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Powers SK. Ventilator-induced diaphragm dysfunction: phenomenology and mechanism(s) of pathogenesis. J Physiol 2024. [PMID: 39216087 DOI: 10.1113/jp283860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 08/12/2024] [Indexed: 09/04/2024] Open
Abstract
Mechanical ventilation (MV) is used to support ventilation and pulmonary gas exchange in patients during critical illness and surgery. Although MV is a life-saving intervention for patients in respiratory failure, an unintended side-effect of MV is the rapid development of diaphragmatic atrophy and contractile dysfunction. This MV-induced diaphragmatic weakness is labelled as 'ventilator-induced diaphragm dysfunction' (VIDD). VIDD is an important clinical problem because diaphragmatic weakness is a risk factor for the failure to wean patients from MV. Indeed, the inability to remove patients from ventilator support results in prolonged hospitalization and increased morbidity and mortality. The pathogenesis of VIDD has been extensively investigated, revealing that increased mitochondrial production of reactive oxygen species within diaphragm muscle fibres promotes a cascade of redox-regulated signalling events leading to both accelerated proteolysis and depressed protein synthesis. Together, these events promote the rapid development of diaphragmatic atrophy and contractile dysfunction. This review highlights the MV-induced changes in the structure/function of diaphragm muscle and discusses the cell-signalling mechanisms responsible for the pathogenesis of VIDD. This report concludes with a discussion of potential therapeutic opportunities to prevent VIDD and suggestions for future research in this exciting field.
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Affiliation(s)
- Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
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Covotta M, Claroni C, Torregiani G, Menga LS, Venti E, Gazzè G, Anzellotti GM, Ceccarelli V, Gaglioti P, Orlando S, Rosà T, Forastiere E, Antonelli M, Grieco DL. Recruitment-to-inflation ratio to assess response to PEEP during laparoscopic surgery: A physiologic study. J Clin Anesth 2024; 98:111569. [PMID: 39106592 DOI: 10.1016/j.jclinane.2024.111569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 06/14/2024] [Accepted: 07/28/2024] [Indexed: 08/09/2024]
Abstract
STUDY OBJECTIVE During laparoscopic surgery, the role of PEEP to improve outcome is controversial. Mechanistically, PEEP benefits depend on the extent of alveolar recruitment, which prevents ventilator-induced lung injury by reducing lung dynamic strain. The hypotheses of this study were that pneumoperitoneum-induced aeration loss and PEEP-induced recruitment are inter-individually variable, and that the recruitment-to-inflation ratio (R/I) can identify patients who benefit from PEEP in terms of strain reduction. DESIGN Sequential study. SETTING Operating room. PATIENTS Seventeen ASA I-III patients receiving robot-assisted prostatectomy during Trendelenburg pneumoperitoneum. INTERVENTIONS AND MEASUREMENTS Patients underwent end-expiratory lung volume (EELV) and respiratory/lung/chest wall mechanics (esophageal manometry and inspiratory/expiratory occlusions) assessment at PEEP = 0 cmH2O before and after pneumoperitoneum, at PEEP = 4 and 12 cmH2O during pneumoperitoneum. Pneumoperitoneum-induced derecruitment and PEEP-induced recruitment were assessed through a simplified method based on multiple pressure-volume curve. Dynamic and static strain changes were evaluated. R/I between 12 and 4 cmH2O was assessed from EELV. Inter-individual variability was rated with the ratio of standard deviation to mean (CoV). MAIN RESULTS Pneumoperitoneum reduced EELV by (median [IqR]) 410 mL [80-770] (p < 0.001) and increased dynamic strain by 0.04 [0.01-0.07] (p < 0.001), with high inter-individual variability (CoV = 70% and 88%, respectively). Compared to PEEP = 4 cmH2O, PEEP = 12 cmH2O yielded variable amount of recruitment (139 mL [96-366] CoV = 101%), causing different extent of dynamic strain reduction (median decrease 0.02 [0.01-0.04], p = 0.002; CoV = 86%) and static strain increases (median increase 0.05 [0.04-0.07], p = 0.01, CoV = 33%). R/I (1.73 [0.58-3.35]) estimated the decrease in dynamic strain (p ≤0.001, r = -0.90) and the increase in static strain (p = 0.009, r = -0.73) induced by PEEP, while PEEP-induced changes in respiratory and lung mechanics did not. CONCLUSIONS Trendelenburg pneumoperitoneum yields variable derecruitment: PEEP capability to revert these phenomena varies significantly among individuals. High R/I identifies patients in whom higher PEEP mostly reduces dynamic strain with limited static strain increases, potentially allowing individualized settings.
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Affiliation(s)
- Marco Covotta
- Department of Anesthesiology, Intensive Care and Pain Therapy, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Claudia Claroni
- Department of Anesthesiology, Intensive Care and Pain Therapy, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Giulia Torregiani
- Department of Anesthesiology, Intensive Care and Pain Therapy, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Luca S Menga
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Emanuela Venti
- Department of Anesthesiology, Intensive Care and Pain Therapy, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Gaetano Gazzè
- Department of Anesthesiology, Critical Care and Pain Medicine, "Sapienza" University of Roma, Rome, Italy
| | - Gian Marco Anzellotti
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia, Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Valentina Ceccarelli
- Department of Anesthesiology, Critical Care and Pain Medicine, "Sapienza" University of Roma, Rome, Italy
| | - Pierpaolo Gaglioti
- Department of Anesthesiology, Critical Care and Pain Medicine, "Sapienza" University of Roma, Rome, Italy
| | - Sara Orlando
- Department of Anesthesiology, Critical Care and Pain Medicine, "Sapienza" University of Roma, Rome, Italy
| | - Tommaso Rosà
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Ester Forastiere
- Department of Anesthesiology, Intensive Care and Pain Therapy, IRCCS Regina Elena National Cancer Institute, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico L Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
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Murgolo F, Grieco DL, Spadaro S, Bartolomeo N, di Mussi R, Pisani L, Fiorentino M, Crovace AM, Lacitignola L, Staffieri F, Grasso S. Recruitment-to-inflation ratio reflects the impact of peep on dynamic lung strain in a highly recruitable model of ARDS. Ann Intensive Care 2024; 14:106. [PMID: 38963617 PMCID: PMC11224186 DOI: 10.1186/s13613-024-01343-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 06/21/2024] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND The recruitment-to-inflation ratio (R/I) has been recently proposed to bedside assess response to PEEP. The impact of PEEP on ventilator-induced lung injury depends on the extent of dynamic strain reduction. We hypothesized that R/I may reflect the potential for lung recruitment (i.e. recruitability) and, consequently, estimate the impact of PEEP on dynamic lung strain, both assessed through computed tomography scan. METHODS Fourteen lung-damaged pigs (lipopolysaccharide infusion) underwent ventilation at low (5 cmH2O) and high PEEP (i.e., PEEP generating a plateau pressure of 28-30 cmH2O). R/I was measured through a one-breath derecruitment maneuver from high to low PEEP. PEEP-induced changes in dynamic lung strain, difference in nonaerated lung tissue weight (tissue recruitment) and amount of gas entering previously nonaerated lung units (gas recruitment) were assessed through computed tomography scan. Tissue and gas recruitment were normalized to the weight and gas volume of previously ventilated lung areas at low PEEP (normalized-tissue recruitment and normalized-gas recruitment, respectively). RESULTS Between high (median [interquartile range] 20 cmH2O [18-21]) and low PEEP, median R/I was 1.08 [0.88-1.82], indicating high lung recruitability. Compared to low PEEP, tissue and gas recruitment at high PEEP were 246 g [182-288] and 385 ml [318-668], respectively. R/I was linearly related to normalized-gas recruitment (r = 0.90; [95% CI 0.71 to 0.97) and normalized-tissue recruitment (r = 0.69; [95% CI 0.25 to 0.89]). Dynamic lung strain was 0.37 [0.29-0.44] at high PEEP and 0.59 [0.46-0.80] at low PEEP (p < 0.001). R/I was significantly related to PEEP-induced reduction in dynamic (r = - 0.93; [95% CI - 0.78 to - 0.98]) and global lung strain (r = - 0.57; [95% CI - 0.05 to - 0.84]). No correlation was found between R/I and and PEEP-induced changes in static lung strain (r = 0.34; [95% CI - 0.23 to 0.74]). CONCLUSIONS In a highly recruitable ARDS model, R/I reflects the potential for lung recruitment and well estimates the extent of PEEP-induced reduction in dynamic lung strain.
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Affiliation(s)
- Francesco Murgolo
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy.
- Dipartimento di Medicina di Precisione e Rigenerativa e Area Jonica (DiMePRe-J), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università Degli Studi "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy.
| | - Domenico L Grieco
- Department of Anesthesia, Intensive Care and Emergency, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | - Savino Spadaro
- Department of Translational Medicine, Section of Anesthesiology and Intensive Care Medicine, University of Ferrara, Ferrara, Italy
| | - Nicola Bartolomeo
- Interdisciplinary Department of Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Rossella di Mussi
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Luigi Pisani
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Marco Fiorentino
- Nephrology, Dialysis and Transplantation Unit, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari, Bari, Italy
| | | | - Luca Lacitignola
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Veterinary Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Francesco Staffieri
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Veterinary Medicine, University of Bari "Aldo Moro", Bari, Italy
| | - Salvatore Grasso
- Department of Precision-Regenerative Medicine and Jonic Area (DiMePRe-J), Section of Anesthesiology and Intensive Care Medicine, University of Bari "Aldo Moro", Bari, Italy
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Rosà T, Bongiovanni F, Michi T, Mastropietro C, Menga LS, DE Pascale G, Antonelli M, Grieco DL. Recruitment-to-inflation ratio for bedside PEEP selection in acute respiratory distress syndrome. Minerva Anestesiol 2024; 90:694-706. [PMID: 39021144 DOI: 10.23736/s0375-9393.24.17982-5] [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: 07/20/2024]
Abstract
In acute respiratory distress syndrome, the role of positive end-expiratory pressure (PEEP) to prevent ventilator-induced lung injury is controversial. Randomized trials comparing higher versus lower PEEP strategies failed to demonstrate a clinical benefit. This may depend on the inter-individually variable potential for lung recruitment (i.e. recruitability), which would warrant PEEP individualization to balance alveolar recruitment and the unavoidable baby lung overinflation produced by high pressure. Many techniques have been used to assess recruitability, including lung imaging, multiple pressure-volume curves and lung volume measurement. The Recruitment-to-Inflation ratio (R/I) has been recently proposed to bedside assess recruitability without additional equipment. R/I assessment is a simplified technique based on the multiple pressure-volume curve concept: it is measured by monitoring respiratory mechanics and exhaled tidal volume during a 10-cmH2O one-breath derecruitment maneuver after a short high-PEEP test. R/I scales recruited volume to respiratory system compliance, and normalizes recruitment to a proxy of actual lung size. With modest R/I (<0.3-0.4), setting low PEEP (5-8 cmH2O) may be advisable; with R/I>0.6-0.7, high PEEP (≥15 cmH2O) can be considered, provided that airway and/or transpulmonary plateau pressure do not exceed safety limits. In case of intermediate R/I (≈0.5), a more granular assessment of recruitability may be needed. This could be accomplished with advanced monitoring tools, like sequential lung volume measurement with granular R/I assessment or electrical impedance tomography monitoring during a decremental PEEP trial. In this review, we discuss R/I rationale, applications and limits, providing insights on its clinical use for PEEP selection in moderate-to-severe acute respiratory distress syndrome.
