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Placenti A, Fratebianchi F. Mean airway pressure as a parameter of lung-protective and heart-protective ventilation. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:466-478. [PMID: 38615712 DOI: 10.1016/j.redare.2024.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 01/30/2024] [Indexed: 04/16/2024]
Abstract
Mean airway pressure (MAP) is the mean pressure generated in the airway during a single breath (inspiration + expiration), and is displayed on most anaesthesia and intensive care ventilators. This parameter, however, is not usually monitored during mechanical ventilation because it is poorly understood and usually only used in research. One of the main determinants of MAP is PEEP. This is because in respiratory cycles with an I:E ratio of 1:2, expiration is twice as long as inspiration. Although MAP can be used as a surrogate for mean alveolar pressure, these parameters differ considerably in some situations. Recently, MAP has been shown to be a useful prognostic factor for respiratory morbidity and mortality in mechanically ventilated patients of various ages. Low MAP has been associated with a lower incidence of 90-day mortality, shorter ICU stay, and shorter mechanical ventilation time. MAP also affects haemodynamics: there is evidence of a causal relationship between high MAP and low perfusion index, both of which are associated with poor prognosis in mechanically ventilated patients. Elevated MAP values have also been associated with high central venous pressure and lactate, which are indicative of ventilator-associated right ventricular failure and tissue hypoperfusion, respectively. MAP, therefore, is an important parameter to measure in clinical practice. The aim of this review has been to identify the determinants of MAP, the pros and cons of using MAP instead of traditional protective ventilation parameters, and the evidence that supports the use of MAP in clinical practice.
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Affiliation(s)
- A Placenti
- División de Anestesia, Analgesia y Reanimación, Hospital de Clínicas "José de San Martín", Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina.
| | - F Fratebianchi
- División de Anestesia, Analgesia y Reanimación, Hospital de Clínicas "José de San Martín", Universidad de Buenos Aires, Ciudad Autónoma de Buenos Aires, Argentina
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2
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Celli BR, Fabbri LM, Aaron SD, Agusti A, Brook R, Criner GJ, Franssen FME, Humbert M, Hurst JR, O'Donnell D, Pantoni L, Papi A, Rodriguez-Roisin R, Sethi S, Torres A, Vogelmeier CF, Wedzicha JA. An Updated Definition and Severity Classification of Chronic Obstructive Pulmonary Disease Exacerbations: The Rome Proposal. Am J Respir Crit Care Med 2021; 204:1251-1258. [PMID: 34570991 DOI: 10.1164/rccm.202108-1819pp] [Citation(s) in RCA: 105] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Bartolome R Celli
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Leonardo M Fabbri
- Section of Respiratory Medicine, Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Shawn D Aaron
- The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Alvar Agusti
- Universitat de Barcelona, Barcelona, Spain.,Institut Clínic Respiratori, Hospital Clínic de Barcelona, Barcelona, Spain.,Instituto de Investigaciones Biomédicas August Pi i Sunyer, Barcelona, Spain.,Centro de Investigación Biomédica en Red Enfermedades Respiratorias, Madrid, Spain
| | | | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Frits M E Franssen
- Department of Research and Education, CIRO, Horn, the Netherlands.,Department of Respiratory Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Marc Humbert
- Service de Pneumologie et Soins Intensifs Respiratoires, Hôpital Bicêtre, Assistance Publique-Hôpitaux de Paris, Le Kremlin-Bicêtre, France.,Université Paris-Saclay and Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche 999, Le Kremlin-Bicêtre, France
