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Bureau C, Schmidt M, Chommeloux J, Rivals I, Similowski T, Hékimian G, Luyt CE, Niérat MC, Dangers L, Dres M, Combes A, Morélot-Panzini C, Demoule A. Increasing Sweep Gas Flow Reduces Respiratory Drive and Dyspnea in Nonintubated Venoarterial Extracorporeal Membrane Oxygenation Patients: A Pilot Study. Anesthesiology 2024; 141:87-99. [PMID: 38436930 DOI: 10.1097/aln.0000000000004962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
BACKGROUND Data on assessment and management of dyspnea in patients on venoarterial extracorporeal membrane oxygenation (ECMO) for cardiogenic shock are lacking. The hypothesis was that increasing sweep gas flow through the venoarterial extracorporeal membrane oxygenator may decrease dyspnea in nonintubated venoarterial ECMO patients exhibiting clinically significant dyspnea, with a parallel reduction in respiratory drive. METHODS Nonintubated, spontaneously breathing, supine patients on venoarterial ECMO for cardiogenic shock who presented with a dyspnea visual analog scale (VAS) score of greater than or equal to 40/100 mm were included. Sweep gas flow was increased up to +6 l/min by three steps of +2 l/min each. Dyspnea was assessed with the dyspnea-VAS and the Multidimensional Dyspnea Profile. The respiratory drive was assessed by the electromyographic activity of the alae nasi and parasternal muscles. RESULTS A total of 21 patients were included in the study. Upon inclusion, median dyspnea-VAS was 50 (interquartile range, 45 to 60) mm, and sweep gas flow was 1.0 l/min (0.5 to 2.0). An increase in sweep gas flow significantly decreased dyspnea-VAS (50 [45 to 60] at baseline vs. 20 [10 to 30] at 6 l/min; P < 0.001). The decrease in dyspnea was greater for the sensory component of dyspnea (-50% [-43 to -75]) than for the affective and emotional components (-17% [-0 to -25] and -12% [-0 to -17]; P < 0.001). An increase in sweep gas flow significantly decreased electromyographic activity of the alae nasi and parasternal muscles (-23% [-36 to -10] and -20 [-41 to -0]; P < 0.001). There was a significant correlation between the sweep gas flow and the dyspnea-VAS (r = -0.91; 95% CI, -0.94 to -0.87), between the respiratory drive and the sensory component of dyspnea (r = 0.29; 95% CI, 0.13 to 0.44) between the respiratory drive and the affective component of dyspnea (r = 0.29; 95% CI, 0.02 to 0.54) and between the sweep gas flow and the alae nasi and parasternal (r = -0.31; 95% CI, -0.44 to -0.22; and r = -0.25; 95% CI, -0.44 to -0.16). CONCLUSIONS In critically ill patients with venoarterial ECMO, an increase in sweep gas flow through the oxygenation membrane decreases dyspnea, possibly mediated by a decrease in respiratory drive. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Côme Bureau
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche S1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière Hospital, Médecine Intensive-Réanimation Unit, Paris, France
| | - Matthieu Schmidt
- Sorbonne Université, RESPIRE, Institut National de la Santé et de la Recherche Médicale, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Médecine Intensive-Réanimation Unit, Cardiologie Institute, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Juliette Chommeloux
- Sorbonne Université, RESPIRE, Institut National de la Santé et de la Recherche Médicale, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Médecine Intensive-Réanimation Unit, Cardiologie Institute, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Isabelle Rivals
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Equipe de Statistique Appliquée, ESPCI Paris, Pitié Salpêtrière Research University, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Thomas Similowski
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris University Hospital Group, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière, Paris, France
| | - Guillaume Hékimian
- Sorbonne Université, RESPIRE, Institut National de la Santé et de la Recherche Médicale, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Médecine Intensive-Réanimation Unit, Cardiologie Institute, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Charles-Edouard Luyt
- Sorbonne Université, RESPIRE, Institut National de la Santé et de la Recherche Médicale, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Médecine Intensive-Réanimation Unit, Cardiologie Institute, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière Hospital, Paris, France
| | - Marie-Cécile Niérat
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Laurence Dangers
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière, Médecine Intensive-Réanimation Unit, Paris, France
| | - Martin Dres
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris, Sorbonne Université, Pitié-Salpêtrière Hospital, Médecine Intensive-Réanimation Unit, F-75013, Paris, France
| | - Alain Combes
- Sorbonne Université, RESPIRE, Institut National de la Santé et de la Recherche Médicale, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France; Médecine Intensive-Réanimation Unit, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris Sorbonne, Pitié-Salpêtrière Hospital, Paris, France
| | - Capucine Morélot-Panzini
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris Groupe Hospitalier Universitaire, Assistance Publique-Hôpitaux de Paris Sorbonne Université, Site Pitié-Salpêtrière, Service de Pneumologie, Paris, France
| | - Alexandre Demoule
- Sorbonne Université, Institut National de la Santé et de la Recherche Médicale, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France; Assistance Publique-Hôpitaux de Paris Sorbonne Université, Pitié-Salpêtrière Hospital, Médecine Intensive-Réanimation Unit, Paris, France
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Rixecker TM, Ast V, Rodriguez E, Mazuru V, Wagenpfeil G, Mang S, Muellenbach RM, Nobile L, Ajouri J, Bals R, Seiler F, Taccone FS, Lepper PM. Carbon Dioxide Targets in Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. ASAIO J 2024:00002480-990000000-00509. [PMID: 38905594 DOI: 10.1097/mat.0000000000002255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2024] Open
Abstract
Target values for arterial carbon dioxide tension (PaCO2) in extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) are unknown. We hypothesized that lower PaCO2 values on ECMO would be associated with lighter sedation. We used data from two independent patient cohorts with ARDS spending 1,177 days (discovery cohort, 69 patients) and 516 days (validation cohort, 70 patients) on ECMO and evaluated the associations between daily PaCO2, pH, and bicarbonate (HCO3) with sedation. Median PaCO2 was 41 (interquartile range [IQR] = 37-46) mm Hg and 41 (IQR = 37-45) mm Hg in the discovery and the validation cohort, respectively. Lower PaCO2 and higher pH but not bicarbonate (HCO3) served as significant predictors for reaching a Richmond Agitation Sedation Scale (RASS) target range of -2 to +1 (lightly sedated to restless). After multivariable adjustment for mortality, tracheostomy, prone positioning, vasoactive inotropic score, Simplified Acute Physiology Score (SAPS) II or Sequential Organ Failure Assessment (SOFA) Score and day on ECMO, only PaCO2 remained significantly associated with the RASS target range (adjusted odds ratio 1.1 [95% confidence interval (CI) = 1.01-1.21], p = 0.032 and 1.29 [95% CI = 1.1-1.51], p = 0.001 per mm Hg decrease in PaCO2 for the discovery and the validation cohort, respectively). A PaCO2 ≤40 mm Hg, as determined by the concordance probability method, was associated with a significantly increased probability of a sedation level within the RASS target range in both patient cohorts (adjusted odds ratio = 2.92 [95% CI = 1.17-7.24], p = 0.021 and 6.82 [95% CI = 1.50-31.0], p = 0.013 for the discovery and the validation cohort, respectively).
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Affiliation(s)
- Torben M Rixecker
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Vanessa Ast
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Elianna Rodriguez
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Vitalie Mazuru
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Gudrun Wagenpfeil
- Department of Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg, Germany
| | - Sebastian Mang
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Ralf M Muellenbach
- Department of Anesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - Leda Nobile
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Jonas Ajouri
- Department of Anesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - Robert Bals
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Frederik Seiler
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Philipp M Lepper
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
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Zhou Y, Wang X, Du W, He H, Wang X, Cui N, Long Y. The level of partial pressure of carbon dioxide affects respiratory effort in COVID-19 patients undergoing pressure support ventilation with extracorporeal membrane oxygenation. BMC Anesthesiol 2024; 24:23. [PMID: 38216876 PMCID: PMC10785506 DOI: 10.1186/s12871-023-02382-9] [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: 06/23/2023] [Accepted: 12/12/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND Patients with COVID-19 undergoing pressure support ventilation (PSV) with extracorporeal membrane oxygenation (ECMO) commonly had high respiratory drive, which could cause self-inflicted lung injury. The aim of this study was to evaluate the influence of different levels of partial pressure of carbon dioxide(PaCO2) on respiratory effort in COVID-19 patients undergoing PSV with ECMO. METHODS ECMO gas flow was downregulated from baseline (respiratory rate < 25 bpm, peak airway pressure < 25 cm H2O, tidal volume < 6 mL/kg, PaCO2 < 40 mmHg) until PaCO2 increased by 5 - 10 mmHg. The pressure muscle index (PMI) and airway pressure swing during occlusion (ΔPOCC) were used to monitor respiratory effort, and they were measured before and after enforcement of the regulations. RESULTS Ten patients with COVID-19 who had undergone ECMO were enrolled in this prospective study. When the PaCO2 increased from 36 (36 - 37) to 42 (41-43) mmHg (p = 0.0020), there was a significant increase in ΔPOCC [from 5.6 (4.7-8.0) to 11.1 (8.5-13.1) cm H2O, p = 0.0020] and PMI [from 3.0 ± 1.4 to 6.5 ± 2.1 cm H2O, p < 0.0001]. Meanwhile, increased inspiratory effort determined by elevated PaCO2 levels led to enhancement of tidal volume from 4.1 ± 1.2 mL/kg to 5.3 ± 1.5 mL/kg (p = 0.0003) and respiratory rate from 13 ± 2 to 15 ± 2 bpm (p = 0.0266). In addition, the increase in PaCO2 was linearly correlated with changes in ΔPOCC and PMI (R2 = 0.7293, p = 0.0003 and R2 = 0.4105, p = 0.0460, respectively). CONCLUSIONS In patients with COVID-19 undergoing PSV with ECMO, an increase of PaCO2 could increase the inspiratory effort.
