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Sánchez Romero EA, Alonso Pérez JL, Vinuesa Suárez I, Corbellini C, Villafañe JH. Spanish experience on the efficacy of airways clearance techniques in SARS-CoV-2 (COVID-19) at intensive care unit: An editorial and case report. SAGE Open Med Case Rep 2022; 10:2050313X221112507. [PMID: 35875169 PMCID: PMC9297451 DOI: 10.1177/2050313x221112507] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 06/22/2022] [Indexed: 12/29/2022] Open
Abstract
COVID-19 pandemic did not impact all countries in the same way, and in Spain, the percentage of intensive care unit (ICU) and the mortality rate patients has been very high. The present work aims to present the first case of the new Coronavirus-2019 (COVID-19) on March 23, 2020, in Tenerife, Canary Islands, Spain, of a patient on Invasive Mechanical Ventilation (IMV) affected by acute pneumonia which was treated by airway clearance techniques (ACT) thinking that she was not infected with COVID-19, since the first polymerase chain reaction (PCR) test was negative. The subject presented septic shock, hypoxemic encephalopathy, and seizures. Right lung base consolidation and pleural effusion were visible in the echography. The thorax x-ray presented subcutaneous emphysema and pleural effusion in the right base and an alveolar-interstitial opacity pattern in the left. Bilateral crackles and rhonchus were evident in the right lung during the lung auscultation. The airway clearance protocol comprises Cough Assist (CA) and chest compressions. The variables collected were the ventilatory parameters, blood gas analysis, and thorax x-ray description. ACT protocol improves gas exchange and expands consolidated lung areas in this atypical clinical case presented. At that time, this type of treatment was not performed on patients affected by COVID-19, and the next day we found that the patient had improved, coinciding with the second PCR test, which was positive.
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Affiliation(s)
- Eleuterio A Sánchez Romero
- Musculoskeletal Pain and Motor Control Research Group, Faculty of Sport Sciences, Universidad Europea de Madrid, Madrid, Spain.,Department of Physiotherapy, Faculty of Sport Sciences, Universidad Europea de Madrid, Madrid, Spain.,Musculoskeletal Pain and Motor Control Research Group, Faculty of Health Sciences, Universidad Europea de Canarias, Tenerife, Spain.,Department of Physiotherapy, Faculty of Health Sciences, Universidad Europea de Canarias, Tenerife, Spain
| | - José Luis Alonso Pérez
- Musculoskeletal Pain and Motor Control Research Group, Faculty of Sport Sciences, Universidad Europea de Madrid, Madrid, Spain.,Department of Physiotherapy, Faculty of Sport Sciences, Universidad Europea de Madrid, Madrid, Spain.,Musculoskeletal Pain and Motor Control Research Group, Faculty of Health Sciences, Universidad Europea de Canarias, Tenerife, Spain.,Department of Physiotherapy, Faculty of Health Sciences, Universidad Europea de Canarias, Tenerife, Spain.,Onelifecenter, Multidisciplinary Pain Treatment Center, Madrid, Spain
| | - Inmaculada Vinuesa Suárez
- Musculoskeletal Pain and Motor Control Research Group, Faculty of Sport Sciences, Universidad Europea de Madrid, Madrid, Spain.,Musculoskeletal Pain and Motor Control Research Group, Faculty of Health Sciences, Universidad Europea de Canarias, Tenerife, Spain.,Hospital Universitario Nuestra Señora de Candelaria, Tenerife, Spain
| | - Camilo Corbellini
- Department of Physiotherapy, LUNEX International University of Health, Exercise and Sports, Differdange, Luxembourg.,Casa di cura "Villa Serena," Piossasco, Italy
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Santa Cruz R, Villarejo F, Irrazabal C, Ciapponi A. High versus low positive end-expiratory pressure (PEEP) levels for mechanically ventilated adult patients with acute lung injury and acute respiratory distress syndrome. Cochrane Database Syst Rev 2021; 3:CD009098. [PMID: 33784416 PMCID: PMC8094163 DOI: 10.1002/14651858.cd009098.pub3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND In patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS), mortality remains high. These patients require mechanical ventilation, which has been associated with ventilator-induced lung injury. High levels of positive end-expiratory pressure (PEEP) could reduce this condition and improve patient survival. This is an updated version of the review first published in 2013. OBJECTIVES To assess the benefits and harms of high versus low levels of PEEP in adults with ALI and ARDS. SEARCH METHODS For our previous review, we searched databases from inception until 2013. For this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS, and the Web of Science from inception until May 2020. We also searched for ongoing trials (www.trialscentral.org; www.clinicaltrial.gov; www.controlled-trials.com), and we screened the reference lists of included studies. SELECTION CRITERIA We included randomised controlled trials that compared high versus low levels of PEEP in ALI and ARDS participants who were intubated and mechanically ventilated in intensive care for at least 24 hours. DATA COLLECTION AND ANALYSIS Two review authors assessed risk of bias and extracted data independently. We contacted investigators to identify additional published and unpublished studies. We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included four new studies (1343 participants) in this review update. In total, we included 10 studies (3851 participants). We found evidence of risk of bias in six studies, and the remaining studies fulfilled all criteria for low risk of bias. In eight studies (3703 participants), a comparison was made between high and low levels of PEEP, with the same tidal volume in both groups. In the remaining two studies (148 participants), the tidal volume was different between high- and low-level groups. In the main analysis, we assessed mortality occurring before hospital discharge only in studies that compared high versus low PEEP, with the same tidal volume in both groups. Evidence suggests that high PEEP may result in little to no difference in mortality compared to low PEEP (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.90 to 1.04; I² = 15%; 7 studies, 3640 participants; moderate-certainty evidence). In addition, high PEEP may result in little to no difference in barotrauma (RR 1.00, 95% CI 0.64 to 1.57; I² = 63%; 9 studies, 3791 participants; low-certainty evidence). High PEEP may improve oxygenation in patients up to the first and third days of mechanical ventilation (first day: mean difference (MD) 51.03, 95% CI 35.86 to 66.20; I² = 85%; 6 studies, 2594 participants; low-certainty evidence; third day: MD 50.32, 95% CI 34.92 to 65.72; I² = 83%; 6 studies, 2309 participants; low-certainty evidence) and probably improves oxygenation up to the seventh day (MD 28.52, 95% CI 20.82 to 36.21; I² = 0%; 5 studies, 1611 participants; moderate-certainty evidence). Evidence suggests that high PEEP results in little to no difference in the number of ventilator-free days (MD 0.45, 95% CI -2.02 to 2.92; I² = 81%; 3 studies, 1654 participants; low-certainty evidence). Available data were insufficient to pool the evidence for length of stay in the intensive care unit. AUTHORS' CONCLUSIONS Moderate-certainty evidence shows that high levels compared to low levels of PEEP do not reduce mortality before hospital discharge. Low-certainty evidence suggests that high levels of PEEP result in little to no difference in the risk of barotrauma. Low-certainty evidence also suggests that high levels of PEEP improve oxygenation up to the first and third days of mechanical ventilation, and moderate-certainty evidence indicates that high levels of PEEP improve oxygenation up to the seventh day of mechanical ventilation. As in our previous review, we found clinical heterogeneity - mainly within participant characteristics and methods of titrating PEEP - that does not allow us to draw definitive conclusions regarding the use of high levels of PEEP in patients with ALI and ARDS. Further studies should aim to determine the appropriate method of using high levels of PEEP and the advantages and disadvantages associated with high levels of PEEP in different ARDS and ALI patient populations.
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Affiliation(s)
- Roberto Santa Cruz
- Department of Intensive Care, Hospital Ramos Mejía, Ciudad Autónoma de Buenos Aires, Argentina
- School of Medicine, Universidad de Magallanes, Punta Arenas, Chile
| | - Fernando Villarejo
- Critical Care Unit, Hospital Nacional Posadas, El Palomar. Morón, Argentina
| | - Celica Irrazabal
- Hospital de Clínicas José de San Martín, Buenos Aires, Argentina
| | - Agustín Ciapponi
- Argentine Cochrane Centre, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires, Argentina
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Kung SC, Hung YL, Chen WL, Wang CM, Chang HC, Liu WL. Effects of Stepwise Lung Recruitment Maneuvers in Patients with Early Acute Respiratory Distress Syndrome: A Prospective, Randomized, Controlled Trial. J Clin Med 2019; 8:jcm8020231. [PMID: 30744214 PMCID: PMC6406466 DOI: 10.3390/jcm8020231] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 01/31/2019] [Accepted: 02/06/2019] [Indexed: 12/16/2022] Open
Abstract
Since the clinical benefit of lung recruitment maneuvers (LRMs) is still conflicting, we performed this prospective, randomized, controlled study to investigate whether LRMs should be used in the routine management of acute respiratory distress syndrome (ARDS). This trial was conducted in four intensive care units (ICUs) to compare application of a modified stepwise LRMs with solely lung-protective ventilation in patients with moderate to severe ARDS within 72 h from the onset. The primary outcome was 28-day mortality, and the secondary outcomes were ventilator-free days and ICU-free days. We collected data on 120 ARDS patients from 2009 to 2012, and there was no difference in 28-day mortality between the two groups (28.3% vs. 30.0%, p = 0.84). However, among survivors, patients in the LRM group had a significant longer median duration of ventilator-free days (18 vs. 13 days; p = 0.04) and ICU-free days (16 vs. 11 days; p = 0.03) at 28 days than in the control group. The respiratory system compliance was significantly higher in the LRM group from day 1 to day 7. The occurrence rate of barotrauma was similar in both groups. We concluded that LRMs combined with lung-protective ventilation in early ARDS may improve patient outcomes.
