness may produce patient–ventilator asynchrony (PVA) during sleep, causing sleep disruption and limiting tolerance. This study investigated whether NIV titrated with polysomnography (PSG) is associated with less PVA and sleep disruption than therapy titrated during daytime alone.Treatment-naive individuals referred for NIV were randomised to control (daytime titration followed by sham polysomnographic titration) or PSG (daytime titration followed by polysomnographic titration) groups. Primary outcomes were PVA and arousal indices on PSG at 10 weeks. Secondary outcomes included adherence, gas exchange, symptoms and health-related quality of life (HRQoL).In total, 60 participants were randomised. Most (88.3%) had a neuromuscular disorder and respiratory muscle weakness but minor derangements in daytime arterial blood gases. PVA events were less frequent in those undergoing polysomnographic titration (median (interquartile range (IQR)): PSG 25.7 (12–68) events·h−1versuscontrol 41.0 (28–182) events·h−1; p=0.046), but arousals were not significantly different (median (IQR): PSG 11.4 (9–19) arousals·h−1versuscontrol 14.6 (11–19) arousals·h−1; p=0.258). Overall adherence was not different except in those with poor early adherence (<4 h·day−1) who increased their use after polysomnographic titration (mean difference: PSG 95 (95% CI 29–161) min·day−1versuscontrol −23 (95% CI −86–39) min·day−1; p=0.01). Arterial carbon dioxide tension, somnolence and sleep quality improved in both groups. There were no differences in nocturnal gas exchange or overall measures of HRQoL.NIV titrated with PSG is associated with less PVA but not less sleep disruption when compared with therapy titrated during daytime alone.
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Carteaux G, Perier F, Maraffi T, Razazi K, De Prost N, Mekontso Dessap A. Patient self-inflicted lung injury : ce que le réanimateur doit connaître. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Bruni A, Garofalo E, Pelaia C, Messina A, Cammarota G, Murabito P, Corrado S, Vetrugno L, Longhini F, Navalesi P. Patient-ventilator asynchrony in adult critically ill patients. Minerva Anestesiol 2019; 85:676-688. [PMID: 30762325 DOI: 10.23736/s0375-9393.19.13436-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Patient-ventilator asynchrony is considered a major clinical problem for mechanically ventilated patients. It occurs during partial ventilatory support, when the respiratory muscles and the ventilator interact to contribute generating the volume output. In this review article, we consider all studies published on patient-ventilator asynchrony in the last 25 years. EVIDENCE ACQUISITION We selected 62 studies. The different forms of asynchrony are first defined and classified. We also describe the methods used for detecting and quantifying asynchronies. We then outline the outcome variables considered for evaluating the clinical consequences of asynchronies. The methodology for detection and quantification of patient-ventilator asynchrony are quite heterogeneous. In particular, the Asynchrony Index is calculated differently among studies. EVIDENCE SYNTHESIS Sixteen studies established some relationship between asynchronies and one or more clinical outcomes, such as duration of mechanical ventilation (seven studies), mortality (five studies), length of intensive care and hospital stay (four studies), patient comfort (four studies), quality of sleep (three studies), and rate of tracheotomy (three studies). In patients with severe patient-ventilator asynchrony, four of seven studies (57%) report prolonged duration of mechanical ventilation, one of five (20%) increased mortality, one of four (25%) longer intensive care and hospital lengths of stay, four of four (100%) worsened comfort, three of four (75%) deteriorated quality of sleep, and one of three (33%) increased rate of tracheotomy. CONCLUSIONS Given the varying outcomes considered and the erratic results, it remains unclear whether asynchronies really affects patient outcome, and the relationship between asynchronies and outcome is causative or associative.
