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De Mey J, Depuydt P. Big Breaths for Small Lungs: Clinician Oversight or Compensation for Dead Space? Chest 2024; 166:e67-e68. [PMID: 39122311 DOI: 10.1016/j.chest.2024.02.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 02/29/2024] [Indexed: 08/12/2024] Open
Affiliation(s)
- Jan De Mey
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium.
| | - Pieter Depuydt
- Department of Intensive Care, Ghent University Hospital, Ghent, Belgium
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Shimoda T, Sekino M, Higashijima U, Matsumoto S, Sato S, Yano R, Egashira T, Araki H, Naoya I, Miki S, Koyanagi R, Hayashi M, Kurihara S, Hara T. Removal of a catheter mount and heat-and-moisture exchanger improves hypercapnia in patients with acute respiratory distress syndrome: A retrospective observational study. Medicine (Baltimore) 2021; 100:e27199. [PMID: 34516524 PMCID: PMC8428744 DOI: 10.1097/md.0000000000027199] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 07/29/2021] [Accepted: 08/24/2021] [Indexed: 01/05/2023] Open
Abstract
ABSTRACT To avoid ventilator-associated lung injury in acute respiratory distress syndrome (ARDS) treatment, respiratory management should be performed at a low tidal volume of 6 to 8 mL/kg and plateau pressure of ≤30 cmH2O. However, such lung-protective ventilation often results in hypercapnia, which is a risk factor for poor outcomes. The purpose of this study was to retrospectively evaluate the effectiveness and safety of the removal of a catheter mount (CM) and using heated humidifiers (HH) instead of a heat-and-moisture exchanger (HME) for reducing the mechanical dead space created by the CM and HME, which may improve hypercapnia in patients with ARDS.This retrospective observational study included adult patients with ARDS, who developed hypercapnia (PaCO2 > 45 mm Hg) during mechanical ventilation, with target tidal volumes between 6 and 8 mL/kg and a plateau pressure of ≤30 cmH2O, and underwent stepwise removal of CM and HME (replaced with HH). The PaCO2 values were measured at 3 points: ventilator circuit with CM and HME (CM + HME) use, with HME (HME), and with HH (HH), and the overall number of accidental extubations was evaluated. Ventilator values (tidal volume, respiratory rate, minutes volume) were evaluated at the same points.A total of 21 patients with mild-to-moderate ARDS who were treated under deep sedation were included. The values of PaCO2 at HME (52.7 ± 7.4 mm Hg, P < .0001) and HH (46.3 ± 6.8 mm Hg, P < .0001) were significantly lower than those at CM + HME (55.9 ± 7.9 mm Hg). Measured ventilator values were similar at CM + HME, HME, and HH. There were no cases of reintubation due to accidental extubation after the removal of CM.The removal of CM and HME reduced PaCO2 values without changing the ventilator settings in deeply sedated patients with mild-to-moderate ARDS on lung-protective ventilation. Caution should be exercised, as the removal of a CM may result in circuit disconnection or accidental extubation. Nevertheless, this intervention may improve hypercapnia and promote lung-protective ventilation.
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Affiliation(s)
- Takaya Shimoda
- Medical Engineering Equipment Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Motohiro Sekino
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ushio Higashijima
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Sojiro Matsumoto
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shuntaro Sato
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Rintaro Yano
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Takashi Egashira
- Department of Intensive Care, Nagasaki Harbor Medical Center, Nagasaki, Japan
| | - Hiroshi Araki
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Iwasaki Naoya
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Suzumura Miki
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ryo Koyanagi
- Medical Engineering Equipment Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Makoto Hayashi
- Medical Engineering Equipment Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Shintaro Kurihara
- Medical Engineering Equipment Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Tetsuya Hara
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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3
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Decrease Dead Space Prior to Calling the ECMO! Chest 2021; 159:1682-1683. [PMID: 34022003 DOI: 10.1016/j.chest.2020.11.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 11/23/2022] Open
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Picazo L, Gracia Arnillas MP, Muñoz-Bermúdez R, Durán X, Álvarez Lerma F, Masclans JR. Active humidification in mechanical ventilation is not associated to an increase in respiratory infectious complications in a quasi-experimental pre-post intervention study. Med Intensiva 2020; 45:354-361. [PMID: 34294233 DOI: 10.1016/j.medine.2019.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 11/19/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE There is controversy regarding the influence of humidification systems upon the incidence of respiratory infections associated to invasive mechanical ventilation (IMV). An evaluation was made of the differences in the incidence of pneumonia and tracheobronchitis associated to mechanical ventilation (VAP and VAT, respectively) with passive and active humidification. DESIGN A retrospective pre-post quasi-experimental study was carried out. SETTING A polyvalent ICU with 14 beds. PATIENTS All patients connected to IMV for >48h during 2014 and 2016 were included. INTERVENTIONS During 2014, passive humidification with an hygroscopic heat and moisture exchanger (HME) was used, while during 2016 active humidification with a heated humidifier (HH) and an inspiratory heated wire was used. Identical measures for the prevention of VAP were established (Zero Pneumonia Project). MAIN OUTCOME MEASURES The incidence of VAP and VAT was estimated for 1000 days of IMV in both groups, and statistically significant differences were assessed using Poisson regression analysis. RESULTS A total of 287 patients were included (116 with HME and 171 with HH). The incidence density of VAP per 1000 days of IMV was 5.68 in the HME group and 5.80 in the HH group (p=ns). The incidence density of VAT was 3.41 and 3.26 cases per 1000 days of VMI with HME and HH respectively (p=ns). The duration of IMV was identified as a risk factor for VAP. CONCLUSIONS In our population, active humidification in patients ventilated for >48h was not associated to an increase in respiratory infectious complications.
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Affiliation(s)
- L Picazo
- Servicio de Medicina Intensiva, Hospital del Mar, Barcelona, Spain; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | - M P Gracia Arnillas
- Servicio de Medicina Intensiva, Hospital del Mar, Barcelona, Spain; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | - R Muñoz-Bermúdez
- Servicio de Medicina Intensiva, Hospital del Mar, Barcelona, Spain; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | - X Durán
- Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain
| | - F Álvarez Lerma
- Servicio de Medicina Intensiva, Hospital del Mar, Barcelona, Spain; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - J R Masclans
- Servicio de Medicina Intensiva, Hospital del Mar, Barcelona, Spain; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, Spain; Universitat Autònoma de Barcelona (UAB), Barcelona, Spain.
