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Franchi F, Detti E, Fogagnolo A, Spadaro S, Cevenini G, Cataldo G, Addabbo T, Biuzzi C, Marianello D, Volta CA, Taccone FS, Scolletta S. Estimation of the transpulmonary pressure from the central venous pressure in mechanically ventilated patients. J Clin Monit Comput 2024; 38:847-858. [PMID: 38512359 PMCID: PMC11297816 DOI: 10.1007/s10877-024-01150-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/05/2024] [Indexed: 03/23/2024]
Abstract
Transpulmonary pressure (PL) calculation requires esophageal pressure (PES) as a surrogate of pleural pressure (Ppl), but its calibration is a cumbersome technique. Central venous pressure (CVP) swings may reflect tidal variations in Ppl and could be used instead of PES, but the interpretation of CVP waveforms could be difficult due to superposition of heartbeat-induced pressure changes. Thus, we developed a digital filter able to remove the cardiac noise to obtain a filtered CVP (f-CVP). The aim of the study was to evaluate the accuracy of CVP and filtered CVP swings (ΔCVP and Δf-CVP, respectively) in estimating esophageal respiratory swings (ΔPES) and compare PL calculated with CVP, f-CVP and PES; then we tested the diagnostic accuracy of the f-CVP method to identify unsafe high PL levels, defined as PL>10 cmH2O. Twenty patients with acute respiratory failure (defined as PaO2/FiO2 ratio below 200 mmHg) treated with invasive mechanical ventilation and monitored with an esophageal balloon and central venous catheter were enrolled prospectively. For each patient a recording session at baseline was performed, repeated if a modification in ventilatory settings occurred. PES, CVP and airway pressure during an end-inspiratory and -expiratory pause were simultaneously recorded; CVP, f-CVP and PES waveforms were analyzed off-line and used to calculate transpulmonary pressure (PLCVP, PLf-CVP, PLPES, respectively). Δf-CVP correlated better than ΔCVP with ΔPES (r = 0.8, p = 0.001 vs. r = 0.08, p = 0.73), with a lower bias in Bland Altman analysis in favor of PLf-CVP (mean bias - 0.16, Limits of Agreement (LoA) -1.31, 0.98 cmH2O vs. mean bias - 0.79, LoA - 3.14, 1.55 cmH2O). Both PLf-CVP and PLCVP correlated well with PLPES (r = 0.98, p < 0.001 vs. r = 0.94, p < 0.001), again with a lower bias in Bland Altman analysis in favor of PLf-CVP (0.15, LoA - 0.95, 1.26 cmH2O vs. 0.80, LoA - 1.51, 3.12, cmH2O). PLf-CVP discriminated high PL value with an area under the receiver operating characteristic curve 0.99 (standard deviation, SD, 0.02) (AUC difference = 0.01 [-0.024; 0.05], p = 0.48). In mechanically ventilated patients with acute respiratory failure, the digital filtered CVP estimated ΔPES and PL obtained from digital filtered CVP represented a reliable value of standard PL measured with the esophageal method and could identify patients with non-protective ventilation settings.
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Affiliation(s)
- Federico Franchi
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy.
| | - Emanuele Detti
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy
| | - Alberto Fogagnolo
- Intensive Care Unit, Department of Translational Medicine and for Romagna, Azienda Ospedaliera Universitaria di Ferrara, University of Ferrara, 44121, Ferrara, Italy
| | - Savino Spadaro
- Intensive Care Unit, Department of Translational Medicine and for Romagna, Azienda Ospedaliera Universitaria di Ferrara, University of Ferrara, 44121, Ferrara, Italy
| | - Gabriele Cevenini
- Department of Medical Biotechnologies, University of Siena, 53100, Siena, Italy
| | - Gennaro Cataldo
- Department of Medical Biotechnologies, University of Siena, 53100, Siena, Italy
| | - Tommaso Addabbo
- Department of Information Engineering and Mathematics, University of Siena, 53100, Siena, Italy
| | - Cesare Biuzzi
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy
| | - Daniele Marianello
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy
| | - Carlo Alberto Volta
- Intensive Care Unit, Department of Translational Medicine and for Romagna, Azienda Ospedaliera Universitaria di Ferrara, University of Ferrara, 44121, Ferrara, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, 1070, Belgium
| | - Sabino Scolletta
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy
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Kyogoku M, Mizuguchi S, Miyasho T, Endo Y, Inata Y, Tachibana K, Fujino Y, Yamashita K, Takeuchi M. Estimating the change in pleural pressure using the change in central venous pressure in various clinical scenarios: a pig model study. Intensive Care Med Exp 2024; 12:4. [PMID: 38224398 PMCID: PMC10789683 DOI: 10.1186/s40635-023-00590-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/21/2023] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND We have previously reported a simple correction method for estimating pleural pressure (Ppl) using central venous pressure (CVP). However, it remains unclear whether this method is applicable to patients with varying levels of intravascular volumes and/or chest wall compliance. This study aimed to investigate the accuracy of our method under different conditions of intravascular volume and chest wall compliance. RESULTS Ten anesthetized and paralyzed pigs (43.2 ± 1.8 kg) were mechanically ventilated and subjected to lung