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Affiliation(s)
- Yuankai Zhou
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xinchen Wang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Wei Du
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Huaiwu He
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Na Cui
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Yun Long
- Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China.
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Jung C, Gillmann HJ, Stueber T. Modification of Respiratory Drive and Lung Stress by Level of Support Pressure and ECMO Sweep Gas Flow in Patients With Severe COVID-19-Associated Acute Respiratory Distress Syndrome: an Exploratory Retrospective Analysis. J Cardiothorac Vasc Anesth 2024; 38:221-229. [PMID: 38197786 DOI: 10.1053/j.jvca.2023.09.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 08/17/2023] [Accepted: 09/26/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVES Patients with severe acute respiratory distress syndrome (ARDS) often exhibit an unusually strong respiratory drive, which predisposes them to effort-induced lung injury. Careful titration of support pressure via the ventilator and carbon dioxide removal via extracorporeal membrane oxygenation (ECMO) may attenuate respiratory drive and lung stress. DESIGN A retrospective cohort study. SETTING At a single center, a university hospital. PARTICIPANTS Ten patients with severe COVID-19-associated ARDS (CARDS) on venovenous ECMO therapy. INTERVENTIONS Assessment of the effect of titrated support pressure and titrated ECMO sweep gas flow on respiratory drive and lung stress in spontaneously breathing patients during ECMO therapy. MEASUREMENTS AND MAIN RESULTS Airway occlusion pressure (P0.1) and the total swing of the transpulmonary pressure were determined as surrogate parameters of respiratory drive and lung stress. Ventilator-mediated elevation of support pressure decreased P0.1 but increased transpulmonary driving pressure, airway pressure, tidal volume, and end-inspiratory transpulmonary occlusion pressure. The increase in ECMO sweep gas flow lowered P0.1, transpulmonary pressures, tidal volume, and respiratory frequency linearly. CONCLUSIONS In patients with CARDS on pressure support ventilation, even moderate support pressure may lead to overassistance during assisted ventilation, which is only reflected by advanced monitoring of respiratory mechanics. Modifying carbon dioxide removal via the extracorporeal system profoundly affects respiratory effort and mechanics. Spontaneously breathing patients with CARDS may benefit from consequent carbon dioxide removal.
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Affiliation(s)
- Carolin Jung
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany.
| | - Hans-Jörg Gillmann
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
| | - Thomas Stueber
- Department of Anaesthesiology and Intensive Care Medicine, Hannover Medical School, Hannover, Germany
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Teijeiro-Paradis R, Cherkos Dawit T, Munshi L, Ferguson ND, Fan E. Liberation From Venovenous Extracorporeal Membrane Oxygenation for Respiratory Failure: A Scoping Review. Chest 2023; 164:1184-1203. [PMID: 37353070 DOI: 10.1016/j.chest.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/03/2023] [Accepted: 06/14/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Safe and timely liberation from venovenous extracorporeal membrane oxygenation (ECMO) would be expected to reduce the duration of ECMO, the risk of complications, and costs. However, how to liberate patients from venovenous ECMO effectively remains understudied. RESEARCH QUESTION What is the current state of the evidence on liberation from venovenous ECMO? STUDY DESIGN AND METHODS We systematically searched for relevant publications on liberation from venovenous ECMO in Medline and EMBASE. Citations were included if the manuscripts provided any of the following: criteria for readiness for liberation, a liberation protocol, or a definition of successful decannulation or decannulation failure. We included randomized trials, observational trials, narrative reviews, guidelines, editorials, and commentaries. We excluded single case reports and citations where the full text was unavailable. RESULTS We screened 1,467 citations to identify 39 key publications on liberation from venovenous ECMO. We then summarized the data into five main topics: current strategies used for liberation, criteria used to define readiness for liberation, conducting liberation trials, criteria used to proceed with decannulation, and parameters used to predict decannulation outcomes. INTERPRETATION Practices on liberation from venovenous ECMO are heterogeneous and are influenced strongly by clinician preference. Additional research on liberation thresholds is needed to define optimal liberation strategies and to close existing knowledge gaps in essential topics on liberation from venovenous ECMO.
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Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Tsega Cherkos Dawit
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Mekelle University College of Health Sciences, Mekelle, Ethiopia
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada.
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Abrams D, Agerstrand C, Beitler JR, Karagiannidis C, Madahar P, Yip NH, Pesenti A, Slutsky AS, Brochard L, Brodie D. Risks and Benefits of Ultra-Lung-Protective Invasive Mechanical Ventilation Strategies with a Focus on Extracorporeal Support. Am J Respir Crit Care Med 2022; 205:873-882. [PMID: 35044901 DOI: 10.1164/rccm.202110-2252cp] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Lung-protective ventilation strategies are the current standard of care for patients with acute respiratory distress syndrome (ARDS) in an effort to provide adequate ventilatory requirements while minimizing ventilator-induced lung injury. Some patients may benefit from ultra-lung-protective ventilation, a strategy that achieves lower airway pressures and tidal volumes than the current standard. Specific physiological parameters beyond severity of hypoxemia, such as driving pressure and respiratory system elastance, may be predictive of those most likely to benefit. Since application of ultra-lung-protective ventilation is often limited by respiratory acidosis, extracorporeal membrane oxygenation (ECMO) or extracorporeal carbon dioxide removal (ECCO2R), which remove carbon dioxide from blood, are attractive options. These strategies are associated with hematological complications, especially when applied at low blood flow rates with devices designed for higher blood flows, and a recent large randomized, controlled trial failed to show a benefit from an ECCO2R-facilitated ultra-lung-protective ventilation strategy. Only in patients with very severe forms of ARDS has the use of an ultra-lung-protective ventilation strategy - accomplished with ECMO - been suggested to have a favorable risk-to-benefit profile. In this Critical Care Perspective, we address key areas of controversy related to ultra-lung-protective ventilation, including the trade-offs between minimizing ventilator-induced lung injury and the risks from strategies to achieve this added protection. In addition, we suggest which patients might benefit most from an ultra-lung-protective strategy and propose areas of future research.