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Pitoni S, D'Arrigo S, Grieco DL, Idone FA, Santantonio MT, Di Giannatale P, Ferrieri A, Natalini D, Eleuteri D, Jonson B, Antonelli M, Maggiore SM. Tidal Volume Lowering by Instrumental Dead Space Reduction in Brain-Injured ARDS Patients: Effects on Respiratory Mechanics, Gas Exchange, and Cerebral Hemodynamics. Neurocrit Care 2020; 34:21-30. [PMID: 32323146 PMCID: PMC7224122 DOI: 10.1007/s12028-020-00969-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Limiting tidal volume (VT), plateau pressure, and driving pressure is essential during the acute respiratory distress syndrome (ARDS), but may be challenging when brain injury coexists due to the risk of hypercapnia. Because lowering dead space enhances CO2 clearance, we conducted a study to determine whether and to what extent replacing heat and moisture exchangers (HME) with heated humidifiers (HH) facilitate safe VT lowering in brain-injured patients with ARDS. Methods Brain-injured patients (head trauma or spontaneous cerebral hemorrhage with Glasgow Coma Scale at admission < 9) with mild and moderate ARDS received three ventilatory strategies in a sequential order during continuous paralysis: (1) HME with VT to obtain a PaCO2 within 30–35 mmHg (HME1); (2) HH with VT titrated to obtain the same PaCO2 (HH); and (3) HME1 settings resumed (HME2). Arterial blood gases, static and quasi-static respiratory mechanics, alveolar recruitment by multiple pressure–volume curves, intracranial pressure, cerebral perfusion pressure, mean arterial pressure, and mean flow velocity in the middle cerebral artery by transcranial Doppler were recorded. Dead space was measured and partitioned by volumetric capnography. Results Eighteen brain-injured patients were studied: 7 (39%) had mild and 11 (61%) had moderate ARDS. At inclusion, median [interquartile range] PaO2/FiO2 was 173 [146–213] and median PEEP was 8 cmH2O [5–9]. HH allowed to reduce VT by 120 ml [95% CI: 98–144], VT/kg predicted body weight by 1.8 ml/kg [95% CI: 1.5–2.1], plateau pressure and driving pressure by 3.7 cmH2O [2.9–4.3], without affecting PaCO2, alveolar recruitment, and oxygenation. This was permitted by lower airway (− 84 ml [95% CI: − 79 to − 89]) and total dead space (− 86 ml [95% CI: − 73 to − 98]). Sixteen patients (89%) showed driving pressure equal or lower than 14 cmH2O while on HH, as compared to 7 (39%) and 8 (44%) during HME1 and HME2 (p < 0.001). No changes in mean arterial pressure, cerebral perfusion pressure, intracranial pressure, and middle cerebral artery mean flow velocity were documented during HH. Conclusion The dead space reduction provided by HH allows to safely reduce VT without modifying PaCO2 nor cerebral perfusion. This permits to provide a wider proportion of brain-injured ARDS patients with less injurious ventilation.
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Affiliation(s)
- Sara Pitoni
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Sonia D'Arrigo
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Francesco Antonio Idone
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Maria Teresa Santantonio
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Pierluigi Di Giannatale
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia, Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Via dei Vestini, 66100, Chieti, Italy
| | - Alessandro Ferrieri
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia, Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Via dei Vestini, 66100, Chieti, Italy
| | - Daniele Natalini
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Davide Eleuteri
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Bjorn Jonson
- Clinical Physiology, Skane University Hospital, 221 85, Lund, Sweden
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Salvatore Maurizio Maggiore
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia, Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Via dei Vestini, 66100, Chieti, Italy.
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Picazo L, Gracia Arnillas MP, Muñoz-Bermúdez R, Durán X, Álvarez Lerma F, Masclans JR. Active humidification in mechanical ventilation is not associated to an increase in respiratory infectious complications in a quasi-experimental pre-post intervention study. Med Intensiva 2020. [PMID: 31924444 DOI: 10.1016/j.medin.2019.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE There is controversy regarding the influence of humidification systems upon the incidence of respiratory infections associated to invasive mechanical ventilation (IMV). An evaluation was made of the differences in the incidence of pneumonia and tracheobronchitis associated to mechanical ventilation (VAP and VAT, respectively) with passive and active humidification. DESIGN A retrospective pre-post quasi-experimental study was carried out. SETTING A polyvalent ICU with 14 beds. PATIENTS All patients connected to IMV for>48hours during 2014 and 2016 were included. INTERVENTIONS During 2014, passive humidification with an hygroscopic heat and moisture exchanger (HME) was used, while during 2016 active humidification with a heated humidifier (HH) and an inspiratory heated wire was used. Identical measures for the prevention of VAP were established (Zero Pneumonia Project). MAIN OUTCOME MEASURES The incidence of VAP and VAT was estimated for 1000 days of IMV in both groups, and statistically significant differences were assessed using Poisson regression analysis. RESULTS A total of 287 patients were included (116 with HME and 171 with HH). The incidence density of VAP per 1000 days of IMV was 5.68 in the HME group and 5.80 in the HH group (p=ns). The incidence density of VAT was 3.41 and 3.26 cases per 1000 days of VMI with HME and HH respectively (p=ns). The duration of IMV was identified as a risk factor for VAP. CONCLUSIONS In our population, active humidification in patients ventilated for>48hours was not associated to an increase in respiratory infectious complications.
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Affiliation(s)
- L Picazo
- Servicio de Medicina Intensiva, Hospital del Mar, Barcelona, España; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España
| | - M P Gracia Arnillas
- Servicio de Medicina Intensiva, Hospital del Mar, Barcelona, España; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España
| | - R Muñoz-Bermúdez
- Servicio de Medicina Intensiva, Hospital del Mar, Barcelona, España; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España
| | - X Durán
- Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España
| | - F Álvarez Lerma
- Servicio de Medicina Intensiva, Hospital del Mar, Barcelona, España; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España; Universitat Autònoma de Barcelona (UAB), Barcelona, España
| | - J R Masclans
- Servicio de Medicina Intensiva, Hospital del Mar, Barcelona, España; Instituto Hospital del Mar de Investigaciones Médicas (IMIM), Barcelona, España; Universitat Autònoma de Barcelona (UAB), Barcelona, España.