injury by saline lung lavage. Each pig was subjected to three different intravascular volumes and two different intraabdominal pressures. For each condition, the changes in the esophageal pressure (ΔPes) and the estimated ΔPpl using ΔCVP (cΔCVP-derived ΔPpl) were compared to the directly measured change in pleural pressure (Δd-Ppl), which was the gold standard estimate in this study. The cΔCVP-derived ΔPpl was calculated as κ × ΔCVP, where "κ" was the ratio of the change in airway pressure to the change in CVP during the occlusion test. The means and standard deviations of the Δd-Ppl, ΔPes, and cΔCVP-derived ΔPpl for all pigs under all conditions were 7.6 ± 4.5, 7.2 ± 3.6, and 8.0 ± 4.8 cmH2O, respectively. The repeated measures correlations showed that both the ΔPes and cΔCVP-derived ΔPpl showed a strong correlation with the Δd-Ppl (ΔPes: r = 0.95, p < 0.0001; cΔCVP-derived ΔPpl: r = 0.97, p < 0.0001, respectively). In the Bland-Altman analysis to test the performance of the cΔCVP-derived ΔPpl to predict the Δd-Ppl, the ΔPes and cΔCVP-derived ΔPpl showed almost the same bias and precision (ΔPes: 0.5 and 1.7 cmH2O; cΔCVP-derived ΔPpl: - 0.3 and 1.9 cmH2O, respectively). No significant difference was found in the bias and precision depending on the intravascular volume and intraabdominal pressure in both comparisons between the ΔPes and Δd-Ppl, and cΔCVP-derived ΔPpl and Δd-Ppl. CONCLUSIONS The CVP method can estimate the ΔPpl with reasonable accuracy, similar to Pes measurement. The accuracy was not affected by the intravascular volume or chest wall compliance.
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Affiliation(s)
- Miyako Kyogoku
- Department of Intensive Care, Osaka Women's and Children's Hospital, 840 Murodo-Cho, Izumi, Osaka, 594-1101, Japan
| | - Soichi Mizuguchi
- Department of Emergency and Critical Care Center, Kyushu University, Fukuoka, Japan
| | - Taku Miyasho
- Laboratory of Animal Biological Responses, Department of Veterinary Science School of Veterinary Medicine, Rakuno Gakuen University, Hokkaido, Japan
| | - Yusuke Endo
- Laboratory of Animal Biological Responses, Department of Veterinary Science School of Veterinary Medicine, Rakuno Gakuen University, Hokkaido, Japan
- Laboratory for Critical Care, Department of Emergency Medicine-Cardio Pulmonary, Feinstein Institutes for Medical Research, Manhasset, NY, USA
| | - Yu Inata
- Department of Intensive Care, Osaka Women's and Children's Hospital, 840 Murodo-Cho, Izumi, Osaka, 594-1101, Japan
| | - Kazuya Tachibana
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Yuji Fujino
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kazuto Yamashita
- Department of Anesthesiology, Rakuno Gakuen University, Hokkaido, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care, Osaka Women's and Children's Hospital, 840 Murodo-Cho, Izumi, Osaka, 594-1101, Japan.
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Al-Qadi MO, Holbrook J, Ford HJ, Ceppe A, LeVarge BL. Prognostic Value of Respiratory Variation in Right Atrial Pressure in Patients With Precapillary Pulmonary Hypertension. Chest 2023; 164:481-489. [PMID: 36990147 DOI: 10.1016/j.chest.2023.03.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/28/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023] Open
Abstract
BACKGROUND Precapillary pulmonary hypertension is characterized by elevated mean pulmonary artery pressure from increased pulmonary vascular resistance. Lack of respiratory variation in right atrial pressure can be viewed as a surrogate for severe pulmonary hypertension and inability of the right ventricle to tolerate preload augmentation during inspiration. RESEARCH QUESTION Is the lack of respiratory variation in right atrial pressure predictive of right ventricular dysfunction and worse clinical outcomes in precapillary pulmonary hypertension? STUDY DESIGN AND METHODS We retrospectively reviewed right atrial pressure tracings of patients with precapillary pulmonary hypertension who underwent right heart catheterization. Patients with respiratory variation in right atrial pressure (end expiratory-end inspiratory) ≤ 2 mm Hg were considered to have effectively no meaningful variation in right atrial pressure. RESULTS Lack of respiratory variation in right atrial pressure was associated with lower cardiac index by indirect Fick (2.34 ± 0.09 vs 2.76 ± 0.1 L/min/m2; P = .001), lower pulmonary artery saturation (60% ± 1.02% vs 64% ± 1.15%; P = .007), higher pulmonary vascular resistance (8.9 ± 0.44 vs 6.1 ± 0.49 Wood units, P < .0001), right ventricular dysfunction on echocardiography (87.3% vs 38.8%; P < .0001), higher pro brain natriuretic peptide (2,163 ± 2,997 vs 633 ± 402 ng/mL; P < .0001), and more hospitalizations within 1 year for right ventricular failure (65.4% vs 29.6%; P < .0001). There was also a trend toward higher mortality at 1 year in patients with no respiratory variation in right atrial pressure (25.4% vs 11.1%; P = .06). INTERPRETATION Lack of respiratory variation in right atrial pressure is associated with poor clinical outcomes, adverse hemodynamic parameters, and right ventricular dysfunction in patients with precapillary pulmonary hypertension. Larger studies are needed to further evaluate its utility in prognosis and potential risk stratification in patients with precapillary pulmonary hypertension.