| | - John R Hurst
- UCL Respiratory, University College London, London, United Kingdom
| | - Denis O'Donnell
- Respiratory Investigation Unit, Queens University and Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Leonardo Pantoni
- "Luigi Sacco" Department of Biomedical and Clinical Sciences, University of Milan, Milan, Italy
| | - Alberto Papi
- Section of Respiratory Medicine, University of Ferrara, Ferrara, Italy.,Emergency Department, St. Anna University Hospital, Ferrara, Italy
| | - Roberto Rodriguez-Roisin
- Universitat de Barcelona, Barcelona, Spain.,Institut Clínic Respiratori, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Sanjay Sethi
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | - Antoni Torres
- Universitat de Barcelona, Barcelona, Spain.,Institut Clínic Respiratori, Hospital Clínic de Barcelona, Barcelona, Spain.,Instituto de Investigaciones Biomédicas August Pi i Sunyer, Barcelona, Spain.,Institució Catalana de Recerca i Estudis Avançats Acadèmia, Centre d'Investigació Biomèdica en Xarxa de Malalties Respiratòries, Barcelona, Spain
| | - Claus F Vogelmeier
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University Medical Center of Giessen and Marburg, Philipps University of Marburg, Member of the German Center for Lung Research (DZL), Marburg, Germany; and
| | - Jadwiga A Wedzicha
- Respiratory Division, National Heart and Lung Institute, Imperial College London, London, United Kingdom
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3
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Elliott AR, Kizhakke Puliyakote AS, Tedjasaputra V, Pazár B, Wagner H, Sá RC, Orr JE, Prisk GK, Wagner PD, Hopkins SR. Ventilation-perfusion heterogeneity measured by the multiple inert gas elimination technique is minimally affected by intermittent breathing of 100% O 2. Physiol Rep 2020; 8:e14488. [PMID: 32638530 PMCID: PMC7340847 DOI: 10.14814/phy2.14488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 05/04/2020] [Accepted: 05/07/2020] [Indexed: 11/24/2022] Open
Abstract
Proton magnetic resonance (MR) imaging to quantify regional ventilation-perfusion ( V ˙ A / Q ˙ ) ratios combines specific ventilation imaging (SVI) and separate proton density and perfusion measures into a composite map. Specific ventilation imaging exploits the paramagnetic properties of O2 , which alters the local MR signal intensity, in an FI O2 -dependent manner. Specific ventilation imaging data are acquired during five wash-in/wash-out cycles of breathing 21% O2 alternating with 100% O2 over ~20 min. This technique assumes that alternating FI O2 does not affect V ˙ A / Q ˙ heterogeneity, but this is unproven. We tested the hypothesis that alternating FI O2 exposure increases V ˙ A / Q ˙ mismatch in nine patients with abnormal pulmonary gas exchange and increased V ˙ A / Q ˙ mismatch using the multiple inert gas elimination technique (MIGET).The following data were acquired (a) breathing air (baseline), (b) breathing alternating air/100% O2 during an emulated-SVI protocol (eSVI), and (c) 20 min after ambient air breathing (recovery). MIGET heterogeneity indices of shunt, deadspace, ventilation versus V ˙ A / Q ˙ ratio, LogSD V ˙ , and perfusion versus V ˙ A / Q ˙ ratio, LogSD Q ˙ were calculated. LogSD V ˙ was not different between eSVI and baseline (1.04 ± 0.39 baseline, 1.05 ± 0.38 eSVI, p = .84); but was reduced compared to baseline during recovery (0.97 ± 0.39, p = .04). There was no significant difference in LogSD Q ˙ across conditions (0.81 ± 0.30 baseline, 0.79 ± 0.15 eSVI, 0.79 ± 0.20 recovery; p = .54); Deadspace was not significantly different (p = .54) but shunt showed a borderline increase during eSVI (1.0% ± 1.0 baseline, 2.6% ± 2.9 eSVI; p = .052) likely from altered hypoxic pulmonary vasoconstriction and/or absorption atelectasis. Intermittent breathing of 100% O2 does not substantially alter V ˙ A / Q ˙ matching and if SVI measurements are made after perfusion measurements, any potential effects will be minimized.