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Plotnikow GA, Accoce M, Navarro E, Tiribelli N. Humidification and heating of inhaled gas in patients with artificial airway. A narrative review. Rev Bras Ter Intensiva 2018; 30:86-97. [PMID: 29742220 PMCID: PMC5885236 DOI: 10.5935/0103-507x.20180015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 08/30/2017] [Indexed: 01/15/2023] Open
Abstract
Instrumentation of the airways in critical patients (endotracheal tube or
tracheostomy cannula) prevents them from performing their function of humidify
and heating the inhaled gas. In addition, the administration of cold and dry
medical gases and the high flows that patients experience during invasive and
non-invasive mechanical ventilation generate an even worse condition. For this
reason, a device for gas conditioning is needed, even in short-term treatments,
to avoid potential damage to the structure and function of the respiratory
epithelium. In the field of intensive therapy, the use of heat and moisture
exchangers is common for this purpose, as is the use of active humidification
systems. Acquiring knowledge about technical specifications and the advantages
and disadvantages of each device is needed for proper use since the conditioning
of inspired gases is a key intervention in patients with artificial airway and
has become routine care. Incorrect selection or inappropriate configuration of a
device can have a negative impact on clinical outcomes. The members of the
Capítulo de Kinesiología Intensivista of the
Sociedad Argentina de Terapia Intensiva conducted a
narrative review aiming to show the available evidence regarding conditioning of
inhaled gas in patients with artificial airways, going into detail on concepts
related to the working principles of each one.
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Affiliation(s)
- Gustavo Adrián Plotnikow
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, Buenos Aires, Argentina
| | - Matias Accoce
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, Buenos Aires, Argentina
| | - Emiliano Navarro
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, Buenos Aires, Argentina
| | - Norberto Tiribelli
- Capítulo de Kinesiología Intensivista, Sociedad Argentina de Terapia Intensiva, Buenos Aires, Argentina
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Lucato JJJ, Cunha TMND, Reis AMD, Picanço PSDA, Barbosa RCC, Liberali J, Righetti RF. Ventilatory changes during the use of heat and moisture exchangers in patients submitted to mechanical ventilation with support pressure and adjustments in ventilation parameters to compensate for these possible changes: a self-controlled intervention study in humans. Rev Bras Ter Intensiva 2018; 29:163-170. [PMID: 28977257 PMCID: PMC5496750 DOI: 10.5935/0103-507x.20170026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 02/03/2017] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To evaluate the possible changes in tidal volume, minute volume and respiratory rate caused by the use of a heat and moisture exchanger in patients receiving pressure support mechanical ventilation and to quantify the variation in pressure support required to compensate for the effect caused by the heat and moisture exchanger. METHODS Patients under invasive mechanical ventilation in pressure support mode were evaluated using heated humidifiers and heat and moisture exchangers. If the volume found using the heat and moisture exchangers was lower than that found with the heated humidifier, an increase in pressure support was initiated during the use of the heat and moisture exchanger until a pressure support value was obtained that enabled the patient to generate a value close to the initial tidal volume obtained with the heated humidifier. The analysis was performed by means of the paired t test, and incremental values were expressed as percentages of increase required. RESULTS A total of 26 patients were evaluated. The use of heat and moisture exchangers increased the respiratory rate and reduced the tidal and minute volumes compared with the use of the heated humidifier. Patients required a 38.13% increase in pressure support to maintain previous volumes when using the heat and moisture exchanger. CONCLUSION The heat and moisture exchanger changed the tidal and minute volumes and respiratory rate parameters. Pressure support was increased to compensate for these changes.
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Affiliation(s)
| | | | - Aline Mela Dos Reis
- Departamento de Pacientes Graves, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | | | | | - Joyce Liberali
- Curso de Fisioterapia, Centro Universitário São Camilo - São Paulo (SP), Brasil
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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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Gillies D, Todd DA, Foster JP, Batuwitage BT. Heat and moisture exchangers versus heated humidifiers for mechanically ventilated adults and children. Cochrane Database Syst Rev 2017; 9:CD004711. [PMID: 28905374 PMCID: PMC6483749 DOI: 10.1002/14651858.cd004711.pub3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Invasive ventilation is used to assist or replace breathing when a person is unable to breathe adequately on their own. Because the upper airway is bypassed during mechanical ventilation, the respiratory system is no longer able to warm and moisten inhaled gases, potentially causing additional breathing problems in people who already require assisted breathing. To prevent these problems, gases are artificially warmed and humidified. There are two main forms of humidification, heat and moisture exchangers (HME) or heated humidifiers (HH). Both are associated with potential benefits and advantages but it is unclear whether HME or HH are more effective in preventing some of the negative outcomes associated with mechanical ventilation. This review was originally published in 2010 and updated in 2017. OBJECTIVES To assess whether heat and moisture exchangers or heated humidifiers are more effective in preventing complications in people receiving invasive mechanical ventilation and to identify whether the age group of participants, length of humidification, type of HME, and ventilation delivered through a tracheostomy had an effect on these findings. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and CINAHL up to May 2017 to identify randomized controlled trials (RCTs) and reference lists of included studies and relevant reviews. There were no language limitations. SELECTION CRITERIA We included RCTs comparing HMEs to HHs in adults and children receiving invasive ventilation. We included randomized cross-over studies. DATA COLLECTION AND ANALYSIS We assessed the quality of each study and extracted the relevant data. Where possible, we analysed data through meta-analysis. For dichotomous outcomes, we calculated the risk ratio (RR) and 95% confidence interval (95% CI). For continuous outcomes, we calculated the mean difference (MD) and 95% CI or standardized mean difference (SMD) and 95% CI for parallel studies. For cross-over trials, we calculated the MD and 95% CI using correlation estimates to correct for paired analyses. We aimed to conduct subgroup analyses based on the age group of participants, how long they received humidification, type of HME and whether ventilation was delivered through a tracheostomy. We also conducted sensitivity analysis to identify whether the quality of trials had an effect on meta-analytic findings. MAIN RESULTS We included 34 trials with 2848 participants; 26 studies were parallel-group design (2725 participants) and eight used a cross-over design (123 participants). Only three included studies reported data for infants or children. Two further studies (76 participants) are awaiting classification.There was no overall statistical difference in artificial airway occlusion (RR 1.59, 95% CI 0.60 to 4.19; participants = 2171; studies = 15; I2 = 54%), mortality (RR 1.03, 95% CI 0.89 to 1.20; participants = 1951; studies = 12; I2 = 0%) or pneumonia (RR 0.93, 95% CI 0.73 to 1.19; participants = 2251; studies = 13; I2 = 27%). There was some evidence that hydrophobic HMEs may reduce the risk of pneumonia compared to HHs (RR 0.48, 95% CI 0.28 to 0.82; participants = 469; studies = 3; I2 = 0%)..The overall GRADE quality of evidence was low. Although the overall methodological risk of bias was generally unclear for selection and detection bias and low risk for follow-up, the selection of study participants who were considered suitable for HME and in some studies removing participants from the HME group made the findings of this review difficult to generalize. AUTHORS' CONCLUSIONS The available evidence suggests no difference between HMEs and HHs on the primary outcomes of airway blockages, pneumonia and mortality. However, the overall low quality of this evidence makes it difficult to be confident about these findings. Further research is needed to compare HMEs to HHs, particularly in paediatric and neonatal populations, but research is also needed to more effectively compare different types of HME to each other as well as different types of HH.