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Affiliation(s)
- Andrea Bruni
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Eugenio Garofalo
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Corrado Pelaia
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | | | - Gianmaria Cammarota
- Unit of Anesthesia and Intensive Care, "Maggiore della Carità" Hospital, Novara, Italy
| | - Paolo Murabito
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", "G. Rodolico" University Policlinic, University of Catania, Catania, Italy
| | - Silvia Corrado
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Luigi Vetrugno
- Department of Anesthesia and Intensive Care, University of Udine, Udine, Italy
| | - Federico Longhini
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy -
| | - Paolo Navalesi
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
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Koutsoukou A, Pecchiari M. Expiratory flow-limitation in mechanically ventilated patients: A risk for ventilator-induced lung injury? World J Crit Care Med 2019; 8:1-8. [PMID: 30697515 PMCID: PMC6347666 DOI: 10.5492/wjccm.v8.i1.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/24/2018] [Accepted: 10/17/2018] [Indexed: 02/06/2023] Open
Abstract
Expiratory flow limitation (EFL), that is the inability of expiratory flow to increase in spite of an increase of the driving pressure, is a common and unrecognized occurrence during mechanical ventilation in a variety of intensive care unit conditions. Recent evidence suggests that the presence of EFL is associated with an increase in mortality, at least in acute respiratory distress syndrome (ARDS) patients, and in pulmonary complications in patients undergoing surgery. EFL is a major cause of intrinsic positive end-expiratory pressure (PEEPi), which in ARDS patients is heterogeneously distributed, with a consequent increase of ventilation/perfusion mismatch and reduction of arterial oxygenation. Airway collapse is frequently concomitant to the presence of EFL. When airways close and reopen during tidal ventilation, abnormally high stresses are generated that can damage the bronchiolar epithelium and uncouple small airways from the alveolar septa, possibly generating the small airways abnormalities detected at autopsy in ARDS. Finally, the high stresses and airway distortion generated downstream the choke points may contribute to parenchymal injury, but this possibility is still unproven. PEEP application can abolish EFL, decrease PEEPi heterogeneity, and limit recruitment/derecruitment. Whether increasing PEEP up to EFL disappearance is a useful criterion for PEEP titration can only be determined by future studies.
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Affiliation(s)
- Antonia Koutsoukou
- ICU, 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens Medical School, Athens 11527, Greece
| | - Matteo Pecchiari
- Dipartimento di Fisiopatologia e dei Trapianti, Università degli Studi di Milano, Milan 20133, Italy
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187
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Duan J, Tang X, Huang S, Jia J, Guo S. A Pilot Study of Short-Term High-Pressure Support Ventilation in Persistent Sudden-Onset Rapid Breathing. Anaesth Intensive Care 2019. [PMID: 23194206 DOI: 10.1177/0310057x1204000608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- J. Duan
- Department of Respiratory Medicine, First Affiliated Hospital, Chongqing Medical University, Chongqing, P. R. China
| | - X. Tang
- Department of Respiratory Medicine, First Affiliated Hospital, Chongqing Medical University, Chongqing, P. R. China
| | - S. Huang
- Department of Respiratory Medicine, First Affiliated Hospital, Chongqing Medical University, Chongqing, P. R. China
| | - J. Jia
- Department of Respiratory Medicine, First Affiliated Hospital, Chongqing Medical University, Chongqing, P. R. China
| | - S. Guo
- Department of Respiratory Medicine, First Affiliated Hospital, Chongqing Medical University, Chongqing, P. R. China
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Lamouret O, Crognier L, Vardon Bounes F, Conil JM, Dilasser C, Raimondi T, Ruiz S, Rouget A, Delmas C, Seguin T, Minville V, Georges B. Neurally adjusted ventilatory assist (NAVA) versus pressure support ventilation: patient-ventilator interaction during invasive ventilation delivered by tracheostomy. Crit Care 2019; 23:2. [PMID: 30616669 PMCID: PMC6323755 DOI: 10.1186/s13054-018-2288-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prolonged weaning is a major issue in intensive care patients and tracheostomy is one of the last resort options. Optimized patient-ventilator interaction is essential to weaning. The purpose of this study was to compare patient-ventilator synchrony between pressure support ventilation (PSV) and neurally adjusted ventilatory assist (NAVA) in a selected population of tracheostomised patients. METHODS We performed a prospective, sequential, non-randomized and single-centre study. Two recording periods of 60 min of airway pressure, flow, and electrical activity of the diaphragm during PSV and NAVA were recorded in a random assignment and eight periods of 1 min were analysed for each mode. We searched for macro-asynchronies (ineffective, double, and auto-triggering) and micro-asynchronies (inspiratory trigger delay, premature, and late cycling). The number and type of asynchrony events per minute and asynchrony index (AI) were determined. The two respiratory phases were compared using the non-parametric Wilcoxon test after testing the equality of the two variances (F-Test). RESULTS Among the 61 patients analysed, the total AI was lower in NAVA than in PSV mode: 2.1% vs 14% (p < 0.0001). This was mainly due to a decrease in the micro-asynchronies index: 0.35% vs 9.8% (p < 0.0001). The occurrence of macro-asynchronies was similar in both ventilator modes except for double triggering, which increased in NAVA. The tidal volume (ml/kg) was lower in NAVA than in PSV (5.8 vs 6.2, p < 0.001), and the respiratory rate was higher in NAVA than in PSV (28 vs 26, p < 0.05). CONCLUSION NAVA appears to be a promising ventilator mode in tracheotomised patients, especially for those requiring prolonged weaning due to the decrease in asynchronies.