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Affiliation(s)
- Shu-Chen Kung
- Department of Respiratory Therapy, Chi Mei Medical Center, Liouying, Tainan 73657, Taiwan.
| | - Yi-Li Hung
- Department of Pediatrics, Cathay General Hospital, Taipei, Taiwan.
- School of Medicine, College of Medicine, Fu Jen Catholic University, Xinzhuang Dist., New Taipei City 24205, Taiwan (R.O.C).
| | - Wan-Ling Chen
- Department of Respiratory Therapy, Chi Mei Medical Center, Liouying, Tainan 73657, Taiwan.
| | - Ching-Min Wang
- Department of Internal Medicine, Chi Mei Medical Center, Liouying, Tainan 73657, Taiwan.
| | - Hui-Chun Chang
- Department of Respiratory Therapy, Chi Mei Medical Center, Liouying, Tainan 73657, Taiwan.
| | - Wei-Lun Liu
- School of Medicine, College of Medicine, Fu Jen Catholic University, Xinzhuang Dist., New Taipei City 24205, Taiwan (R.O.C).
- Division of Critical Care Medicine, Department of Emergency and Critical Care Medicine, Fu Jen Catholic University Hospital, Fu Jen Catholic University, New Taipei City 24352, Taiwan (R.O.C.).
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Voelker MT, Bergmann A, Busch T, Jahn N, Laudi S, Noreikat K, Simon P, Bercker S. The effects of hemoglobin glutamer-200 and iNO on pulmonary vascular tone and arterial oxygenation in an experimental acute respiratory distress syndrome. Pulm Pharmacol Ther 2018; 49:130-133. [DOI: 10.1016/j.pupt.2018.01.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 12/16/2017] [Accepted: 01/25/2018] [Indexed: 11/17/2022]
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Pépin JL, Timsit JF, Tamisier R, Borel JC, Lévy P, Jaber S. Prevention and care of respiratory failure in obese patients. THE LANCET RESPIRATORY MEDICINE 2017; 4:407-18. [PMID: 27304558 DOI: 10.1016/s2213-2600(16)00054-0] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/25/2016] [Accepted: 01/28/2016] [Indexed: 12/14/2022]
Abstract
With the increase in the global prevalence of obesity, there is a parallel rise in the proportion of obese patients admitted to intensive care units, referred for major surgery or requiring long-term non-invasive ventilation (NIV) at home for chronic respiratory failure. We describe the physiological effect of obesity on the respiratory system mainly in terms of respiratory mechanics, respiratory drive, and patency of the upper airways. Particular attention is given to the prevention and the clinical management of respiratory failure in obese patients with a main focus on invasive and NIV in intensive care during the perioperative period and long-term use of NIV on return home. We also address other aspects of care of obese patients, including antibiotic dosing and catheter-related infections.
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Affiliation(s)
- Jean Louis Pépin
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France.
| | - Jean François Timsit
- IAME, INSERM UMR 1137, Paris Diderot University, Paris, France; Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University and Bichat Hospital, Paris, France
| | - Renaud Tamisier
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean Christian Borel
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France
| | - Patrick Lévy
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France
| | - Samir Jaber
- Intensive Care Unit, Department of Anesthesia and Critical Care Medicine, University of Montpellier, Saint Eloi Teaching Hospital, Montpellier, France; Centre National de la Recherche Scientifique (CNRS 9214), Institut National de la Santé et de la Recherche Medicale (INSERM U-1046), Montpellier University, Montpellier, France
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Rello J, Valenzuela-Sánchez F, Ruiz-Rodriguez M, Moyano S. Sepsis: A Review of Advances in Management. Adv Ther 2017; 34:2393-2411. [PMID: 29022217 PMCID: PMC5702377 DOI: 10.1007/s12325-017-0622-8] [Citation(s) in RCA: 234] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Indexed: 12/28/2022]
Abstract
Infections represent a common health problem in people of all ages. Usually, the response given to them is appropriate and so little treatment is needed. Sometimes, however, the response to the infection is inadequate and may lead to organ dysfunction; this is the condition known as sepsis. Sepsis can be caused by bacteria, fungi or viruses and at present there is no specific treatment; its management basically focuses on containing the infection through source control and antibiotics plus organ function support. This article reviews key elements of sepsis management, focusing on diagnosis, biomarkers and therapy. The main recent advance in therapy is the strategy of personalized medicine, based on a precise approach using biomarkers to identify specific individuals who are likely to benefit from more personalized attention.
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Affiliation(s)
- Jordi Rello
- CIBERES, Vall d'Hebron Institut of Research, Barcelona, Spain.
| | | | | | - Silvia Moyano
- CIBERES, Vall d'Hebron Institut of Research, Barcelona, Spain
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Shosholcheva M, Јankulovski N, Kartalov A, Kuzmanovska B, Miladinova D. Synergistic Effect of Hyperoxia and Biotrauma On Ventilator-Induced Lung Injury. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2017; 38:91-96. [PMID: 28593896 DOI: 10.1515/prilozi-2017-0012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Patients undergoing mechanical ventilation in intensive care units (ICUs) may develop ventilator-induced lung injury (VILI). Beside the high tidal volume (Vt) and plateau pressure (Pplat), hyperoxia is supposed to precipitate lung injury. Oxygen toxicity is presumed to occur at levels of fraction of inspired oxygen (FiO2) exceeding 0.40. The exposure time to hyperoxia is certainly very important and patients who spend extended time on mechanical ventilation (MV) are probably more exposed to severe hyperoxic acute lung injury (HALI). Together, hyperoxia and biotrauma (release of cytokines) have a synergistic effect and can induce VILI. In the clinical practice, the reduction of FiO2 to safe levels through the appropriate use of the positive end expiratory pressure (PEEP) and the alignment of mean airway pressure is an appropriate goal. The strategy for lung protective ventilation must include setting up FiO2 to a safe level that is accomplished by using PaO2/FiO2 ratio with a lower limit of FiO2 to achieve acceptable levels of PaO2, which will be safe for the patient without local (lungs) or systemic inflammatory response. The protocol from the ARDS-net study is used for ventilator setup and adjustment. Cytokines (IL-1, IL-6, TNFα and MIP-2) that are involved in the inflammatory response are determined in order to help the therapeutic approach in counteracting HALI. Computed tomography findings reflect the pathological phases of the diffuse alveolar damage. At least preferably the lowest level of FiO2 should be used in order to provide full lung protection against the damage induced by MV.
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Affiliation(s)
- Mirjana Shosholcheva
- University Clinic of Surgery "Ss. Naum Ohridski", Medical Faculty, "Ss. Cyril and Methodius" University
| | - Nikola Јankulovski
- University Clinic for Abdominal Surgery, Medical Faculty, "Ss. Cyril and Methodius" University
| | - Andrijan Kartalov
- Clinic for Anesthesiology, Reanimatology and Intensive Care Unit, Medical Faculty, "Ss. Cyril and Methodius" University
| | - Biljana Kuzmanovska
- Clinic for Anesthesiology, Reanimatology and Intensive Care Unit, Medical Faculty, "Ss. Cyril and Methodius" University
| | - Daniela Miladinova
- Institute of Pathophysiology and Nuclear Medicine, Medical Faculty, "Ss. Cyril and Methodius" University
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8
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Postoperative Care of the Liver Transplant Recipient. ANESTHESIA AND PERIOPERATIVE CARE FOR ORGAN TRANSPLANTATION 2017. [PMCID: PMC7120127 DOI: 10.1007/978-1-4939-6377-5_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Hodgson C, Goligher EC, Young ME, Keating JL, Holland AE, Romero L, Bradley SJ, Tuxen D. Recruitment manoeuvres for adults with acute respiratory distress syndrome receiving mechanical ventilation. Cochrane Database Syst Rev 2016; 11:CD006667. [PMID: 27855477 PMCID: PMC6464835 DOI: 10.1002/14651858.cd006667.pub3] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Recruitment manoeuvres involve transient elevations in airway pressure applied during mechanical ventilation to open ('recruit') collapsed lung units and increase the number of alveoli participating in tidal ventilation. Recruitment manoeuvres are often used to treat patients in intensive care who have acute respiratory distress syndrome (ARDS), but the effect of this treatment on clinical outcomes has not been well established. This systematic review is an update of a Cochrane review originally published in 2009. OBJECTIVES Our primary objective was to determine the effects of recruitment manoeuvres on mortality in adults with acute respiratory distress syndrome.Our secondary objective was to determine, in the same population, the effects of recruitment manoeuvres on oxygenation and adverse events (e.g. rate of barotrauma). SEARCH METHODS For this updated review, we searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), Embase (OVID), the Cumulative Index to Nursing and Allied Health Literature (CINAHL, EBSCO), Latin American and Caribbean Health Sciences (LILACS) and the International Standard Randomized Controlled Trial Number (ISRCTN) registry from inception to August 2016. SELECTION CRITERIA We included randomized controlled trials (RCTs) of adults who were mechanically ventilated that compared recruitment manoeuvres versus standard care for patients given a diagnosis of ARDS. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. MAIN RESULTS Ten trials met the inclusion criteria for this review (n = 1658 participants). We found five trials to be at low risk of bias and five to be at moderate risk of bias. Six of the trials included recruitment manoeuvres as part of an open lung ventilation strategy that was different from control ventilation in aspects other than the recruitment manoeuvre (such as mode of ventilation, higher positive end-expiratory pressure (PEEP) titration and lower tidal volume or plateau pressure). Six studies reported mortality outcomes. Pooled data from five trials (1370 participants) showed a reduction in intensive care unit (ICU) mortality (risk ratio (RR) 0.83, 95% confidence interval (CI) 0.72 to 0.97, P = 0.02, low-quality evidence), pooled data from five trials (1450 participants) showed no difference in 28-day mortality (RR 0.86, 95% CI 0.74 to 1.01, P = 0.06, low-quality evidence) and pooled data from four trials (1313 participants) showed no difference in in-hospital mortality (RR 0.88, 95% CI 0.77 to 1.01, P = 0.07, low-quality evidence). Data revealed no differences in risk of barotrauma (RR 1.09, 95% CI 0.78 to 1.53, P = 0.60, seven studies, 1508 participants, moderate-quality evidence). AUTHORS' CONCLUSIONS We identified significant clinical heterogeneity in the 10 included trials. Results are based upon the findings of several (five) trials that included an "open lung ventilation strategy", whereby the intervention group differed from the control group in aspects other than the recruitment manoeuvre (including co-interventions such as higher PEEP, different modes of ventilation and higher plateau pressure), making interpretation of the results difficult. A ventilation strategy that included recruitment manoeuvres in participants with ARDS reduced intensive care unit mortality without increasing the risk of barotrauma but had no effect on 28-day and hospital mortality. We downgraded the quality of the evidence to low, as most of the included trials provided co-interventions as part of an open lung ventilation strategy, and this might have influenced results of the outcome.