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Affiliation(s)
| | - David A Todd
- The Canberra HospitalNeonatal UnitCentre for Newborn CarePO Box 11, WodenCanberraACTAustralia2606
| | - Jann P Foster
- Western Sydney UniversitySchool of Nursing and MidwiferyPenrith DCAustralia
| | - Bisanth T Batuwitage
- Queen Alexandra Hospital, Portsmouth Hospitals NHS TrustDepartment of AnaesthesiaSouthwick Hill RoadPortsmouthUKPO6 3LY
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Vargas M, Chiumello D, Sutherasan Y, Ball L, Esquinas AM, Pelosi P, Servillo G. Heat and moisture exchangers (HMEs) and heated humidifiers (HHs) in adult critically ill patients: a systematic review, meta-analysis and meta-regression of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:123. [PMID: 28552074 PMCID: PMC5447307 DOI: 10.1186/s13054-017-1710-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 05/09/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND The aims of this systematic review and meta-analysis of randomized controlled trials are to evaluate the effects of active heated humidifiers (HHs) and moisture exchangers (HMEs) in preventing artificial airway occlusion and pneumonia, and on mortality in adult critically ill patients. In addition, we planned to perform a meta-regression analysis to evaluate the relationship between the incidence of artificial airway occlusion, pneumonia and mortality and clinical features of adult critically ill patients. METHODS Computerized databases were searched for randomized controlled trials (RCTs) comparing HHs and HMEs and reporting artificial airway occlusion, pneumonia and mortality as predefined outcomes. Relative risk (RR), 95% confidence interval for each outcome and I 2 were estimated for each outcome. Furthermore, weighted random-effect meta-regression analysis was performed to test the relationship between the effect size on each considered outcome and covariates. RESULTS Eighteen RCTs and 2442 adult critically ill patients were included in the analysis. The incidence of artificial airway occlusion (RR = 1.853; 95% CI 0.792-4.338), pneumonia (RR = 932; 95% CI 0.730-1.190) and mortality (RR = 1.023; 95% CI 0.878-1.192) were not different in patients treated with HMEs and HHs. However, in the subgroup analyses the incidence of airway occlusion was higher in HMEs compared with HHs with non-heated wire (RR = 3.776; 95% CI 1.560-9.143). According to the meta-regression, the effect size in the treatment group on artificial airway occlusion was influenced by the percentage of patients with pneumonia (β = -0.058; p = 0.027; favors HMEs in studies with high prevalence of pneumonia), and a trend was observed for an effect of the duration of mechanical ventilation (MV) (β = -0.108; p = 0.054; favors HMEs in studies with longer MV time). CONCLUSIONS In this meta-analysis we found no superiority of HMEs and HHs, in terms of artificial airway occlusion, pneumonia and mortality. A trend favoring HMEs was observed in studies including a high percentage of patients with pneumonia diagnosis at admission and those with prolonged MV. However, the choice of humidifiers should be made according to the clinical context, trying to avoid possible complications and reaching the appropriate performance at lower costs.
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Affiliation(s)
- Maria Vargas
- Department of Neurosciences, Reproductive and Odonthostomatological Sciences, University of Naples "Federico II", Naples, Italy.
| | - Davide Chiumello
- Dipartimento di Emergenza - Urgenza, ASST Santi Paolo e Carlo; Dipartimento di Scienze della salute, Università degli Studi di Milano, Milan, Italy
| | - Yuda Sutherasan
- Division of pulmonary and critical care medicine, Faculty of medicine Ramathibodi hospital, Mahidol University, 270 RAMA VI road, Bangkok, 10400, Thailand
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, AOU IRCCS San Martino- IST, University of Genoa, Genoa, Italy
| | | | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, AOU IRCCS San Martino- IST, University of Genoa, Genoa, Italy
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odonthostomatological Sciences, University of Naples "Federico II", Naples, Italy
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The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia. Intensive Care Med 2016; 42:699-711. [PMID: 27040102 PMCID: PMC4828494 DOI: 10.1007/s00134-016-4325-4] [Citation(s) in RCA: 119] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Accepted: 03/10/2016] [Indexed: 12/28/2022]
Abstract
Purpose Severe ARDS is often associated with refractory hypoxemia, and early identification and treatment of hypoxemia is mandatory. For the management of severe ARDS ventilator settings, positioning therapy, infection control, and supportive measures are essential to improve survival. Methods and results A precise definition of life-threating hypoxemia is not identified. Typical clinical determinations are: arterial partial pressure of oxygen < 60 mmHg and/or arterial oxygenation < 88 % and/or the ratio of PaO2/FIO2 < 100. For mechanical ventilation specific settings are recommended: limitation of tidal volume (6 ml/kg predicted body weight), adequate high PEEP (>12 cmH2O), a recruitment manoeuvre in special situations, and a ‘balanced’ respiratory rate (20-30/min). Individual bedside methods to guide PEEP/recruitment (e.g., transpulmonary pressure) are not (yet) available. Prone positioning [early (≤ 48 hrs after onset of severe ARDS) and prolonged (repetition of 16-hr-sessions)] improves survival. An advanced infection management/control includes early diagnosis of bacterial, atypical, viral and fungal specimen (blood culture, bronchoalveolar lavage), and of infection sources by CT scan, followed by administration of broad-spectrum anti-infectives. Neuromuscular blockage (Cisatracurium ≤ 48 hrs after onset of ARDS), as well as an adequate sedation strategy (score guided) is an important supportive therapy. A negative fluid balance is associated with improved lung function and the use of hemofiltration might be indicated for specific indications. Conclusions A specific standard of care is required for the management of severe ARDS with refractory hypoxemia.