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Affiliation(s)
- Ann R. Elliott
- Department of MedicineUniversity of California San DiegoLa JollaCAUSA
- The Pulmonary Imaging LaboratoryUniversity of California San DiegoLa JollaCAUSA
| | - Abhilash S. Kizhakke Puliyakote
- The Pulmonary Imaging LaboratoryUniversity of California San DiegoLa JollaCAUSA
- Department of RadiologyUniversity of California San DiegoLa JollaCAUSA
| | - Vincent Tedjasaputra
- Department of MedicineUniversity of California San DiegoLa JollaCAUSA
- The Pulmonary Imaging LaboratoryUniversity of California San DiegoLa JollaCAUSA
| | - Beni Pazár
- The Pulmonary Imaging LaboratoryUniversity of California San DiegoLa JollaCAUSA
- Department of RadiologyUniversity of California San DiegoLa JollaCAUSA
| | - Harrieth Wagner
- Department of MedicineUniversity of California San DiegoLa JollaCAUSA
| | - Rui C. Sá
- Department of MedicineUniversity of California San DiegoLa JollaCAUSA
- The Pulmonary Imaging LaboratoryUniversity of California San DiegoLa JollaCAUSA
| | - Jeremy E. Orr
- Department of MedicineUniversity of California San DiegoLa JollaCAUSA
| | - G. Kim Prisk
- Department of MedicineUniversity of California San DiegoLa JollaCAUSA
- The Pulmonary Imaging LaboratoryUniversity of California San DiegoLa JollaCAUSA
- Department of RadiologyUniversity of California San DiegoLa JollaCAUSA
| | - Peter D. Wagner
- Department of MedicineUniversity of California San DiegoLa JollaCAUSA
| | - Susan R. Hopkins
- Department of MedicineUniversity of California San DiegoLa JollaCAUSA
- The Pulmonary Imaging LaboratoryUniversity of California San DiegoLa JollaCAUSA
- Department of RadiologyUniversity of California San DiegoLa JollaCAUSA
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Murphy C, Arad D. Case Report: Hepatopulmonary syndrome as the first clinical manifestation of cirrhosis in a patient with underlying chronic lung disease. F1000Res 2019; 7:1175. [PMID: 31354935 PMCID: PMC6635985 DOI: 10.12688/f1000research.15434.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2019] [Indexed: 11/20/2022] Open
Abstract
An 86 year old woman with multiple chronic lung diseases (including chronic obstructive pulmonary disease, bronchiectasis, and untreated mycobacterium avium-intracellulare) presented with two weeks of increased shortness of breath, notably worse when seated as compared to when lying down. After treatments focused on her known conditions did not resolve her dyspnea, the differential diagnosis was broadened and she was found to have evidence of cirrhosis on imaging. As a result of this new diagnosis, transthoracic echocardiography and arterial blood gas analysis were performed and together yielded the diagnosis of hepatopulmonary syndrome. We describe a rare presentation of hepatopulmonary syndrome manifesting as a patient’s first clinical evidence of suspected cirrhosis, a diagnosis made difficult by this patient’s numerous other lung diseases which muddied the picture.
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Affiliation(s)
- Charles Murphy
- Internal Medicine, Montefiore Medical Center, Bronx, Bronx, NY, 10029, USA
| | - Danit Arad
- Internal Medicine, Montefiore Medical Center, Bronx, Bronx, NY, 10029, USA
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5
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Rodríguez-Roisin R, Krowka MJ, Agustí A. Hepatopulmonary Disorders: Gas Exchange and Vascular Manifestations in Chronic Liver Disease. Compr Physiol 2018; 8:711-729. [PMID: 29687908 DOI: 10.1002/cphy.c170020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
This review concentrates on the determinants of gas exchange abnormalities in liver-induced pulmonary vascular disorders, more specifically in the hepatopulmonary syndrome. Increased alveolar-arterial O2 difference, with or without different levels of arterial hypoxemia, and reduced diffusing capacity represent the most characteristic gas exchange disturbances in the absence of cardiac and pulmonary comorbidities. Pulmonary gas exchange abnormalities in the hepatopulmonary syndrome are unique encompassing all three pulmonary factors determining arterial PO2 , that is, ventilation-perfusion imbalance, increased intrapulmonary shunt and oxygen diffusion limitation that, combined, interplay with two relevant nonpulmonary determinants, that is, increased total ventilation and high cardiac output. Behind the complexity of this lung-liver association there is an abnormal pulmonary vascular tone that combines inhibition of hypoxic pulmonary vasoconstriction with a reduced (or blunted) hypoxic vascular response. The pathology and pathobiology include the presence of intrapulmonary vascular dilatations with or without pulmonary vascular remodeling, i.e. angiogenesis. Liver transplantation, the only effective therapeutic approach to successfully improve and resolve the vast majority of complications induced by the hepatopulmonary syndrome, along with a large list of frustrating pharmacologic interventions, are also reviewed. Another liver-induced pulmonary vascular disorder with less gas exchange involvement, such as portopulmonary hypertension, is also considered. © 2018 American Physiological Society. Compr Physiol 8:711-729, 2018.