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Affiliation(s)
- Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
- Institute of Anesthesiology and Resuscitation, Catholic University of the Sacred Heart, Rome, Italy
| | - Filippo Bongiovanni
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
- Institute of Anesthesiology and Resuscitation, Catholic University of the Sacred Heart, Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
- Institute of Anesthesiology and Resuscitation, Catholic University of the Sacred Heart, Rome, Italy
| | - Claudia Mastropietro
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
- Institute of Anesthesiology and Resuscitation, Catholic University of the Sacred Heart, Rome, Italy
| | - Luca S Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
- Institute of Anesthesiology and Resuscitation, Catholic University of the Sacred Heart, Rome, Italy
| | - Gennaro DE Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
- Institute of Anesthesiology and Resuscitation, Catholic University of the Sacred Heart, Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
- Institute of Anesthesiology and Resuscitation, Catholic University of the Sacred Heart, Rome, Italy
| | - Domenico L Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy -
- Institute of Anesthesiology and Resuscitation, Catholic University of the Sacred Heart, Rome, Italy
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Coudroy R, Lejars A, Rodriguez M, Frat JP, Rault C, Arrivé F, Le Pape S, Thille AW. Physiologic Effects of Reconnection to the Ventilator for 1 Hour Following a Successful Spontaneous Breathing Trial. Chest 2024; 165:1406-1414. [PMID: 38295948 DOI: 10.1016/j.chest.2024.01.038] [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: 11/02/2023] [Revised: 01/16/2024] [Accepted: 01/20/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND Reconnection to the ventilator for 1 h following a successful spontaneous breathing trial (SBT) may reduce reintubation rates compared with direct extubation. However, the physiologic mechanisms leading to this effect are unclear. RESEARCH QUESTION Does reconnection to the ventilator for 1 h reverse alveolar derecruitment induced by SBT, and is alveolar derecruitment more pronounced with a T-piece than with pressure-support ventilation (PSV)? STUDY DESIGN AND METHODS This is an ancillary study of a randomized clinical trial comparing SBT performed with a T-piece or with PSV. Alveolar recruitment was assessed by using measurement of end-expiratory lung volume (EELV). RESULTS Of the 25 patients analyzed following successful SBT, 11 underwent SBT with a T-piece and 14 with PSV. At the end of the SBT, EELV decreased by -30% (95% CI, -37 to -23) compared with baseline prior to the SBT. This reduction was greater with a T-piece than with PSV: -43% (95% CI, -51 to -35) vs -20% (95% CI, -26 to -13); P < .001. Following reconnection to the ventilator for 1 h, EELV accounted for 96% (95% CI, 92 to 101) of baseline EELV and did not significantly differ from prior to the SBT (P = .104). Following 10 min of reconnection to the ventilator, EELV wasted at the end of the SBT was completely recovered using PSV (P = .574), whereas it remained lower than prior to the SBT using a T-piece (P = .010). INTERPRETATION Significant alveolar derecruitment was observed at the end of an SBT and was markedly more pronounced with a T-piece than with PSV. Reconnection to the ventilator for 1 h allowed complete recovery of alveolar derecruitment. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT04227639; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Rémi Coudroy
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France; INSERM CIC 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France.
| | - Alice Lejars
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Maeva Rodriguez
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Jean-Pierre Frat
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France; INSERM CIC 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
| | - Christophe Rault
- INSERM CIC 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France; CHU de Poitiers, Service d'Explorations Fonctionnelles, de Physiologie Respiratoire et de l'Exercice, Poitiers, France
| | - François Arrivé
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Sylvain Le Pape
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France
| | - Arnaud W Thille
- CHU de Poitiers, Service de Médecine Intensive Réanimation, Poitiers, France; INSERM CIC 1402, IS-ALIVE Research Group, Université de Poitiers, Poitiers, France
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Bello G, Giammatteo V, Bisanti A, Delle Cese L, Rosà T, Menga LS, Montini L, Michi T, Spinazzola G, De Pascale G, Pennisi MA, Ribeiro De Santis Santiago R, Berra L, Antonelli M, Grieco DL. High vs Low PEEP in Patients With ARDS Exhibiting Intense Inspiratory Effort During Assisted Ventilation: A Randomized Crossover Trial. Chest 2024; 165:1392-1405. [PMID: 38295949 DOI: 10.1016/j.chest.2024.01.040] [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: 10/01/2023] [Revised: 01/21/2024] [Accepted: 01/23/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Positive end-expiratory pressure (PEEP) can potentially modulate inspiratory effort (ΔPes), which is the major determinant of self-inflicted lung injury. RESEARCH QUESTION Does high PEEP reduce ΔPes in patients with moderate-to-severe ARDS on assisted ventilation? STUDY DESIGN AND METHODS Sixteen patients with Pao2/Fio2 ≤ 200 mm Hg and ΔPes ≥ 10 cm H2O underwent a randomized sequence of four ventilator settings: PEEP = 5 cm H2O or PEEP = 15 cm H2O + synchronous (pressure support ventilation [PSV]) or asynchronous (pressure-controlled intermittent mandatory ventilation [PC-IMV]) inspiratory assistance. ΔPes and respiratory system, lung, and chest wall mechanics were assessed with esophageal manometry and occlusions. PEEP-induced alveolar recruitment and overinflation, lung dynamic strain, and tidal volume distribution were assessed with electrical impedance tomography. RESULTS ΔPes was not systematically different at high vs low PEEP (pressure support ventilation: median, 20 cm H2O; interquartile range (IQR), 15-24 cm H2O vs median, 15 cm H2O; IQR, 13-23 cm H2O; P = .24; pressure-controlled intermittent mandatory ventilation: median, 20; IQR, 18-23 vs median, 19; IQR, 17-25; P = .67, respectively). Similarly, respiratory system and transpulmonary driving pressures, tidal volume, lung/chest wall mechanics, and pendelluft extent were not different between study phases. High PEEP resulted in lower or higher ΔPes, respiratory system driving pressure, and transpulmonary driving pressure according to whether this increased or decreased respiratory system compliance (r = -0.85, P < .001; r = -0.75, P < .001; r = -0.80, P < .001, respectively). PEEP-induced changes in respiratory system compliance were driven by its lung component and were dependent on the extent of PEEP-induced alveolar overinflation (r = -0.66, P = .006). High PEEP caused variable recruitment and systematic redistribution of tidal volume toward dorsal lung regions, thereby reducing dynamic strain in ventral areas (pressure support ventilation: median, 0.49; IQR, 0.37-0.83 vs median, 0.96; IQR, 0.62-1.56; P = .003; pressure-controlled intermittent mandatory ventilation: median, 0.65; IQR, 0.42-1.31 vs median, 1.14; IQR, 0.79-1.52; P = .002). All results were consistent during synchronous and asynchronous inspiratory assistance. INTERPRETATION The impact of high PEEP on ΔPes and lung stress is interindividually variable according to different effects on the respiratory system and lung compliance resulting from alveolar overinflation. High PEEP may help mitigate the risk of self-inflicted lung injury solely if it increases lung/respiratory system compliance. TRIAL REGISTRATION ClinicalTrials.gov; No.: NCT04241874; URL: www. CLINICALTRIALS gov.
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Affiliation(s)
- Giuseppe Bello
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Valentina Giammatteo
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy; Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, MA
| | - Alessandra Bisanti
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Luca Delle Cese
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Tommaso Rosà
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Luca S Menga
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Luca Montini
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Giorgia Spinazzola
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Gennaro De Pascale
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Mariano Alberto Pennisi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Roberta Ribeiro De Santis Santiago
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, MA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, MA
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy
| | - Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS; Rome, Italy; Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy.
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Seybold B, Deutsch AM, Deutsch BL, Simeliunas E, Weigand MA, Fiedler-Kalenka MO, Kalenka A. Differential Effects of Intra-Abdominal Hypertension and ARDS on Respiratory Mechanics in a Porcine Model. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:843. [PMID: 38929460 PMCID: PMC11205316 DOI: 10.3390/medicina60060843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Revised: 05/17/2024] [Accepted: 05/18/2024] [Indexed: 06/28/2024]
Abstract
Background and Objectives: Intra-abdominal hypertension (IAH) and acute respiratory distress syndrome (ARDS) are common concerns in intensive care unit patients with acute respiratory failure (ARF). Although both conditions lead to impairment of global respiratory parameters, their underlying mechanisms differ substantially. Therefore, a separate assessment of the different respiratory compartments should reveal differences in respiratory mechanics. Materials and Methods: We prospectively investigated alterations in lung and chest wall mechanics in 18 mechanically ventilated pigs exposed to varying levels of intra-abdominal pressures (IAP) and ARDS. The animals were divided into three groups: group A (IAP 10 mmHg, no ARDS), B (IAP 20 mmHg, no ARDS), and C (IAP 10 mmHg, with ARDS). Following induction of IAP (by inflating an intra-abdominal balloon) and ARDS (by saline lung lavage and injurious ventilation), respiratory mechanics were monitored for six hours. Statistical analysis was performed using one-way ANOVA to compare the alterations within each group. Results: After six hours of ventilation, end-expiratory lung volume (EELV) decreased across all groups, while airway and thoracic pressures increased. Significant differences were noted between group (B) and (C) regarding alterations in transpulmonary pressure (TPP) (2.7 ± 0.6 vs. 11.3 ± 2.1 cmH2O, p < 0.001), elastance of the lung (EL) (8.9 ± 1.9 vs. 29.9 ± 5.9 cmH2O/mL, p = 0.003), and elastance of the chest wall (ECW) (32.8 ± 3.2 vs. 4.4 ± 1.8 cmH2O/mL, p < 0.001). However, global respiratory parameters such as EELV/kg bodyweight (-6.1 ± 1.3 vs. -11.0 ± 2.5 mL/kg), driving pressure (12.5 ± 0.9 vs. 13.2 ± 2.3 cmH2O), and compliance of the respiratory system (-21.7 ± 2.8 vs. -19.5 ± 3.4 mL/cmH2O) did not show significant differences among the groups. Conclusions: Separate measurements of lung and chest wall mechanics in pigs with IAH or ARDS reveals significant differences in TPP, EL, and ECW, whereas global respiratory parameters do not differ significantly. Therefore, assessing the compartments of the respiratory system separately could aid in identifying the underlying cause of ARF.
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Affiliation(s)
- Benjamin Seybold
- Department of Anesthesiology, Medical Faculty, Heidelberg University Hospital, University Heidelberg, 69120 Heidelberg, Germany; (A.M.D.); (B.L.D.); (E.S.); (M.A.W.); (M.O.F.-K.); (A.K.)
| | - Anna M. Deutsch
- Department of Anesthesiology, Medical Faculty, Heidelberg University Hospital, University Heidelberg, 69120 Heidelberg, Germany; (A.M.D.); (B.L.D.); (E.S.); (M.A.W.); (M.O.F.-K.); (A.K.)