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Affiliation(s)
- Mazen O Al-Qadi
- Division of Pulmonary and Critical Care Medicine and Pulmonary Hypertension Program, University of North Carolina at Chapel Hill, Chapel Hill, NC; Marsico Lung Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Jason Holbrook
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - H James Ford
- Division of Pulmonary and Critical Care Medicine and Pulmonary Hypertension Program, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Agathe Ceppe
- Division of Pulmonary and Critical Care Medicine and Pulmonary Hypertension Program, University of North Carolina at Chapel Hill, Chapel Hill, NC; Marsico Lung Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Barbara L LeVarge
- Division of Pulmonary and Critical Care Medicine and Pulmonary Hypertension Program, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Jonkman AH, Telias I, Spinelli E, Akoumianaki E, Piquilloud L. The oesophageal balloon for respiratory monitoring in ventilated patients: updated clinical review and practical aspects. Eur Respir Rev 2023; 32:220186. [PMID: 37197768 PMCID: PMC10189643 DOI: 10.1183/16000617.0186-2022] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/22/2023] [Indexed: 05/19/2023] Open
Abstract
There is a well-recognised importance for personalising mechanical ventilation settings to protect the lungs and the diaphragm for each individual patient. Measurement of oesophageal pressure (P oes) as an estimate of pleural pressure allows assessment of partitioned respiratory mechanics and quantification of lung stress, which helps our understanding of the patient's respiratory physiology and could guide individualisation of ventilator settings. Oesophageal manometry also allows breathing effort quantification, which could contribute to improving settings during assisted ventilation and mechanical ventilation weaning. In parallel with technological improvements, P oes monitoring is now available for daily clinical practice. This review provides a fundamental understanding of the relevant physiological concepts that can be assessed using P oes measurements, both during spontaneous breathing and mechanical ventilation. We also present a practical approach for implementing oesophageal manometry at the bedside. While more clinical data are awaited to confirm the benefits of P oes-guided mechanical ventilation and to determine optimal targets under different conditions, we discuss potential practical approaches, including positive end-expiratory pressure setting in controlled ventilation and assessment of inspiratory effort during assisted modes.
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Affiliation(s)
- Annemijn H Jonkman
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital-Unity Health Toronto, Toronto, ON, Canada
| | - Elena Spinelli
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Evangelia Akoumianaki
- Adult Intensive Care Unit, University Hospital of Heraklion, Heraklion, Greece
- Medical School, University of Crete, Heraklion, Greece
| | - Lise Piquilloud
- Adult Intensive Care Unit, Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
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Umbrello M, Cereghini S, Muttini S. Respiratory Variations of Central Venous Pressure as Indices of Pleural Pressure Swings: A Narrative Review. Diagnostics (Basel) 2023; 13:diagnostics13061022. [PMID: 36980329 PMCID: PMC10047347 DOI: 10.3390/diagnostics13061022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 03/03/2023] [Accepted: 03/04/2023] [Indexed: 03/30/2023] Open
Abstract
The measurement of pleural (or intrathoracic) pressure is a key element for a proper setting of mechanical ventilator assistance as both under- and over-assistance may cause detrimental effects on both the lungs and the diaphragm. Esophageal pressure (Pes) is the gold standard tool for such measurements; however, it is invasive and seldom used in daily practice, and easier, bedside-available tools that allow for rapid and continuous monitoring are greatly needed. The tidal swing of central venous pressure (CVP) has long been proposed as a surrogate for pleural pressure (Ppl); however, despite the wide availability of central venous catheters, this variable is very often overlooked in critically ill patients. In the present narrative review, the physiological basis for the use of CVP waveforms to estimate Ppl is presented; the findings of previous and recent papers that addressed this topic are systematically reviewed, and the studies are divided into those reporting positive findings (i.e., CVP was found to be a reliable estimate of Pes or Ppl) and those reporting negative findings. Both the strength and pitfalls of this approach are highlighted, and the current knowledge gaps and direction for future research are delineated.