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Affiliation(s)
- Carol Hodgson
- Monash UniversityAustralian and New Zealand Intensive Care Research Centre (ANZIC‐RC), Department of Epidemiology and Preventive MedicineMelbourneAustralia3181
- The Alfred HospitalDepartment of PhysiotherapyMelbourneAustralia
| | - Ewan C Goligher
- Toronto Western HospitalDepartment of Medicine, Division of Respirology, University Health Network2MCL‐411QTorontoONCanadaM5T 2S8
| | - Meredith E Young
- Monash UniversityAustralian and New Zealand Intensive Care Research Centre (ANZIC‐RC), Department of Epidemiology and Preventive MedicineMelbourneAustralia3181
| | - Jennifer L Keating
- Monash UniversityDepartment of PhysiotherapyPO Box 527MelbourneAustralia3199
| | - Anne E Holland
- School of Allied Health, Department of Rehabilitation, Nutrition and Sport, La Trobe UniversityDiscipline of PhysiotherapyMelbourneVictoriaAustralia3086
| | - Lorena Romero
- The Alfred HospitalThe Ian Potter Library55 Commercial RoadMelbourneVictoriaAustralia3000
| | - Scott J Bradley
- The Alfred HospitalDepartment of PhysiotherapyMelbourneAustralia
| | - David Tuxen
- The Alfred HospitalDepartment of Intensive CareCommercial RoadMelbourneAustralia3181
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Cho YJ, Moon JY, Shin ES, Kim JH, Jung H, Park SY, Kim HC, Sim YS, Rhee CK, Lim J, Lee SJ, Lee WY, Lee HJ, Kwak SH, Kang EK, Chung KS, Choi WI. Clinical Practice Guideline of Acute Respiratory Distress Syndrome. Tuberc Respir Dis (Seoul) 2016; 79:214-233. [PMID: 27790273 PMCID: PMC5077725 DOI: 10.4046/trd.2016.79.4.214] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 06/27/2016] [Accepted: 08/16/2016] [Indexed: 12/29/2022] Open
Abstract
There is no well-stated practical guideline for mechanically ventilated patients with or without acute respiratory distress syndrome (ARDS). We generate strong (1) and weak (2) grade of recommendations based on high (A), moderate (B) and low (C) grade in the quality of evidence. In patients with ARDS, we recommend low tidal volume ventilation (1A) and prone position if it is not contraindicated (1B) to reduce their mortality. However, we did not support high-frequency oscillatory ventilation (1B) and inhaled nitric oxide (1A) as a standard treatment. We also suggest high positive end-expiratory pressure (2B), extracorporeal membrane oxygenation as a rescue therapy (2C), and neuromuscular blockage for 48 hours after starting mechanical ventilation (2B). The application of recruitment maneuver may reduce mortality (2B), however, the use of systemic steroids cannot reduce mortality (2B). In mechanically ventilated patients, we recommend light sedation (1B) and low tidal volume even without ARDS (1B) and suggest lung protective ventilation strategy during the operation to lower the incidence of lung complications including ARDS (2B). Early tracheostomy in mechanically ventilated patients can be performed only in limited patients (2A). In conclusion, of 12 recommendations, nine were in the management of ARDS, and three for mechanically ventilated patients.
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Affiliation(s)
- Young-Jae Cho
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae Young Moon
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Korea
| | - Ein-Soon Shin
- Research Agency for Clinical Practice Guidelines, Korean Academy of Medical Sciences Research Center, Seoul, Korea
| | - Je Hyeong Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Hoon Jung
- Department of Pulmonary and Critical Care Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
| | - So Young Park
- Department of Pulmonary and Critical Care Medicine, Kyung Hee University Medical Center, Seoul, Korea
| | - Ho Cheol Kim
- Department of Internal Medicine, Gyeongsang National University Changwon Hospital, Gyeongsang National University School of Medicine, Changwon, Korea
| | - Yun Su Sim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Chin Kook Rhee
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jaemin Lim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Seok Jeong Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Won-Yeon Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyun Jeong Lee
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Sang Hyun Kwak
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Eun Kyeong Kang
- Department of Pediatrics, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Kyung Soo Chung
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Institute of Chest Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Won-Il Choi
- Department of Internal Medicine, Keimyung University Dongsan Hospital, Daegu, Korea
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Barton G, Vanderspank-Wright B, Shea J. Optimizing Oxygenation in the Mechanically Ventilated Patient: Nursing Practice Implications. Crit Care Nurs Clin North Am 2016; 28:425-435. [PMID: 28236390 DOI: 10.1016/j.cnc.2016.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Critical care nurses constitute front-line care provision for patients in the intensive care unit (ICU). Hypoxemic respiratory compromise/failure is a primary reason that patients require ICU admission and mechanical ventilation. Critical care nurses must possess advanced knowledge, skill, and judgment when caring for these patients to ensure that interventions aimed at optimizing oxygenation are both effective and safe. This article discusses fundamental aspects of respiratory physiology and clinical indices used to describe oxygenation status. Key nursing interventions including patient assessment, positioning, pharmacology, and managing hemodynamic parameters are discussed, emphasizing their effects toward mitigating ventilation-perfusion mismatch and optimizing oxygenation.
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Affiliation(s)
- Glenn Barton
- Department of Practice, Performance and Innovation, Health Systems Innovation and External Relations, Royal College of Physicians and Surgeons of Canada, 774 Echo Drive, Ottawa, Ontario K1S 5N8, Canada.
| | - Brandi Vanderspank-Wright
- Faculty of Health Sciences, School of Nursing, University of Ottawa, 3245B Roger Guindon Hall, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada
| | - Jacqueline Shea
- Surgery, The Ottawa Hospital, General Campus, 450 Smyth Road, Ottawa, Ontario K1H 8M5, Canada
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12
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Venovenous Extracorporeal Membrane Oxygenation in Intractable Pulmonary Insufficiency: Practical Issues and Future Directions. BIOMED RESEARCH INTERNATIONAL 2016; 2016:9367464. [PMID: 27127794 PMCID: PMC4835630 DOI: 10.1155/2016/9367464] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 03/03/2016] [Indexed: 01/19/2023]
Abstract
Venovenous extracorporeal membrane oxygenation (vv-ECMO) is a highly invasive method for organ support that is gaining in popularity due to recent technical advances and its successful application in the recent H1N1 epidemic. Although running a vv-ECMO program is potentially feasible for many hospitals, there are many theoretical concepts and practical issues that merit attention and require expertise. In this review, we focus on indications for vv-ECMO, components of the circuit, and management of patients on vv-ECMO. Concepts regarding oxygenation and decarboxylation and how they can be influenced are discussed. Day-to-day management, weaning, and most frequent complications are covered in light of the recent literature.