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Affiliation(s)
- Darryl Abrams
- Columbia University Medical Center, Medicine, Division of Pulmonary, Allergy, & Critical Care, New York, New York, United States
| | - Cara Agerstrand
- Columbia University Medical Center, Medicine, Division of Pulmonary, Allergy, & Critical Care, New York, New York, United States
| | - Jeremy R Beitler
- Columbia University College of Physicians and Surgeons, 12294, Center for Acute Respiratory Failure and Division of Pulmonary, Allergy, and Critical Care Medicine, New York, New York, United States.,NewYork-Presbyterian Hospital, 25065, New York, New York, United States
| | - Christian Karagiannidis
- Hospital Cologne-Merheim, 61060, Department of Pneumology and Critical Care Medicine, Koln, Germany.,Witten/Herdecke University, 12263, Cologne, Germany
| | - Purnema Madahar
- Columbia University Medical Center, Medicine, Division of Pulmonary, Allergy, & Critical Care, New York, New York, United States
| | - Natalie H Yip
- Columbia University Medical Center, Dept of Medicine Pulmonary, New York City, New York, United States
| | - Antonio Pesenti
- Universita degli Studi di Milano, 9304, Department of Pathophysiology and Transplantation, Milano, Italy
| | | | - Laurent Brochard
- St Michael's Hospital in Toronto, Li Ka Shing Knowledge Institute, Keenan Research Centre, Toronto, Ontario, Canada.,University of Toronto, 7938, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Daniel Brodie
- Columbia, Critical Care, New York, New York, United States;
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Diaphragm function in acute respiratory failure and the potential role of phrenic nerve stimulation. Curr Opin Crit Care 2021; 27:282-289. [PMID: 33899818 DOI: 10.1097/mcc.0000000000000828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The aim of this review was to describe the risk factors for developing diaphragm dysfunction, discuss the monitoring techniques for diaphragm activity and function, and introduce potential strategies to incorporate diaphragm protection into conventional lung-protective mechanical ventilation strategies. RECENT FINDINGS It is increasingly apparent that an approach that addresses diaphragm-protective ventilations goals is needed to optimize ventilator management and improve patient outcomes. Ventilator-induced diaphragm dysfunction (VIDD) is common and is associated with increased ICU length of stay, prolonged weaning and increased mortality. Over-assistance, under-assistance and patient-ventilator dyssynchrony may have important downstream clinical consequences related to VIDD. Numerous monitoring techniques are available to assess diaphragm function, including respiratory system pressures, oesophageal manometry, diaphragm ultrasound and electromyography. Novel techniques including phrenic nerve stimulation may facilitate the achievement of lung and diaphragm-protective goals for mechanical ventilation. SUMMARY Diaphragm protection is an important consideration in optimizing ventilator management in patients with acute respiratory failure. The delicate balance between lung and diaphragm-protective goals is challenging. Phrenic nerve stimulation may be uniquely situated to achieve and balance these two commonly conflicting goals.
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Extracorporeal support to achieve lung-protective and diaphragm-protective ventilation. Curr Opin Crit Care 2020; 26:66-72. [PMID: 31876625 DOI: 10.1097/mcc.0000000000000686] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Extracorporeal support allows ultraprotective controlled and assisted ventilation, which can prevent lung and diaphragm injury. We focused on most recent findings in the application of extracorporeal support to achieve lung protection and diaphragm- protection, as well as on relevant monitoring. RECENT FINDINGS A recent randomized trial comparing the efficacy of extracorporeal support as a rescue therapy to conventional protective mechanical ventilation was stopped for futility but post hoc analyses suggested that extracorporeal support is beneficial for patients with very severe acute respiratory distress syndrome. However, the optimal ventilation settings during extracorporeal support are still debated. It is conceivable that they should enable the highest amount of CO2 removal with lowest mechanical power.Extracorporeal CO2 removal can minimize acidosis and enable the use of ultra-protective lung ventilation strategies when hypoxemia is not a major issue. Moreover, it can protect lung and diaphragm function during assisted ventilation through control of the respiratory effort.Lung mechanics, gas exchange, diaphragm electrical activity, ultrasound, electrical impedance tomography could be integrated into clinical management to define lung and diaphragm protection and guide personalized ventilation settings. SUMMARY Technological improvement and the latest evidence indicate that extracorporeal support may be an effective tool for lung and diaphragm protection.
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Goligher EC, Jonkman AH, Dianti J, Vaporidi K, Beitler JR, Patel BK, Yoshida T, Jaber S, Dres M, Mauri T, Bellani G, Demoule A, Brochard L, Heunks L. Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort. Intensive Care Med 2020; 46:2314-2326. [PMID: 33140181 PMCID: PMC7605467 DOI: 10.1007/s00134-020-06288-9] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/08/2020] [Indexed: 12/12/2022]
Abstract
Mechanical ventilation may have adverse effects on both the lung and the diaphragm. Injury to the lung is mediated by excessive mechanical stress and strain, whereas the diaphragm develops atrophy as a consequence of low respiratory effort and injury in case of excessive effort. The lung and diaphragm-protective mechanical ventilation approach aims to protect both organs simultaneously whenever possible. This review summarizes practical strategies for achieving lung and diaphragm-protective targets at the bedside, focusing on inspiratory and expiratory ventilator settings, monitoring of inspiratory effort or respiratory drive, management of dyssynchrony, and sedation considerations. A number of potential future adjunctive strategies including extracorporeal CO2 removal, partial neuromuscular blockade, and neuromuscular stimulation are also discussed. While clinical trials to confirm the benefit of these approaches are awaited, clinicians should become familiar with assessing and managing patients’ respiratory effort, based on existing physiological principles. To protect the lung and the diaphragm, ventilation and sedation might be applied to avoid excessively weak or very strong respiratory efforts and patient-ventilator dysynchrony.
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Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada.,Toronto General Hospital Research Institute, Toronto, Canada
| | - Annemijn H Jonkman
- Department of Intensive Care, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Bhakti K Patel
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL, USA
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Samir Jaber
- Critical Care and Anesthesia Department (DAR B), Hôpital Saint-Éloi, CHU de Montpellier, PhyMedExp, Université de Montpellier, Montpellier, France
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.,Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| | - Tommaso Mauri
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB, Italy
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.,Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Leo Heunks
- Department of Intensive Care, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
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Ventilatory management of patients on ECMO. Indian J Thorac Cardiovasc Surg 2020; 37:248-253. [PMID: 33967448 PMCID: PMC8062618 DOI: 10.1007/s12055-020-01021-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 07/16/2020] [Accepted: 07/22/2020] [Indexed: 01/09/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is the final treatment offered to patients of acute respiratory distress syndrome (ARDS). The survival (to discharge) of patients on veno-venous ECMO is approximately 59% with an average duration of 8 days. The ventilatory management of lungs during the ECMO may have an impact on mortality. An ideal ventilation modality should promote recovery, prevent further damage to the alveoli, and enable weaning from mechanical ventilation. This article reviews the concept of “baby lung” in ARDS and the current evidence for the use of lung protective ventilation, prevention of ventilator-induced lung injury, recommended modes of mechanical ventilation, ideal ventilatory parameters (tidal volume, positive end expiratory pressure, plateau pressure, respiratory rate, fractional inspired oxygen concentration), and use of adjuncts (prone positioning, neuromuscular blocking agents) during the ECMO course.
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Arens J, Grottke O, Haverich A, Maier LS, Schmitz-Rode T, Steinseifer U, Wendel H, Rossaint R. Toward a Long-Term Artificial Lung. ASAIO J 2020; 66:847-854. [PMID: 32740342 PMCID: PMC7386861 DOI: 10.1097/mat.0000000000001139] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Only a very small portion of end-stage organ failures can be treated by transplantation because of the shortage of donor organs. Although artificial long-term organ support such as ventricular assist devices provide therapeutic options serving as a bridge-to-transplantation or destination therapy for end-stage heart failure, suitable long-term artificial lung systems are still at an early stage of development. Although a short-term use of an extracorporeal lung support is feasible today, the currently available technical solutions do not permit the long-term use of lung replacement systems in terms of an implantable artificial lung. This is currently limited by a variety of factors: biocompatibility problems lead to clot formation within the system, especially in areas with unphysiological flow conditions. In addition, proteins, cells, and fibrin are deposited on the membranes, decreasing gas exchange performance and thus, limiting long-term use. Coordinated basic and translational scientific research to solve these problems is therefore necessary to enable the long-term use and implantation of an artificial lung. Strategies for improving the biocompatibility of foreign surfaces, for new anticoagulation regimes, for optimization of gas and blood flow, and for miniaturization of these systems must be found. These strategies must be validated by in vitro and in vivo tests, which remain to be developed. In addition, the influence of long-term support on the pathophysiology must be considered. These challenges require well-connected interdisciplinary teams from the natural and material sciences, engineering, and medicine, which take the necessary steps toward the development of an artificial implantable lung.