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Affiliation(s)
- Michele Umbrello
- SC Terapia Intensiva Neurochirurgica, ASST Santi Paolo e Carlo Polo Universitario, Ospedale San Carlo Borromeo, Via Pio II, 3, 20151 Milano, Italy
| | - Sergio Cereghini
- SC Terapia Intensiva Neurochirurgica, ASST Santi Paolo e Carlo Polo Universitario, Ospedale San Carlo Borromeo, Via Pio II, 3, 20151 Milano, Italy
| | - Stefano Muttini
- SC Terapia Intensiva Neurochirurgica, ASST Santi Paolo e Carlo Polo Universitario, Ospedale San Carlo Borromeo, Via Pio II, 3, 20151 Milano, Italy
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Khirfan G, Melillo CA, Al Abdi S, Lane JE, Dweik RA, Chatburn RL, Hatipoğlu U, Tonelli AR. Impact of Esophageal Pressure Measurement on Pulmonary Hypertension Diagnosis in Patients With Obesity. Chest 2022; 162:684-692. [PMID: 35405108 PMCID: PMC9808718 DOI: 10.1016/j.chest.2022.04.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 03/28/2022] [Accepted: 04/03/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Elevated intrathoracic pressure could affect pulmonary vascular pressure measurements and influence pulmonary hypertension (PH) diagnosis and classification. Esophageal pressure (Pes) measurement adjusts for the increase in intrathoracic pressure, better reflecting the pulmonary hemodynamics in patients with obesity. RESEARCH QUESTION In individuals with obesity, what is the impact of adjusting pulmonary hemodynamic determinations for Pes on PH diagnosis and classification? Can Pes be estimated by positional or respiratory hemodynamic changes? STUDY DESIGN AND METHODS In this prospective cohort study, we included patients with obesity who underwent right heart catheterization and demonstrated elevated pulmonary artery wedge pressure (PAWP; ≥ 12 mm Hg). After placement of an esophageal balloon, we performed pressure determination using an air-filled transducer connected to a regular hemodynamic monitor. We measured pulmonary pressures changes when sitting and the variations during the respiratory cycle. RESULTS We included 53 patients (mean ± SD age, 59 ± 12 years; mean ± SD BMI, 44.4 ± 10.2 kg/m2). Supine end-expiratory pressures revealed a mean pulmonary artery pressure of > 20 mm Hg in all patients and a PAWP of >15 mm Hg in most patients (n = 50). The Pes adjustment led to a significant decrease in percentage of patients with postcapillary PH (from 60% to 8%) and combined precapillary and postcapillary PH (from 34% to 11%), at the expense of an increase in percentage of patients with no PH (0% to 23%), isolated precapillary PH (2% to 25%), and undifferentiated PH (4% to 34%). INTERPRETATION Adjusting pulmonary hemodynamics for Pes in patients with obesity leads to a pronounced reduction in the number of patients who receive a diagnosis of postcapillary PH. Measuring Pes should be considered in patients with obesity, particularly those with elevated PAWP.
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Affiliation(s)
- Ghaleb Khirfan
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland
| | - Celia A Melillo
- Department of Inflammation and Immunity, Cleveland Clinic, Cleveland
| | - Sami Al Abdi
- Department of Internal Medicine, Cleveland Clinic Fairview Hospital, Fairview, OH
| | | | - Raed A Dweik
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland
| | | | - Umur Hatipoğlu
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland
| | - Adriano R Tonelli
- Department of Pulmonary and Critical Care Medicine, Cleveland Clinic, Cleveland.
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Okuda N, Kyogoku M, Inata Y, Isaka K, Moon K, Hatachi T, Shimizu Y, Takeuchi M. Estimation of change in pleural pressure in assisted and unassisted spontaneous breathing pediatric patients using fluctuation of central venous pressure: A preliminary study. PLoS One 2021; 16:e0247360. [PMID: 33647041 PMCID: PMC7920368 DOI: 10.1371/journal.pone.0247360] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 02/05/2021] [Indexed: 11/18/2022] Open
Abstract
Background It is important to evaluate the size of respiratory effort to prevent patient self-inflicted lung injury and ventilator-induced diaphragmatic dysfunction. Esophageal pressure (Pes) measurement is the gold standard for estimating respiratory effort, but it is complicated by technical issues. We previously reported that a change in pleural pressure (ΔPpl) could be estimated without measuring Pes using change in CVP (ΔCVP) that has been adjusted with a simple correction among mechanically ventilated, paralyzed pediatric patients. This study aimed to determine whether our method can be used to estimate ΔPpl in assisted and unassisted spontaneous breathing patients during mechanical ventilation. Methods The study included hemodynamically stable children (aged <18 years) who were mechanically ventilated, had spontaneous breathing, and had a central venous catheter and esophageal balloon catheter in place. We measured the change in Pes (ΔPes), ΔCVP, and ΔPpl that was calculated using a corrected ΔCVP (cΔCVP-derived ΔPpl) under three pressure support levels (10, 5, and 0 cmH2O). The cΔCVP-derived ΔPpl value was calculated as follows: cΔCVP-derived ΔPpl = k × ΔCVP, where k was the ratio of the change in airway pressure (ΔPaw) to the ΔCVP during airway occlusion test. Results Of the 14 patients enrolled in the study, 6 were excluded because correct positioning of the esophageal balloon could not be confirmed, leaving eight patients for analysis (mean age, 4.8 months). Three variables that reflected ΔPpl (ΔPes, ΔCVP, and cΔCVP-derived ΔPpl) were measured and yielded the following results: -6.7 ± 4.8, − -2.6 ± 1.4, and − -7.3 ± 4.5 cmH2O, respectively. The repeated measures correlation between cΔCVP-derived ΔPpl and ΔPes showed that cΔCVP-derived ΔPpl had good correlation with ΔPes (r = 0.84, p< 0.0001). Conclusions ΔPpl can be estimated reasonably accurately by ΔCVP using our method in assisted and unassisted spontaneous breathing children during mechanical ventilation.