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Affiliation(s)
- Olivier Lamouret
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France. .,Department of Anaesthesiology and Critical Care Unit, University Hospital of Toulouse, 31059, Toulouse Cedex 9, France.
| | - Laure Crognier
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Fanny Vardon Bounes
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Jean-Marie Conil
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Caroline Dilasser
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Thibaut Raimondi
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Stephanie Ruiz
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Antoine Rouget
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Clément Delmas
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Thierry Seguin
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Vincent Minville
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Bernard Georges
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
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189
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Kataoka J, Kuriyama A, Norisue Y, Fujitani S. Proportional modes versus pressure support ventilation: a systematic review and meta-analysis. Ann Intensive Care 2018; 8:123. [PMID: 30535648 PMCID: PMC6288104 DOI: 10.1186/s13613-018-0470-y] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/04/2018] [Indexed: 12/29/2022] Open
Abstract
Background Proportional modes (proportional assist ventilation, PAV, and neurally adjusted ventilatory assist, NAVA) could improve patient–ventilator interaction and consequently may be efficient as a weaning mode. The purpose of this systematic review is to examine whether proportional modes improved patient–ventilator interaction and whether they had an impact on the weaning success and length of mechanical ventilation, in comparison with PSV.
Methods We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception through May 13, 2018. We included both parallel-group and crossover randomized studies that examined the efficacy of proportional modes in comparison with PSV in mechanically ventilated adults. The primary outcomes were (1) asynchrony index (AI), (2) weaning failure, and (3) duration of mechanical ventilation. Results We included 15 studies (four evaluated PAV, ten evaluated NAVA, and one evaluated both modes). Although the use of proportional modes was not associated with a reduction in AI (WMD − 1.43; 95% CI − 3.11 to 0.25; p = 0.096; PAV—one study, and NAVA—seven studies), the use of proportional modes was associated with a reduction in patients with AI > 10% (RR 0.15; 95% CI 0.04–0.58; p = 0.006; PAV—two studies, and NAVA—five studies), compared with PSV. There was a significant heterogeneity among studies for AI, especially with NAVA. Compared with PSV, use of proportional modes was associated with a reduction in weaning failure (RR 0.44; 95% CI 0.26–0.75; p = 0.003; PAV—three studies) and duration of mechanical ventilation (WMD − 1.78 days; 95% CI − 3.24 to − 0.32; p = 0.017; PAV—three studies, and NAVA—two studies). Reduced duration of mechanical ventilation was found with PAV but not with NAVA. Conclusion The use of proportional modes was associated with a reduction in the incidence with AI > 10%, weaning failure and duration of mechanical ventilation, compared with PSV. However, reduced weaning failure and duration of mechanical ventilation were found with only PAV. Due to a significant heterogeneity among studies and an insufficient number of studies, further investigation seems warranted to better understand the impact of proportional modes. Clinical trial registration PROSPERO registration number, CRD42017059791. Registered 20 March 2017 Electronic supplementary material The online version of this article (10.1186/s13613-018-0470-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jun Kataoka
- Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu, 2790001, Japan.
| | - Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama, 7108602, Japan
| | - Yasuhiro Norisue
- Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu, 2790001, Japan
| | - Shigeki Fujitani
- Department of Emergency Medicine and Critical Care Medicine, St. Marianna University, 2-16-1 Sugao, Miyamae-ku, Kawasaki, 2168511, Japan
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190
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Bulleri E, Fusi C, Bambi S, Pisani L. Patient-ventilator asynchronies: types, outcomes and nursing detection skills. ACTA BIO-MEDICA : ATENEI PARMENSIS 2018; 89:6-18. [PMID: 30539927 PMCID: PMC6502136 DOI: 10.23750/abm.v89i7-s.7737] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 10/05/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Mechanical ventilation is often employed as partial ventilatory support where both the patient and the ventilator work together. The ventilator settings should be adjusted to maintain a harmonious patient-ventilator interaction. However, this balance is often altered by many factors able to generate a patient ventilator asynchrony (PVA). The aims of this review were: to identify PVAs, their typologies and classifications; to describe how and to what extent their occurrence can affect the patients' outcomes; to investigate the levels of nursing skill in detecting PVAs. METHODS Literature review performed on Cochrane Library, Medline and CINAHL databases. RESULTS 1610 records were identified; 43 records were included after double blind screening. PVAs have been classified with respect to the phase of the respiratory cycle or based on the circumstance of occurrence. There is agreement on the existence of 7 types of PVAs: ineffective effort, double trigger, premature cycling, delayed cycling, reverse triggering, flow starvation and auto-cycling. PVAs can be identified through the ventilator graphics monitoring of pressure and flow waveforms. The influence on patient outcomes varies greatly among studies but PVAs are mostly associated with poorer outcomes. Adequately trained nurses can learn and retain how to correctly detect PVAs. CONCLUSIONS Since its challenging interpretation and the potential advantages of its implementation, ventilator graphics monitoring can be classified as an advanced competence for ICU nurses. The knowledge and skills to adequately manage PVAs should be provided by specific post-graduate university courses.
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191
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Marchuk Y, Magrans R, Sales B, Montanya J, López-Aguilar J, de Haro C, Gomà G, Subirà C, Fernández R, Kacmarek RM, Blanch L. Predicting Patient-ventilator Asynchronies with Hidden Markov Models. Sci Rep 2018; 8:17614. [PMID: 30514876 PMCID: PMC6279839 DOI: 10.1038/s41598-018-36011-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 11/12/2018] [Indexed: 01/31/2023] Open
Abstract
In mechanical ventilation, it is paramount to ensure the patient's ventilatory demand is met while minimizing asynchronies. We aimed to develop a model to predict the likelihood of asynchronies occurring. We analyzed 10,409,357 breaths from 51 critically ill patients who underwent mechanical ventilation >24 h. Patients were continuously monitored and common asynchronies were identified and regularly indexed. Based on discrete time-series data representing the total count of asynchronies, we defined four states or levels of risk of asynchronies, z1 (very-low-risk) - z4 (very-high-risk). A Poisson hidden Markov model was used to predict the probability of each level of risk occurring in the next period. Long periods with very few asynchronous events, and consequently very-low-risk, were more likely than periods with many events (state z4). States were persistent; large shifts of states were uncommon and most switches were to neighbouring states. Thus, patients entering states with a high number of asynchronies were very likely to continue in that state, which may have serious implications. This novel approach to dealing with patient-ventilator asynchrony is a first step in developing smart alarms to alert professionals to patients entering high-risk states so they can consider actions to improve patient-ventilator interaction.
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Affiliation(s)
| | - Rudys Magrans
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
| | | | | | - Josefina López-Aguilar
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Candelaria de Haro
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Gemma Gomà
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Carles Subirà
- Intensive Care Unit, Fundació Althaia, Universitat Internacional de Catalunya, Manresa, Spain
| | - Rafael Fernández
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Intensive Care Unit, Fundació Althaia, Universitat Internacional de Catalunya, Manresa, Spain
| | - Robert M Kacmarek
- Department of Respiratory Care, Department of Anesthesiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lluis Blanch
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí, Universitat Autònoma de Barcelona, Sabadell, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
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192
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Grieco DL, Bitondo MM, Aguirre-Bermeo H, Italiano S, Idone FA, Moccaldo A, Santantonio MT, Eleuteri D, Antonelli M, Mancebo J, Maggiore SM. Patient-ventilator interaction with conventional and automated management of pressure support during difficult weaning from mechanical ventilation. J Crit Care 2018; 48:203-210. [DOI: 10.1016/j.jcrc.2018.08.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 08/27/2018] [Accepted: 08/29/2018] [Indexed: 12/21/2022]
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193
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Schreiber A, Bertoni M, Goligher EC. Avoiding Respiratory and Peripheral Muscle Injury During Mechanical Ventilation: Diaphragm-Protective Ventilation and Early Mobilization. Crit Care Clin 2018; 34:357-381. [PMID: 29907270 DOI: 10.1016/j.ccc.2018.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Both limb muscle weakness and respiratory muscle weakness are exceedingly common in critically ill patients. Respiratory muscle weakness prolongs ventilator dependence, predisposing to nosocomial complications and death. Limb muscle weakness persists for months after discharge from intensive care and results in poor long-term functional status and quality of life. Major mechanisms of muscle injury include critical illness polymyoneuropathy, sepsis, pharmacologic exposures, metabolic derangements, and excessive muscle loading and unloading. The diaphragm may become weak because of excessive unloading (leading to atrophy) or because of excessive loading (either concentric or eccentric) owing to insufficient ventilator assistance.