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Affiliation(s)
- Jutta Arens
- From the Chair in Engineering Organ Support Technologies, Department of Biomechanical Engineering, Faculty of Engineering Technologies, University of Twente, Enschede, The Netherlands
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty
| | - Oliver Grottke
- Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Axel Haverich
- Thoracic, Cardiac and Vascular Surgery, Medizinische Hochschule Hannover, Hannover, Germany
| | - Lars S. Maier
- Internal Medicine II, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Thomas Schmitz-Rode
- Institute of Applied Medical Engineering, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Ulrich Steinseifer
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Medical Faculty
| | - H.P. Wendel
- Thoracic, Cardiac and Vascular Surgery, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, Medical Faculty, RWTH Aachen University, Aachen, Germany
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Yu T, Wu R, Yao L, Wang K, Wang G, Fan Z, Wu N, Fang X. Neurally adjusted ventilatory assist after surgical treatment of intracerebral hemorrhage: a randomized crossover study. J Int Med Res 2020; 48:300060520939837. [PMID: 32720550 PMCID: PMC7388128 DOI: 10.1177/0300060520939837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We assessed the neuromechanical efficiency (NME), neuroventilatory efficiency (NVE), and diaphragmatic function effects between pressure support ventilation (PSV) and neutrally adjusted ventilatory assist (NAVA). METHODS Fifteen patients who had undergone surgical treatment of intracerebral hemorrhage were enrolled in this randomized crossover study. The patients were assigned to PSV for the first 24 hours and then to NAVA for the following 24 hours or vice versa. The monitored ventilatory parameters under the two ventilation models were compared. NME, NVE, and diaphragmatic function were compared between the two ventilation models. RESULTS One patient's illness worsened during the study. The study was stopped for this patient, and intact data were obtained from the other 14 patients and analyzed. The monitored tidal volume was significantly higher with PSV than NAVA (487 [443-615] vs. 440 [400-480] mL, respectively). NME, NVE, diaphragmatic function, and the partial pressures of arterial carbon dioxide and oxygen were not significantly different between the two ventilation models. CONCLUSION The tidal volume was lower with NAVA than PSV; however, the patients' selected respiratory pattern during NAVA did not change the NME, NVE, or diaphragmatic function.Clinical trial registration no. ChiCTR1900022861.
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Affiliation(s)
- Tao Yu
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Rongrong Wu
- Department of Education, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Lin Yao
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Kui Wang
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Guiliang Wang
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Zhen Fan
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Nianlong Wu
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Xinggen Fang
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
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Migdady I, Stephens RS, Price C, Geocadin RG, Whitman G, Cho SM. The use of apnea test and brain death determination in patients on extracorporeal membrane oxygenation: A systematic review. J Thorac Cardiovasc Surg 2020; 162:867-877.e1. [PMID: 32312535 DOI: 10.1016/j.jtcvs.2020.03.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To review practices of brain death (BD) determination in patients on extracorporeal membrane oxygenation (ECMO). METHODS A systematic search was applied to PubMed and 6 electronic databases from inception to May 22, 2019. Studies reporting methods of BD assessment in adult patients (>18 years old) while on ECMO were included, after which data regarding BD assessment were extracted. RESULTS Twenty-two studies (n = 177 patients) met the inclusion criteria. Eighty-eight patients (50%) in 19 studies underwent the apnea test (AT); most commonly through decreasing the ECMO sweep flow in 14 studies (n = 42, 48%), followed by providing CO2 through the ventilator in 2 studies (n = 6, 7%), and providing CO2 through the ECMO oxygenator in 1 study (n = 1, 1%). The details of the AT were not reported in 2 studies (n = 39, 44%). In 19 patients (22%), the AT was nonconfirmatory due to hemodynamic instability, hypoxia, insufficient CO2 rise, or unreliability of the AT. A total of 157 ancillary tests were performed, including electroencephalogram (62%), computed tomography angiography (22%), transcranial Doppler ultrasound (6%), cerebral blood flow nuclear study (5%), cerebral angiography (4%), and other (1%). Forty-seven patients (53% of patients with AT) with confirmatory AT still underwent additional ancillary for BD confirmation. Only 21 patients (12% of all patients) were declared brain-dead using confirmatory ATs alone without ancillary testing. CONCLUSIONS Performing AT for patients with ECMO was associated with high failure rate and hemodynamic complications. Our study highlights the variability in practice in regard to the AT and supports the use of ancillary tests to determine BD in patients on ECMO.
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Affiliation(s)
- Ibrahim Migdady
- Department of Neurology, Neurological Institute, Cleveland Clinic, Cleveland, Ohio
| | - Robert Scott Stephens
- Medical Intensive Care, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Carrie Price
- Welch Medical Library, Johns Hopkins University, Baltimore, Md
| | - Romergryko G Geocadin
- Departments of Neurology, Neurological Intensive Care, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Glenn Whitman
- Cardiovascular Surgical Intensive Care, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Sung-Min Cho
- Departments of Neurology, Neurological Intensive Care, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.
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Camboni D, Philipp A, Foltan M, Schmid C. Extrakorporale Lungenunterstützung mithilfe der venovenösen Membranoxygenierung. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2019. [DOI: 10.1007/s00398-018-0271-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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16
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Standardized Unloading of Respiratory Muscles during Neurally Adjusted Ventilatory Assist: A Randomized Crossover Pilot Study. Anesthesiology 2019; 129:769-777. [PMID: 30045094 DOI: 10.1097/aln.0000000000002335] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Currently, there is no standardized method to set the support level in neurally adjusted ventilatory assist (NAVA). The primary aim was to explore the feasibility of titrating NAVA to specific diaphragm unloading targets, based on the neuroventilatory efficiency (NVE) index. The secondary outcome was to investigate the effect of reduced diaphragm unloading on distribution of lung ventilation. METHODS This is a randomized crossover study between pressure support and NAVA at different diaphragm unloading at a single neurointensive care unit. Ten adult patients who had started weaning from mechanical ventilation completed the study. Two unloading targets were used: 40 and 60%. The NVE index was used to guide the titration of the assist in NAVA. Electrical impedance tomography data, blood-gas samples, and ventilatory parameters were collected. RESULTS The median unloading was 43% (interquartile range 32, 60) for 40% unloading target and 60% (interquartile range 47, 69) for 60% unloading target. NAVA with 40% unloading led to more dorsal ventilation (center of ventilation at 55% [51, 56]) compared with pressure support (52% [49, 56]; P = 0.019). No differences were found in oxygenation, CO2, and respiratory parameters. The electrical activity of the diaphragm was higher during NAVA with 40% unloading than in pressure support. CONCLUSIONS In this pilot study, NAVA could be titrated to different diaphragm unloading levels based on the NVE index. Less unloading was associated with greater diaphragm activity and improved ventilation of the dependent lung regions.
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Fan E. "There Is Nothing New Except What Has Been Forgotten": The Story of Mechanical Ventilation during Extracorporeal Support. Am J Respir Crit Care Med 2019; 199:550-553. [PMID: 30281337 DOI: 10.1164/rccm.201809-1728ed] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Eddy Fan
- 1 Interdepartmental Division of Critical Care Medicine.,2 Institute of Health Policy, Management and Evaluation University of Toronto Toronto, Canada and.,3 University Health Network Toronto, Canada
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18
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Karagiannidis C, Strassmann S, Schwarz S, Merten M, Fan E, Beck J, Sinderby C, Windisch W. Control of respiratory drive by extracorporeal CO 2 removal in acute exacerbation of COPD breathing on non-invasive NAVA. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:135. [PMID: 31014366 PMCID: PMC6480839 DOI: 10.1186/s13054-019-2404-y] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/21/2019] [Indexed: 01/19/2023]
Abstract
Background Veno-venous extracorporeal CO2 removal (vv-ECCO2R) and non-invasive neurally adjusted ventilator assist (NIV-NAVA) are two promising techniques which may prevent complications related to prolonged invasive mechanical ventilation in patients with acute exacerbation of COPD. Methods A physiological study of the electrical activity of the diaphragm (Edi) response was conducted with varying degrees of extracorporeal CO2 removal to control the respiratory drive in patients with severe acute exacerbation of COPD breathing on NIV-NAVA. Results Twenty COPD patients (SAPS II 37 ± 5.6, age 57 ± 9 years) treated with vv-ECCO2R and supported by NIV-NAVA were studied during stepwise weaning of vv-ECCO2R. Based on dyspnea, tolerance, and blood gases, weaning from vv-ECCO2R was successful in 12 and failed in eight patients. Respiratory drive (measured via the Edi) increased to 19 ± 10 μV vs. 56 ± 20 μV in the successful and unsuccessful weaning groups, respectively, resulting in all patients keeping their CO2 and pH values stable. Edi was the best predictor for vv-ECCO2R weaning failure (ROC analysis AUC 0.95), whereas respiratory rate, rapid shallow breathing index, and tidal volume had lower predictive values. Eventually, 19 patients were discharged home, while one patient died. Mortality at 90 days and 180 days was 15 and 25%, respectively. Conclusions This study demonstrates for the first time the usefulness of the Edi signal to monitor and guide patients with severe acute exacerbation of COPD on vv-ECCO2R and NIV-NAVA. The Edi during vv-ECCO2R weaning was found to be the best predictor of tolerance to removing vv-ECCO2R. Electronic supplementary material The online version of this article (10.1186/s13054-019-2404-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.