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, 10249 Berlin, Germany
| | - Barbara Luise Deutsch
- Department of Anesthesiology, Medical Faculty, Heidelberg University Hospital, University Heidelberg, 69120 Heidelberg, Germany; (A.M.D.); (B.L.D.); (E.S.); (M.A.W.); (M.O.F.-K.); (A.K.)
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Asklepios Klinik Wandsbek, 22043 Hamburg, Germany
| | - Emilis Simeliunas
- Department of Anesthesiology, Medical Faculty, Heidelberg University Hospital, University Heidelberg, 69120 Heidelberg, Germany; (A.M.D.); (B.L.D.); (E.S.); (M.A.W.); (M.O.F.-K.); (A.K.)
- Department of Anesthesiology and Intensive Care Medicine, Bürgerspital Solothurn, 4500 Solothurn, Switzerland
| | - Markus A. Weigand
- Department of Anesthesiology, Medical Faculty, Heidelberg University Hospital, University Heidelberg, 69120 Heidelberg, Germany; (A.M.D.); (B.L.D.); (E.S.); (M.A.W.); (M.O.F.-K.); (A.K.)
- German Center for Lung Research (DZL), Translational Lung Research Center Heidelberg (TLRC), 69120 Heidelberg, Germany
| | - Mascha O. Fiedler-Kalenka
- Department of Anesthesiology, Medical Faculty, Heidelberg University Hospital, University Heidelberg, 69120 Heidelberg, Germany; (A.M.D.); (B.L.D.); (E.S.); (M.A.W.); (M.O.F.-K.); (A.K.)
- German Center for Lung Research (DZL), Translational Lung Research Center Heidelberg (TLRC), 69120 Heidelberg, Germany
| | - Armin Kalenka
- Department of Anesthesiology, Medical Faculty, Heidelberg University Hospital, University Heidelberg, 69120 Heidelberg, Germany; (A.M.D.); (B.L.D.); (E.S.); (M.A.W.); (M.O.F.-K.); (A.K.)
- Hospital Bergstrasse, 64646 Heppenheim, Germany
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8
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Menga LS, Subirà C, Wong A, Sousa M, Brochard LJ. Setting positive end-expiratory pressure: does the 'best compliance' concept really work? Curr Opin Crit Care 2024; 30:20-27. [PMID: 38085857 DOI: 10.1097/mcc.0000000000001121] [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: 01/03/2024]
Abstract
PURPOSE OF REVIEW Determining the optimal positive end-expiratory pressure (PEEP) setting remains a central yet debated issue in the management of acute respiratory distress syndrome (ARDS).The 'best compliance' strategy set the PEEP to coincide with the peak respiratory system compliance (or 2 cmH 2 O higher) during a decremental PEEP trial, but evidence is conflicting. RECENT FINDINGS The physiological rationale that best compliance is always representative of functional residual capacity and recruitment has raised serious concerns about its efficacy and safety, due to its association with increased 28-day all-cause mortality in a randomized clinical trial in ARDS patients.Moreover, compliance measurement was shown to underestimate the effects of overdistension, and neglect intra-tidal recruitment, airway closure, and the interaction between lung and chest wall mechanics, especially in obese patients. In response to these concerns, alternative approaches such as recruitment-to-inflation ratio, the nitrogen wash-in/wash-out technique, and electrical impedance tomography (EIT) are gaining attention to assess recruitment and overdistention more reliably and precisely. SUMMARY The traditional 'best compliance' strategy for determining optimal PEEP settings in ARDS carries risks and overlooks some key physiological aspects. The advent of new technologies and methods presents more reliable strategies to assess recruitment and overdistention, facilitating personalized approaches to PEEP optimization.
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Affiliation(s)
- Luca S Menga
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
- Università Cattolica del Sacro Cuore, Facoltà di Medicina e Chirurgia, Anesthesiology and Intensive Care Medicine
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Anesthesia, Emergency and Intensive Care Medicine, Roma, Italy
| | - Carles Subirà
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid
- Critical Care Department, Althaia Xarxa Assistencial Universitària de Manresa, IRIS Research Institute, Manresa, Spain
- Grup de Recerca de Malalt Crític (GMC). Institut de Recerca Biomèdica Catalunya Central IRIS-CC
| | - Alfred Wong
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Mayson Sousa
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Laurent J Brochard
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
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9
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Pavlovsky B, Desprez C, Richard JC, Fage N, Lesimple A, Chean D, Courtais A, Mauri T, Mercat A, Beloncle F. Bedside personalized methods based on electrical impedance tomography or respiratory mechanics to set PEEP in ARDS and recruitment-to-inflation ratio: a physiologic study. Ann Intensive Care 2024; 14:1. [PMID: 38180544 PMCID: PMC10769993 DOI: 10.1186/s13613-023-01228-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 12/10/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Various Positive End-Expiratory Pressure (PEEP) titration strategies have been proposed to optimize ventilation in patients with acute respiratory distress syndrome (ARDS). We aimed to compare PEEP titration strategies based on electrical impedance tomography (EIT) to methods derived from respiratory system mechanics with or without esophageal pressure measurements, in terms of PEEP levels and association with recruitability. METHODS Nineteen patients with ARDS were enrolled. Recruitability was assessed by the estimated Recruitment-to-Inflation ratio (R/Iest) between PEEP 15 and 5 cmH2O. Then, a decremental PEEP trial from PEEP 20 to 5 cmH2O was performed. PEEP levels determined by the following strategies were studied: (1) plateau pressure 28-30 cmH2O (Express), (2) minimal positive expiratory transpulmonary pressure (Positive PLe), (3) center of ventilation closest to 0.5 (CoV) and (4) intersection of the EIT-based overdistension and lung collapse curves (Crossing Point). In addition, the PEEP levels determined by the Crossing Point strategy were assessed using different PEEP ranges during the decremental PEEP trial. RESULTS Express and CoV strategies led to higher PEEP levels than the Positive PLe and Crossing Point ones (17 [14-17], 20 [17-20], 8 [5-11], 10 [8-11] respectively, p < 0.001). For each strategy, there was no significant association between the optimal PEEP level and R/Iest (Crossing Point: r2 = 0.073, p = 0.263; CoV: r2 < 0.001, p = 0.941; Express: r2 < 0.001, p = 0.920; Positive PLe: r2 = 0.037, p = 0.461). The PEEP level obtained with the Crossing Point strategy was impacted by the PEEP range used during the decremental PEEP trial. CONCLUSIONS CoV and Express strategies led to higher PEEP levels than the Crossing Point and Positive PLe strategies. Optimal PEEP levels proposed by these four methods were not associated with recruitability. Recruitability should be specifically assessed in ARDS patients to optimize PEEP titration.
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Affiliation(s)
- Bertrand Pavlovsky
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France.
| | - Christophe Desprez
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Jean-Christophe Richard
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Nicolas Fage
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Arnaud Lesimple
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Dara Chean
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Antonin Courtais
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, IRCCS (Institute for Treatment and Research, Ca' Granda Maggiore Policlinico Hospital Foundation, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alain Mercat
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - François Beloncle
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
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10
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Grieco DL, Pintaudi G, Bongiovanni F, Anzellotti GM, Menga LS, Cesarano M, Dell’Anna AM, Rosá T, Delle Cese L, Bello G, Giammatteo V, Gennenzi V, Tanzarella ES, Cutuli SL, De Pascale G, De Gaetano A, Maggiore SM, Antonelli M. Recruitment-to-inflation Ratio Assessed through Sequential End-expiratory Lung Volume Measurement in Acute Respiratory Distress Syndrome. Anesthesiology 2023; 139:801-814. [PMID: 37523486 PMCID: PMC10723770 DOI: 10.1097/aln.0000000000004716] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/15/2022] [Accepted: 07/25/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Positive end-expiratory pressure (PEEP) benefits in acute respiratory distress syndrome are driven by lung dynamic strain reduction. This depends on the variable extent of alveolar recruitment. The recruitment-to-inflation ratio estimates recruitability across a 10-cm H2O PEEP range through a simplified maneuver. Whether recruitability is uniform or not across this range is unknown. The hypotheses of this study are that the recruitment-to-inflation ratio represents an accurate estimate of PEEP-induced changes in dynamic strain, but may show nonuniform behavior across the conventionally tested PEEP range (15 to 5 cm H2O). METHODS Twenty patients with moderate-to-severe COVID-19 acute respiratory distress syndrome underwent a decremental PEEP trial (PEEP 15 to 13 to 10 to 8 to 5 cm H2O). Respiratory mechanics and end-expiratory lung volume by nitrogen dilution were measured the end of each step. Gas exchange, recruited volume, recruitment-to-inflation ratio, and changes in dynamic, static, and total strain were computed between 15 and 5 cm H2O (global recruitment-to-inflation ratio) and within narrower PEEP ranges (granular recruitment-to-inflation ratio). RESULTS Between 15 and 5 cm H2O, median [interquartile range] global recruitment-to-inflation ratio was 1.27 [0.40 to 1.69] and displayed a linear correlation with PEEP-induced dynamic strain reduction (r = -0.94; P < 0.001). Intraindividual recruitment-to-inflation ratio variability within the narrower ranges was high (85% [70 to 109]). The relationship between granular recruitment-to-inflation ratio and PEEP was mathematically described by a nonlinear, quadratic equation (R2 = 0.96). Granular recruitment-to-inflation ratio across the narrower PEEP ranges itself had a linear correlation with PEEP-induced reduction in dynamic strain (r = -0.89; P < 0.001). CONCLUSIONS Both global and granular recruitment-to-inflation ratio accurately estimate PEEP-induced changes in lung dynamic strain. However, the effect of 10 cm H2O of PEEP on lung strain may be nonuniform. Granular recruitment-to-inflation ratio assessment within narrower PEEP ranges guided by end-expiratory lung volume measurement may aid more precise PEEP selection, especially when the recruitment-to-inflation ratio obtained with the simplified maneuver between PEEP 15 and 5 cm H2O yields intermediate values that are difficult to interpret for a proper choice between a high and low PEEP strategy. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gabriele Pintaudi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Bongiovanni
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gian Marco Anzellotti
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia, Analgesia, Perioperative and Intensive Care, SS, Annunziata Hospital, Gabriele d’Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Luca Salvatore Menga
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Melania Cesarano
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio M. Dell’Anna
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Rosá
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca Delle Cese
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giuseppe Bello
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valentina Giammatteo
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Veronica Gennenzi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Eloisa S. Tanzarella
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Salvatore L. Cutuli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gennaro De Pascale
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea De Gaetano
- Consiglio Nazionale delle Ricerche, IRIB Istituto per la Ricerca e l’Innovazione Biomedica, Palermo, Italy; IASI Istituto per l’Analisi dei Sistemi ed Informatica, Rome, Italy; Department of Biomatics, Óbuda University, Budapest, Hungary
| | - Salvatore M. Maggiore
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia, Analgesia, Perioperative and Intensive Care, SS, Annunziata Hospital, Gabriele d’Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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11
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Beloncle FM, Richard JC, Merdji H, Desprez C, Pavlovsky B, Yvin E, Piquilloud L, Olivier PY, Chean D, Studer A, Courtais A, Campfort M, Rahmani H, Lesimple A, Meziani F, Mercat A. Advanced respiratory mechanics assessment in mechanically ventilated obese and non-obese patients with or without acute respiratory distress syndrome. Crit Care 2023; 27:343. [PMID: 37667379 PMCID: PMC10476380 DOI: 10.1186/s13054-023-04623-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/22/2023] [Indexed: 09/06/2023] Open
Abstract
BACKGROUND Respiratory mechanics is a key element to monitor mechanically ventilated patients and guide ventilator settings. Besides the usual basic assessments, some more complex explorations may allow to better characterize patients' respiratory mechanics and individualize ventilation strategies. These advanced respiratory mechanics assessments including esophageal pressure measurements and complete airway closure detection may be particularly relevant in critically ill obese patients. This study aimed to comprehensively assess respiratory mechanics in obese and non-obese ICU patients with or without ARDS and evaluate the contribution of advanced respiratory mechanics assessments compared to basic assessments in these patients. METHODS All intubated patients admitted in two ICUs for any cause were prospectively included. Gas exchange and respiratory mechanics including esophageal pressure and end-expiratory lung volume (EELV) measurements and low-flow insufflation to detect complete airway closure were assessed in standardized conditions (tidal volume of 6 mL kg-1 predicted body weight (PBW), positive end-expiratory pressure (PEEP) of 5 cmH2O) within 24 h after intubation. RESULTS Among the 149 analyzed patients, 52 (34.9%) were obese and 90 (60.4%) had ARDS (65.4% and 57.8% of obese and non-obese patients, respectively, p = 0.385). A complete airway closure was found in 23.5% of the patients. It was more frequent in obese than in non-obese patients (40.4% vs 14.4%, p < 0.001) and in ARDS than in non-ARDS patients (30% vs. 13.6%, p = 0.029). Respiratory system and lung compliances and EELV/PBW were similarly decreased in obese patients without ARDS and obese or non-obese patients with ARDS. Chest wall compliance was not impacted by obesity or ARDS, but end-expiratory esophageal pressure was higher in obese than in non-obese patients. Chest wall contribution to respiratory system compliance differed widely between patients but was not predictable by their general characteristics. CONCLUSIONS Most respiratory mechanics features are similar in obese non-ARDS and non-obese ARDS patients, but end-expiratory esophageal pressure is higher in obese patients. A complete airway closure can be found in around 25% of critically ill patients ventilated with a PEEP of 5 cmH2O. Advanced explorations may allow to better characterize individual respiratory mechanics and adjust ventilation strategies in some patients. Trial registration NCT03420417 ClinicalTrials.gov (February 5, 2018).