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Affiliation(s)
- Annia Schreiber
- Respiratory Intensive Care Unit and Pulmonary Rehabilitation Unit, Istituti Clinici Scientifici Maugeri, Scientific Institute of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy
| | - Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Spedali Civili 1, Brescia 25123, Italy
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto General Hospital, 585 University Avenue, Peter Munk Building, 11th Floor Room 192, Toronto, ON M5G 2N2, Canada.
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194
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Aarrestad S, Qvarfort M, Kleiven AL, Tollefsen E, Skjønsberg OH, Janssens JP. Diagnostic accuracy of simple tools in monitoring patients with chronic hypoventilation treated with non-invasive ventilation; a prospective cross-sectional study. Respir Med 2018; 144:30-35. [DOI: 10.1016/j.rmed.2018.09.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 09/24/2018] [Accepted: 09/25/2018] [Indexed: 12/14/2022]
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195
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Yoshida T, Nakamura MAM, Morais CCA, Amato MBP, Kavanagh BP. Reverse Triggering Causes an Injurious Inflation Pattern during Mechanical Ventilation. Am J Respir Crit Care Med 2018; 198:1096-1099. [DOI: 10.1164/rccm.201804-0649le] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Takeshi Yoshida
- St. Michael's HospitalToronto, Ontario, Canadaand
- University of TorontoToronto, Ontario, Canada
| | | | | | | | - Brian P. Kavanagh
- University of TorontoToronto, Ontario, Canada
- Hospital for Sick ChildrenToronto, Ontario, Canada
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196
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Weaning from Mechanical Ventilation in ARDS: Aspects to Think about for Better Understanding, Evaluation, and Management. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5423639. [PMID: 30402484 PMCID: PMC6198583 DOI: 10.1155/2018/5423639] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/22/2018] [Accepted: 08/26/2018] [Indexed: 12/14/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by severe inflammatory response and hypoxemia. The use of mechanical ventilation (MV) for correction of gas exchange can cause worsening of this inflammatory response, called “ventilator-induced lung injury” (VILI). The process of withdrawing mechanical ventilation, referred to as weaning from MV, may cause worsening of lung injury by spontaneous ventilation. Currently, there are few specific studies in patients with ARDS. Herein, we reviewed the main aspects of spontaneous ventilation and also discussed potential methods to predict the failure of weaning in this patient category. We also reviewed new treatments (modes of mechanical ventilation, neuromuscular blocker use, and extracorporeal membrane oxygenation) that could be considered in weaning ARDS patients from MV.
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197
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Sobral dos Santos S, Wanderley HV, Neto FBDL. Automatic Selector Between Cardiogenic Oscillation and Airway Secretion in Mechanical Ventilation Flow Signals Using Artificial Immune System. INTERNATIONAL JOURNAL OF SWARM INTELLIGENCE RESEARCH 2018. [DOI: 10.4018/ijsir.2018100104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The accumulation of secretions in the airways of ventilator-dependent patients is a common problem, and if not detected and treated in due time, it greatly increases the risk of infections and asynchrony. Unfortunately, cardiogenic oscillation modifies the flow signal shape that can confuse clinical staff and modern lung ventilators. In this article, the authors use an artificial immune system algorithm in a pre-processed flow signal. The authors' approach was able to automatically detect the presence or absence of airway secretions, even if the sample contains the influence of cardiogenic oscillation. The training and validation of the algorithm was carried out using a database containing flow signals of 457 respiratory cycles, obtained from three patients in different ventilation modes. The algorithm trained with 60% of the base cycles, was able to achieve specificity and sensitivity above 0.96 in the classification of the remaining cycles of the base.
