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Kreit J. Respiratory-Cardiovascular Interactions During Mechanical Ventilation: Physiology and Clinical Implications. Compr Physiol 2022; 12:3425-3448. [PMID: 35578946 DOI: 10.1002/cphy.c210003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Positive-pressure inspiration and positive end-expiratory pressure (PEEP) increase pleural, alveolar, lung transmural, and intra-abdominal pressure, which decrease right and left ventricular (RV; LV) preload and LV afterload and increase RV afterload. The magnitude and clinical significance of the resulting changes in ventricular function are determined by the delivered tidal volume, the total level of PEEP, the compliance of the lungs and chest wall, intravascular volume, baseline RV and LV function, and intra-abdominal pressure. In mechanically ventilated patients, the most important, adverse consequences of respiratory-cardiovascular interactions are a PEEP-induced reduction in cardiac output, systemic oxygen delivery, and blood pressure; RV dysfunction in patients with ARDS; and acute hemodynamic collapse in patients with pulmonary hypertension. On the other hand, the hemodynamic changes produced by respiratory-cardiovascular interactions can be beneficial when used to assess volume responsiveness in hypotensive patients and by reducing dyspnea and improving hypoxemia in patients with cardiogenic pulmonary edema. Thus, a thorough understanding of the physiological principles underlying respiratory-cardiovascular interactions is essential if critical care practitioners are to anticipate, recognize, manage, and utilize their hemodynamic effects. © 2022 American Physiological Society. Compr Physiol 12:1-24, 2022.
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Affiliation(s)
- John Kreit
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Lung volumes and lung volume recruitment in ARDS: a comparison between supine and prone position. Ann Intensive Care 2018; 8:25. [PMID: 29445887 PMCID: PMC5812959 DOI: 10.1186/s13613-018-0371-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 02/08/2018] [Indexed: 12/26/2022] Open
Abstract
Background The use of positive end-expiratory pressure (PEEP) and prone position (PP) is common in the management of severe acute respiratory distress syndrome patients (ARDS). We conducted this study to analyze the variation in lung volumes and PEEP-induced lung volume recruitment with the change from supine position (SP) to PP in ARDS patients. Methods The investigation was conducted in a multidisciplinary intensive care unit. Patients who met the clinical criteria of the Berlin definition for ARDS were included. The responsible physician set basal PEEP. To avoid hypoxemia, FiO2 was increased to 0.8 1 h before starting the protocol. End-expiratory lung volume (EELV) and functional residual capacity (FRC) were measured using the nitrogen washout/washin technique. After the procedures in SP, the patients were turned to PP and 1 h later the same procedures were made in PP. Results Twenty-three patients were included in the study, and twenty were analyzed. The change from SP to PP significantly increased FRC (from 965 ± 397 to 1140 ± 490 ml, p = 0.008) and EELV (from 1566 ± 476 to 1832 ± 719 ml, p = 0.008), but PEEP-induced lung volume recruitment did not significantly change (269 ± 186 ml in SP to 324 ± 188 ml in PP, p = 0.263). Dynamic strain at PEEP decreased with the change from SP to PP (0.38 ± 0.14 to 0.33 ± 0.13, p = 0.040). Conclusions As compared to supine, prone position increases resting lung volumes and decreases dynamic lung strain. Electronic supplementary material The online version of this article (10.1186/s13613-018-0371-0) contains supplementary material, which is available to authorized users.