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Affiliation(s)
- François M Beloncle
- Medical ICU, University Hospital of Angers, Vent'Lab, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France.
- CNRS, INSERM 1083, MITOVASC, University of Angers, Angers, France.
| | - Jean-Christophe Richard
- Medical ICU, University Hospital of Angers, Vent'Lab, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
- Med2Lab, ALMS, Antony, France
| | - Hamid Merdji
- Medical ICU, University Hospital of Strasbourg, University of Strasbourg, Strasbourg, France
- UMR 1260, Regenerative Nanomedicine (RNM), FMTS, INSERM (French National Institute of Health and Medical Research), Strasbourg, France
| | - Christophe Desprez
- Medical ICU, University Hospital of Angers, Vent'Lab, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Bertrand Pavlovsky
- Medical ICU, University Hospital of Angers, Vent'Lab, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Elise Yvin
- Medical ICU, University Hospital of Angers, Vent'Lab, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pierre-Yves Olivier
- Medical ICU, University Hospital of Angers, Vent'Lab, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Dara Chean
- Medical ICU, University Hospital of Angers, Vent'Lab, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Antoine Studer
- Medical ICU, University Hospital of Strasbourg, University of Strasbourg, Strasbourg, France
| | - Antonin Courtais
- Medical ICU, University Hospital of Angers, Vent'Lab, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Maëva Campfort
- Medical ICU, University Hospital of Angers, Vent'Lab, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Hassene Rahmani
- Medical ICU, University Hospital of Strasbourg, University of Strasbourg, Strasbourg, France
| | - Arnaud Lesimple
- CNRS, INSERM 1083, MITOVASC, University of Angers, Angers, France
- Med2Lab, ALMS, Antony, France
| | - Ferhat Meziani
- Medical ICU, University Hospital of Strasbourg, University of Strasbourg, Strasbourg, France
- UMR 1260, Regenerative Nanomedicine (RNM), FMTS, INSERM (French National Institute of Health and Medical Research), Strasbourg, France
| | - Alain Mercat
- Medical ICU, University Hospital of Angers, Vent'Lab, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
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12
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Grieco DL, Russo A, Anzellotti GM, Romanò B, Bongiovanni F, Dell'Anna AM, Mauti L, Cascarano L, Gallotta V, Rosà T, Varone F, Menga LS, Polidori L, D'Indinosante M, Cappuccio S, Galletta C, Tortorella L, Costantini B, Gueli Alletti S, Sollazzi L, Scambia G, Antonelli M. Lung-protective ventilation during Trendelenburg pneumoperitoneum surgery: A randomized clinical trial. J Clin Anesth 2023; 85:111037. [PMID: 36495775 DOI: 10.1016/j.jclinane.2022.111037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/31/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
Study objective To assess the effects of a protective ventilation strategy during Trendelenburg pneumoperitoneum surgery on postoperative oxygenation. DESIGNS Parallel-group, randomized trial. SETTING Operating room of a university hospital, Italy. PATIENTS Morbidly obese patients undergoing Trendelenburg pneumoperitoneum gynaecological surgery. INTERVENTIONS Participants were randomized to standard (SV: tidal volume = 10 ml/kg of predicted body weight, PEEP = 5 cmH2O) or protective (PV: tidal volume = 6 ml/kg of predicted body weight, PEEP = 10 cmH2O, recruitment maneuvers) ventilation during anesthesia. MEASUREMENTS Primary outcome was PaO2/FiO2 one hour after extubation. Secondary outcomes included day-1 PaO2/FiO2, day-2 respiratory function and intraoperative respiratory/lung mechanics, assessed through esophageal manometry, end-expiratory lung volume (EELV) measurement and pressure-volume curves. MAIN RESULTS Sixty patients were analyzed (31 in SV group, 29 in PV group). Median [IqR] tidal volume was 350 ml [300-360] in PV group and 525 [500-575] in SV group. Median PaO2/FiO2 one hour after extubation was 280 mmHg [246-364] in PV group vs. 298 [250-343] in SV group (p = 0.64). Day-1 PaO2/FiO2, day-2 forced vital capacity, FEV-1 and Tiffenau Index were not different between groups (all p > 0.10). Intraoperatively, 59% of patients showed complete airway closure during pneumoperitoneum, without difference between groups: median airway opening pressure was 17 cmH2O. In PV group, airway and transpulmonary driving pressure were lower (12 ± 5 cmH2O vs. 17 ± 7, p < 0.001; 9 ± 4 vs. 13 ± 7, p < 0.001), PaCO2 and respiratory rate were higher (48 ± 8 mmHg vs. 42 ± 12, p < 0.001; 23 ± 5 breaths/min vs. 16 ± 4, p < 0.001). Intraoperative EELV was similar between PV and SV group (1193 ± 258 ml vs. 1207 ± 368, p = 0.80); ratio of tidal volume to EELV was lower in PV group (0.45 ± 0.12 vs. 0.32 ± 0.09, p < 0.001). CONCLUSIONS In obese patients undergoing Trendelenburg pneumoperitoneum surgery, PV did not improve postoperative oxygenation nor day-2 respiratory function. PV was associated with intraoperative respiratory mechanics indicating less injurious ventilation. The high prevalence of complete airway closure may have affected study results. TRIAL REGISTRATION Prospectively registered on http://clinicaltrials.govNCT03157479 on May 17th, 2017.
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Affiliation(s)
- Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Andrea Russo
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Gian Marco Anzellotti
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Bruno Romanò
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Filippo Bongiovanni
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Antonio M Dell'Anna
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Mauti
- Department of Internal medicine, Catholic University of The Sacred Heart, Rome, Italy; Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Laura Cascarano
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valerio Gallotta
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tommaso Rosà
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Varone
- Department of Internal medicine, Catholic University of The Sacred Heart, Rome, Italy; Respiratory Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca S Menga
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lorenzo Polidori
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Marco D'Indinosante
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Serena Cappuccio
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Claudia Galletta
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lucia Tortorella
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Barbara Costantini
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Salvatore Gueli Alletti
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Liliana Sollazzi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Scambia
- Department of Obstetrics and Gynecology, Catholic University of The Sacred Heart, Rome, Italy; Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy; Anesthesia, Emergency and Intensive Care Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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13
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Comparison of Inflation and Ventilation with Hydrogen Sulfide during the Warm Ischemia Phase on Ischemia-Reperfusion Injury in a Rat Model of Non-Heart-Beating Donor Lung Transplantation. BIOMED RESEARCH INTERNATIONAL 2023; 2023:3645304. [PMID: 36778057 PMCID: PMC9911243 DOI: 10.1155/2023/3645304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 12/25/2022] [Accepted: 12/30/2022] [Indexed: 02/05/2023]
Abstract
Donor lung ventilation and inflation during the warm ischemia could attenuate ischemia-reperfusion injury (IRI) after lung transplantation. Hydrogen sulfide (H2S), as a kind of protective gas, has demonstrated the antilung IRI effect. This study is aimed at observing the different methods of administering H2S in the setting of warm ischemia, ventilation, and inflation on the lung graft from a rat non-heart-beating donor. After 1 h of cardiac arrest, donor lungs in situ were inflated with 80 ppm H2S (FS group), ventilated with 80 ppm H2S (VS group), or deflated (control group) for 2 h. Then, the lung transplantation was performed after 3 h cold ischemia. The rats without ischemia and reperfusion were in the sham group. Pulmonary surfactant in the bronchoalveolar lavage fluid was measured in donor lung. The inflammatory response, cell apoptosis, and lung graft function were assessed at 3 h after reperfusion. The lung injury was exacerbated in the control group, which was attenuated significantly after the H2S treatment. Compared with the FS group, the pulmonary surfactant in the donor was deteriorated, the lung oxygenation function was decreased, and the inflammatory response and cell apoptosis were increased in the graft in the VS group (P < 0.05). In conclusion, H2S inflation during the warm ischemia phase improved the function of lung graft via regulating pulmonary surfactant stability and decreased the lung graft IRI via decreasing the inflammatory response and cell apoptosis.