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Prat G, Guinard S, Bizien N, Nowak E, Tonnelier JM, Alavi Z, Renault A, Boles JM, L'Her E. Can lung ultrasonography predict prone positioning response in acute respiratory distress syndrome patients? J Crit Care 2015; 32:36-41. [PMID: 26806842 DOI: 10.1016/j.jcrc.2015.12.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 11/18/2015] [Accepted: 12/18/2015] [Indexed: 12/23/2022]
Abstract
PURPOSE The purpose was to assess whether lung ultrasonography (L-US) is a useful tool in prediction of prone positioning (PP) oxygenation response in patients with acute respiratory distress syndrome (ARDS). METHODS In a prospective study, 19 ARDS patients were included for assessment of PP oxygenation response. The latter was assessed for at least 12 hours 6 different ultrasonography windows were performed on each hemithorax before prone (H0, H2, H12 before return to supine and at H14 (2 hours after return to supine). Patients were classified into 2 groups (responders / non responders) according their oxygenation response to PP. Ultrasonography videos were blindly evaluated by 3 expert clinicians to classify lung regions as "normal", "moderate loss of aeration," "severe loss of aeration," or "lung consolidation." Oxygenation parameters were collected at H0, H2, and H14. RESULTS Association of each lung region aspect to PP oxygenation response was compared between the 2 groups. The normal aspect of the anterobasal regions was significantly associated with the oxygenation response (P = .0436), with a positive predictive value equal to or near 100%. DISCUSSION Our results demonstrated that a simple and short L-US examination could be a useful tool in prediction of PP oxygenation response in ARDS patients. A normal L-US pattern of both anterobasal lung regions in supine position may predict a significant PaO2/FIO2 ratio improvement.
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Affiliation(s)
- Gwenaël Prat
- Réanimation Médicale, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France.
| | - Solène Guinard
- Réanimation Médicale, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France.
| | - Nicolas Bizien
- Réanimation Médicale, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France.
| | - Emmanuel Nowak
- UBO, CIC INSERM 1412, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France.
| | - Jean-Marie Tonnelier
- Réanimation Médicale, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France.
| | - Zarrin Alavi
- UBO, CIC INSERM 1412, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France.
| | - Anne Renault
- Réanimation Médicale, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France.
| | - Jean-Michel Boles
- Réanimation Médicale, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France.
| | - Erwan L'Her
- Réanimation Médicale, CHRU de la Cavale Blanche, Bvd Tanguy-Prigent, 29609 Brest Cedex, France; LATIM INSERM UMR1101, CHRU de Brest, Université de Bretagne Occidentale, 29200 Brest, France.
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Lellouche F. Quelle technique d’humidification pour la ventilation invasive et non invasive ? MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1131-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Lellouche F, Delorme M, Bussières J, Ouattara A. Perioperative ventilatory strategies in cardiac surgery. Best Pract Res Clin Anaesthesiol 2015; 29:381-95. [PMID: 26643102 PMCID: PMC10068651 DOI: 10.1016/j.bpa.2015.08.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 08/22/2015] [Accepted: 08/26/2015] [Indexed: 01/19/2023]
Abstract
Recent data promote the utilization of prophylactic protective ventilation even in patients without acute respiratory distress syndrome (ARDS), and especially after cardiac surgery. The implementation of specific perioperative ventilatory strategies in patients undergoing cardiac surgery can improve both respiratory and extra-pulmonary outcomes. Protective ventilation is not limited to tidal volume reduction. The major components of ventilatory management include assist-controlled mechanical ventilation with low tidal volumes (6-8 mL kg(-1) of predicted body weight) associated with higher positive end-expiratory pressure (PEEP), limitation of fraction of inspired oxygen (FiO2), ventilation maintenance during cardiopulmonary bypass, and finally recruitment maneuvers. In order for such strategies to be fully effective, they should be integrated into a multimodal approach beginning from the induction and continuing over the postoperative period.
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Affiliation(s)
- François Lellouche
- Institut Universitaire de Cardiologie et Pneumologie de Québec, Faculté de Médecine, Université Laval, Ville de Québec, Canada.
| | - Mathieu Delorme
- Institut Universitaire de Cardiologie et Pneumologie de Québec, Faculté de Médecine, Université Laval, Ville de Québec, Canada; CHU de Bordeaux, Service d'Anesthésie-Réanimation II, Univ. Bordeaux, Adaptation Cardiovasculaire à l'ischémie, U1034 et INSERM, Adaptation Cardiovasculaire à l'ischémie, U1034, F-33600 Pessac, France.
| | - Jean Bussières
- Institut Universitaire de Cardiologie et Pneumologie de Québec, Faculté de Médecine, Université Laval, Ville de Québec, Canada.
| | - Alexandre Ouattara
- CHU de Bordeaux, Service d'Anesthésie-Réanimation II, Univ. Bordeaux, Adaptation Cardiovasculaire à l'ischémie, U1034 et INSERM, Adaptation Cardiovasculaire à l'ischémie, U1034, F-33600 Pessac, France.