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Affiliation(s)
- Nao Okuda
- Center for Infectious Disease, Nara Medical University Hospital, Kashihara-shi, Nara, Japan
- Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Izumi-shi, Osaka, Japan
| | - Miyako Kyogoku
- Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Izumi-shi, Osaka, Japan
| | - Yu Inata
- Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Izumi-shi, Osaka, Japan
| | - Kanako Isaka
- Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Izumi-shi, Osaka, Japan
| | - Kazue Moon
- Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Izumi-shi, Osaka, Japan
| | - Takeshi Hatachi
- Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Izumi-shi, Osaka, Japan
| | - Yoshiyuki Shimizu
- Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Izumi-shi, Osaka, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Izumi-shi, Osaka, Japan
- * E-mail:
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Colombo J, Spinelli E, Grasselli G, Pesenti AM, Protti A. Detection of strong inspiratory efforts from the analysis of central venous pressure swings: a preliminary clinical study. Minerva Anestesiol 2020; 86:1296-1304. [PMID: 32755084 DOI: 10.23736/s0375-9393.20.14323-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Swings of central venous pressure (ΔCVP) may reflect those of pleural and esophageal (ΔPES) pressure and, therefore, the strength of inspiration. Strong inspiratory efforts can produce some harm. Herein we preliminarily assessed the diagnostic accuracy of ΔCVP for strong inspiratory efforts in critically-ill subjects breathing spontaneously. METHODS We measured ΔCVP and ΔPES in 48 critically-ill subjects breathing spontaneously with zero end-expiratory pressure (ZEEP) or 10 cmH<inf>2</inf>O of continuous positive airway pressure (CPAP). The overall diagnostic accuracy of ΔCVP for strong inspiratory efforts (arbitrarily defined as ΔPES >8 mmHg) was described as the area under the receiver operating characteristic (ROC) curve, with 0.50 indicating random guess. The agreement between ΔCVP and ΔPES was assessed with the Bland-Altman analysis. RESULTS ΔCVP recognized strong inspiratory efforts with an area under the ROC curve of 0.95 (95% confidence intervals, 0.85-0.99) with ZEEP and 0.89 (0.76-0.96) with CPAP, both significantly larger than 0.50 (P<0.001). With the best cut-off value around 8 mmHg, the diagnostic accuracy of ΔCVP was 0.92 (0.80-0.98) with ZEEP and 0.94 (0.83-0.99) with CPAP. With ZEEP, the median difference between ΔCVP and ΔPES (bias) was -0.2 mmHg, and the 95% limits of agreement (LoA) were -3.9 and +5.5 mmHg. With CPAP, bias was -0.1 mmHg, and 95%-LoA were -5.8 and +4.5 mmHg. In both cases, ΔCVP correlated with ΔPES (r<inf>s</inf> 0.81 and 0.67; P<0.001 for both). CONCLUSIONS In critically-ill subjects breathing spontaneously, ΔCVP recognized strong inspiratory efforts with acceptable accuracy. Even so, it sometimes largely differed from ∆PES.
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Affiliation(s)
- Jacopo Colombo
- Department of CardioThoracoVascular Anesthesia and Intensive Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Antonio M Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alessandro Protti
- Department of Anesthesia and Intensive Care Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy -
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Kyogoku M, Takeuchi M, Inata Y, Okuda N, Shimizu Y, Hatachi T, Moon K, Tachibana K. A novel method for transpulmonary pressure estimation using fluctuation of central venous pressure. J Clin Monit Comput 2019; 34:725-731. [PMID: 31346899 DOI: 10.1007/s10877-019-00368-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 07/19/2019] [Indexed: 11/26/2022]
Abstract
The objective of the study is to develop a correction method for estimating the change in pleural pressure (ΔPpl) and plateau transpulmonary pressure (PL) by using the change in central venous pressure (ΔCVP). Seven children (aged < 15 years) with acute respiratory failure (PaO2/FIO2 < 300 mmHg), who were paralyzed and mechanically ventilated with a PEEP of < 10 cmH2O and had central venous catheters and esophageal balloon catheters placed for clinical purposes, were enrolled prospectively. We compared change in esophageal pressure (ΔPes), ΔCVP, and ΔPpl calculated using a corrected ΔCVP (cΔCVP-derived ΔPpl). cΔCVP-derived ΔPpl was calculated as κ × ΔCVP, where κ was the ratio of the change in airway pressure (ΔPaw) to ΔCVP during the occlusion test. cΔCVP-derived ΔPpl correlated better than ΔCVP with ΔPes (R2 = 0.48, p = 0.08 vs. R2 = 0.14, p = 0.4) with lesser bias and precision in Bland-Altman analysis. The plateau PL calculated using the cΔCVP-derived ΔPpl (17.6 ± 2.6 cmH2O) correlated well with the ΔPes-derived plateau PL (18.1 ± 2.3 cmH2O) (R2 = 0.90, p = 0.001). Our correction method can estimate ΔPpl and plateau PL from ΔCVP with a reasonable accuracy in paralyzed and mechanically ventilated pediatric patients with respiratory failure.