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Tidal volume and plateau pressure use for acute lung injury from 2000 to present: a systematic literature review. Crit Care Med 2014; 42:2278-89. [PMID: 25098333 DOI: 10.1097/ccm.0000000000000504] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Since publication of the Respiratory Management of Acute Lung Injury and Acute Respiratory Distress Syndrome (ARMA) trial in 2000, use of tidal volume (VT) less than or equal to 6 mL/kg predicted body weight with corresponding plateau airway pressures (PPlat) less than or equal to 30 cm H2O has been advocated for acute lung injury. However, compliance with these recommendations is unknown. We therefore investigated VT (mL/kg predicted body weight) and PPlat (cm H2O) practices reported in studies of acute lung injury since ARMA using a systematic literature review (i.e., not a meta-analysis). DATA SOURCES PubMed, Scopus, and EMBASE. STUDY SELECTION Randomized controlled trials and nonrandomized studies enrolling patients with acute lung injury from May 2000 to June 2013 and reporting VT. DATA EXTRACTION Whether the study was a randomized controlled trial or a nonrandomized study and performed or not at an Acute Respiratory Distress Syndrome Network center; in randomized controlled trials, the pre- and postrandomization VT (mL/kg predicted body weight) and PPlat (cm H2O) and whether a VT protocol was used postrandomization; in nonrandomized studies, baseline VT and PPlat. DATA SYNTHESIS Twenty-two randomized controlled trials and 71 nonrandomized studies were included. Since 2000 at acute respiratory distress syndrome Network centers, routine VT was similar comparing randomized controlled trials and nonrandomized studies (p = 0.25) and unchanged over time (p = 0.75) with a mean value of 6.81 (95% CI, 6.45, 7.18). At non-acute respiratory distress syndrome Network centers, routine VT was also similar when comparing randomized controlled trials and nonrandomized studies (p = 0.71), but decreased (p = 0.001); the most recent estimate for it was 6.77 (6.22, 7.32). All VT estimates were significantly greater than 6 (p ≤ 0.02). In randomized controlled trials employing VT protocols, routine VT was reduced in both acute respiratory distress syndrome Network (n = 4) and non-acute respiratory distress syndrome Network (n = 11) trials (p ≤ 0.01 for both), but even postrandomization was greater than 6 (6.47 [6.29, 6.65] and 6.80 [6.42, 7.17], respectively; p ≤ 0.0001 for both). In 59 studies providing data, routine PPlat, averaged across acute respiratory distress syndrome Network or non-acute respiratory distress syndrome Network centers, was significantly less than 30 (p ≤ 0.02). CONCLUSIONS For clinicians treating acute lung injury since 2000, achieving VT less than or equal to 6 mL/kg predicted body weight may not have been as attainable or important as PPlat less than or equal to 30 cm H2O. If so, there may be equipoise to test if VT less than or equal to 6 mL/kg predicted body weight are necessary to improve acute lung injury outcome.
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Norrenberg M, Vincent JL. Rééducation motrice dans le cadre d’un séjour en réanimation. MEDECINE INTENSIVE REANIMATION 2011. [DOI: 10.1007/s13546-011-0320-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
AIMS This article reviews the current evidence, benefits and drawbacks for the use of continuous lateral replacement therapy in the treatment and prevention of nosocomial infections in the ventilated patient. RELEVANT TO PRACTICE The acquisition of nosocomial infections and the development of pressure sores continue to be major issues in the care of the critically ill, ventilated patient. The use of continuous lateral rotation therapy (CLRT) as an adjunct in the prevention and treatment of pneumonia has increased in popularity in recent years. A number of institutions routinely advocate the use of CLRT in critically ill patients. CONCLUSION While there is some data to suggest that CLRT may have an impact on prevention of and treatment for nosocomial infections acquired by ventilated patients, there still remains insufficient evidence to its inclusion as a fully validated treatment. Clearly, there is a requirement for more robust, in-depth research into the efficacy of this proposed treatment.
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Affiliation(s)
- Stephen Wanless
- Department of Skills and Simulation, Faculty of Health, Birmingham City University, Edgbaston, Birmingham B15 3TN, UK.
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Mentzelopoulos SD, Roussos C, Koutsoukou A, Sourlas S, Malachias S, Lachana A, Zakynthinos SG. Acute effects of combined high-frequency oscillation and tracheal gas insufflation in severe acute respiratory distress syndrome. Crit Care Med 2007; 35:1500-8. [PMID: 17440419 DOI: 10.1097/01.ccm.0000265738.80832.be] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In acute respiratory distress syndrome (ARDS), high-frequency oscillation (HFO) improves oxygenation relative to conventional mechanical ventilation (CMV). Alveolar ventilation is improved by adding tracheal gas insufflation (TGI) to CMV. We hypothesized that combined HFO and TGI (HFO-TGI) might result in improved gas exchange relative to both standard HFO and CMV according to the ARDS Network protocol. DESIGN Prospective, randomized, crossover study. SETTING A 30-bed university intensive care unit. PATIENTS A total of 14 patients with early (<72 hrs in duration), severe (PaO2/FiO2 of <150 mm Hg and prerecruitment oxygenation index of 22.8 +/- 1.9 [mean +/- SEM]), primary ARDS. INTERVENTIONS Patients were ventilated with HFO without (60 mins) and combined with TGI (6.1 +/- 0.1 L/min, 60 mins) in random order. HFO sessions were repeated in inverse order within 24 hrs. HFO sessions were preceded and followed by ARDS Network CMV. Four recruitment maneuvers were performed during the study period. During HFO sessions, mean airway pressure was set at 1 cm H2O above the point of maximal curvature of the respiratory system expiratory pressure-volume curve. MEASUREMENTS AND MAIN RESULTS Gas exchange and hemodynamics were determined before, during, and after HFO sessions. HFO-TGI improved PaO2/FiO2 relative to HFO and CMV (174.5 +/- 10.4 vs. 136.0 +/- 10.0 and 105.0 +/- 3.7 mm Hg, respectively, p < .05 for both) and oxygenation index relative to HFO (17.1 +/- 1.3 vs. 22.3 +/- 1.7, respectively p < .05). PaO2/FiO2 returned to baseline within 3 hrs after HFO. During HFO-TGI, shunt fraction and mixed venous oxygen saturation improved relative to CMV (0.36 +/- 0.01 vs. 0.45 +/- 0.01 and 77.8% +/- 1.2% vs. 71.8% +/- 1.3%, respectively, p < .05 for both). PaCO2 and hemodynamics were unaffected by HFO sessions. Respiratory mechanics remained unchanged throughout the study period. CONCLUSIONS In early onset, primary, severe ARDS, short-term HFO-TGI improves oxygenation relative to standard HFO and ARDS Network CMV.