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Cerpa F, Cáceres D, Romero-Dapueto C, Giugliano-Jaramillo C, Pérez R, Budini H, Hidalgo V, Gutiérrez T, Molina J, Keymer J. Humidification on Ventilated Patients: Heated Humidifications or Heat and Moisture Exchangers? Open Respir Med J 2015; 9:104-11. [PMID: 26312102 PMCID: PMC4541464 DOI: 10.2174/1874306401509010104] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 04/16/2015] [Accepted: 04/16/2015] [Indexed: 12/16/2022] Open
Abstract
The normal physiology of conditioning of inspired gases is altered when the patient requires an artificial airway access and an invasive mechanical ventilation (IMV). The endotracheal tube (ETT) removes the natural mechanisms of filtration, humidification and warming of inspired air. Despite the noninvasive ventilation (NIMV) in the upper airways, humidification of inspired gas may not be optimal mainly due to the high flow that is being created by the leakage compensation, among other aspects. Any moisture and heating deficit is compensated by the large airways of the tracheobronchial tree, these are poorly suited for this task, which alters mucociliary function, quality of secretions, and homeostasis gas exchange system. To avoid the occurrence of these events, external devices that provide humidification, heating and filtration have been developed, with different degrees of evidence that support their use.
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Affiliation(s)
- F Cerpa
- Servicio de Medicina Física y Rehabilitación, Clínica Alemana de Santiago, Santiago, Chile
| | - D Cáceres
- Servicio de Medicina Física y Rehabilitación, Clínica Alemana de Santiago, Santiago, Chile
| | - C Romero-Dapueto
- Servicio de Medicina Física y Rehabilitación, Clínica Alemana de Santiago, Santiago, Chile
| | - C Giugliano-Jaramillo
- Servicio de Medicina Física y Rehabilitación, Clínica Alemana de Santiago, Santiago, Chile
| | - R Pérez
- Servicio de Medicina Física y Rehabilitación, Clínica Alemana de Santiago, Santiago, Chile
| | - H Budini
- Servicio de Medicina Física y Rehabilitación, Clínica Alemana de Santiago, Santiago, Chile
| | - V Hidalgo
- Servicio de Medicina Física y Rehabilitación, Clínica Alemana de Santiago, Santiago, Chile
| | - T Gutiérrez
- Servicio de Medicina Física y Rehabilitación, Clínica Alemana de Santiago, Santiago, Chile
| | - J Molina
- Escuela de Kinesiología, Universidad del Desarrollo, Santiago, Chile
| | - J Keymer
- Servicio de Medicina Física y Rehabilitación, Clínica Alemana de Santiago, Santiago, Chile
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Charles MP, Kali A, Easow JM, Joseph NM, Ravishankar M, Srinivasan S, Kumar S, Umadevi S. Ventilator-associated pneumonia. Australas Med J 2014; 7:334-44. [PMID: 25279009 DOI: 10.4066/amj.2014.2105] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Ventilator-associated pneumonia (VAP) is a type of nosocomial pneumonia that occurs in patients who receive mechanical ventilation (MV). According to the International Nosocomial Infection Control Consortium (INICC), the overall rate of VAP is 13.6 per 1,000 ventilator days. The incidence varies according to the patient group and hospital setting. The incidence of VAP ranges from 13-51 per 1,000 ventilation days. Early diagnosis of VAP with appropriate antibiotic therapy can reduce the emergence of resistant organisms. METHOD The aim of this review was to provide an overview of the incidence, risk factors, aetiology, pathogenesis, treatment, and prevention of VAP. A literature search for VAP was done through the PUBMED/MEDLINE database. This review outlines VAP's risk factors, diagnostic methods, associated organisms, and treatment modalities. CONCLUSION VAP is a common nosocomial infection associated with ventilated patients. The mortality associated with VAP is high. The organisms associated with VAP and their resistance pattern varies depending on the patient group and hospital setting. The diagnostic methods available for VAP are not universal; however, a proper infection control policy with appropriate antibiotic usage can reduce the mortality rate among ventilated patients.
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Affiliation(s)
- Mv Pravin Charles
- Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - Arunava Kali
- Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - Joshy M Easow
- Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - Noyal Maria Joseph
- Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - M Ravishankar
- Department of Anaesthesiology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - Srirangaraj Srinivasan
- Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - Shailesh Kumar
- Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
| | - Sivaraman Umadevi
- Department of Microbiology, Mahatma Gandhi Medical College and Research Institute, Pondicherry, India
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Humidification during mechanical ventilation in the adult patient. BIOMED RESEARCH INTERNATIONAL 2014; 2014:715434. [PMID: 25089275 PMCID: PMC4096064 DOI: 10.1155/2014/715434] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 05/19/2014] [Accepted: 05/27/2014] [Indexed: 12/17/2022]
Abstract
Humidification of inhaled gases has been standard of care in mechanical ventilation for a long period of time. More than a century ago, a variety of reports described important airway damage by applying dry gases during artificial ventilation. Consequently, respiratory care providers have been utilizing external humidifiers to compensate for the lack of natural humidification mechanisms when the upper airway is bypassed. Particularly, active and passive humidification devices have rapidly evolved. Sophisticated systems composed of reservoirs, wires, heating devices, and other elements have become part of our usual armamentarium in the intensive care unit. Therefore, basic knowledge of the mechanisms of action of each of these devices, as well as their advantages and disadvantages, becomes a necessity for the respiratory care and intensive care practitioner. In this paper, we review current methods of airway humidification during invasive mechanical ventilation of adult patients. We describe a variety of devices and describe the eventual applications according to specific clinical conditions.