| | - Stephan Strassmann
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Sarah Schwarz
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Michaela Merten
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Extracorporeal Life Support Program, Toronto General Hospital, Toronto, Canada
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science and Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science and Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Wolfram Windisch
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
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Karagiannidis C, Hesselmann F, Fan E. Physiological and Technical Considerations of Extracorporeal CO 2 Removal. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:75. [PMID: 30849995 PMCID: PMC6408850 DOI: 10.1186/s13054-019-2367-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2019. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2019. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.
| | - Felix Hesselmann
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Helmholtz Institute Aachen, RWTH Aachen University, Aachen, Germany
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto and the Extracorporeal Life Support Program, Toronto General Hospital, Toronto, Canada
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Neurally adjusted ventilatory assist for children on veno-venous ECMO. J Artif Organs 2019; 22:118-125. [DOI: 10.1007/s10047-018-01087-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 12/24/2018] [Indexed: 01/25/2023]
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Schreiber A, Bertoni M, Goligher EC. Avoiding Respiratory and Peripheral Muscle Injury During Mechanical Ventilation: Diaphragm-Protective Ventilation and Early Mobilization. Crit Care Clin 2018; 34:357-381. [PMID: 29907270 DOI: 10.1016/j.ccc.2018.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Both limb muscle weakness and respiratory muscle weakness are exceedingly common in critically ill patients. Respiratory muscle weakness prolongs ventilator dependence, predisposing to nosocomial complications and death. Limb muscle weakness persists for months after discharge from intensive care and results in poor long-term functional status and quality of life. Major mechanisms of muscle injury include critical illness polymyoneuropathy, sepsis, pharmacologic exposures, metabolic derangements, and excessive muscle loading and unloading. The diaphragm may become weak because of excessive unloading (leading to atrophy) or because of excessive loading (either concentric or eccentric) owing to insufficient ventilator assistance.
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Affiliation(s)
- Annia Schreiber
- Respiratory Intensive Care Unit and Pulmonary Rehabilitation Unit, Istituti Clinici Scientifici Maugeri, Scientific Institute of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy
| | - Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Spedali Civili 1, Brescia 25123, Italy
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto General Hospital, 585 University Avenue, Peter Munk Building, 11th Floor Room 192, Toronto, ON M5G 2N2, Canada.
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Mechanical Ventilation in Adults with Acute Respiratory Distress Syndrome. Summary of the Experimental Evidence for the Clinical Practice Guideline. Ann Am Thorac Soc 2018; 14:S261-S270. [PMID: 28985479 DOI: 10.1513/annalsats.201704-345ot] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
RATIONALE The American Thoracic Society/European Society for Intensive Care Medicine/Society of Critical Care Medicine guidelines on mechanical ventilation in adult patients with acute respiratory distress syndrome (ARDS) provide treatment recommendations derived from a thorough analysis of the clinical evidence on six clinical interventions. However, each of the recommendations contains areas of uncertainty and controversy, which may affect their appropriate clinical application. OBJECTIVES To provide a critical review of the experimental evidence surrounding the pathophysiology of ventilator-induced lung injury and to help clinicians apply the clinical recommendations to individual patients. METHODS We conducted a literature search and narrative review. RESULTS A large number of experimental studies have been performed with the aim of improving understanding of the pathophysiological effects of mechanical ventilation. These studies have formed the basis for the design of many clinical trials. Translational research has fundamentally advanced understanding of the mechanisms of ventilator-induced lung injury, thus informing the design of interventions that improve survival in patients with ARDS. CONCLUSIONS Because daily management of patients with ARDS presents the challenge of competing considerations, clinicians should consider the mechanism of ventilator-induced lung injury, as well as the rationale for interventions designed to mitigate it, when applying evidence-based recommendations at the bedside.
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Pesenti A, Carlesso E, Langer T, Mauri T. Ventilation during extracorporeal support. Med Klin Intensivmed Notfmed 2017; 113:26-30. [DOI: 10.1007/s00063-017-0384-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 10/31/2017] [Indexed: 12/12/2022]
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Zhang Z, Gu WJ, Chen K, Ni H. Mechanical Ventilation during Extracorporeal Membrane Oxygenation in Patients with Acute Severe Respiratory Failure. Can Respir J 2017; 2017:1783857. [PMID: 28127231 PMCID: PMC5239989 DOI: 10.1155/2017/1783857] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 11/28/2016] [Accepted: 12/18/2016] [Indexed: 02/07/2023] Open
Abstract
Conventionally, a substantial number of patients with acute respiratory failure require mechanical ventilation (MV) to avert catastrophe of hypoxemia and hypercapnia. However, mechanical ventilation per se can cause lung injury, accelerating the disease progression. Extracorporeal membrane oxygenation (ECMO) provides an alternative to rescue patients with severe respiratory failure that conventional mechanical ventilation fails to maintain adequate gas exchange. The physiology behind ECMO and its interaction with MV were reviewed. Next, we discussed the timing of ECMO initiation based on the risks and benefits of ECMO. During the running of ECMO, the protective ventilation strategy can be employed without worrying about catastrophic hypoxemia and carbon dioxide retention. There is a large body of evidence showing that protective ventilation with low tidal volume, high positive end-expiratory pressure, and prone positioning can provide benefits on mortality outcome. More recently, there is an increasing popularity on the use of awake and spontaneous breathing for patients undergoing ECMO, which is thought to be beneficial in terms of rehabilitation.
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Affiliation(s)
- Zhongheng Zhang
- 1Department of Emergency Medicine, Sir Run-Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
- *Zhongheng Zhang:
| | - Wan-Jie Gu
- 2Department of Anesthesiology, Nanjing Drum Tower Hospital, Medical College of Nanjing University, Nanjing 210008, China
| | - Kun Chen
- 3Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Zhejiang, China
| | - Hongying Ni
- 3Department of Critical Care Medicine, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, Zhejiang, China
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Sen A, Callisen HE, Alwardt CM, Larson JS, Lowell AA, Libricz SL, Tarwade P, Patel BM, Ramakrishna H. Adult venovenous extracorporeal membrane oxygenation for severe respiratory failure: Current status and future perspectives. Ann Card Anaesth 2016; 19:97-111. [PMID: 26750681 PMCID: PMC4900379 DOI: 10.4103/0971-9784.173027] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) for severe acute respiratory failure was proposed more than 40 years ago. Despite the publication of the ARDSNet study and adoption of lung protective ventilation, the mortality for acute respiratory failure due to acute respiratory distress syndrome has continued to remain high. This technology has evolved over the past couple of decades and has been noted to be safe and successful, especially during the worldwide H1N1 influenza pandemic with good survival rates. The primary indications for ECMO in acute respiratory failure include severe refractory hypoxemic and hypercarbic respiratory failure in spite of maximum lung protective ventilatory support. Various triage criteria have been described and published. Contraindications exist when application of ECMO may be futile or technically impossible. Knowledge and appreciation of the circuit, cannulae, and the physiology of gas exchange with ECMO are necessary to ensure lung rest, efficiency of oxygenation, and ventilation as well as troubleshooting problems. Anticoagulation is a major concern with ECMO, and the evidence is evolving with respect to diagnostic testing and use of anticoagulants. Clinical management of the patient includes comprehensive critical care addressing sedation and neurologic issues, ensuring lung recruitment, diuresis, early enteral nutrition, treatment and surveillance of infections, and multisystem organ support. Newer technology that delinks oxygenation and ventilation by extracorporeal carbon dioxide removal may lead to ultra-lung protective ventilation, avoidance of endotracheal intubation in some situations, and ambulatory therapies as a bridge to lung transplantation. Risks, complications, and long-term outcomes and resources need to be considered and weighed in before widespread application. Ethical challenges are a reality and a multidisciplinary approach that should be adopted for every case in consideration.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Harish Ramakrishna
- Department of Anesthesiology, Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Arizona, USA
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Will all ARDS patients be receiving mechanical ventilation in 2035? Yes. Intensive Care Med 2016; 43:568-569. [PMID: 27515160 DOI: 10.1007/s00134-016-4461-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Accepted: 07/21/2016] [Indexed: 10/21/2022]
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Control of Respiratory Drive and Effort in Extracorporeal Membrane Oxygenation Patients Recovering from Severe Acute Respiratory Distress Syndrome. Anesthesiology 2016; 125:159-67. [DOI: 10.1097/aln.0000000000001103] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background
The amount of extracorporeal carbon dioxide removal may influence respiratory drive in acute respiratory distress syndrome (ARDS) patients undergoing extracorporeal membrane oxygenation (ECMO). The authors evaluated the effects of different levels of extracorporeal carbon dioxide removal in patients recovering from severe ARDS undergoing pressure support ventilation (PSV) and neurally adjusted ventilatory assist (NAVA).