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13
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Wang C, Wang X, Chi C, Guo L, Guo L, Zhao N, Wang W, Pi X, Sun B, Lian A, Shi J, Li E. Lung ventilation strategies for acute respiratory distress syndrome: a systematic review and network meta-analysis. Sci Rep 2016; 6:22855. [PMID: 26955891 PMCID: PMC4783789 DOI: 10.1038/srep22855] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 02/23/2016] [Indexed: 02/03/2023] Open
Abstract
To identify the best lung ventilation strategy for acute respiratory distress syndrome (ARDS), we performed a network meta-analysis. The Cochrane Central Register of Controlled Trials, EMBASE, MEDLINE, CINAHL, and the Web of Science were searched, and 36 eligible articles were included. Compared with higher tidal volumes with FiO2-guided lower positive end-expiratory pressure [PEEP], the hazard ratios (HRs) for mortality were 0.624 (95% confidence interval (CI) 0.419-0.98) for lower tidal volumes with FiO2-guided lower PEEP and prone positioning and 0.572 (0.34-0.968) for pressure-controlled ventilation with FiO2-guided lower PEEP. Lower tidal volumes with FiO2-guided higher PEEP and prone positioning had the greatest potential to reduce mortality, and the possibility of receiving the first ranking was 61.6%. Permissive hypercapnia, recruitment maneuver, and low airway pressures were most likely to be the worst in terms of all-cause mortality. Compared with higher tidal volumes with FiO2-guided lower PEEP, pressure-controlled ventilation with FiO2-guided lower PEEP and lower tidal volumes with FiO2-guided lower PEEP and prone positioning ventilation are associated with lower mortality in ARDS patients. Lower tidal volumes with FiO2-guided higher PEEP and prone positioning ventilation and lower tidal volumes with pressure-volume (P-V) static curve-guided individual PEEP are potential optimal strategies for ARDS patients.
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Affiliation(s)
- Changsong Wang
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of critical care medicine, the Third Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xiaoyang Wang
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China.,Department of Anesthesiology, JILIN GUO WEN Hospital, Gongzhuling, China
| | - Chunjie Chi
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Libo Guo
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lei Guo
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Nana Zhao
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Weiwei Wang
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xin Pi
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Bo Sun
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ailing Lian
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jinghui Shi
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Enyou Li
- Department of Anesthesiology, the First Affiliated Hospital of Harbin Medical University, Harbin, China
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Jauncey-Cooke J, Schibler A, Bogossian F, Gibbons K, Grant CA, East CE. Lung recruitment manoeuvres in mechanically ventilated children for reducing respiratory morbidity. Hippokratia 2016. [DOI: 10.1002/14651858.cd008866.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Andreas Schibler
- Mater Children’s Hospital; Paediatric Critical Care Research Group; South Brisbane Queensland Australia 4101
| | - Fiona Bogossian
- School of Nursing and Midwifery; The University of Queensland; Herston Australia
| | - Kristen Gibbons
- Mater Research Institute; South Brisbane Queensland Australia 4101
| | - Caroline A Grant
- Mater Children's Hospital; Paediatric Intensive Care Unit; Raymond Terrace South Brisbane Queensland Australia 4001
| | - Christine E East
- Monash University/Monash Health; School of Nursing and Midwifery/Maternity Services; 246 Clayton Road Clayton Victoria Australia 3168
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15
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Andrews PL, Sadowitz B, Kollisch-Singule M, Satalin J, Roy S, Snyder K, Gatto LA, Nieman GF, Habashi NM. Alveolar instability (atelectrauma) is not identified by arterial oxygenation predisposing the development of an occult ventilator-induced lung injury. Intensive Care Med Exp 2015. [PMID: 26215818 PMCID: PMC4480795 DOI: 10.1186/s40635-015-0054-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Improperly set mechanical ventilation (MV) with normal lungs can advance lung injury and increase the incidence of acute respiratory distress syndrome (ARDS). A key mechanism of ventilator-induced lung injury (VILI) is an alteration in alveolar mechanics including alveolar instability or recruitment/derecruitment (R/D). We hypothesize that R/D cannot be identified by PaO2 (masking occult VILI), and if protective ventilation is not applied, ARDS incidence will increase. METHODS Sprague-Dawley rats (n = 8) were anesthetized, surgically instrumented, and placed on MV. A thoracotomy was performed and an in vivo microscope attached to the pleural surface of the lung with baseline dynamic changes in alveolar size during MV recorded. Alveolar instability was induced by intra-tracheal instillation of Tween and alveolar R/D identified as a marked change in alveolar size from inspiration to expiration with increases in positive end-expiratory pressure (PEEP) levels. RESULTS Despite maintaining a clinically acceptable PaO2 (55-80 mmHg), the alveoli remained unstable with significant R/D at low PEEP levels. Although PaO2 consistently increased with an increase in PEEP, R/D did not plateau until PEEP was >9 cmH2O. CONCLUSIONS PaO2 remained clinically acceptable while alveolar instability persisted at all levels of PEEP (especially PEEP <9 cmH2O). Therefore, PaO2 levels cannot be used reliably to guide protective MV strategies or infer that VILI is not occurring. Using PaO2 to set a PEEP level necessary to stabilize the alveoli could underestimate the potential for VILI. These findings highlight the need for more accurate marker(s) of alveolar stability to guide protective MV necessary to prevent VILI.
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Affiliation(s)
- Penny L Andrews
- Department of Critical Care, R Adams Cowley Shock Trauma Center, Baltimore, MD, USA,
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16
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CLAESSON J, FREUNDLICH M, GUNNARSSON I, LAAKE JH, VANDVIK PO, VARPULA T, AASMUNDSTAD TA. Scandinavian clinical practice guideline on mechanical ventilation in adults with the acute respiratory distress syndrome. Acta Anaesthesiol Scand 2015; 59:286-97. [PMID: 25524779 DOI: 10.1111/aas.12449] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 11/03/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The objective of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) task force on mechanical ventilation in adults with the acute respiratory distress syndrome (ARDS) is to formulate treatment recommendations based on available evidence from systematic reviews and randomised trials. METHODS This guideline was developed according to standards for trustworthy guidelines through a systematic review of the literature and the use of the Grading of Recommendations Assessment, Development and Evaluation system for assessment of the quality of evidence and for moving from evidence to recommendations in a systematic and transparent process. RESULTS We found evidence of moderately high quality to support a strong recommendation for pressure limitation and small tidal volumes in patients with ARDS. Also, we suggest positive end-expiratory pressure (PEEP) > 5 cm H2O in moderate to severe ARDS and prone ventilation 16/24 h for the first week in moderate to severe ARDS (weak recommendation, low quality evidence). Volume controlled ventilation or pressure control may be equally beneficial or harmful and partial modes of ventilatory support may be used if clinically feasible (weak recommendation, very low quality evidence). We suggest utilising recruitment manoeuvres as a rescue measure in catastrophic hypoxaemia only (weak recommendation, low quality evidence). Based on high-quality evidence, we strongly recommend not to use high-frequency oscillatory ventilation. We could find no relevant data from randomised trials to guide decisions on choice of FiO2 or utilisation of non-invasive ventilation. CONCLUSION We strongly recommend pressure- and volume limitation and suggest using higher PEEP and prone ventilation in patients with severe respiratory failure.
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Affiliation(s)
- J. CLAESSON
- Department of Intensive Care Surgical Division Umeå University Hospital Umeå Sweden
| | - M. FREUNDLICH
- Clinic for Anaesthesiology Aalborg University Hospital Aalborg Denmark
| | - I. GUNNARSSON
- Department of Anaesthesiology and Intensive Care Medicine Landspitali University Hospital Reykjavik Iceland
| | - J. H. LAAKE
- Department of Anaesthesiology Division of Critical Care Oslo University Hospital Oslo Norway
| | - P. O. VANDVIK
- Department of Medicine Innlandet Hospital Trust‐Division Gjøvik Gjøvik Norway
- Norwegian Knowledge Centre for the Health Services Oslo Norway
| | - T. VARPULA
- Department of Intensive Care Medicine Helsinki University Hospital Helsinki Finland
| | - T. A. AASMUNDSTAD
- Department of Anaesthesiology Division of Critical Care Oslo University Hospital Oslo Norway
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Suzumura EA, Figueiró M, Normilio-Silva K, Laranjeira L, Oliveira C, Buehler AM, Bugano D, Passos Amato MB, Ribeiro Carvalho CR, Berwanger O, Cavalcanti AB. Effects of alveolar recruitment maneuvers on clinical outcomes in patients with acute respiratory distress syndrome: a systematic review and meta-analysis. Intensive Care Med 2014; 40:1227-40. [PMID: 25097070 DOI: 10.1007/s00134-014-3413-6] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 07/18/2014] [Indexed: 12/28/2022]
Abstract
PURPOSE To assess the effects of alveolar recruitment maneuvers (ARMs) on clinical outcomes in patients with acute respiratory distress syndrome (ARDS). METHODS We conducted a search of the MEDLINE, EMBASE, LILACS, CINAHL, CENTRAL, Scopus, and Web of Science (from inception to July 2014) databases for all (i.e. no language restriction) randomized controlled trials (RCTs) evaluating the effects of ARMs versus no ARMs in adults with ARDS. Four teams of two reviewers independently assessed the eligibility of the studies identified during the search and appraised the risk of bias and extracted data from those which were assessed as meeting the inclusion criteria. Data were pooled using the random-effects model. Trial sequential analysis (TSA) was used to establish monitoring boundaries to limit global type I error due to repetitive testing for our primary outcome (in-hospital mortality). The GRADE system was used to rate the quality of evidence. RESULTS Our database search identified ten RCTs (1,594 patients, 612 events) which satisfied the inclusion criteria. The meta-analysis assessing the effect of ARMs on in-hospital mortality showed a risk ratio (RR) of 0.84 [95 % confidence interval (CI) 0.74-0.95; I(2) = 0 %], although the quality of evidence was considered to be low due to the risk of bias in the included trials and the indirectness of the evidence--that is, ARMs were usually conducted together with other ventilatory interventions which may affect the outcome of interest. There were no differences in the rates of barotrauma (RR 1.11; 95 % CI 0.78-1.57; I(2) = 0 %) or need for rescue therapies (RR 0.76, 95 % CI 0.41-1.40; I(2) = 56 %). Most trials found no difference between groups in terms of duration of mechanical ventilation and length of stay in the intensive care unit and hospital. The TSA showed that the available evidence for the effect of ARMs on in-hospital mortality is precise in the case of a type I error of 5 %, but it is not precise with a type I error of 1 %. CONCLUSIONS Although ARMs may decrease the mortality of patients with ARDS without increasing the risk for major adverse events, current evidence is not definitive. Large-scale ongoing trials addressing this question may provide data better applicable to clinical practice.