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Retamal J, Libuy J, Jiménez M, Delgado M, Besa C, Bugedo G, Bruhn A. Preliminary study of ventilation with 4 ml/kg tidal volume in acute respiratory distress syndrome: feasibility and effects on cyclic recruitment - derecruitment and hyperinflation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R16. [PMID: 23351488 PMCID: PMC4056568 DOI: 10.1186/cc12487] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 01/14/2013] [Indexed: 02/07/2023]
Abstract
Introduction Cyclic recruitment-derecruitment and overdistension contribute to ventilator-induced lung injury. Tidal volume (Vt) may influence both, cyclic recruitment-derecruitment and overdistension. The goal of this study was to determine if decreasing Vt from 6 to 4 ml/kg reduces cyclic recruitment-derecruitment and hyperinflation, and if it is possible to avoid severe hypercapnia. Methods Patients with pulmonary acute respiratory distress syndrome (ARDS) were included in a crossover study with two Vt levels: 6 and 4 ml/kg. The protocol had two parts: one bedside and other at the CT room. To avoid severe hypercapnia in the 4 ml/kg arm, we replaced the heat and moisture exchange filter by a heated humidifier, and respiratory rate was increased to keep minute ventilation constant. Data on lung mechanics and gas exchange were taken at baseline and after 30 minutes at each Vt (bedside). Thereafter, a dynamic CT (4 images/sec for 8 sec) was taken at each Vt at a fixed transverse region between the middle and lower third of the lungs. Afterward, CT images were analyzed and cyclic recruitment-derecruitment was determined as non-aerated tissue variation between inspiration and expiration, and hyperinflation as maximal hyperinflated tissue at end-inspiration, expressed as % of lung tissue weight. Results We analyzed 10 patients. Decreasing Vt from 6 to 4 ml/kg consistently decreased cyclic recruitment-derecruitment from 3.6 (2.5 to 5.7) % to 2.9 (0.9 to 4.7) % (P <0.01) and end-inspiratory hyperinflation from 0.7 (0.3 to 2.2) to 0.6 (0.2 to 1.7) % (P = 0.01). No patient developed severe respiratory acidosis or severe hypercapnia when decreasing Vt to 4 ml/kg (pH 7.29 (7.21 to 7.46); PaCO2 48 (26 to 51) mmHg). Conclusions Decreasing Vt from 6 to 4 ml/kg reduces cyclic recruitment-derecruitment and hyperinflation. Severe respiratory acidosis may be effectively prevented by decreasing instrumental dead space and by increasing respiratory rate.
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Prophylactic protective ventilation: lower tidal volumes for all critically ill patients? Intensive Care Med 2012; 39:6-15. [PMID: 23108608 DOI: 10.1007/s00134-012-2728-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 09/28/2012] [Indexed: 12/17/2022]
Abstract
High tidal volumes have historically been recommended for mechanically ventilated patients during general anesthesia. High tidal volumes have been shown to increase morbidity and mortality in patients suffering from acute respiratory distress syndrome (ARDS). Barriers exist in implementing a tidal volume reduction strategy related to the inherent difficulty in changing one's practice patterns, to the current need to individualize low tidal volume settings only for a specific subgroup of mechanically ventilated patients (i.e., ARDS patients), the difficulty in determining the predicated body weight (requiring the patient's height and a complex formula). Consequently, a protective ventilation strategy is often under-utilized as a therapeutic option, even in ARDS. Recent data supports the generalization of this strategy prophylactically to almost all mechanically ventilated patients beginning immediately following intubation. Using tools to rapidly and reliably determine the predicted body weight (PBW), as well as the use of automated modes of ventilation are some of the potential solutions to facilitate the practice of protective ventilation and to finally ventilate our patients' lungs in a more gentle fashion to help prevent ARDS.
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Lipes J, Bojmehrani A, Lellouche F. Low Tidal Volume Ventilation in Patients without Acute Respiratory Distress Syndrome: A Paradigm Shift in Mechanical Ventilation. Crit Care Res Pract 2012; 2012:416862. [PMID: 22536499 PMCID: PMC3318889 DOI: 10.1155/2012/416862] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 01/07/2012] [Accepted: 01/09/2012] [Indexed: 01/11/2023] Open
Abstract
Protective ventilation with low tidal volume has been shown to reduce morbidity and mortality in patients suffering from acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Low tidal volume ventilation is associated with particular clinical challenges and is therefore often underutilized as a therapeutic option in clinical practice. Despite some potential difficulties, data have been published examining the application of protective ventilation in patients without lung injury. We will briefly review the physiologic rationale for low tidal volume ventilation and explore the current evidence for protective ventilation in patients without lung injury. In addition, we will explore some of the potential reasons for its underuse and provide strategies to overcome some of the associated clinical challenges.
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Affiliation(s)
- Jed Lipes
- Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Université Laval, Quebec, QC, Canada G1V 4G5
- Department of Adult Critical Care, Jewish General Hospital, McGill University, Montreal, QC, Canada H3T 1E2
| | - Azadeh Bojmehrani
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Université Laval, Quebec, QC, Canada G1V 4G5
| | - Francois Lellouche
- Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Quebec, Université Laval, Quebec, QC, Canada G1V 4G5
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Kelly M, Gillies D, Todd DA, Lockwood C. Heated humidification versus heat and moisture exchangers for ventilated adults and children. Cochrane Database Syst Rev 2010:CD004711. [PMID: 20393939 DOI: 10.1002/14651858.cd004711.pub2] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Humidification by artificial means must be provided when the upper airway is bypassed during mechanical ventilation. Heated humidification (HH) and heat and moisture exchangers (HME) are the most commonly used types of artificial humidification in this situation. OBJECTIVES To determine whether HHs or HMEs are more effective in preventing mortality and other complications in people who are mechanically ventilated. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2010, Issue 4) and MEDLINE, EMBASE and CINAHL (January, 2010) to identify relevant randomized controlled trials (RCTs). SELECTION CRITERIA We included RCTs comparing heat and moisture exchangers (HMEs) to heated humidifiers (HHs) in mechanically ventilated adults and children. We included randomized crossover studies. DATA COLLECTION AND ANALYSIS We assessed the quality of each study and extracted the relevant data. Where appropriate, results from relevant studies were meta-analysed for individual outcomes. MAIN RESULTS We included 33 trials with 2833 participants, 25 studies were parallel group design (n = 2710) and eight crossover design (n = 123). Only three included studies reported data for infants or children. There was no overall effect on artificial airway occlusion, mortality, pneumonia, or respiratory complications; however, the PaCO(2) and minute ventilation were increased when HMEs were compared to HHs and body temperature was lower. The cost of HMEs was lower in all studies that reported this outcome. There was some evidence that hydrophobic HMEs may reduce the risk of pneumonia and that blockages of artificial airways may be increased with the use of HMEs in certain subgroups of patients. AUTHORS' CONCLUSIONS There is little evidence of an overall difference between HMEs and HHs. However, hydrophobic HMEs may reduce the risk of pneumonia and the use of an HME may increase artificial airway occlusion in certain subgroups of patients. Therefore, HMEs may not be suitable for patients with limited respiratory reserve or prone to airway blockage. Further research is needed relating to hydrophobic versus hygroscopic HMEs and the use of HMEs in the paediatric and neonatal populations. As the design of HMEs evolves, evaluation of new generation HMEs will also need to be undertaken.