Methods
The authors conducted a prospective, randomized, crossover study on eight spontaneously breathing ARDS patients undergoing venovenous ECMO since 28 ± 20 days. To modulate carbon dioxide extraction, ECMO gas flow (GF) was decreased from baseline resting protective conditions (i.e., GF100%, set to obtain pressure generated in the first 100 ms of inspiration against an occluded airway less than 2 cm H2O, respiratory rate less than or equal to 25 bpm, tidal volume less than 6 ml/kg, and peak airway pressure less than 25 cm H2O) to GF50%-GF25%-GF0% during both PSV and NAVA (random order for ventilation mode). Continuous recordings of airway pressure and flow and esophageal pressure were obtained and analyzed during all study phases.
Results
At higher levels of extracorporeal carbon dioxide extraction, pressure generated in the first 100 ms of inspiration against an occluded airway decreased from 2.8 ± 2.7 cm H2O (PSV, GF0%) and 3.0 ± 2.1 cm H2O (NAVA, GF0%) to 0.9 ± 0.5 cm H2O (PSV, GF100%) and 1.0 ± 0.8 cm H2O (NAVA, GF100%; P < 0.001) and patients’ inspiratory muscle pressure passed from 8.5 ± 6.3 and 6.5 ± 5.5 cm H2O to 4.5 ± 3.1 and 4.2 ± 3.7 cm H2O (P < 0.001). In time, decreased inspiratory drive and effort determined by higher carbon dioxide extraction led to reduction of tidal volume from 6.6 ± 0.9 and 7.5 ± 1.2 ml/kg to 4.9 ± 0.8 and 5.3 ± 1.3 ml/kg (P < 0.001) and of peak airway pressure from 21 ± 3 and 25 ± 4 cm H2O to 21 ± 3 and 21 ± 5 cm H2O (P < 0.001). Finally, transpulmonary pressure linearly decreased when the amount of carbon dioxide extracted by ECMO increased (R2 = 0.823, P < 0.001).
Conclusions
In patients recovering from ARDS undergoing ECMO, the amount of carbon dioxide removed by the artificial lung may influence spontaneous breathing. The effects of carbon dioxide removal on spontaneous breathing during the earlier acute phases of ARDS remain to be elucidated.
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Venovenous extracorporeal membrane oxygenation for acute respiratory failure : A clinical review from an international group of experts. Intensive Care Med 2016; 42:712-724. [PMID: 27007108 DOI: 10.1007/s00134-016-4314-7] [Citation(s) in RCA: 117] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 03/08/2016] [Indexed: 01/15/2023]
Abstract
Despite expensive life-sustaining interventions delivered in the ICU, mortality and morbidity in patients with acute respiratory failure (ARF) remain unacceptably high. Extracorporeal membrane oxygenation (ECMO) has emerged as a promising intervention that may provide more efficacious supportive care to these patients. Improvements in technology have made ECMO safer and easier to use, allowing for the potential of more widespread application in patients with ARF. A greater appreciation of the complications associated with the placement of an artificial airway and mechanical ventilation has led clinicians and researchers to seek viable alternatives to providing supportive care in these patients. Thus, this review will summarize the current knowledge regarding the use of venovenous (VV)-ECMO for ARF and describe some of the recent controversies in the field, such as mechanical ventilation, anticoagulation and transfusion therapy, and ethical concerns in patients supported with VV-ECMO.
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Les dispositifs d’épuration extracorporelle du CO2 en réanimation : principes, indications potentielles, résultats actuels. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-015-1145-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Purpose of review Compared with the conventional forms of partial support, neurally adjusted ventilatory assist was repeatedly shown to improve patient–ventilator synchrony and reduce the risk of overassistance, while guaranteeing adequate inspiratory effort and gas exchange. A few animal studies also suggested the potential of neurally adjusted ventilatory assist in averting the risk of ventilator-induced lung injury. Recent work adds new information on the physiological effects of neurally adjusted ventilatory assist. Recent findings Compared with pressure support, neurally adjusted ventilatory assist has been shown to improve patient–ventilator interaction and synchrony in patients with the most challenging respiratory system mechanics, such as very low compliance consequent to severe acute respiratory distress syndrome and high resistance and air trapping due to chronic airflow obstruction; enhance redistribution of the ventilation in the dependent lung regions; avert the risk of patient–ventilator asynchrony due to sedation; avoid central apneas; limit the risk of high (injurious) tidal volumes in patients with acute respiratory distress syndrome of varied severity; and improve patient–ventilator interaction and synchrony during noninvasive ventilation, irrespective of the interface utilized. Summary Several studies nowadays prove the physiological benefits of neurally adjusted ventilatory assist, as opposed to the conventional modes of partial support. Whether these advantages translate into improvement of clinical outcomes remains to be determined.
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Abstract
Abstract
Background:
In patients with acute respiratory distress syndrome (ARDS), the use of assisted mechanical ventilation is a subject of debate. Assisted ventilation has benefits over controlled ventilation, such as preserved diaphragm function and improved oxygenation. Therefore, higher level of “patient control” of ventilator assist may be preferable in ARDS. However, assisted modes may also increase the risk of high tidal volumes and lung-distending pressures. The current study aims to quantify how differences in freedom to control the ventilator affect lung-protective ventilation, breathing pattern variability, and patient–ventilator interaction.
Methods:
Twelve patients with ARDS were ventilated in a randomized order with assist pressure control ventilation (PCV), pressure support ventilation (PSV), and neurally adjusted ventilatory assist (NAVA). Transpulmonary pressure, tidal volume, diaphragm electrical activity, and patient–ventilator interaction were measured. Respiratory variability was assessed using the coefficient of variation of tidal volume.
Results:
During inspiration, transpulmonary pressure was slightly lower with NAVA (10.3 ± 0.7, 11.2 ± 0.7, and 9.4 ± 0.7 cm H2O for PCV, PSV, and NAVA, respectively; P < 0.01). Tidal volume was similar between modes (6.6 [5.7 to 7.0], 6.4 [5.8 to 7.0], and 6.0 [5.6 to 7.3] ml/kg for PCV, PSV, and NAVA, respectively), but respiratory variability was higher with NAVA (8.0 [6.4 to 10.0], 7.1 [5.9 to 9.0], and 17.0 [12.0 to 36.1] % for PCV, PSV, and NAVA, respectively; P < 0.001). Patient–ventilator interaction improved with NAVA (6 [5 to 8] % error) compared with PCV (29 [14 to 52] % error) and PSV (12 [9 to 27] % error); P < 0.0001.
Conclusion:
In patients with mild-to-moderate ARDS, increasing freedom to control the ventilator maintains lung-protective ventilation in terms of tidal volume and lung-distending pressure, but it improves patient–ventilator interaction and preserves respiratory variability.
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Comment ventiler un patient sous ECMO ou ECCO2R ? MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1020-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Spontaneous breathing in mild and moderate versus severe acute respiratory distress syndrome. Curr Opin Crit Care 2014; 20:69-76. [PMID: 24335656 DOI: 10.1097/mcc.0000000000000055] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW This review summarizes the most recent clinical and experimental data on the impact of spontaneous breathing in acute respiratory distress syndrome (ARDS). RECENT FINDINGS Spontaneous breathing during assisted as well as nonassisted modes of mechanical ventilation improves lung function and reduces lung damage in mild and moderate ARDS. New modes of assisted mechanical ventilation with improved patient ventilator interaction and enhanced variability of the respiratory pattern offer additional benefit on lung function and damage. However, data supporting an outcome benefit of spontaneous breathing in ARDS, even in its mild and moderate forms, are missing. In contrast, controlled mechanical ventilation with muscle paralysis in the first 48 h of severe ARDS has been shown to improve survival, as compared with placebo. Currently, it is unclear whether ventilator settings, rather than the severity of lung injury, determine the potential of spontaneous breathing for benefit or harm. SUMMARY Clinical and experimental studies show that controlled mechanical ventilation with muscle paralysis in the early phase of severe ARDS reduces lung injury and even mortality. At present, spontaneous breathing should be avoided in the early phase of severe ARDS, but considered in mild-to-moderate ARDS.