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Affiliation(s)
- Miyako Kyogoku
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka, 594-1101, Japan.
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka, 594-1101, Japan
| | - Yu Inata
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka, 594-1101, Japan
| | - Nao Okuda
- Center for Infectious Diseases, Nara Medical University Hospital, Nara, Japan
| | - Yoshiyuki Shimizu
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka, 594-1101, Japan
| | - Takeshi Hatachi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka, 594-1101, Japan
| | - Kazue Moon
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka, 594-1101, Japan
| | - Kazuya Tachibana
- Department of Anesthesiology, Osaka Women's and Children's Hospital, Osaka, Japan
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Magder S. Heart-Lung interaction in spontaneous breathing subjects: the basics. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:348. [PMID: 30370275 DOI: 10.21037/atm.2018.06.19] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Heart-lung interactions occur primarily because of two components of lung inflation, changes in pleural pressure and changes in transpulmonary pressure. Of these, changes in pleural pressure dominate during spontaneous breathing. Because the heart is surrounded by pleural pressure, during inspiration the environment of the heart falls relative to the rest of the body. This alters inflow into the right heart and outflow from the left heart. Alterations in transpulmonary pressure can alter the outflow from the right heart and the inflow to the left heart. These interactions are modified by the cardiac and respiratory frequency, ventricular function and magnitude of the respiratory efforts.
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Affiliation(s)
- Sheldon Magder
- Department of Critical Care, McGill University Health Centre, Montreal, Quebec, Canada
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Godoy DA, Lubillo S, Rabinstein AA. Pathophysiology and Management of Intracranial Hypertension and Tissular Brain Hypoxia After Severe Traumatic Brain Injury: An Integrative Approach. Neurosurg Clin N Am 2018; 29:195-212. [PMID: 29502711 DOI: 10.1016/j.nec.2017.12.001] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Monitoring intracranial pressure in comatose patients with severe traumatic brain injury (TBI) is considered necessary by most experts. Acute intracranial hypertension (IHT), when severe and sustained, is a life-threatening complication that demands emergency treatment. Yet, secondary anoxic-ischemic injury after brain trauma can occur in the absence of IHT. In such cases, adding other monitoring modalities can alert clinicians when the patient is in a state of energy failure. This article reviews the mechanisms, diagnosis, and treatment of IHT and brain hypoxia after TBI, emphasizing the need to develop a physiologically integrative approach to the management of these complex situations.
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Affiliation(s)
- Daniel Agustín Godoy
- Intensive Care Unit, San Juan Bautista Hospital, Catamarca, Argentina; Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina.
| | - Santiago Lubillo
- Intensive Care Unit, Hospital Universitario NS de Candelaria, Tenerife, Spain
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Godoy DA, Videtta W, Di Napoli M. Practical Approach to Posttraumatic Intracranial Hypertension According to Pathophysiologic Reasoning. Neurol Clin 2017; 35:613-640. [DOI: 10.1016/j.ncl.2017.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Magder S, Serri K, Verscheure S, Chauvin R, Goldberg P. Active Expiration and the Measurement of Central Venous Pressure. J Intensive Care Med 2016; 33:430-435. [PMID: 27872408 DOI: 10.1177/0885066616678578] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To obtain a point prevalence estimate of alterations in central venous pressure (CVP) produced by active expiration in a consecutive series of intensive care patients. METHODS We evaluated CVP tracings taken by the nurses at their morning shift change in a consecutive series of 60 cardiac surgery and 59 noncardiac surgery patients. We also assessed change in values due to the change in transducer level. Three physicians and a nurse instructor independently reviewed the tracings and determined whether there was evidence of forced expiration and whether it was type A, defined by decreasing CVP during expiration, or type B, defined by increasing CVP during expiration. RESULTS Agreement for CVP value was 96% between a physician and a bedside nurse. Twenty-nine percent of participants had active expiration, evenly distributed between A and B types. Active expiration was not related to the type of surgery, use of bronchodilators, and the presence of chronic obstructive lung disease or abdominal distention. Active expiration was more common in nonventilated patients and patients not receiving vasopressor drugs, suggesting they were more awake. CONCLUSION Active expiration is common in critically ill patients. Failure to recognize it can result in important errors in the estimation of CVP and other hemodynamic measurements.