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Affiliation(s)
- Erica Aranha Suzumura
- Research Institute of the Hospital do Coração (Heart Hospital)-IEP/HCor, Rua Abílio Soares 250, No. 12 andar, 04005-000, São Paulo, SP, Brazil,
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18
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Abstract
Patients admitted to the Cardiac Intensive Care Unit (CICU) are of increasing complexity and often require ventilatory support. A deep understanding of respiratory physiology and the interactions between the cardiovascular and respiratory systems is essential. Ventilatory support should be tailored to the specific patient condition, ensuring effective minute ventilation, reducing work of breathing and minimizing adverse hemodynamic effects. The weaning process can stress the cardiovascular system and cardiac failure is a common cause of failure to wean. Identification of patients likely to fail and prompt pre-emptive intervention is crucial for successful weaning and avoiding complications related to prolonged mechanical ventilation.
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Affiliation(s)
- Carlos Corredor
- Anaesthesia and Critical Care Department, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
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19
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Eldh AC, Vogel G, Söderberg A, Blomqvist H, Wengström Y. Use of evidence in clinical guidelines and everyday practice for mechanical ventilation in Swedish intensive care units. Worldviews Evid Based Nurs 2013; 10:198-207. [PMID: 23796046 DOI: 10.1111/wvn.12008] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2013] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIM One way to support evidence-based decisions in health care is by clinical guidelines, in particular, in highly specialized care such as intensive care units (ICUs). The aim of this study was to explore the development and dissemination of guidelines regarding mechanical ventilation (MV) in Swedish ICUs, and the use of evidence on MV in guidelines and everyday practice. METHODS Inviting all general ICUs in Sweden (N = 65), a national survey was performed on occurrence of MV guidelines, and a review of submitted ICU guidelines by four evidence items from the AGREE instrument. In addition, ICU head nurses and senior physicians were interviewed using semistructured and open-ended questions to explore development and dissemination of MV guidelines, staff adherence or nonadherence to guidelines, and everyday practice of MV management bedside. FINDINGS Fifty-five ICUs (85%) participated in the study; 51 ICUs submitted a total of 245 guidelines, including recommendations for medical or nursing MV actions. None of the documents included how evidence had been sought or assessed, while 22% included a list of references (n = 54). No guidelines included patients' experiences of MV. According to the managers, the guidelines were most often compiled by a multiprofessional team sharing the information through the ICU's website. The guidelines were mainly used as a basis for MV management bedside, but variation occurred as a result of personal preferences, lack of awareness, and adjustment to patients' needs. CONCLUSIONS Local MV guidelines seem to constitute a basis for healthcare practice in Swedish ICUs, even though the evidence proposed was limited with respect to how it was attained and lacked patient perspectives. In addition, the strategies used for dissemination were limited, suggesting that further initiatives are needed to support knowledge translation in advanced healthcare environments such as ICUs.
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Affiliation(s)
- Ann Catrine Eldh
- Research Fellow, Karolinska Institutet, Department of Neurobiology, Care Sciences and Society, Stockholm, Sweden
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20
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Santa Cruz R, Rojas JI, Nervi R, Heredia R, Ciapponi A. High versus low positive end-expiratory pressure (PEEP) levels for mechanically ventilated adult patients with acute lung injury and acute respiratory distress syndrome. Cochrane Database Syst Rev 2013; 2013:CD009098. [PMID: 23740697 PMCID: PMC6517097 DOI: 10.1002/14651858.cd009098.pub2] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Mortality in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) remains high. These patients require mechanical ventilation, but this modality has been associated with ventilator-induced lung injury. High levels of positive end-expiratory pressure (PEEP) could reduce this condition and improve patient survival. OBJECTIVES To assess the benefits and harms of high versus low levels of PEEP in patients with ALI and ARDS. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2013, Issue 4), MEDLINE (1950 to May 2013), EMBASE (1982 to May 2013), LILACS (1982 to May 2013) and SCI (Science Citation Index). We used the Science Citation Index to find references that have cited the identified trials. We did not specifically conduct manual searches of abstracts of conference proceedings for this review. We also searched for ongoing trials (www.trialscentral.org; www.clinicaltrial.gov and www.controlled-trials.com). SELECTION CRITERIA We included randomized controlled trials that compared the effects of two levels of PEEP in ALI and ARDS participants who were intubated and mechanically ventilated in intensive care for at least 24 hours. DATA COLLECTION AND ANALYSIS Two review authors assessed the trial quality and extracted data independently. We contacted investigators to identify additional published and unpublished studies. MAIN RESULTS We included seven studies that compared high versus low levels of PEEP (2565 participants). In five of the studies (2417 participants), a comparison was made between high and low levels of PEEP with the same tidal volume in both groups, but in the remaining two studies (148 participants), the tidal volume was different between high- and low-level groups. We saw evidence of risk of bias in three studies, and the remaining studies fulfilled all criteria for adequate trial quality.In the main analysis, we assessed mortality occurring before hospital discharge only in those studies that compared high versus low PEEP with the same tidal volume in both groups. With the three studies that were included, the meta-analysis revealed no statistically significant differences between the two groups (relative risk (RR) 0.90, 95% confidence interval (CI) 0.81 to 1.01), nor was any statistically significant difference seen in the risk of barotrauma (RR 0.97, 95% CI 0.66 to 1.42). Oxygenation was improved in the high-PEEP group, although data derived from the studies showed a considerable degree of statistical heterogeneity. The number of ventilator-free days showed no significant difference between the two groups. Available data were insufficient to allow pooling of length of stay in the intensive care unit (ICU). The subgroup of participants with ARDS showed decreased mortality in the ICU, although it must be noted that in two of the three included studies, the authors used a protective ventilatory strategy involving a low tidal volume and high levels of PEEP. AUTHORS' CONCLUSIONS Available evidence indicates that high levels of PEEP, as compared with low levels, did not reduce mortality before hospital discharge. The data also show that high levels of PEEP produced no significant difference in the risk of barotrauma, but rather improved participants' oxygenation to the first, third, and seventh days. This review indicates that the included studies were characterized by clinical heterogeneity.
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Affiliation(s)
- Roberto Santa Cruz
- Department of Intensive Care,Hospital Regional of RioGallegos, Rio Gallegos, Argentina.
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21
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Silversides JA, Ferguson ND. Clinical review: Acute respiratory distress syndrome - clinical ventilator management and adjunct therapy. Crit Care 2013; 17:225. [PMID: 23672857 PMCID: PMC3672489 DOI: 10.1186/cc11867] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a potentially devastating form of acute inflammatory lung injury with a high short-term mortality rate and significant long-term consequences among survivors. Supportive care, principally with mechanical ventilation, remains the cornerstone of therapy - although the goals of this support have changed in recent years - from maintaining normal physiological parameters to avoiding ventilator-induced lung injury while providing adequate gas exchange. In this article we discuss the current evidence base for ventilatory support and adjunctive therapies in patients with ARDS. Key components of such a strategy include avoiding lung overdistension by limiting tidal volumes and airway pressures, and the use of positive end-expiratory pressure with or without lung recruitment manoeuvres in patients with severe ARDS. Adjunctive therapies discussed include pharmacologic techniques (for example, vasodilators, diuretics, neuromuscular blockade) and nonpharmacologic techniques (for example, prone position, alternative modes of ventilation).