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14
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Qian X, Jiang Y, Jia J, Shen W, Ding Y, He Y, Xu P, Pan Q, Xu Y, Ge H. PEEP application during mechanical ventilation contributes to fibrosis in the diaphragm. Respir Res 2023; 24:46. [PMID: 36782202 PMCID: PMC9926671 DOI: 10.1186/s12931-023-02356-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 02/01/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Positive end-expiratory airway pressure (PEEP) is a potent component of management for patients receiving mechanical ventilation (MV). However, PEEP may cause the development of diaphragm remodeling, making it difficult for patients to be weaned from MV. The current study aimed to explore the role of PEEP in VIDD. METHODS Eighteen adult male New Zealand rabbits were divided into three groups at random: nonventilated animals (the CON group), animals with volume-assist/control mode without/ with PEEP 8 cmH2O (the MV group/ the MV + PEEP group) for 48 h with mechanical ventilation. Ventilator parameters and diaphragm were collected during the experiment for further analysis. RESULTS There was no difference among the three groups in arterial blood gas and the diaphragmatic excursion during the experiment. The tidal volume, respiratory rate and minute ventilation were similar in MV + PEEP group and MV group. Airway peak pressure in MV + PEEP group was significantly higher than that in MV group (p < 0.001), and mechanical power was significantly higher (p < 0.001). RNA-seq showed that genes associated with fibrosis were enriched in the MV + PEEP group. This results were further confirmed on mRNA expression. As shown by Masson's trichrome staining, there was more collagen fiber in the MV + PEEP group than that in the MV group (p = 0.001). Sirius red staining showed more positive staining of total collagen fibers and type I/III fibers in the MV + PEEP group (p = 0.001; p = 0.001). The western blot results also showed upregulation of collagen types 1A1, III, 6A1 and 6A2 in the MV + PEEP group compared to the MV group (p < 0.001, all). Moreover, the positive immunofluorescence of COL III in the MV + PEEP group was more intense (p = 0.003). Furthermore, the expression of TGF-β1, one of the most potent fibrogenic factors, was upregulated at both the mRNA and protein levels in the MV + PEEP group (mRNA: p = 0.03; protein: p = 0.04). CONCLUSIONS We demonstrated that PEEP application for 48 h in mechanically ventilated rabbits will cause collagen deposition and fibrosis in the diaphragm. Moreover, activation of the TGF-β1 signaling pathway and myofibroblast differentiation may be the potential mechanism of this diaphragmatic fibrosis. These findings might provide novel therapeutic targets for PEEP application-induced diaphragm dysfunction.
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Affiliation(s)
- Xiaoli Qian
- grid.13402.340000 0004 1759 700XDepartment of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016 China
| | - Ye Jiang
- grid.13402.340000 0004 1759 700XDepartment of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016 China
| | - Jianwei Jia
- grid.13402.340000 0004 1759 700XDepartment of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016 China
| | - Weimin Shen
- grid.13402.340000 0004 1759 700XDepartment of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016 China
| | - Yuejia Ding
- grid.13402.340000 0004 1759 700XDepartment of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016 China
| | - Yuhan He
- grid.13402.340000 0004 1759 700XDepartment of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016 China
| | - Peifeng Xu
- grid.13402.340000 0004 1759 700XDepartment of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016 China
| | - Qing Pan
- grid.469325.f0000 0004 1761 325XCollege of Information Engineering, Zhejiang University of Technology, Liuhe Rd. 288, Hangzhou, 310023 China
| | - Ying Xu
- Department of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016, China.
| | - Huiqing Ge
- Department of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016, China.
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15
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Bongiovanni F, Michi T, Natalini D, Grieco DL, Antonelli M. Advantages and drawbacks of helmet noninvasive support in acute respiratory failure. Expert Rev Respir Med 2023; 17:27-39. [PMID: 36710082 DOI: 10.1080/17476348.2023.2174974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Non-invasive ventilation (NIV) represents an effective strategy for managing acute respiratory failure. Facemask NIV is strongly recommended in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with hypercapnia and acute cardiogenic pulmonary edema (ACPE). Its role in managing acute hypoxemic respiratory failure (AHRF) remains a debated issue. NIV and continuous positive airway pressure (CPAP) delivered through the helmet are recently receiving growing interest for AHRF management. AREAS COVERED In this narrative review, we discuss the clinical applications of helmet support compared to the other available noninvasive strategies in the different phenotypes of acute respiratory failure. EXPERT OPINION Helmets enable the use of high positive end-expiratory pressure, which may protect from self-inflicted lung injury: in AHRF, the possible superiority of helmet support over other noninvasive strategies in terms of clinical outcome has been hypothesized in a network metanalysis and a randomized trial, but has not been confirmed by other investigations and warrants confirmation. In AECOPD patients, helmet efficacy may be inferior to that of face masks, and its use prompts caution due to the risk of CO2 rebreathing. Helmet support can be safely applied in hypoxemic patients with ACPE, with no advantages over facemasks.
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Affiliation(s)
- Filippo Bongiovanni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
| | - Teresa Michi
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
| | - Daniele Natalini
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
| | - Domenico L Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Rome, Italy
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16
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Dilken O, Rezoagli E, Yartaş Dumanlı G, Ürkmez S, Demirkıran O, Dikmen Y. Effect of prone positioning on end-expiratory lung volume, strain and oxygenation change over time in COVID-19 acute respiratory distress syndrome: A prospective physiological study. Front Med (Lausanne) 2022; 9:1056766. [PMID: 36530873 PMCID: PMC9755177 DOI: 10.3389/fmed.2022.1056766] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/21/2022] [Indexed: 11/12/2023] Open
Abstract
Background Prone position (PP) is a recommended intervention in severe classical acute respiratory distress syndrome (ARDS). Changes in lung resting volume, respiratory mechanics and gas exchange during a 16-h cycle of PP in COVID-19 ARDS has not been yet elucidated. Methods Patients with severe COVID-19 ARDS were enrolled between May and September 2021 in a prospective cohort study in a University Teaching Hospital. Lung resting volume was quantitatively assessed by multiple breath nitrogen wash-in/wash-out technique to measure the end-expiratory lung volume (EELV). Timepoints included the following: Baseline, Supine Position (S1); start of PP (P0), and every 4-h (P4; P8; P12) until the end of PP (P16); and Supine Position (S2). Respiratory mechanics and gas exchange were assessed at each timepoint. Measurements and main results 40 mechanically ventilated patients were included. EELV/predicted body weight (PBW) increased significantly over time. The highest increase was observed at P4. The highest absolute EELV/PBW values were observed at the end of the PP (P16 vs S1; median 33.5 ml/kg [InterQuartileRange, 28.2-38.7] vs 23.4 ml/kg [18.5-26.4], p < 0.001). Strain decreased immediately after PP and remained stable between P4 and P16. PaO2/FiO2 increased during PP reaching the highest level at P12 (P12 vs S1; 163 [138-217] vs 81 [65-97], p < 0.001). EELV/PBW, strain and PaO2/FiO2 decreased at S2 although EELV/PBW and PaO2/FiO2 were still significantly higher as compared to S1. Both absolute values over time and changes of strain and PaO2/FiO2 at P16 and S2 versus S1 were strongly associated with EELV/PBW levels. Conclusion In severe COVID-19 ARDS, EELV steadily increased over a 16-h cycle of PP peaking at P16. Strain gradually decreased, and oxygenation improved over time. Changes in strain and oxygenation at the end of PP and back to SP were strongly associated with changes in EELV/PBW. Whether the change in EELV and oxygenation during PP may play a role on outcomes in COVID-ARDS deserves further investigation. Clinical trial registration [www.ClinicalTrials.gov], identifier [NCT04818164].
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Affiliation(s)
- Olcay Dilken
- Department of Intensive Care, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, ECMO Center, ASST Monza, San Gerardo University Teaching Hospital, Monza, Italy
| | - Güleren Yartaş Dumanlı
- Department of Intensive Care, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Seval Ürkmez
- Department of Intensive Care, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Oktay Demirkıran
- Department of Intensive Care, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Yalım Dikmen
- Department of Intensive Care, Cerrahpaşa Faculty of Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
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17
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Rezoagli E, Laffey JG, Bellani G. Monitoring Lung Injury Severity and Ventilation Intensity during Mechanical Ventilation. Semin Respir Crit Care Med 2022; 43:346-368. [PMID: 35896391 DOI: 10.1055/s-0042-1748917] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a severe form of respiratory failure burden by high hospital mortality. No specific pharmacologic treatment is currently available and its ventilatory management is a key strategy to allow reparative and regenerative lung tissue processes. Unfortunately, a poor management of mechanical ventilation can induce ventilation induced lung injury (VILI) caused by physical and biological forces which are at play. Different parameters have been described over the years to assess lung injury severity and facilitate optimization of mechanical ventilation. Indices of lung injury severity include variables related to gas exchange abnormalities, ventilatory setting and respiratory mechanics, ventilation intensity, and the presence of lung hyperinflation versus derecruitment. Recently, specific indexes have been proposed to quantify the stress and the strain released over time using more comprehensive algorithms of calculation such as the mechanical power, and the interaction between driving pressure (DP) and respiratory rate (RR) in the novel DP multiplied by four plus RR [(4 × DP) + RR] index. These new parameters introduce the concept of ventilation intensity as contributing factor of VILI. Ventilation intensity should be taken into account to optimize protective mechanical ventilation strategies, with the aim to reduce intensity to the lowest level required to maintain gas exchange to reduce the potential for VILI. This is further gaining relevance in the current era of phenotyping and enrichment strategies in ARDS.
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Affiliation(s)
- Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy
| | - John G Laffey
- School of Medicine, National University of Ireland, Galway, Ireland.,Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy
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18
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Zhuang S, Wu H, Lin H, Yan N, Zhang F, Wang W. Efficacy analysis of the lung recruitment maneuver in correcting pulmonary atelectasis in neurological intensive care unit-a retrospective study. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:315. [PMID: 35433997 PMCID: PMC9011305 DOI: 10.21037/atm-22-554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/15/2022] [Indexed: 12/16/2022]
Abstract
Background Atelectasis after supratentorial craniotomy is common. It can lead to the decrease of arterial partial pressure of oxygen (PaO2) in patients with neurosurgical intensive care units (NICU), and the recovery of neurological function is more and more difficult. However, due to the particularity of maintaining the stability of intracranial pressure (ICP), there are few reports on effective ways to alleviate atelectasis and improve oxygenation in patients with NICU effectively. Methods A retrospective analysis was conducted to analyze the clinical data of patients with atelectasis who received lung recruitment maneuver in the NICU. This study collected data on 33 patients. Of these, 17 patients had traumatic brain injury and 16 patients had spontaneous intracranial hemorrhage. PaO2, oxygenation index (OI), tidal volume, positive end-expiratory pressure (PEEP), respiratory system compliance, plateau pressure, respiratory rate, minute ventilation and chest computed tomography (CT) or portable chest X-ray images were compared before and after recruitment. As for safety evaluation indicators, we reviewed the invasive arterial blood pressure, heart rate, heart rhythm, and subcutaneous emphysema in all patients. Before and after lung recruitment, the data were compared using the paired t-test and the Wilcoxon test. Results Compared with tidal volume 8.1 [6.85-10.05] mL/kg, minute ventilation volume (9.3±1.3 L/min), respiratory system compliance 60 [39-80] mL/cmH2O, respiratory rate 17 [16-21.5] breaths/min, PEEP 4 [4-6] cmH2O, plateau pressure 19 [17-23] cmH2O, PaO2 (104.2±33.17 mmHg) and OI (250.6±87.65 mmHg) before lung recruitment, tidal volume 9 [8.05-10.65] mL/kg, minute ventilation (9.7±1.1 L/min), respiratory system compliance 69 [50-82.5] mL/cmH2O, respiratory rate 17 [14-18.5] breaths/min, PEEP 4 [4-5] cmH2O, plateau pressure 18 [16-19.5] cmH2O, PaO2 (127.3±34.95 mmHg) and OI (306.9±96.52 mmHg) of patients were significantly improved after recruitment after recruitment (all P<0.05). In all patients, chest CT showed a decrease in atelectasis area and bilateral pulmonary exudates in 25 patients after lung recruitment maneuver. X-ray after recruitment in 2 patients showed increased lung tissue transparency and decreased ground-glass shadowing, while improvements were not obvious in 6 patients. Conclusions For patients diagnosed with atelectasis in the NICU, lung recruitment maneuver can improve atelectasis, increase PaO2, and improve oxygenation.