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Affiliation(s)
- Sheldon Magder
- 1 Division of Critical Care, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Karim Serri
- 2 Critical Care Department, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montréal, Québec
| | - Sara Verscheure
- 1 Division of Critical Care, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Renée Chauvin
- 1 Division of Critical Care, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada
| | - Peter Goldberg
- 1 Division of Critical Care, Royal Victoria Hospital, McGill University Health Centre, Montreal, Quebec, Canada
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Measurement of pleural pressure swings with a fluid-filled esophageal catheter vs pulmonary artery occlusion pressure. J Crit Care 2016; 37:65-71. [PMID: 27636673 DOI: 10.1016/j.jcrc.2016.08.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 07/27/2016] [Accepted: 08/25/2016] [Indexed: 11/24/2022]
Abstract
PURPOSE Pleural pressure measured with esophageal balloon catheters (Peso) can guide ventilator management and help with the interpretation of hemodynamic measurements, but these catheters are not readily available or easy to use. We tested the utility of an inexpensive, fluid-filled esophageal catheter (Peso) by comparing respiratory-induced changes in pulmonary artery occlusion (Ppao), central venous (CVP), and Peso pressures. METHODS We studied 30 patients undergoing elective cardiac surgery who had pulmonary artery and esophageal catheters in place. Proper placement was confirmed by chest compression with airway occlusion. Measurements were made during pressure-regulated volume control (VC) and pressure support (PS) ventilation. RESULTS The fluid-filled esophageal catheter provided a high-quality signal. During VC and PS, change in Ppao (∆Ppao) was greater than ∆Peso (bias = -2 mm Hg) indicating an inspiratory increase in cardiac filling. During VC, ∆CVP bias was 0 indicating no change in right heart filling, but during PS, CVP fell less than Peso indicating an inspiratory increase in filling. Peso measurements detected activation of expiratory muscles, development of non-west zone 3 lung conditions during inspiration, and ventilator-triggered inspiratory efforts. CONCLUSIONS A fluid-filled esophageal catheter provides a high-quality, easily accessible, and inexpensive measure of change in pleural pressure and provided insights into patient-ventilator interactions.
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Abstract
Although invasive hemodynamic monitoring requires considerable skill, studies have shown a striking lack of knowledge of the measurements obtained with the pulmonary artery catheter (PAC). This article reviews monitoring using a PAC. Issues addressed include basic physiology that determines cardiac output and blood pressure; methodology in the measurement of data obtained from a PAC; use of the PAC in making a diagnosis and for patient management, with emphasis on a responsive approach to management; and uses of the PAC that are not indications by themselves for placing the catheter, but can provide useful information when a PAC is in place.
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Affiliation(s)
- Sheldon Magder
- Department of Critical Care, Royal Victoria Hospital, McGill University Health Centre, 687 Pine Avenue West, Montreal, Quebec H3A 1A1, Canada.
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Abstract
PURPOSE OF REVIEW Intracranial pressure (ICP) control is a mainstay of traumatic brain injury (TBI) management. However, development of intracranial hypertension (ICH) may be affected by factors outside of the cranial vault in addition to the local effects of the TBI. This review will examine the pathophysiology of multiple compartment syndrome (MCS) and current treatment considerations for patients with TBI given the effects of MCS. RECENT FINDINGS Elevated intra-abdominal pressure (IAP) is associated with ICP elevation, and decompressive laparotomy in patients with concurrent elevations in IAP and ICP can reduce ICP. Elevated intrathoracic pressure may be similarly associated with ICP elevation, although the ideal ventilator management strategy for TBI patients when considering MCS is unclear. SUMMARY In MCS, intracranial, intrathoracic and intra-abdominal compartment pressures are interrelated. TBI patient care should include ICP control as well as minimization of intrathoracic and intra-abdominal pressure as clinically possible.
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Matching positive end-expiratory pressure to intra-abdominal pressure prevents end-expiratory lung volume decline in a pig model of intra-abdominal hypertension. Crit Care Med 2012; 40:1879-86. [PMID: 22488004 DOI: 10.1097/ccm.0b013e31824e0e80] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Intra-abdominal hypertension is common in critically ill patients and is associated with increased morbidity and mortality. In a previous experimental study, positive end-expiratory pressures of up to 15 cm H2O did not prevent end-expiratory lung volume decline caused by intra-abdominal hypertension. Therefore, we examined the effect of matching positive end-expiratory pressure to the intra-abdominal pressure on cardio-respiratory parameters. DESIGN Experimental pig model of intra-abdominal hypertension. SETTING Large animal facility, University of Western Australia. SUBJECTS Nine anesthetized, nonparalyzed, and ventilated pigs (48 ± 7 kg). INTERVENTIONS Four levels of intra-abdominal pressure (baseline, 12, 18, and 22 mm Hg) were generated in a randomized order by inflating an intra-abdominal balloon. At each level of intra-abdominal pressure, three levels of positive end-expiratory pressure were randomly applied with varying degrees of matching the corresponding intra-abdominal pressure: baseline positive end-expiratory pressure (= 5 cm H2O), moderate positive end-expiratory pressure (= half intra-abdominal pressure in cm H2O + 5 cm H2O), and high positive end-expiratory pressure (= intra-abdominal pressure in cm H2O). MEASUREMENTS We measured end-expiratory lung volume, arterial oxygen levels, respiratory mechanics, and cardiac output 5 mins after each new intra-abdominal pressure and positive end-expiratory pressure setting. MAIN RESULTS Intra-abdominal hypertension decreased end-expiratory lung volume and PaO2 (-49% [p < .001] and -8% [p < .05], respectively, at 22 mm Hg intra-abdominal pressure compared with baseline intra-abdominal pressure) but did not change cardiac output (p = .5). At each level of intra-abdominal pressure, moderate positive end-expiratory pressure increased end-expiratory lung volume (+119% [p < .001] at 22 mm Hg intra-abdominal pressure compared with 5 cm H2O positive end-expiratory pressure) while minimally decreasing cardiac output (-8%, p < .05). High positive end-expiratory pressure further increased end-expiratory lung volume (+233% [p < .001] at 22 mm Hg intra-abdominal pressure compared with 5 cm H2O positive end-expiratory pressure) but led to a greater decrease in cardiac output (-26%, p < .05). Neither moderate nor high positive end-expiratory pressure improved PaO2 (p = .7). Intra-abdominal hypertension decreased end-expiratory transpulmonary pressure but did not alter end-inspiratory transpulmonary pressure. Intra-abdominal hypertension decreased total respiratory compliance through a decrease in chest wall compliance. Positive end-expiratory pressure decreased the respiratory compliance by reducing lung compliance. CONCLUSIONS In a pig model of intra-abdominal hypertension, positive end-expiratory pressure matched to intra-abdominal pressure led to a preservation of end-expiratory lung volume, but did not improve arterial oxygen tension and caused a reduction in cardiac output. Therefore, we do not recommend routine application of positive end-expiratory pressure matched to intra-abdominal pressure to prevent intra-abdominal pressure-induced end-expiratory lung volume decline in healthy lungs.