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Affiliation(s)
- Jonathan A Silversides
- Interdepartmental Division of Critical Care, University of Toronto, 600 University Avenue, Suite 18-206, Toronto, ON, Canada M5G 1X5
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care, University of Toronto, 600 University Avenue, Suite 18-206, Toronto, ON, Canada M5G 1X5
- Department of Medicine, Division of Respirology, University Health Network and Mount Sinai Hospital, University of Toronto, Mount Sinai Hospital, 600 University Avenue, Suite 18-206, Toronto, ON, Canada M5G 1X5
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Villar J, Kacmarek RM. What is new in refractory hypoxemia? Intensive Care Med 2013; 39:1207-10. [PMID: 23575611 DOI: 10.1007/s00134-013-2905-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 03/16/2013] [Indexed: 01/19/2023]
Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
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23
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Engel M, Nowacki RME, Reiss LK, Uhlig S, Willems CHMP, Kloosterboer N, van Iwaarden JF, Sewing ACP, Seehase M, Lambermont VAC, Collins JJP, Zimmermann LJI, Vos GD, Kramer BW. Comparison of recruitment manoeuvres in ventilated sheep with acute respiratory distress syndrome. Lung 2012; 191:77-86. [PMID: 23117276 DOI: 10.1007/s00408-012-9428-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Accepted: 09/24/2012] [Indexed: 01/05/2023]
Abstract
BACKGROUND Recruitment manoeuvres are widely used in clinical practice to open the lung and prevent lung injury by derecruitment, although the evidence is still discussed. In this study two different recruitment manoeuvres were compared to no recruitment manoeuvres (control) in ventilated sheep with acute respiratory distress syndrome (ARDS), induced by lung lavage. METHODS We performed a prospective, randomised study in 26 ventilated sheep with ARDS, to evaluate the effect of two different recruitment manoeuvres on gas exchange, blood pressure and lung injury. The two different recruitment manoeuvres, the high pressure recruitment manoeuvre (HPRM), with high peak pressure, and the smooth and moderate recruitment manoeuvre (SMRM), with lower peak pressure, were compared to controls (no recruitment) after disconnection. Oxygenation index and ventilation efficacy index were calculated to evaluate gas exchange. Lung injury was assessed by inflammatory response in broncho-alveolar lavage fluid (BALF) and blood and histology of the lung. RESULTS Oxygenation index improved significantly after both recruitment manoeuvres compared with controls, but no significant difference was found between the recruitment manoeuvres. Blood pressure decreased after HPRM but not after SMRM. HPRM induced a higher number of total cells and more neutrophils in the BALF. In the histology of the lung, mean alveolar size was increased in the dorsocranial region of the lung of SMRM compared to controls. CONCLUSION Recruitment manoeuvres improved oxygenation, but SMRM was superior, with respect to hemodynamics and pulmonary inflammation, in ventilated sheep suffering from ARDS induced by lung lavage.
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Affiliation(s)
- Monique Engel
- Department of Paediatrics, School for Oncology and Developmental Biology-GROW, Maastricht University Medical Centre (MUMC+), P. Debyelaan 25, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.
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Wilson MR, Patel BV, Takata M. Ventilation with "clinically relevant" high tidal volumes does not promote stretch-induced injury in the lungs of healthy mice. Crit Care Med 2012; 40:2850-7. [PMID: 22890257 PMCID: PMC3698535 DOI: 10.1097/ccm.0b013e31825b91ef] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Ventilator-induced lung injury is a crucial determinant of the outcome of mechanically ventilated patients. Increasing numbers of mouse studies have identified numerous pathways and mediators that are modulated by ventilation, but it is conceptually difficult to reconcile these into a single paradigm. There is substantial variability in tidal volumes used in these studies and no certainty about the pathophysiology that such varied models actually represent. This study was designed to investigate whether ventilation strategies ranging from "very high" to more "clinically relevant" tidal volumes induce similar pathophysiologies in healthy mice or represent distinct entities. DESIGN In vivo study. SETTING University research laboratory. SUBJECTS C57/Bl6 mice. INTERVENTIONS Anesthetized mice were ventilated with various tidal volumes up to 40 mL/kg. MEASUREMENTS AND MAIN RESULTS Respiratory system compliance and arterial blood gases were used to evaluate physiological variables of injury. Lung wet:dry weight ratio, lavage fluid protein, and cytokines were used to assess pulmonary edema and inflammation. All ventilation strategies induced changes in respiratory system compliance, although the pattern of change was unique for each strategy. Ventilation with 10 mL/kg and 40 mL/kg also induced decreases in arterial PO2 and blood pressure. Any physiological changes induced during the 10, 20, and 30 mL/kg strategies were largely reversed by recruitment maneuvers at the end of the protocol. Markers of pulmonary edema and inflammation indicated that only 40 mL/kg induced substantial increases in both, consistent with development of lung injury. CONCLUSIONS Tidal volumes up to 20 mL/kg are unlikely to induce substantial lung overstretch in models using healthy, young mice. Signs of injury/inflammation using such models are likely to result from other factors, particularly alveolar derecruitment and atelectasis. The results of such studies may need to be reevaluated before clinical relevance can be accurately determined.
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Affiliation(s)
- Michael R Wilson
- Section of Anaesthetics, Pain Medicine and Intensive Care, Faculty of Medicine, Imperial College London, Chelsea and Westminster Hospital, London, United Kingdom.
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25
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Goal-directed mechanical ventilation: are we aiming at the right goals? A proposal for an alternative approach aiming at optimal lung compliance, guided by esophageal pressure in acute respiratory failure. Crit Care Res Pract 2012; 2012:597932. [PMID: 23019524 PMCID: PMC3457592 DOI: 10.1155/2012/597932] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Revised: 08/12/2012] [Accepted: 08/13/2012] [Indexed: 11/25/2022] Open
Abstract
Patients with acute respiratory failure and decreased respiratory system compliance due to ARDS frequently present a formidable challenge. These patients are often subjected to high inspiratory pressure, and in severe cases in order to improve oxygenation and preserve life, we may need to resort to unconventional measures. The currently accepted ARDSNet guidelines are characterized by a generalized approach in which an algorithm for PEEP application and limited plateau pressure are applied to all mechanically ventilated patients. These guidelines do not make any distinction between patients, who may have different chest wall mechanics with diverse pathologies and different mechanical properties of their respiratory system. The ability of assessing pleural pressure by measuring esophageal pressure allows us to partition the respiratory system into its main components of lungs and chest wall. Thus, identifying the dominant factor affecting respiratory system may better direct and optimize mechanical ventilation. Instead of limiting inspiratory pressure by plateau pressure, PEEP and inspiratory pressure adjustment would be individualized specifically for each patient's lung compliance as indicated by transpulmonary pressure. The main goal of this approach is to specifically target transpulmonary pressure instead of plateau pressure, and therefore achieve the best lung compliance with the least transpulmonary pressure possible.
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Bakowitz M, Bruns B, McCunn M. Acute lung injury and the acute respiratory distress syndrome in the injured patient. Scand J Trauma Resusc Emerg Med 2012; 20:54. [PMID: 22883052 PMCID: PMC3518173 DOI: 10.1186/1757-7241-20-54] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 06/11/2012] [Indexed: 12/27/2022] Open
Abstract
Acute lung injury and acute respiratory distress syndrome are clinical entities of multi-factorial origin frequently seen in traumatically injured patients requiring intensive care. We performed an unsystematic search using PubMed and the Cochrane Database of Systematic Reviews up to January 2012. The purpose of this article is to review recent evidence for the pathophysiology and the management of acute lung injury/acute respiratory distress syndrome in the critically injured patient. Lung protective ventilation remains the most beneficial therapy. Future trials should compare intervention groups to controls receiving lung protective ventilation, and focus on relevant outcome measures such as duration of mechanical ventilation, length of intensive care unit stay, and mortality.
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Affiliation(s)
- Magdalena Bakowitz
- Department of Anesthesiology & Critical Care, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Jauncey-Cooke J, Bogossian F, Hough JL, Schibler A, Davies MW, Grant CA, Gibbons K, East CE. Lung recruitment manoeuvres for reducing respiratory morbidity in mechanically ventilated neonates. Hippokratia 2012. [DOI: 10.1002/14651858.cd009969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
| | - Fiona Bogossian
- School of Nursing and Midwifery; The University of Queensland; Herston Australia
| | - Judith L Hough
- Mater Medical Research Institute; South Brisbane Queensland Australia 4101
| | - Andreas Schibler
- Mater Children's Hospital; Paediatric Intensive Care Unit; Raymond Terrace South Brisbane Queensland Australia 4101
| | - Mark W Davies
- Department of Paediatrics & Child Health, The University of Queensland; Grantley Stable Neonatal Unit, Royal Brisbane and Women's Hospital; Butterfield St Herston Brisbane Queensland Australia 4029
| | - Caroline A Grant
- Mater Children's Hospital; Paediatric Intensive Care Unit; Raymond Terrace South Brisbane Queensland Australia 4101
| | - Kristen Gibbons
- Mater Medical Research Institute; Clinical Research Support Unit; Level 3, Quarters Building Raymond Terrace South Brisbane Queensland Australia 4101
| | - Christine E East
- School of Nursing and Midwifery, Monash University / Southern Health; School of Nursing and Midwifery, University of Queensland; 246 Clayton Rd Clayton Victoria Australia 3168
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Archambault PM, St-Onge M. Invasive and Noninvasive Ventilation in the Emergency Department. Emerg Med Clin North Am 2012; 30:421-49, ix. [DOI: 10.1016/j.emc.2011.10.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pierrakos C, Karanikolas M, Scolletta S, Karamouzos V, Velissaris D. Acute respiratory distress syndrome: pathophysiology and therapeutic options. J Clin Med Res 2012; 4:7-16. [PMID: 22383921 PMCID: PMC3279495 DOI: 10.4021/jocmr761w] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2011] [Indexed: 01/01/2023] Open
Abstract
Acute Respiratory Distress Syndrome (ARDS) is a common entity in critical care. ARDS is associated with many diagnoses, including trauma and sepsis, can lead to multiple organ failure and has high mortality. The present article is a narrative review of the literature on ARDS, including ARDS pathophysiology and therapeutic options currently being evaluated or in use in clinical practice. The literature review covers relevant publications until January 2011. Recent developments in the therapeutic approach to ARDS include refinements of mechanical ventilatory support with emphasis on protective lung ventilation using low tidal volumes, increased PEEP with use of recruitment maneuvers to promote reopening of collapsed lung alveoli, prone position as rescue therapy for severe hypoxemia, and high frequency ventilation. Supportive measures in the management of ARDS include attention to fluid balance, restrictive transfusion strategies, and minimization of sedatives and neuromuscular blocking agents. Inhaled bronchodilators such as inhaled nitric oxide and prostaglandins confer short term improvement without proven effect on survival, but are currently used in many centers. Use of corticosteroids is also important, and appropriate timely use may reduce mortality. Finally, extra corporeal oxygenation methods are very useful as rescue therapy in patients with intractable hypoxemia, even though a survival benefit has not, to this date been demonstrated. Despite intense ongoing research on the pathophysiology and treatment of ARDS, mortality remains high. Many pharmacologic and supportive strategies have shown promising results, but data from large randomized clinical trials are needed to fully evaluate the true effectiveness of these therapies.