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Affiliation(s)
- Shunfu Zhuang
- Department of Neurosurgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hong Wu
- Department of Neurosurgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Hong Lin
- Department of Neurosurgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Ning Yan
- Department of Neurosurgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Feifei Zhang
- Department of Neurosurgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Weiwei Wang
- Department of Neurosurgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
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19
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Prediction and estimation of pulmonary response and elastance evolution for volume-controlled and pressure-controlled ventilation. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2021.103367] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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20
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Individualized positive end-expiratory pressure guided by end-expiratory lung volume in early acute respiratory distress syndrome: study protocol for the multicenter, randomized IPERPEEP trial. Trials 2022; 23:63. [PMID: 35057852 PMCID: PMC8772175 DOI: 10.1186/s13063-021-05993-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 12/30/2021] [Indexed: 12/16/2022] Open
Abstract
Background In acute respiratory distress syndrome (ARDS), response to positive end-expiratory pressure (PEEP) is variable according to different degrees of lung recruitability. The search for a tool to individualize PEEP based on patients’ individual response is warranted. End-expiratory lung volume (EELV) assessment by nitrogen washing-washout aids bedside estimation of PEEP-induced alveolar recruitment and may therefore help titrate PEEP on patient’s individual recruitability. We designed a randomized trial to test whether an individualized PEEP setting protocol driven by EELV measurement may improve a composite clinical outcome in patients with moderate-to-severe ARDS (IPERPEEP trial). Methods IPERPEEP is an open-label, multicenter, randomized trial that will be conducted in 10 intensive care units in Italy and will enroll 132 ARDS patients showing PaO2/FiO2 ratio ≤ 150 mmHg within 24 h from endotracheal intubation while on mechanical ventilation with PEEP 5 cmH2O. To standardize lung volumes at study initiation, all patients will undergo mechanical ventilation with tidal volume of 6 ml/kg of predicted body weight and PEEP set to obtain a plateau pressure within 28 and 30 cmH2O for 30 min (EXPRESS PEEP). Afterwards, a 5-step decremental PEEP trial will be conducted (EXPRESS PEEP to PEEP 5 cmH2O), and EELV will be measured at each step. Recruitment-to-inflation ratio will be calculated for each PEEP range from EELV difference. Patients will be then randomized to receive mechanical ventilation with PEEP set according to the optimal recruitment observed in the PEEP trial (IPERPEEP arm) trial or to achieve a plateau pressure of 28–30 cmH2O (control arm, EXPRESS strategy). In both groups, tidal volume size, use of prone positioning and neuromuscular blocking agents, and weaning from PEEP and from mechanical ventilation will be standardized. The primary endpoint of the study is a composite clinical outcome incorporating in-ICU mortality, 60-day ventilator-free days, and serum interleukin-6 concentration over the course of the initial 72 h of treatment. Discussion The IPERPEEP study is a randomized trial powered to elucidate whether an individualized PEEP setting protocol based on bedside assessment of lung recruitability can improve a composite clinical outcome during moderate-to-severe ARDS. Trial registration ClinicalTrials.govNCT04012073. Registered 9 July 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05993-0.
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Rollas K, Hanci P, Topeli A. Effects of end-expiratory lung volume versus PaO 2 guided PEEP determination on respiratory mechanics and oxygenation in moderate to severe ARDS. Exp Lung Res 2021; 48:12-22. [PMID: 34957895 DOI: 10.1080/01902148.2021.2021326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
There is no ideal method for determination of positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS) patients. We compared the effects of end-expiratory lung volume (EELV)-guided versus PaO2-guided PEEP determination on respiratory mechanics and oxygenation during the first 48 hours in moderate to severe ARDS. Twenty-two patients with moderate to severe ARDS admitted to an academic medical ICU were assigned to PaO2-guided (n = 11) or to EELV-guided PEEP determination (n = 11) group. First, an incremental PEEP trial was performed by increasing PEEP by 3 cmH2O steps from 8 to 20 cmH2O and in each step EELV and lung mechanics were measured in both groups. Then, oxygenation and respiratory mechanics were measured under the determined PEEP at 4, 12, 24, and 48th hours. After the incremental PEEP trial, over the 48 hours of the study period, in the EELV-guided group PaO2 and PaO2/FiO2 increased (p = 0.04 and p = 0.02; respectively), whereas they did not change in PaO2-guided group (p = 0.09 and p = 0.27; respectively). In all patients, the median value of EELV change (ΔEELV) during incremental PEEP trial was 25%. In patients with ΔEELV > 25% (n = 11) PaO2, PaO2/FiO2 and Cs increased over time in 48 hours (p = 0.03, p < 0.01, and p = 0.04; respectively), whereas they did not change in those with ΔEELV ≤ 25% (n = 11) (p = 0.73, p = 0.51, and p = 0.73; respectively). Compared to PaO2-guided PEEP determination, EELV-guided PEEP determination resulted in greater improvement in oxygenation over time. Patients who had > 25% improvement in EELV during a PEEP trial had greater improvement in oxygenation and compliance over 48 hours. Supplemental data for this article is available online at.
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Affiliation(s)
- Kazim Rollas
- Division of Intensive Care Medicine, Department of Anaesthesiology, Tepecik Training and Research Hospital, Izmir, Turkey
| | - Pervin Hanci
- Division of Intensive Care Medicine, Department of Pulmonology, Trakya University Faculty of Medicine, Edirne, Turkey
| | - Arzu Topeli
- Division of Intensive Care Medicine, Department of Internal Medicine, Faculty of Medicine, Hacettepe University, Ankara, Turkey
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Su PL, Lin WC, Ko YF, Cheng KS, Chen CW. Electrical Impedance Tomography Analysis Between Two Similar Respiratory System Compliance During Decremetal PEEP Titration in ARDS Patients. J Med Biol Eng 2021; 41:888-894. [PMID: 34803552 PMCID: PMC8593398 DOI: 10.1007/s40846-021-00668-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 10/21/2021] [Indexed: 12/16/2022]
Abstract
Purpose The positive end-expiratory pressure (PEEP) level with best respiratory system compliance (Crs) is frequently used for PEEP selection in acute respiratory distress syndrome (ARDS) patients. On occasion, two similar best Crs (where the difference between the Crs of two PEEP levels is < 1 ml/cm H2O) may be identified during decremental PEEP titration. Selecting PEEP under such conditions is challenging. The aim of this study was to provide supplementary rationale for PEEP selection by assessing the global and regional ventilation distributions between two PEEP levels in this situation. Methods Eight ARDS cases with similar best Crs at two different PEEP levels were analyzed using examination-specific electrical impedance tomography (EIT) measures and airway stress index (SIaw). Five Crs were measured at PEEP values of 25 cm H2O (PEEP25), 20 cm H2O (PEEP20), 15 cm H2O (PEEPH), 11 cm H2O (PEEPI), and 7 cm H2O (PEEPL). The higher PEEP value of the two PEEPs with similar best Crs was designated as PEEPupper, while the lower designated as PEEPlower. Results PEEPH and PEEPI shared the best Crs in two cases, while similar Crs was found at PEEPI and PEEPL in the remaining six cases. SIaw was higher with PEEPupper as compared to PEEPlower (1.06 ± 0.10 versus 0.99 ± 0.09, p = 0.05). Proportion of lung hyperdistension was significantly higher with PEEPupper than PEEPlower (7.0 ± 5.1% versus 0.3 ± 0.5%, p = 0.0002). In contrast, proportion of recruitable lung collapse was higher with PEEPlower than PEEPupper (18.6 ± 4.4% versus 5.9 ± 3.7%, p < 0.0001). Cyclic alveolar collapse and reopening during tidal breathing was higher at PEEPlower than PEEPupper (34.4 ± 19.3% versus 16.0 ± 9.1%, p = 0.046). The intratidal gas distribution (ITV) index was also significantly higher at PEEPlower than PEEPupper (2.6 ± 1.3 versus 1.8 ± 0.7, p = 0.042). Conclusions PEEPupper is a rational selection in ARDS cases with two similar best Crs. EIT provides additional information for the selection of PEEP in such circumstances. Supplementary Information The online version contains supplementary material available at 10.1007/s40846-021-00668-2.
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Affiliation(s)
- Po-Lan Su
- Institute of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan.,Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan, 70403 Taiwan
| | - Wei-Chieh Lin
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan, 70403 Taiwan
| | - Yen-Fen Ko
- Institute of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Kuo-Sung Cheng
- Institute of Biomedical Engineering, National Cheng Kung University, Tainan, Taiwan
| | - Chang-Wen Chen
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng-Kung University, Tainan, 70403 Taiwan.,Medical Device Innovation Center, National Cheng Kung University, Tainan, Taiwan
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Bitker L, Carvalho NC, Reidt S, Schranz C, Novotni D, Orkisz M, Davila Serrano E, Revelly JP, Richard JC. Validation of a novel system to assess end-expiratory lung volume and alveolar recruitment in an ARDS model. Intensive Care Med Exp 2021; 9:46. [PMID: 34505190 PMCID: PMC8428961 DOI: 10.1186/s40635-021-00410-x] [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] [Received: 05/10/2021] [Accepted: 08/10/2021] [Indexed: 11/23/2022] Open
Abstract
Background Personalizing mechanical ventilation requires the development of reliable bedside monitoring techniques. The multiple-breaths nitrogen washin–washout (MBNW) technique is currently available to measure end-expiratory lung volume (EELVMBNW), but the precision of the technique may be poor, with percentage errors ranging from 28 to 57%. The primary aim of the study was to evaluate the reliability of a novel MBNW bedside system using fast mainstream sensors to assess EELV in an experimental acute respiratory distress syndrome (ARDS) model, using computed tomography (CT) as the gold standard. The secondary aims of the study were: (1) to evaluate trending ability of the novel system to assess EELV; (2) to evaluate the reliability of estimated alveolar recruitment induced by positive end-expiratory pressure (PEEP) changes computed from EELVMBNW, using CT as the gold standard. Results Seven pigs were studied in 6 experimental conditions: at baseline, after experimental ARDS and during a decremental PEEP trial at PEEP 16, 12, 6 and 2 cmH2O. EELV was computed at each PEEP step by both the MBNW technique (EELVMBNW) and CT (EELVCT). Repeatability was assessed by performing replicate measurements. Alveolar recruitment between two consecutive PEEP levels after lung injury was measured with CT (VrecCT), and computed from EELV measurements (VrecMBNW) as ΔEELV minus the product of ΔPEEP by static compliance. EELVMBNW and EELVCT were significantly correlated (R2 = 0.97). An acceptable non-constant bias between methods was identified, slightly decreasing toward more negative values as EELV increased. The conversion equation between EELVMBNW and EELVCT was: EELVMBNW = 0.92 × EELVCT + 36. The 95% prediction interval of the bias amounted to ± 86 mL and the percentage error between both methods amounted to 13.7%. The median least significant change between repeated measurements amounted to 8% [CI95%: 4–10%]. EELVMBNW adequately tracked EELVCT changes over time (concordance rate amounting to 100% [CI95%: 87%–100%] and angular bias amounting to − 2° ± 10°). VrecMBNW and VrecCT were significantly correlated (R2 = 0.92). A non-constant bias between methods was identified, slightly increasing toward more positive values as Vrec increased. Conclusions We report a new bedside MBNW technique that reliably assesses EELV in an experimental ARDS model with high precision and excellent trending ability. Supplementary Information The online version contains supplementary material available at 10.1186/s40635-021-00410-x.