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Lakhal K, Ehrmann S, Benzekri-Lefèvre D, Runge I, Legras A, Dequin PF, Mercier E, Wolff M, Régnier B, Boulain T. Respiratory pulse pressure variation fails to predict fluid responsiveness in acute respiratory distress syndrome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R85. [PMID: 21385348 PMCID: PMC3219343 DOI: 10.1186/cc10083] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2011] [Revised: 02/02/2011] [Accepted: 03/07/2011] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Fluid responsiveness prediction is of utmost interest during acute respiratory distress syndrome (ARDS), but the performance of respiratory pulse pressure variation (ΔRESPPP) has scarcely been reported. In patients with ARDS, the pathophysiology of ΔRESPPP may differ from that of healthy lungs because of low tidal volume (Vt), high respiratory rate, decreased lung and sometimes chest wall compliance, which increase alveolar and/or pleural pressure. We aimed to assess ΔRESPPP in a large ARDS population. METHODS Our study population of nonarrhythmic ARDS patients without inspiratory effort were considered responders if their cardiac output increased by >10% after 500-ml volume expansion. RESULTS Among the 65 included patients (26 responders), the area under the receiver-operating curve (AUC) for ΔRESPPP was 0.75 (95% confidence interval (CI95): 0.62 to 0.85), and a best cutoff of 5% yielded positive and negative likelihood ratios of 4.8 (CI95: 3.6 to 6.2) and 0.32 (CI95: 0.1 to 0.8), respectively. Adjusting ΔRESPPP for Vt, airway driving pressure or respiratory variations in pulmonary artery occlusion pressure (ΔPAOP), a surrogate for pleural pressure variations, in 33 Swan-Ganz catheter carriers did not markedly improve its predictive performance. In patients with ΔPAOP above its median value (4 mmHg), AUC for ΔRESPPP was 1 (CI95: 0.73 to 1) as compared with 0.79 (CI95: 0.52 to 0.94) otherwise (P = 0.07). A 300-ml volume expansion induced a ≥ 2 mmHg increase of central venous pressure, suggesting a change in cardiac preload, in 40 patients, but none of the 28 of 40 nonresponders responded to an additional 200-ml volume expansion. CONCLUSIONS During protective mechanical ventilation for early ARDS, partly because of insufficient changes in pleural pressure, ΔRESPPP performance was poor. Careful fluid challenges may be a safe alternative.
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Affiliation(s)
- Karim Lakhal
- Service de réanimation médicale et maladies infectieuses, Hôpital Bichat- Claude Bernard, Assistance Publique des Hôpitaux de Paris, 18 rue Henri Huchard, F-75018 Paris, France
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Abstract
This article focuses on static methods for determining preload, specifically pressure and volumetric indices measured at the bedside. The underlying ventricular function will determine where the patient is located on Frank-Starling ventricular function curve and the patient's response to a fluid challenge. The proper interpretation and use of such measures, coupled with an understanding of their limitations and knowledge of alternative methods, is necessary to guide properly volume resuscitation in the critically ill.
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Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Lemaire F, Gerlach H, Groeneveld J, Hedenstierna G, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Metnitz P, Pugin J, Wernerman J, Zhang H. Year in review in Intensive Care Medicine, 2007. II. Haemodynamics, pneumonia, infections and sepsis, invasive and non-invasive mechanical ventilation, acute respiratory distress syndrome. Intensive Care Med 2008; 34:405-22. [PMID: 18236026 DOI: 10.1007/s00134-008-1009-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Accepted: 01/07/2008] [Indexed: 01/14/2023]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anaesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli 8, 00168 Rome, Italy.
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Malbrain MLNG, Wilmer A. The polycompartment syndrome: towards an understanding of the interactions between different compartments! Intensive Care Med 2007; 33:1869-72. [PMID: 17786404 DOI: 10.1007/s00134-007-0843-4] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2007] [Accepted: 06/29/2007] [Indexed: 12/16/2022]
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