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Affiliation(s)
- Robert Rodríguez-Roisin
- Department of Medicine, Universitat de Barcelona (UB), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona
| | - Michael J Krowka
- Division of Pulmonary and Critical Care, Transplant Research Center, Mayo Clinic, Rochester, MN, US
| | - Alvar Agustí
- Service of Pneumology, Respiratory Institute, Hospital Clínic, UB, Centro de Investigaciones Biomédicas en Red sobre Enfermedades Respiratorias (CIBERES), Barcelona
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6
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Radermacher P, Maggiore SM, Mercat A. FiftyYears ofResearch inARDS.Gas Exchange in Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017; 196:964-984. [DOI: 10.1164/rccm.201610-2156so] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Peter Radermacher
- Institute of Anaesthesiological Pathophysiology and Process Engineering, University Medical School, Ulm, Germany
| | - Salvatore Maurizio Maggiore
- Section of Anesthesia, Analgesia, Perioperative, and Intensive Care, Department of Medical, Oral, and Biotechnological Sciences, School of Medicine and Health Sciences, “SS. Annunziata” Hospital, “Gabriele d’Annunzio” University of Chieti-Pescara, Chieti, Italy; and
| | - Alain Mercat
- Department of Medical Intensive Care and Hyperbaric Medicine, Angers University Hospital, Angers, France
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7
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DuBrock HM, Krowka MJ, Forde KA, Krok K, Patel M, Sharkoski T, Sprys M, Lin G, Oh JK, Mottram CD, Scanlon PD, Fallon MB, Kawut SM. Clinical Impact of Intrapulmonary Vascular Dilatation in Candidates for Liver Transplant. Chest 2017; 153:414-426. [PMID: 28987478 DOI: 10.1016/j.chest.2017.09.035] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 07/17/2017] [Accepted: 09/06/2017] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Intrapulmonary vascular dilatations (IPVD) frequently are detected in patients with liver disease by the delayed appearance of microbubbles at contrast-enhanced echocardiography. IPVD with an elevated alveolar-arterial (A-a) gradient define hepatopulmonary syndrome (HPS); however, the importance of IPVD in the absence of abnormal gas exchange is unknown. We aimed to determine the clinical impact of IPVD in patients with liver disease. METHODS We performed a cross-sectional study within the Pulmonary Vascular Complications of Liver Disease 2 Study, a multicenter, prospective cohort study of patients being evaluated for liver transplant. We excluded patients with obstructive or restrictive lung disease, HPS, or intracardiac shunting. We compared patients with and those without IPVD. RESULTS Forty-six patients with IPVD and 81 patients without IPVD were included. Patients with IPVD were more likely to have autoimmune hepatitis and less likely to have cryptogenic cirrhosis and hepatocellular carcinoma. Patients with IPVD had higher Child-Pugh scores (6 [interquartile range (IQR), 5-7] vs 5 [IQR, 4-7]; P = .04), possibly higher Model for End-Stage Liver Disease scores (14.5 [IQR, 11.6-15.8] vs 12.2 [IQR, 9.4-15.5]; P = .06), higher PaO2 levels (97.9 [IQR, 92.0-103.0] vs 89.0 [IQR, 82.0-96.9] mm Hg; P < .001), and lower A-a gradients (9.9 [IQR, 6.2-13.5] vs 14.9 [IQR, 9.0-21.8] mm Hg; P < .001). Symptoms and quality of life were similar between the groups. CONCLUSIONS Autoimmune hepatitis and increased liver disease severity were associated with the presence of IPVD, which was characterized by higher PaO2 levels. Future studies to better characterize IPVD pathogenesis and the relationship of IPVD to HPS are warranted.
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Affiliation(s)
- Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - Michael J Krowka
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Kimberly A Forde
- Center for Clinical Epidemiology and Biostatistics and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Karen Krok
- Division of Gastroenterology, Department of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Mamta Patel
- Center for Clinical Epidemiology and Biostatistics and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tiffany Sharkoski
- Center for Clinical Epidemiology and Biostatistics and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael Sprys
- Center for Clinical Epidemiology and Biostatistics and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Grace Lin
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Jae K Oh
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Carl D Mottram
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Paul D Scanlon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Steven M Kawut
- Center for Clinical Epidemiology and Biostatistics and the Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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