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Mentzelopoulos SD, Roussos C, Zakynthinos SG. Prone position in early and severe acute respiratory distress syndrome: a design for a definitive randomized controlled trial. Anesth Analg 2007; 104:466-8. [PMID: 17242128 DOI: 10.1213/01.ane.0000253691.32957.8b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Bed rest is a commonly prescribed activity restriction among patients in the ICU. Although bed rest may promote rest, recovery and safety, inactivity related to bed rest also may lead to complications and adverse outcomes. The biological mechanisms that lead to immediate and long-term sequelae from bed rest have not been elucidated. It may be the inflammatory factors common to critical illness combined with bed rest lead to a positive feedback loop, contributing to inflammatory disequilibrium. This disequilibrium has a profound affect on muscles. Muscle decay has serious and long-term adverse outcomes on survivors of critical illness. Mobility therapy may improve inflammatory disequilibrium and preserve muscles, leading to improved functional outcome. Investigations in the laboratory, in healthy people and among patients with systemic inflammatory disease, suggest that activity does not exacerbate inflammation. Clinically, exercise is beneficial to patients with various chronic inflammatory diseases. Further study is needed to best understand the role, duration, and frequency of activity in promoting recovery for critically ill patients.
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Affiliation(s)
- Chris Winkelman
- Frances Payne Bolton School of Nursing, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, OH 44106, USA.
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Goldhill DR, Imhoff M, McLean B, Waldmann C. Rotational Bed Therapy to Prevent and Treat Respiratory Complications: A Review and Meta-Analysis. Am J Crit Care 2007. [DOI: 10.4037/ajcc2007.16.1.50] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
• Background Immobility is associated with complications involving many body systems.
• Objective To review the effect of rotational therapy (use of therapeutic surfaces that turn on their longitudinal axes) on prevention and/or treatment of respiratory complications in critically ill patients.
• Methods Published articles evaluating prophylaxis and/or treatment were reviewed. Prospective randomized controlled trials were assessed for quality and included in meta-analyses.
• Results A literature search yielded 15 nonrandomized, uncontrolled, or retrospective studies. Twenty prospective randomized controlled trials on rotational therapy were published between 1987 and 2004. Various types of beds were studied, but few details on the rotational parameters were reported. The usual control was manual turning of patients by nurses every 2 hours. One animal investigation and 12 clinical trials addressed the effectiveness of rotational therapy in preventing respiratory complications. Significant benefits were reported in the animal study and 4 of the trials. Significant benefits to patients were reported in 2 of another 4 studies focused on treatment of established complications. Researchers have examined the effects of rotational therapy on mucus transport, intrapulmonary shunt, hemodynamic effects, urine output, and intracranial pressure. Little convincing evidence is available, however, on the most effective rotation parameters (eg, degree, pause time, and amount of time per day). Meta-analysis suggests that rotational therapy decreases the incidence of pneumonia but has no effect on duration of mechanical ventilation, number of days in intensive care, or hospital mortality.
• Conclusions Rotational therapy may be useful for preventing and treating respiratory complications in selected critically ill patients receiving mechanical ventilation.