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Affiliation(s)
- Laurent Bitker
- Service de Médecine Intensive - Réanimation, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France.,Université de Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, Villeurbanne, France
| | | | - Sascha Reidt
- Research and New Technology Department, Hamilton Medical AG, Bonaduz, Switzerland
| | - Christoph Schranz
- Research and New Technology Department, Hamilton Medical AG, Bonaduz, Switzerland
| | - Dominik Novotni
- Research and New Technology Department, Hamilton Medical AG, Bonaduz, Switzerland
| | - Maciej Orkisz
- Université de Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, Villeurbanne, France
| | - Eduardo Davila Serrano
- Université de Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, Villeurbanne, France
| | - Jean-Pierre Revelly
- Research and New Technology Department, Hamilton Medical AG, Bonaduz, Switzerland
| | - Jean-Christophe Richard
- Service de Médecine Intensive - Réanimation, Hôpital De La Croix Rousse, Hospices Civils de Lyon, 103 Grande Rue de la Croix Rousse, 69004, Lyon, France. .,Université de Lyon, Université Claude Bernard Lyon 1, INSA-Lyon, UJM-Saint Etienne, CNRS, Inserm, CREATIS UMR 5220, U1206, Villeurbanne, France.
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Abstract
Today's management of the ventilated patient still relies on the measurement of old parameters such as airway pressures and flow. Graphical presentations reveal the intricacies of patient-ventilator interactions in times of supporting the patient on the ventilator instead of fully ventilating the heavily sedated patient. This opens a new pathway for several bedside technologies based on basic physiologic knowledge; however, it may increase the complexity of measurements. The spread of the COVID-19 infection has confronted the anesthesiologist and intensivist with one of the most severe pulmonary pathologies of the last decades. Optimizing the patient at the bedside is an old and newly required skill for all physicians in the intensive care unit, supported by mobile technologies such as lung ultrasound and electrical impedance tomography. This review summarizes old knowledge and presents a brief insight into extended monitoring options.
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Affiliation(s)
- Ralph Gertler
- Department of Anaesthesiology and Intensive Care, HELIOS Klinikum München West, Teaching Hospital of the Ludwig-Maximilians-Universität, Steinerweg 5, München 85241, Germany.
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Estimating Airway Opening Pressure, Trapped Gas Volume, and Hidden Intrinsic Positive End-Expiratory Pressure in Mechanically Ventilated Patients. Ann Am Thorac Soc 2021; 18:356-360. [PMID: 33522867 DOI: 10.1513/annalsats.202008-927cc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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The authors reply. Crit Care Med 2021; 49:e208-e209. [PMID: 33438986 DOI: 10.1097/ccm.0000000000004755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Personalized Positive End-Expiratory Pressure and Tidal Volume in Acute Respiratory Distress Syndrome: Bedside Physiology-Based Approach. Crit Care Explor 2021; 3:e0486. [PMID: 34278316 PMCID: PMC8280087 DOI: 10.1097/cce.0000000000000486] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES: Positive end-expiratory pressure and tidal volume may have a key role for the outcome of patients with acute respiratory distress syndrome. The variety of acute respiratory distress syndrome phenotypes implies personalization of those settings. To guide personalized positive end-expiratory pressure and tidal volume, physicians need to have an in-depth understanding of the physiologic effects and bedside methods to measure the extent of these effects. In the present article, a step-by-step physiologic approach to select personalized positive end-expiratory pressure and tidal volume at the bedside is described. DATA SOURCES: The present review is a critical reanalysis of the traditional and latest literature on the topic. STUDY SELECTION: Relevant clinical and physiologic studies on positive end-expiratory pressure and tidal volume setting were reviewed. DATA EXTRACTION: Reappraisal of the available physiologic and clinical data. DATA SYNTHESIS: Positive end-expiratory pressure is aimed at stabilizing alveolar recruitment, thus reducing the risk of volutrauma and atelectrauma. Bedside assessment of the potential for lung recruitment is a preliminary step to recognize patients who benefit from higher positive end-expiratory pressure level. In patients with higher potential for lung recruitment, positive end-expiratory pressure could be selected by physiology-based methods balancing recruitment and overdistension. In patients with lower potential for lung recruitment or in shock, positive end-expiratory pressure could be maintained in the 5–8 cm H2O range. Tidal volume induces alveolar recruitment and improves gas exchange. After setting personalized positive end-expiratory pressure, tidal volume could be based on lung inflation (collapsed lung size) respecting safety thresholds of static and dynamic lung stress. Positive end-expiratory pressure and tidal volume could be kept stable for some hours in order to allow early recognition of changes in the clinical course of acute respiratory distress syndrome but also frequently reassessed to avoid crossing of safety thresholds. CONCLUSIONS: The setting of personalized positive end-expiratory pressure and tidal volume based on sound physiologic bedside measures may represent an effective strategy for treating acute respiratory distress syndrome patients.
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Aggressive alveolar recruitment in ARDS: More shadows than lights. Med Intensiva 2021; 45:431-436. [PMID: 34238723 DOI: 10.1016/j.medine.2021.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 03/18/2020] [Indexed: 12/16/2022]
Abstract
Alveolar recruitment in acute respiratory distress syndrome (ARDS) is defined as the penetration of gas into previously unventilated areas or poorly ventilated areas. Alveolar recruitment during recruitment maneuvering (RM) depends on the duration of the maneuver, the recruitable lung tissue, and the balance between the recruitment of collapsed areas and over-insufflation of the ventilated areas. Alveolar recruitment is estimated using computed tomography of the lung and, at the patient bedside, through assessment of the recruited volume using pressure-volume curves and assessing lung morphology with pulmonary ultrasound and/or impedance tomography. The scientific evidence on RM in patients with ARDS remains subject to controversy. Randomized studies on ARDS have shown no benefit or have even reflected an increase in mortality. The routine use of RM is therefore not recommended.
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Physiological effects of adding ECCO 2R to invasive mechanical ventilation for COPD exacerbations. Ann Intensive Care 2020; 10:126. [PMID: 32990836 PMCID: PMC7523267 DOI: 10.1186/s13613-020-00743-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/18/2020] [Indexed: 11/13/2022] Open
Abstract
Background Extracorporeal CO2 removal (ECCO2R) could be a valuable additional modality for invasive mechanical ventilation (IMV) in COPD patients suffering from severe acute exacerbation (AE). We aimed to evaluate in such patients the effects of a low-to-middle extracorporeal blood flow device on both gas exchanges and dynamic hyperinflation, as well as on work of breathing (WOB) during the IMV weaning process. Study design and methods Open prospective interventional study in 12 deeply sedated IMV AE-COPD patients studied before and after ECCO2R initiation. Gas exchange and dynamic hyperinflation were compared after stabilization without and with ECCO2R (Hemolung, Alung, Pittsburgh, USA) combined with a specific adjustment algorithm of the respiratory rate (RR) designed to improve arterial pH. When possible, WOB with and without ECCO2R was measured at the end of the weaning process. Due to study size, results are expressed as median (IQR) and a non-parametric approach was adopted. Results An improvement in PaCO2, from 68 (63; 76) to 49 (46; 55) mmHg, p = 0.0005, and in pH, from 7.25 (7.23; 7.29) to 7.35 (7.32; 7.40), p = 0.0005, was observed after ECCO2R initiation and adjustment of respiratory rate, while intrinsic PEEP and Functional Residual Capacity remained unchanged, from 9.0 (7.0; 10.0) to 8.0 (5.0; 9.0) cmH2O and from 3604 (2631; 4850) to 3338 (2633; 4848) mL, p = 0.1191 and p = 0.3013, respectively. WOB measurements were possible in 5 patients, indicating near-significant higher values after stopping ECCO2R: 11.7 (7.5; 15.0) versus 22.6 (13.9; 34.7) Joules/min., p = 0.0625 and 1.1 (0.8; 1.4) versus 1.5 (0.9; 2.8) Joules/L, p = 0.0625. Three patients died in-ICU. Other patients were successfully hospital-discharged. Conclusions Using a formalized protocol of RR adjustment, ECCO2R permitted to effectively improve pH and diminish PaCO2 at the early phase of IMV in 12 AE-COPD patients, but not to diminish dynamic hyperinflation in the whole group. A trend toward a decrease in WOB was also observed during the weaning process. Trial registration ClinicalTrials.gov: Identifier: NCT02586948.
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Turbil E, Terzi N, Cour M, Argaud L, Einav S, Guérin C. Positive end-expiratory pressure-induced recruited lung volume measured by volume-pressure curves in acute respiratory distress syndrome: a physiologic systematic review and meta-analysis. Intensive Care Med 2020; 46:2212-2225. [PMID: 32915255 PMCID: PMC7484614 DOI: 10.1007/s00134-020-06226-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/20/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE Recruitment of lung volume is often cited as the reason for using positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS) patients. We performed a systematic review on PEEP-induced recruited lung volume measured from inspiratory volume-pressure (VP) curves in ARDS patients to assess the prevalence of patients with PEEP-induced recruited lung volume and the mortality in recruiters and non-recruiters. METHODS We conducted a systematic search of PubMed to identify studies including ARDS patients in which the intervention of an increase in PEEP was accompanied by measurement of the recruited volume (Vrec increase versus no increase) using the VP curve in order to assess the relation between Vrec and mortality at ICU discharge. We first analysed the pooled data from the papers identified and then analysed individual patient level data received from the authors via personal contact. The risk of bias of the included papers was assessed using the quality in prognosis studies tool and the certainty of the evidence regarding the relationship of mortality to Vrec by the GRADE approach. Recruiters were defined as patients with a Vrec > 150 ml. A random effects model was used for the pooled data. Multivariable logistic regression analysis was used for individual patient data. RESULTS We identified 16 papers with a total of 308 patients for the pooled data meta-analysis and 14 papers with a total of 384 patients for the individual data analysis. The quality of the articles was moderate. In the pooled data, the prevalence of recruiters was 74% and the mortality was not significantly different between recruiters and non-recruiters (relative risk 1.20 [95% confidence intervals 0.88-1.63]). The certainty of the evidence regarding this association was very low and publication bias evident. In the individual data, the prevalence of recruiters was 70%. In the multivariable logistic regression, Vrec was not associated with mortality but Simplified Acute Physiology Score II and driving pressure at PEEP of 5 cmH2O were. CONCLUSION After a PEEP increment, most patients are recruiters. Vrec was not associated with ICU mortality. The presence of similar findings in the individual patient level analysis and the driving pressure at PEEP of 5 cmH2O was associated with mortality as previously reported validate our findings. Publication bias and the lack of prospective studies suggest more research is required.