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Reiss LK, Kowallik A, Uhlig S. Recurrent recruitment manoeuvres improve lung mechanics and minimize lung injury during mechanical ventilation of healthy mice. PLoS One 2011; 6:e24527. [PMID: 21935418 PMCID: PMC3174196 DOI: 10.1371/journal.pone.0024527] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Accepted: 08/12/2011] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Mechanical ventilation (MV) of mice is increasingly required in experimental studies, but the conditions that allow stable ventilation of mice over several hours have not yet been fully defined. In addition, most previous studies documented vital parameters and lung mechanics only incompletely. The aim of the present study was to establish experimental conditions that keep these parameters within their physiological range over a period of 6 h. For this purpose, we also examined the effects of frequent short recruitment manoeuvres (RM) in healthy mice. METHODS Mice were ventilated at low tidal volume V(T) = 8 mL/kg or high tidal volume V(T) = 16 mL/kg and a positive end-expiratory pressure (PEEP) of 2 or 6 cm H(2)O. RM were performed every 5 min, 60 min or not at all. Lung mechanics were followed by the forced oscillation technique. Blood pressure (BP), electrocardiogram (ECG), heart frequency (HF), oxygen saturation and body temperature were monitored. Blood gases, neutrophil-recruitment, microvascular permeability and pro-inflammatory cytokines in bronchoalveolar lavage (BAL) and blood serum as well as histopathology of the lung were examined. RESULTS MV with repetitive RM every 5 min resulted in stable respiratory mechanics. Ventilation without RM worsened lung mechanics due to alveolar collapse, leading to impaired gas exchange. HF and BP were affected by anaesthesia, but not by ventilation. Microvascular permeability was highest in atelectatic lungs, whereas neutrophil-recruitment and structural changes were strongest in lungs ventilated with high tidal volume. The cytokines IL-6 and KC, but neither TNF nor IP-10, were elevated in the BAL and serum of all ventilated mice and were reduced by recurrent RM. Lung mechanics, oxygenation and pulmonary inflammation were improved by increased PEEP. CONCLUSIONS Recurrent RM maintain lung mechanics in their physiological range during low tidal volume ventilation of healthy mice by preventing atelectasis and reduce the development of pulmonary inflammation.
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Affiliation(s)
- Lucy Kathleen Reiss
- Institute of Pharmacology and Toxicology, Medical Faculty of RWTH Aachen University, Aachen, Germany.
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31
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Hodgson CL, Tuxen DV, Davies AR, Bailey MJ, Higgins AM, Holland AE, Keating JL, Pilcher DV, Westbrook AJ, Cooper DJ, Nichol AD. A randomised controlled trial of an open lung strategy with staircase recruitment, titrated PEEP and targeted low airway pressures in patients with acute respiratory distress syndrome. CRITICAL CARE (LONDON, ENGLAND) 2011. [PMID: 21635753 DOI: 10.1186/cc10249cc10249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Tidal volume and plateau pressure minimisation are the standard components of a protective lung ventilation strategy for patients with acute respiratory distress syndrome (ARDS). Open lung strategies, including higher positive end-expiratory pressure (PEEP) and recruitment manoeuvres to date have not proven efficacious. This study examines the effectiveness and safety of a novel open lung strategy, which includes permissive hypercapnia, staircase recruitment manoeuvres (SRM) and low airway pressure with PEEP titration. METHOD Twenty ARDS patients were randomised to treatment or ARDSnet control ventilation strategies. The treatment group received SRM with decremental PEEP titration and targeted plateau pressure < 30 cm H2O. Gas exchange and lung compliance were measured daily for 7 days and plasma cytokines in the first 24 hours and on days 1, 3, 5 and 7 (mean ± SE). Duration of ventilation, ICU stay and hospital stay (median and interquartile range) and hospital survival were determined. RESULTS There were significant overall differences between groups when considering plasma IL-8 and TNF-α. For plasma IL-8, the control group was 41% higher than the treatment group over the seven-day period (ratio 1.41 (1.11 to 1.79), P = 0.01), while for TNF-α the control group was 20% higher over the seven-day period (ratio 1.20 (1.01 to 1.42) P = 0.05). PaO2/FIO2 (204 ± 9 versus 165 ± 9 mmHg, P = 0.005) and static lung compliance (49.1 ± 2.9 versus 33.7 ± 2.7 mls/cm H2O, P < 0.001) were higher in the treatment group than the control group over seven days. There was no difference in duration of ventilation (180 (87 to 298) versus 341 (131 to 351) hrs, P = 0.13), duration of ICU stay (9.9 (5.6 to 14.8) versus 16.0 (8.1 to 19.3) days, P = 0.19) and duration of hospital stay (17.9 (13.7 to 34.5) versus 24.7 (20.5 to 39.8) days, P = 0.16) between the treatment and control groups. CONCLUSIONS This open lung strategy was associated with greater amelioration in some systemic cytokines, improved oxygenation and lung compliance over seven days. A larger trial powered to examine clinically-meaningful outcomes is warranted. TRIAL REGISTRATION ACTRN12607000465459.
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Affiliation(s)
- Carol L Hodgson
- Intensive Care Unit, The Alfred, Commercial Road, Melbourne, VIC 3181, Australia.
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Hodgson CL, Tuxen DV, Davies AR, Bailey MJ, Higgins AM, Holland AE, Keating JL, Pilcher DV, Westbrook AJ, Cooper DJ, Nichol AD. A randomised controlled trial of an open lung strategy with staircase recruitment, titrated PEEP and targeted low airway pressures in patients with acute respiratory distress syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R133. [PMID: 21635753 PMCID: PMC3219001 DOI: 10.1186/cc10249] [Citation(s) in RCA: 102] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2011] [Revised: 04/21/2011] [Accepted: 06/02/2011] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Tidal volume and plateau pressure minimisation are the standard components of a protective lung ventilation strategy for patients with acute respiratory distress syndrome (ARDS). Open lung strategies, including higher positive end-expiratory pressure (PEEP) and recruitment manoeuvres to date have not proven efficacious. This study examines the effectiveness and safety of a novel open lung strategy, which includes permissive hypercapnia, staircase recruitment manoeuvres (SRM) and low airway pressure with PEEP titration. METHOD Twenty ARDS patients were randomised to treatment or ARDSnet control ventilation strategies. The treatment group received SRM with decremental PEEP titration and targeted plateau pressure < 30 cm H2O. Gas exchange and lung compliance were measured daily for 7 days and plasma cytokines in the first 24 hours and on days 1, 3, 5 and 7 (mean ± SE). Duration of ventilation, ICU stay and hospital stay (median and interquartile range) and hospital survival were determined. RESULTS There were significant overall differences between groups when considering plasma IL-8 and TNF-α. For plasma IL-8, the control group was 41% higher than the treatment group over the seven-day period (ratio 1.41 (1.11 to 1.79), P = 0.01), while for TNF-α the control group was 20% higher over the seven-day period (ratio 1.20 (1.01 to 1.42) P = 0.05). PaO2/FIO2 (204 ± 9 versus 165 ± 9 mmHg, P = 0.005) and static lung compliance (49.1 ± 2.9 versus 33.7 ± 2.7 mls/cm H2O, P < 0.001) were higher in the treatment group than the control group over seven days. There was no difference in duration of ventilation (180 (87 to 298) versus 341 (131 to 351) hrs, P = 0.13), duration of ICU stay (9.9 (5.6 to 14.8) versus 16.0 (8.1 to 19.3) days, P = 0.19) and duration of hospital stay (17.9 (13.7 to 34.5) versus 24.7 (20.5 to 39.8) days, P = 0.16) between the treatment and control groups. CONCLUSIONS This open lung strategy was associated with greater amelioration in some systemic cytokines, improved oxygenation and lung compliance over seven days. A larger trial powered to examine clinically-meaningful outcomes is warranted. TRIAL REGISTRATION ACTRN12607000465459.