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Affiliation(s)
- David R. Goldhill
- The Royal National Orthopaedic Hospital, Stanmore, Middlesex, United Kingdom (drg), Department for Medical Informatics, Biometrics, and Epidemiology, Ruhr-Universität Bochum, Bochum, Germany (mi), Atlanta Medical Center, Atlanta, Ga (bm), and The Royal Berkshire Hospital, Reading, United Kingdom (cw)
| | - Michael Imhoff
- The Royal National Orthopaedic Hospital, Stanmore, Middlesex, United Kingdom (drg), Department for Medical Informatics, Biometrics, and Epidemiology, Ruhr-Universität Bochum, Bochum, Germany (mi), Atlanta Medical Center, Atlanta, Ga (bm), and The Royal Berkshire Hospital, Reading, United Kingdom (cw)
| | - Barbara McLean
- The Royal National Orthopaedic Hospital, Stanmore, Middlesex, United Kingdom (drg), Department for Medical Informatics, Biometrics, and Epidemiology, Ruhr-Universität Bochum, Bochum, Germany (mi), Atlanta Medical Center, Atlanta, Ga (bm), and The Royal Berkshire Hospital, Reading, United Kingdom (cw)
| | - Carl Waldmann
- The Royal National Orthopaedic Hospital, Stanmore, Middlesex, United Kingdom (drg), Department for Medical Informatics, Biometrics, and Epidemiology, Ruhr-Universität Bochum, Bochum, Germany (mi), Atlanta Medical Center, Atlanta, Ga (bm), and The Royal Berkshire Hospital, Reading, United Kingdom (cw)
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Andrews P, Azoulay E, Antonelli M, Brochard L, Brun-Buisson C, de Backer D, Dobb G, Fagon JY, Gerlach H, Groeneveld J, Mancebo J, Metnitz P, Nava S, Pugin J, Pinsky M, Radermacher P, Richard C, Tasker R. Year in review in intensive care medicine. 2005. I. Acute respiratory failure and acute lung injury, ventilation, hemodynamics, education, renal failure. Intensive Care Med 2006; 32:207-216. [PMID: 16450098 DOI: 10.1007/s00134-005-0027-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2005] [Accepted: 12/08/2005] [Indexed: 01/20/2023]
Affiliation(s)
- Peter Andrews
- Intensive Care Medicine Unit, Western General Hospital, Edinburgh, UK
| | - Elie Azoulay
- Intensive Care Medicine Unit, Saint Louis Hospital, Paris, France
| | - Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Universita Cattolica del Sacro Cuore, Rome, Italy
| | - Laurent Brochard
- Réanimation Médicale, AP-HP, Hôpital Henri Mondor, INSERM U 615, Université, Paris 12, France.
| | - Christian Brun-Buisson
- Medical Intensive Care Unit, University Hospital Henri Mondor, 51 avenue du Marechal de Lattre de Tassigny, 94000, Creteil, France
| | - Daniel de Backer
- Service des Soins Intensifs, Hôpital Erasme, 808 route de Lennick, 1070, Bruxelles, Belgium
| | - Geoffrey Dobb
- Intensive Care Medicine Unit, Royal Perth Hospital, Perth, Australia
| | - Jean-Yves Fagon
- Intensive Care Medicine Unit, European Georges Pompidou Hospital, Paris, France
| | - Herwig Gerlach
- Department of Anesthesiology, Vivantes-Klinikum Neukoelln, Berlin, Germany
| | | | - Jordi Mancebo
- Intensive Care Medicine Unit, Hospital Sant Pau, Barcelona, Spain
| | - Philipp Metnitz
- Department of Anesthesia and General Intensive Care Medicine, University Hospital of Vienna, Vienna, Austria
| | - Stefano Nava
- Intensive Care Medicine Unit, Fondazione S. Maugeri, Pavia, Italy
| | - Jerome Pugin
- Intensive Care Medicine Unit, University Hospital of Geneva, Geneva, Switzerland
| | - Michael Pinsky
- Intensive Care Medicine Unit, University of Pittsburgh Medical Center, Pittsburgh, Pa., USA
| | - Peter Radermacher
- Department of Anesthesia, University Medical School of Ulm, Ulm, Germany
| | - Christian Richard
- Intensive Care Medicine Unit, University Hospital of Le Kremlin-Bicetre, Le Kremlin Bicetre, France
| | - Robert Tasker
- Pediatric Intensive Care Unit, Addenbrooke's Hospital, Cambridge, UK
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