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Affiliation(s)
- Margaret Kelly
- Nursing Research & Practice Development Unit, The Children's Hospital at Westmead, Locked Bag 4001, Westmead, NSW, Australia, 2145
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Morán I, Bellapart J, Vari A, Mancebo J. Heat and moisture exchangers and heated humidifiers in acute lung injury/acute respiratory distress syndrome patients. Effects on respiratory mechanics and gas exchange. Intensive Care Med 2006; 32:524-31. [PMID: 16498531 DOI: 10.1007/s00134-006-0073-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2006] [Accepted: 01/17/2006] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To compare, in acute lung injury/acute respiratory distress syndrome (ALI/ARDS) patients, the short-term effects of heat and moisture exchangers (HME) and heated humidifiers (HH) on gas exchange, and also on respiratory system mechanics when isocapnic conditions are met. DESIGN Prospective open clinical study. SETTING Intensive Care Service. PATIENTS Seventeen invasively ventilated ALI/ARDS patients. INTERVENTION The study was performed in three phases: (1) determinations were made during basal ventilatory settings with HME; (2) basal ventilatory settings were maintained and HME was replaced by an HH; (3) using the same HH, tidal volume (Vt) was decreased until basal PaCO2 levels were reached. FiO2, respiratory rate and PEEP were kept unchanged. MEASUREMENTS AND RESULTS Respiratory mechanics, Vdphys, gas exchange and hemodynamic parameters were obtained at each phase. By using HH instead of HME and without changing Vt, PaCO2 decreased from 46+/-9 to 40+/-8 mmHg (p<0.001) and Vdphys decreased from 352+/-63 to 310+/-74 ml (p<0.001). Comparing the first phase with the third, Vt decreased from 521+/-106 to 440+/-118 ml (p<0.001) without significant changes in PaCO2, Vd/Vt decreased from 0.69+/-0.11 to 0.62+/-0.12 (p<0.001), plateau airway pressure decreased from 25+/-6 to 21+/-6 cmH2O (p<0.001) and respiratory system compliance improved from 35+/-12 to 42+/-15 ml/cmH2O (p<0.001). PaO2 remained unchanged in the three phases. CONCLUSIONS Reducing dead space with the use of HH decreases PaCO2 and more importantly, if isocapnic conditions are maintained by reducing Vt, this strategy improves respiratory system compliance and reduces plateau airway pressure.
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Affiliation(s)
- Indalecio Morán
- Servei de Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Sant Antoni M Claret 167, 08025, Barcelona, Spain
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Chiumello D, Pelosi P, Park G, Candiani A, Bottino N, Storelli E, Severgnini P, D'Onofrio D, Gattinoni L, Chiaranda M. In vitro and in vivo evaluation of a new active heat moisture exchanger. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2004; 8:R281-8. [PMID: 15469569 PMCID: PMC1065017 DOI: 10.1186/cc2904] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2004] [Revised: 05/19/2004] [Accepted: 06/09/2004] [Indexed: 11/10/2022]
Abstract
INTRODUCTION In order to improve the efficiency of heat moisture exchangers (HMEs), new hybrid humidifiers (active HMEs) that add water and heat to HMEs have been developed. In this study we evaluated the efficiency, both in vitro and in vivo, of a new active HME (the Performer; StarMed, Mirandola, Italy) as compared with that of existing HMEs (Hygroster and Hygrobac; Mallinckrodt, Mirandola, Italy). METHODS We tested the efficiency by measuring the temperature and absolute humidity (AH) in vitro using a test lung ventilated at three levels of minute ventilation (5, 10 and 15 l/min) and at two tidal volumes (0.5 and 1 l), and in vivo in 42 patients with acute lung injury (arterial oxygen tension/fractional inspired oxygen ratio 283 +/- 72 mmHg). We also evaluated the efficiency in vivo after 12 hours. RESULTS In vitro, passive Performer and Hygrobac had higher airway temperature and AH (29.2 +/- 0.7 degrees C and 29.2 +/- 0.5 degrees C, [P < 0.05]; AH: 28.9 +/- 1.6 mgH2O/l and 28.1 +/- 0.8 mgH2O/l, [P < 0.05]) than did Hygroster (airway temperature: 28.1 +/- 0.3 degrees C [P < 0.05]; AH: 27 +/- 1.2 mgH2O/l [P < 0.05]). Both devices suffered a loss of efficiency at the highest minute ventilation and tidal volume, and at the lowest minute ventilation. Active Performer had higher airway temperature and AH (31.9 +/- 0.3 degrees C and 34.3 +/- 0.6 mgH2O/l; [P < 0.05]) than did Hygrobac and Hygroster, and was not influenced by minute ventilation or tidal volume. In vivo, the efficiency of passive Performer was similar to that of Hygrobac but better than Hygroster, whereas Active Performer was better than both. The active Performer exhibited good efficiency when used for up to 12 hours in vivo. CONCLUSION This study showed that active Performer may provide adequate conditioning of inspired gases, both as a passive and as an active device.
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Affiliation(s)
- Davide Chiumello
- Institute of Anesthesia and Critical Care, University of Milan, Policlinico Hospital, IRCCS, Milan, Italy.
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Abraham E, Andrews P, Antonelli M, Brochard L, Brun-Buisson C, Dobb G, Fagon JY, Groeneveld J, Mancebo J, Metnitz P, Nava S, Pinsky M, Radermacher P, Ranieri M, Richard C, Tasker R, Vallet B. Year in review in Intensive Care Medicine-2003. Part 1: Respiratory failure, infection and sepsis. Intensive Care Med 2004; 30:1017-31. [PMID: 15170528 DOI: 10.1007/s00134-004-2321-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2004] [Indexed: 11/25/2022]
Affiliation(s)
- Edward Abraham
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Colorado Health Sciences Center, Denver, CO, USA
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