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Lehle K, Philipp A, Hiller KA, Zeman F, Buchwald D, Schmid C, Dornia C, Lunz D, Müller T, Lubnow M. Efficiency of gas transfer in venovenous extracorporeal membrane oxygenation: analysis of 317 cases with four different ECMO systems. Intensive Care Med 2014; 40:1870-7. [PMID: 25323118 DOI: 10.1007/s00134-014-3489-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 09/05/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Polymethylpentene membrane oxygenators used in venovenous extracorporeal membrane oxygenation (vvECMO) differ in their physical characteristics. The aim of the study was to analyze the gas transfer capability of different ECMO systems in clinical practice, as the choice of the appropriate system may be influenced by the needs of the patient. METHODS Retrospective study on prospectively collected data of adults with severe respiratory failure requiring vvECMO support (Regensburg ECMO Registry, 2009-2013). Oxygen (O2) transfer and carbon dioxide (CO2) elimination of four different ECMO systems (PLS system, n = 163; Cardiohelp system (CH), n = 59, Maquet Cardiopulmonary, Rastatt, Germany; Hilite 7000 LT system, n = 56, Medos Medizintechnik, Stolberg, Germany; ECC.05 system, n = 39, Sorin Group, Mirandola (MO), Italy) were analyzed. RESULTS Gas transfer depended on type of ECMO system, blood flow, and gas flow (p ≤ 0.05, each). CO2 removal is dependent on sweep gas flow and blood flow, with higher blood flow and/or gas flow eliminating more CO2 (p ≤ 0.001). CO2 elimination capacity was highest with the PLS system (p ≤ 0.001). O2 transfer at blood flow rates below 3 l/min depended on blood flow, at higher blood flow rates on blood flow and gas flow. The system with the smallest gas exchange surface (ECC.05 system) was least effective in O2 transfer, but in terms of the gas exchange surface was the most effective. CONCLUSION Our analysis suggests that patients with severe hypoxemia and need for high flow ECMO benefit more from the PLS/CH or Hilite 7000 LT system. The ECC.05 system is advisable for patients with moderate hypoxemia and/or hypercapnia.
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Affiliation(s)
- Karla Lehle
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, 93042, Regensburg, Germany
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Karagiannidis C, Kampe KA, Sipmann FS, Larsson A, Hedenstierna G, Windisch W, Mueller T. Veno-venous extracorporeal CO2 removal for the treatment of severe respiratory acidosis: pathophysiological and technical considerations. Crit Care 2014; 18:R124. [PMID: 24942014 PMCID: PMC4095596 DOI: 10.1186/cc13928] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 05/27/2014] [Indexed: 11/10/2022] Open
Abstract
Introduction While non-invasive ventilation aimed at avoiding intubation has become the modality of choice to treat mild to moderate acute respiratory acidosis, many severely acidotic patients (pH <7.20) still need intubation. Extracorporeal veno-venous CO2 removal (ECCO2R) could prove to be an alternative. The present animal study tested in a systematic fashion technical requirements for successful ECCO2R in terms of cannula size, blood and sweep gas flow. Methods ECCO2R with a 0.98 m2 surface oxygenator was performed in six acidotic (pH <7.20) pigs using either a 14.5 French (Fr) or a 19Fr catheter, with sweep gas flow rates of 8 and 16 L/minute, respectively. During each experiment the blood flow was incrementally increased to a maximum of 400 mL/minute (14.5Fr catheter) and 1000 mL/minute (19Fr catheter). Results Amelioration of severe respiratory acidosis was only feasible when blood flow rates of 750 to 1000 mL/minute (19Fr catheter) were used. Maximal CO2-elimination was 146.1 ± 22.6 mL/minute, while pH increased from 7.13 ± 0.08 to 7.41 ± 0.07 (blood flow of 1000 mL/minute; sweep gas flow 16 L/minute). Accordingly, a sweep gas flow of 8 L/minute resulted in a maximal CO2-elimination rate of 138.0 ± 16.9 mL/minute. The 14.5Fr catheter allowed a maximum CO2 elimination rate of 77.9 mL/minute, which did not result in the normalization of pH. Conclusions Veno-venous ECCO2R may serve as a treatment option for severe respiratory acidosis. In this porcine model, ECCO2R was most effective when using blood flow rates ranging between 750 and 1000 mL/minute, while an increase in sweep gas flow from 8 to 16 L/minute had less impact on ECCO2R in this setting.
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Suarez-Sipmann F. New modes of assisted mechanical ventilation. Med Intensiva 2014; 38:249-60. [PMID: 24507472 DOI: 10.1016/j.medin.2013.10.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 10/22/2013] [Accepted: 10/27/2013] [Indexed: 10/25/2022]
Abstract
Recent major advances in mechanical ventilation have resulted in new exciting modes of assisted ventilation. Compared to traditional ventilation modes such as assisted-controlled ventilation or pressure support ventilation, these new modes offer a number of physiological advantages derived from the improved patient control over the ventilator. By implementing advanced closed-loop control systems and using information on lung mechanics, respiratory muscle function and respiratory drive, these modes are specifically designed to improve patient-ventilator synchrony and reduce the work of breathing. Depending on their specific operational characteristics, these modes can assist spontaneous breathing efforts synchronically in time and magnitude, adapt to changing patient demands, implement automated weaning protocols, and introduce a more physiological variability in the breathing pattern. Clinicians have now the possibility to individualize and optimize ventilatory assistance during the complex transition from fully controlled to spontaneous assisted ventilation. The growing evidence of the physiological and clinical benefits of these new modes is favoring their progressive introduction into clinical practice. Future clinical trials should improve our understanding of these modes and help determine whether the claimed benefits result in better outcomes.
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Affiliation(s)
- F Suarez-Sipmann
- Servicio de Medicina Intensiva, Hospital Universitario de Uppsala, Laboratorio Hedenstierna, Departamento de Ciencias Quirúrgicas, Universidad de Uppsala, Uppsala, Suecia.
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Abstract
Neurally adjusted ventilatory assist (NAVA) uses the electrical activity of the diaphragm (Edi) as a neural trigger to synchronize mechanical ventilatory breaths with the patient's neural respiratory drive. Using this signal enables the ventilator to proportionally support the patient's instantaneous drive on a breath-by-breath basis. Synchrony can be achieved even in the presence of significant air leaks, which make this an attractive choice for invasive and non-invasive ventilation of the neonate. This paper describes the Edi signal, neuroventilatory coupling, and patient-ventilator synchrony including the functional concept of NAVA. Safety features, NAVA terminology, and clinical application of NAVA to unload respiratory musculature are presented. The use of the Edi signal as a respiratory vital sign for conventional ventilation is discussed. The results of animal and adult studies are briefly summarized and detailed descriptions of all NAVA-related research in pediatric and neonatal patients are provided. Further studies are needed to determine whether NAVA will have significant impact on the overall outcomes of neonates.
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Schmidt M, Pellegrino V, Combes A, Scheinkestel C, Cooper DJ, Hodgson C. Mechanical ventilation during extracorporeal membrane oxygenation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:203. [PMID: 24447458 PMCID: PMC4057516 DOI: 10.1186/cc13702] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The timing of extracorporeal membrane oxygenation (ECMO) initiation and its outcome in the management of respiratory and cardiac failure have received considerable attention, but very little attention has been given to mechanical ventilation during ECMO. Mechanical ventilation settings in non-ECMO studies have been shown to have an effect on survival and may also have contributed to a treatment effect in ECMO trials. Protective lung ventilation strategies established for non-ECMO-supported respiratory failure patients may not be optimal for more severe forms of respiratory failure requiring ECMO support. The influence of positive end-expiratory pressure on the reduction of the left ventricular compliance may be a matter of concern for patients receiving ECMO support for cardiac failure. The objectives of this review were to describe potential mechanisms for lung injury during ECMO for respiratory or cardiac failure, to assess the possible benefits from the use of ultra-protective lung ventilation strategies and to review published guidelines and expert opinions available on mechanical ventilation-specific management of patients requiring ECMO, including mode and ventilator settings. Articles were identified through a detailed search of PubMed, Ovid, Cochrane databases and Google Scholar. Additional references were retrieved from the selected studies. Growing evidence suggests that mechanical ventilation settings are important in ECMO patients to minimize further lung damage and improve outcomes. An ultra-protective ventilation strategy may be optimal for mechanical ventilation during ECMO for respiratory failure. The effects of airway pressure on right and left ventricular afterload should be considered during venoarterial ECMO support of cardiac failure. Future studies are needed to better understand the potential impact of invasive mechanical ventilation modes and settings on outcomes.
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Skorko A, Hadfield D, Shah A, Hopkins P. Advances in Ventilation — Neurally Adjusted Ventilatory Assist (NAVA). J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400409] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
This review aims to introduce neurally-adjusted ventilatory assist (NAVA) to readers who do not have experience in using this form of ventilation. We will describe the basic principles and theoretical advantages of NAVA together with our experiences of introducing and using this mode in an intensive care unit.