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198
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He X, Luo XY, Chen GQ, Zhou JX. Detection of reverse triggering in a 55-year-old man under deep sedation and controlled mechanical ventilation. J Thorac Dis 2018; 10:E682-E685. [PMID: 30416816 DOI: 10.21037/jtd.2018.08.09] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Xuan He
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Xu-Ying Luo
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Guang-Qiang Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
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199
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200
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Ciorba C, Gonzalez-Bermejo J, Salva MAQ, Annane D, Orlikowski D, Lofaso F, Prigent H. Flow and airway pressure analysis for detecting ineffective effort during mechanical ventilation in neuromuscular patients. Chron Respir Dis 2018; 16:1479972318790267. [PMID: 30064272 PMCID: PMC6302971 DOI: 10.1177/1479972318790267] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Ineffective efforts (IEs) are among the most common types of patient–ventilator
asynchrony. The objective of this study is to validate IE detection during
expiration using pressure and flow signals, with respiratory effort detection by
esophageal pressure (Pes) measurement as the reference, in patients with
neuromuscular diseases (NMDs). We included 10 patients diagnosed with chronic
respiratory failure related to NMD. Twenty-eight 5-minute recordings of daytime
ventilation were studied for IE detection. Standard formulas were used to
calculate sensitivity, specificity, positive predictive value (PPV), and
negative predictive value (NPV) of IE detection using pressure and flow signals
compared to Pes measurement. Mean sensitivity and specificity of flow and
pressure signal-based IE detection versus Pes measurement were 97.5% ± 5.3% and
91.4% ± 13.7%, respectively. NPV was 98.1% ± 8.2% and PPV was 67.6% ± 33.8%.
Spearman’s rank correlation coefficient indicated a moderately significant
correlation between frequencies of IEs and controlled cycles (ρ
= 0.50 and p = 0.01). Among respiratory cycles, 311 (11.2%)
were false-positive IEs overall. Separating false-positive IEs according to
their mechanisms, we observed premature cycling in 1.2% of cycles, delayed
ventilator triggering in 0.1%, cardiac contraction in 9.2%, and upper airway
instability during expiration in 0.3%. Using flow and pressure signals to detect
IEs is a simple and rapid method that produces adequate data to support clinical
decisions.
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Affiliation(s)
- Cristina Ciorba
- 1 Service Physiologie et Explorations-Fonctionnelles, INSERM CIC 1429, AP-HP, Hôpital Raymond Poincaré, Garches, France
| | - Jesus Gonzalez-Bermejo
- 2 Service de Pneumologie et Réanimation Médicale ( Département " R3S"), INSERM UMRS1158, AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris, France
| | - Maria-Antonia Quera Salva
- 1 Service Physiologie et Explorations-Fonctionnelles, INSERM CIC 1429, AP-HP, Hôpital Raymond Poincaré, Garches, France
| | - Djillali Annane
- 3 Service de Réanimation médicale et unité de ventilation à domicile, INSERM CIC 1429, AP-HP, Hôpital Raymond Poincaré, Garches, France
| | - David Orlikowski
- 3 Service de Réanimation médicale et unité de ventilation à domicile, INSERM CIC 1429, AP-HP, Hôpital Raymond Poincaré, Garches, France.,4 INSERM U 1179, Hôpital Raymond Poincaré, Université de Versailles Saint-Quentin-en-Yvelines, Garches, France
| | - Frédéric Lofaso
- 1 Service Physiologie et Explorations-Fonctionnelles, INSERM CIC 1429, AP-HP, Hôpital Raymond Poincaré, Garches, France.,4 INSERM U 1179, Hôpital Raymond Poincaré, Université de Versailles Saint-Quentin-en-Yvelines, Garches, France
| | - Hélène Prigent
- 1 Service Physiologie et Explorations-Fonctionnelles, INSERM CIC 1429, AP-HP, Hôpital Raymond Poincaré, Garches, France.,4 INSERM U 1179, Hôpital Raymond Poincaré, Université de Versailles Saint-Quentin-en-Yvelines, Garches, France
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