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Affiliation(s)
- Carol L Hodgson
- Intensive Care Unit, The Alfred, Commercial Road, Melbourne, VIC 3181, Australia.
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Guerin C, Debord S, Leray V, Delannoy B, Bayle F, Bourdin G, Richard JC. Efficacy and safety of recruitment maneuvers in acute respiratory distress syndrome. Ann Intensive Care 2011; 1:9. [PMID: 21906333 PMCID: PMC3224504 DOI: 10.1186/2110-5820-1-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2011] [Accepted: 04/19/2011] [Indexed: 11/13/2022] Open
Abstract
Recruitment maneuvers (RM) consist of a ventilatory strategy that increases the transpulmonary pressure transiently to reopen the recruitable lung units in acute respiratory distress syndrome (ARDS). The rationales to use RM in ARDS are that there is a massive loss of aerated lung and that once the end-inspiratory pressure surpasses the regional critical opening pressure of the lung units, those units are likely to reopen. There are different methods to perform RM when using the conventional ICU ventilator. The three RM methods that are mostly used and investigated are sighs, sustained inflation, and extended sigh. There is no standardization of any of the above RM. Meta-analysis recommended not to use RM in routine in stable ARDS patients but to run them in case of life-threatening hypoxemia. There are some concerns regarding the safety of RM in terms of hemodynamics preservation and lung injury as well. The rapid rising in pressure can be a factor that explains the potential harmful effects of the RM. In this review, we describe the balance between the beneficial effects and the harmful consequences of RM. Recent animal studies are discussed.
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Affiliation(s)
- Claude Guerin
- Service de Réanimation Médicale, Hôpital de la Croix-Rousse, 103 Grande Rue de la Croix-Rousse, Lyon, 69004 France.
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Noble DW, Peek GJ. Extracorporeal membrane oxygenation for respiratory failure: past, present and future. Anaesthesia 2011; 65:971-4. [PMID: 21198465 DOI: 10.1111/j.1365-2044.2010.06507.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
General anesthesia and mechanical ventilation affect gas exchange, ventilation and pulmonary perfusion and there is an increasing body of evidence that mechanical ventilation itself promotes lung injury. Lung protective mechanical ventilation in patients suffering from acute lung injury or acute respiratory distress syndrome by means of reduced tidal volumes and limited plateau pressures has been shown to result in reduction of systemic inflammatory mediators, increased ventilator-free days and reduction in mortality. Experimental studies suggest that mechanical ventilation of uninjured lungs may also induce lung damage; however, the clinical relevance remains unknown. Human prospective studies comparing mechanical ventilation strategies during general anesthesia have shown inconsistent results with respect to inflammatory mediators. There is a lack of clinical evidence that lung protective ventilation strategies as used in patients with lung injury may improve clinical outcome of patients with uninjured lungs. The question of which ventilatory strategy will best protect normal human lungs remains unanswered.
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36
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Silva PL, Cruz FF, Fujisaki LC, Oliveira GP, Samary CS, Ornellas DS, Maron-Gutierrez T, Rocha NN, Goldenberg R, Garcia CSNB, Morales MM, Capelozzi VL, Gama de Abreu M, Pelosi P, Rocco PRM. Hypervolemia induces and potentiates lung damage after recruitment maneuver in a model of sepsis-induced acute lung injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R114. [PMID: 20546573 PMCID: PMC2911760 DOI: 10.1186/cc9063] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2010] [Revised: 04/21/2010] [Accepted: 06/14/2010] [Indexed: 01/02/2023]
Abstract
Introduction Recruitment maneuvers (RMs) seem to be more effective in extrapulmonary acute lung injury (ALI), caused mainly by sepsis, than in pulmonary ALI. Nevertheless, the maintenance of adequate volemic status is particularly challenging in sepsis. Since the interaction between volemic status and RMs is not well established, we investigated the effects of RMs on lung and distal organs in the presence of hypovolemia, normovolemia, and hypervolemia in a model of extrapulmonary lung injury induced by sepsis. Methods ALI was induced by cecal ligation and puncture surgery in 66 Wistar rats. After 48 h, animals were anesthetized, mechanically ventilated and randomly assigned to 3 volemic status (n = 22/group): 1) hypovolemia induced by blood drainage at mean arterial pressure (MAP)≈70 mmHg; 2) normovolemia (MAP≈100 mmHg), and 3) hypervolemia with colloid administration to achieve a MAP≈130 mmHg. In each group, animals were further randomized to be recruited (CPAP = 40 cm H2O for 40 s) or not (NR) (n = 11/group), followed by 1 h of protective mechanical ventilation. Echocardiography, arterial blood gases, static lung elastance (Est,L), histology (light and electron microscopy), lung wet-to-dry (W/D) ratio, interleukin (IL)-6, IL-1β, caspase-3, type III procollagen (PCIII), intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1) mRNA expressions in lung tissue, as well as lung and distal organ epithelial cell apoptosis were analyzed. Results We observed that: 1) hypervolemia increased lung W/D ratio with impairment of oxygenation and Est,L, and was associated with alveolar and endothelial cell damage and increased IL-6, VCAM-1, and ICAM-1 mRNA expressions; and 2) RM reduced alveolar collapse independent of volemic status. In hypervolemic animals, RM improved oxygenation above the levels observed with the use of positive-end expiratory pressure (PEEP), but increased lung injury and led to higher inflammatory and fibrogenetic responses. Conclusions Volemic status should be taken into account during RMs, since in this sepsis-induced ALI model hypervolemia promoted and potentiated lung injury compared to hypo- and normovolemia.
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Affiliation(s)
- Pedro L Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Av Carlos Chagas Filho, Rio de Janeiro 21949-902, Brazil.
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Pelosi P, Gama de Abreu M, Rocco PRM. New and conventional strategies for lung recruitment in acute respiratory distress syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:210. [PMID: 20236454 PMCID: PMC2887103 DOI: 10.1186/cc8851] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
This article is one of ten reviews selected from the Yearbook of Intensive Care and Emergency Medicine 2010 (Springer Verlag) and co-published as a series in Critical Care. Other articles in the series can be found online at http://ccforum.com/series/yearbook. Further information about the Yearbook of Intensive Care and Emergency Medicine is available from http://www.springer.com/series/2855.
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Affiliation(s)
- Paolo Pelosi
- Department of Ambient Health and Safety, Servizio Anestesia B, Ospedale di Circolo, University of Insubria, Viale Borri 57, Varese, Italy.
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Biatto JFP, Costa ELV, Pastore L, Kallás EG, Deheinzelin D, Schettino G. Prone position ventilation, recruitment maneuver and intravenous zanamivir in severe refractory hypoxemia caused by influenza A (H1N1). Clinics (Sao Paulo) 2010; 65:1211-3. [PMID: 21243298 PMCID: PMC2999721 DOI: 10.1590/s1807-59322010001100026] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Villar J, Kacmarek RM. Rescue strategies for refractory hypoxemia: a critical appraisal. F1000 MEDICINE REPORTS 2009; 1. [PMID: 20948686 PMCID: PMC2948334 DOI: 10.3410/m1-91] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Mechanical ventilation is the most important aspect of supportive care of patients with severe acute respiratory failure. Most research directed to improving the prognosis of these patients has focused on improving support of the injured lung. In this report, current knowledge on innovative ways to manage refractory hypoxemia and ventilation without further damaging the injured lung is briefly discussed.
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Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos IIISinesio Delgado 6, 28029 MadridSpain
- Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrin, Barranco de la Ballenas/n - 4th Floor, South Wing, 35010 Las Palmas de Gran CanariaSpain
- Keenan Research Center at the Li Ka Shing Knowledge Institute of St. Michael’s Hospital30 Bond St, Toronto, ON, M5B 1W8Canada
| | - Robert M Kacmarek
- Department of Anesthesia, Harvard Medical SchoolBoston, MAUSA
- Department of Respiratory Care, Massachusetts General Hospital55 Fruit Street, Ellison 401, Boston, MA 02114-2696USA
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Lanza F, Damasceno M, Leme F, Yagui A, Paiva K, Luque A, Beppu O. Variable positive end-expiratory pressure can maintain oxygenation in experimental acute respiratory distress syndrome induced by oleic acid in dogs. Braz J Med Biol Res 2009; 42:731-7. [DOI: 10.1590/s0100-879x2009000800007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Accepted: 06/08/2009] [Indexed: 11/21/2022] Open
Affiliation(s)
- F.C. Lanza
- Universidade Federal de São Paulo, Brasil; Centro Universitário São Camilo, Brasil
| | | | - F. Leme
- Universidade Federal de São Paulo, Brasil
| | | | - K.C. Paiva
- Universidade Federal de São Paulo, Brasil
| | - A. Luque
- Centro Universitário São Camilo, Brasil; Universidade de São Paulo, Brasil
| | - O.S. Beppu
- Universidade Federal de São Paulo, Brasil
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