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Affiliation(s)
- Agnieszka Skorko
- Clinical Research Fellow in Intensive Care, King's College Hospital, London
| | | | - Anand Shah
- Foundation Year 1, The Whittington Hospital
| | - Philip Hopkins
- Consultant in Intensive Care, King's College Hospital, London
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Bein T, Weber-Carstens S, Goldmann A, Müller T, Staudinger T, Brederlau J, Muellenbach R, Dembinski R, Graf BM, Wewalka M, Philipp A, Wernecke KD, Lubnow M, Slutsky AS. Lower tidal volume strategy (≈3 ml/kg) combined with extracorporeal CO2 removal versus 'conventional' protective ventilation (6 ml/kg) in severe ARDS: the prospective randomized Xtravent-study. Intensive Care Med 2013; 39:847-56. [PMID: 23306584 PMCID: PMC3625408 DOI: 10.1007/s00134-012-2787-6] [Citation(s) in RCA: 361] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 11/29/2012] [Indexed: 01/11/2023]
Abstract
Background Acute respiratory distress syndrome is characterized by damage to the lung caused by various insults, including ventilation itself, and tidal hyperinflation can lead to ventilator induced lung injury (VILI). We investigated the effects of a low tidal volume (VT) strategy (VT ≈ 3 ml/kg/predicted body weight [PBW]) using pumpless extracorporeal lung assist in established ARDS. Methods Seventy-nine patients were enrolled after a ‘stabilization period’ (24 h with optimized therapy and high PEEP). They were randomly assigned to receive a low VT ventilation (≈3 ml/kg) combined with extracorporeal CO2 elimination, or to a ARDSNet strategy (≈6 ml/kg) without the extracorporeal device. The primary outcome was the 28-days and 60-days ventilator-free days (VFD). Secondary outcome parameters were respiratory mechanics, gas exchange, analgesic/sedation use, complications and hospital mortality. Results Ventilation with very low VT’s was easy to implement with extracorporeal CO2-removal. VFD’s within 60 days were not different between the study group (33.2 ± 20) and the control group (29.2 ± 21, p = 0.469), but in more hypoxemic patients (PaO2/FIO2 ≤150) a post hoc analysis demonstrated significant improved VFD-60 in study patients (40.9 ± 12.8) compared to control (28.2 ± 16.4, p = 0.033). The mortality rate was low (16.5 %) and did not differ between groups. Conclusions The use of very low VT combined with extracorporeal CO2 removal has the potential to further reduce VILI compared with a ‘normal’ lung protective management. Whether this strategy will improve survival in ARDS patients remains to be determined (Clinical trials NCT 00538928). Electronic supplementary material The online version of this article (doi:10.1007/s00134-012-2787-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas Bein
- Department of Anesthesia and Operative Intensive Care, Regensburg University Hospital, Regensburg, Germany.
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Corbelli R, Habre W. Ventilating the Lungs Safely: What’s New for Infants and Children? CURRENT ANESTHESIOLOGY REPORTS 2013. [DOI: 10.1007/s40140-012-0008-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Schmidt M, Tachon G, Devilliers C, Muller G, Hekimian G, Bréchot N, Merceron S, Luyt CE, Trouillet JL, Chastre J, Leprince P, Combes A. Blood oxygenation and decarboxylation determinants during venovenous ECMO for respiratory failure in adults. Intensive Care Med 2013; 39:838-46. [DOI: 10.1007/s00134-012-2785-8] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 12/05/2012] [Indexed: 12/21/2022]
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Mauri T, Bellani G, Grasselli G, Confalonieri A, Rona R, Patroniti N, Pesenti A. Patient–ventilator interaction in ARDS patients with extremely low compliance undergoing ECMO: a novel approach based on diaphragm electrical activity. Intensive Care Med 2012. [DOI: 10.1007/s00134-012-2755-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Doorduin J, van Hees HWH, van der Hoeven JG, Heunks LMA. Monitoring of the respiratory muscles in the critically ill. Am J Respir Crit Care Med 2012; 187:20-7. [PMID: 23103733 DOI: 10.1164/rccm.201206-1117cp] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Evidence has accumulated that respiratory muscle dysfunction develops in critically ill patients and contributes to prolonged weaning from mechanical ventilation. Accordingly, it seems highly appropriate to monitor the respiratory muscles in these patients. Today, we are only at the beginning of routinely monitoring respiratory muscle function. Indeed, most clinicians do not evaluate respiratory muscle function in critically ill patients at all. In our opinion, however, practical issues and the absence of sound scientific data for clinical benefit should not discourage clinicians from having a closer look at respiratory muscle function in critically ill patients. This perspective discusses the latest developments in the field of respiratory muscle monitoring and possible implications of monitoring respiratory muscle function in critically ill patients.
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Affiliation(s)
- Jonne Doorduin
- Department of Critical Care Medicine, Radboud University Nijmegen Medical Centre, The Netherlands
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Synchronized mechanical ventilation using electrical activity of the diaphragm in neonates. Clin Perinatol 2012; 39:525-42. [PMID: 22954267 DOI: 10.1016/j.clp.2012.06.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The electrical activity of the diaphragm (Edi) is measured by a specialized nasogastric/orogastric tube positioned in the esophagus at the level of the crural diaphragm. Neurally adjusted ventilatory assist (NAVA) uses the Edi signal as a neural trigger and intrabreath controller to synchronize mechanical ventilatory breaths with the patient's respiratory drive and to proportionally support the patient's respiratory efforts on a breath-by-breath basis. NAVA improves patient-ventilator interaction and synchrony even in the presence of large air leaks, and might therefore be an optimal option for noninvasive ventilation in neonates.
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Terzi N, Piquilloud L, Rozé H, Mercat A, Lofaso F, Delisle S, Jolliet P, Sottiaux T, Tassaux D, Roesler J, Demoule A, Jaber S, Mancebo J, Brochard L, Richard JCM. Clinical review: Update on neurally adjusted ventilatory assist--report of a round-table conference. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:225. [PMID: 22715815 PMCID: PMC3580602 DOI: 10.1186/cc11297] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Conventional mechanical ventilators rely on pneumatic pressure and flow sensors and controllers to detect breaths. New modes of mechanical ventilation have been developed to better match the assistance delivered by the ventilator to the patient's needs. Among these modes, neurally adjusted ventilatory assist (NAVA) delivers a pressure that is directly proportional to the integral of the electrical activity of the diaphragm recorded continuously through an esophageal probe. In clinical settings, NAVA has been chiefly compared with pressure-support ventilation, one of the most popular modes used during the weaning phase, which delivers a constant pressure from breath to breath. Comparisons with proportional-assist ventilation, which has numerous similarities, are lacking. Because of the constant level of assistance, pressure-support ventilation reduces the natural variability of the breathing pattern and can be associated with asynchrony and/or overinflation. The ability of NAVA to circumvent these limitations has been addressed in clinical studies and is discussed in this report. Although the underlying concept is fascinating, several important questions regarding the clinical applications of NAVA remain unanswered. Among these questions, determining the optimal NAVA settings according to the patient's ventilatory needs and/or acceptable level of work of breathing is a key issue. In this report, based on an investigator-initiated round table, we review the most recent literature on this topic and discuss the theoretical advantages and disadvantages of NAVA compared with other modes, as well as the risks and limitations of NAVA.
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Abstract
PURPOSE OF REVIEW New developments in mechanical ventilation have focused on increasing the patient's control of the ventilator by implementing information on lung mechanics and respiratory drive. Effort-adapted modes of assisted breathing are presented and their potential advantages are discussed. RECENT FINDINGS Adaptive support ventilation, proportional assist ventilation with load adjustable gain factors and neurally adjusted ventilatory assist are ventilatory modes that follow the concept of adapting the assist to a defined target, instantaneous changes in respiratory drive or lung mechanics. Improved patient ventilator interaction, sufficient unloading of the respiratory muscles and increased comfort have been recently associated with these ventilator modalities. There are, however, scarce data with regard to outcome improvement, such as length of mechanical ventilation, ICU stay or mortality (commonly accepted targets to demonstrate clinical superiority). SUMMARY Within recent years, a major step forward in the evolution of assisted (effort-adapted) modes of mechanical ventilation was accomplished. There is growing evidence that supports the physiological concept of closed-loop effort-adapted assisted modes of mechanical ventilation. However, at present, the translation into a clear outcome benefit remains to be proven. In order to fill the knowledge gap that impedes the broader application, larger randomized controlled trials are urgently needed. However, with clearly proven drawbacks of conventional assisted modes such as pressure support ventilation, it is probably about time to leave these modes introduced decades ago behind.
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Use of neural trigger during neurally adjusted ventilatory assist in a patient with a large broncho-pleural fistula and air leakage. Intensive Care Med 2012; 38:922-3. [DOI: 10.1007/s00134-012-2515-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2012] [Indexed: 11/26/2022]
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