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Affiliation(s)
- Emanuele Turbil
- Department of Anesthesia and Critical Care, University of Sassari, Sassari, Italy
| | - Nicolas Terzi
- Médecine Intensive-Réanimation, CHU Grenoble-Alpes, Grenoble, France.,University of Grenoble-Alpes, Grenoble, France
| | - Martin Cour
- Médecine Intensive-Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France.,Université de Lyon, Faculté de Médecine Lyon-Est, Lyon, France
| | - Laurent Argaud
- Médecine Intensive-Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France.,Université de Lyon, Faculté de Médecine Lyon-Est, Lyon, France
| | | | - Claude Guérin
- Médecine Intensive-Réanimation, Groupement Hospitalier Centre, Hôpital Edouard Herriot, 5 Place d'Arsonval, 69003, Lyon, France. .,Université de Lyon, Faculté de Médecine Lyon-Est, Lyon, France. .,Institut Mondor de Recherches Biomédicales, INSERM 955, CNRS ERL 7000, Créteil, France.
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Intraabdominal Pressure Targeted Positive End-expiratory Pressure during Laparoscopic Surgery: An Open-label, Nonrandomized, Crossover, Clinical Trial. Anesthesiology 2020; 132:667-677. [PMID: 32011334 DOI: 10.1097/aln.0000000000003146] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pneumoperitoneum for laparoscopic surgery is associated with a rise of driving pressure. The authors aimed to assess the effects of positive end-expiratory pressure (PEEP) on driving pressure at varying intraabdominal pressure levels. It was hypothesized that PEEP attenuates pneumoperitoneum-related rises in driving pressure. METHODS Open-label, nonrandomized, crossover, clinical trial in patients undergoing laparoscopic cholecystectomy. "Targeted PEEP" (2 cm H2O above intraabdominal pressure) was compared with "standard PEEP" (5 cm H2O), with respect to the transpulmonary and respiratory system driving pressure at three predefined intraabdominal pressure levels, and each patient was ventilated with two levels of PEEP at the three intraabdominal pressure levels in the same sequence. The primary outcome was the difference in transpulmonary driving pressure between targeted PEEP and standard PEEP at the three levels of intraabdominal pressure. RESULTS Thirty patients were included and analyzed. Targeted PEEP was 10, 14, and 17 cm H2O at intraabdominal pressure of 8, 12, and 15 mmHg, respectively. Compared to standard PEEP, targeted PEEP resulted in lower median transpulmonary driving pressure at intraabdominal pressure of 8 mmHg (7 [5 to 8] vs. 9 [7 to 11] cm H2O; P = 0.010; difference 2 [95% CI 0.5 to 4 cm H2O]); 12 mmHg (7 [4 to 9] vs.10 [7 to 12] cm H2O; P = 0.002; difference 3 [1 to 5] cm H2O); and 15 mmHg (7 [6 to 9] vs.12 [8 to 15] cm H2O; P < 0.001; difference 4 [2 to 6] cm H2O). The effects of targeted PEEP compared to standard PEEP on respiratory system driving pressure were comparable to the effects on transpulmonary driving pressure, though respiratory system driving pressure was higher than transpulmonary driving pressure at all intraabdominal pressure levels. CONCLUSIONS Transpulmonary driving pressure rises with an increase in intraabdominal pressure, an effect that can be counterbalanced by targeted PEEP. Future studies have to elucidate which combination of PEEP and intraabdominal pressure is best in term of clinical outcomes.
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Wang YM, Sun XM, Zhou YM, Chen JR, Cheng KM, Li HL, Yang YL, Zhou JX. Effect of positive end-expiratory pressure on functional residual capacity in two experimental models of acute respiratory distress syndrome. J Int Med Res 2020; 48:300060520920426. [PMID: 32529868 PMCID: PMC7294389 DOI: 10.1177/0300060520920426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/30/2020] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Measurement of positive end-expiratory pressure (PEEP)-induced recruitment lung volume using passive spirometry is based on the assumption that the functional residual capacity (FRC) is not modified by the PEEP changes. We aimed to investigate the influence of PEEP on FRC in different models of acute respiratory distress syndrome (ARDS). METHODS A randomized crossover study was performed in 12 pigs. Pulmonary (n = 6) and extra-pulmonary (n = 6) ARDS models were established using an alveolar instillation of hydrochloric acid and a right atrium injection of oleic acid, respectively. Low (5 cmH2O) and high (15 cmH2O) PEEP were randomly applied in each animal. FRC and recruitment volume were determined using the nitrogen wash-in/wash-out technique and release maneuver. RESULTS FRC was not significantly different between the two PEEP levels in either pulmonary ARDS (299 ± 92 mL and 309 ± 130 mL at 5 and 15 cmH2O, respectively) or extra-pulmonary ARDS (305 ± 143 mL and 328 ± 197 mL at 5 and 15 cmH2O, respectively). The recruitment volume was not significantly different between the two models (pulmonary, 341 ± 100 mL; extra-pulmonary, 351 ± 170 mL). CONCLUSIONS PEEP did not influence FRC in either the pulmonary or extra-pulmonary ARDS pig model.
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Affiliation(s)
- Yu-Mei Wang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiu-Mei Sun
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi-Min Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jing-Ran Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kun-Ming Cheng
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hong-Liang Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Beloncle FM, Pavlovsky B, Desprez C, Fage N, Olivier PY, Asfar P, Richard JC, Mercat A. Recruitability and effect of PEEP in SARS-Cov-2-associated acute respiratory distress syndrome. Ann Intensive Care 2020; 10:55. [PMID: 32399901 PMCID: PMC7215140 DOI: 10.1186/s13613-020-00675-7] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 05/04/2020] [Indexed: 12/21/2022] Open
Abstract
Background A large proportion of patients with a SARS-Cov-2-associated respiratory failure develop an acute respiratory distress syndrome (ARDS). It has been recently suggested that SARS-Cov-2-associated ARDS may differ from usual non-SARS-Cov-2-associated ARDS by higher respiratory system compliance (CRS), lower potential for recruitment with positive end-expiratory pressure (PEEP) contrasting with severe shunt fraction. The purpose of the study was to systematically assess respiratory mechanics and recruitability in SARS-Cov-2-associated ARDS. Methods Gas exchanges, CRS and hemodynamics were assessed at 2 levels of PEEP (15 cmH2O and 5 cmH2O) within 36 h (day1) and from 4 to 6 days (day 5) after intubation. The recruited volume was computed as the difference between the volume expired from PEEP 15 to 5 cmH2O and the volume predicted by compliance at PEEP 5 cmH2O (or above airway opening pressure). The recruitment-to-inflation (R/I) ratio (i.e. the ratio between the recruited lung compliance and CRS at PEEP 5 cmH2O) was used to assess lung recruitability. A R/I ratio value higher than or equal to 0.5 was used to define highly recruitable patients. Results The R/I ratio was calculated in 25 of the 26 enrolled patients at day 1 and in 15 patients at day 5. At day 1, 16 (64%) were considered as highly recruitable (R/I ratio median [interquartile range] 0.7 [0.55–0.94]) and 9 (36%) were considered as poorly recruitable (R/I ratio 0.41 [0.31–0.48]). The PaO2/FiO2 ratio at PEEP 15 cmH2O was higher compared to PEEP 5 cmH2O only in highly recruitable patients (173 [139–236] vs 135 [89–167] mmHg; p < 0.01). Neither PaO2/FiO2 or CRS measured at PEEP 15 cmH2O or at PEEP 5 cmH2O nor changes in PaO2/FiO2 or CRS in response to PEEP changes allowed to identify highly or poorly recruitable patients. Conclusion In this series of 25 patients with SARS-Cov-2 associated ARDS, 64% were considered as highly recruitable and only 36% as poorly recruitable based on the R/I ratio performed on the day of intubation. This observation suggests that a systematic R/I ratio assessment may help to guide initial PEEP titration to limit harmful effect of unnecessary high PEEP in the context of Covid-19 crisis.
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Affiliation(s)
- François M Beloncle
- Département de Médecine Intensive-Réanimation, CHU d'Angers, Université d'Angers, 4 rue Larrey, 49933, Angers Cedex 9, France.
| | - Bertrand Pavlovsky
- Département de Médecine Intensive-Réanimation, CHU d'Angers, Université d'Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Christophe Desprez
- Département de Médecine Intensive-Réanimation, CHU d'Angers, Université d'Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Nicolas Fage
- Département de Médecine Intensive-Réanimation, CHU d'Angers, Université d'Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Pierre-Yves Olivier
- Département de Médecine Intensive-Réanimation, CHU d'Angers, Université d'Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Pierre Asfar
- Département de Médecine Intensive-Réanimation, CHU d'Angers, Université d'Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Jean-Christophe Richard
- Département de Médecine Intensive-Réanimation, CHU d'Angers, Université d'Angers, 4 rue Larrey, 49933, Angers Cedex 9, France.,INSERM, UMR 955, Créteil, France
| | - Alain Mercat
- Département de Médecine Intensive-Réanimation, CHU d'Angers, Université d'Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
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Pitoni S, D'Arrigo S, Grieco DL, Idone FA, Santantonio MT, Di Giannatale P, Ferrieri A, Natalini D, Eleuteri D, Jonson B, Antonelli M, Maggiore SM. Tidal Volume Lowering by Instrumental Dead Space Reduction in Brain-Injured ARDS Patients: Effects on Respiratory Mechanics, Gas Exchange, and Cerebral Hemodynamics. Neurocrit Care 2020; 34:21-30. [PMID: 32323146 PMCID: PMC7224122 DOI: 10.1007/s12028-020-00969-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Limiting tidal volume (VT), plateau pressure, and driving pressure is essential during the acute respiratory distress syndrome (ARDS), but may be challenging when brain injury coexists due to the risk of hypercapnia. Because lowering dead space enhances CO2 clearance, we conducted a study to determine whether and to what extent replacing heat and moisture exchangers (HME) with heated humidifiers (HH) facilitate safe VT lowering in brain-injured patients with ARDS. Methods Brain-injured patients (head trauma or spontaneous cerebral hemorrhage with Glasgow Coma Scale at admission < 9) with mild and moderate ARDS received three ventilatory strategies in a sequential order during continuous paralysis: (1) HME with VT to obtain a PaCO2 within 30–35 mmHg (HME1); (2) HH with VT titrated to obtain the same PaCO2 (HH); and (3) HME1 settings resumed (HME2). Arterial blood gases, static and quasi-static respiratory mechanics, alveolar recruitment by multiple pressure–volume curves, intracranial pressure, cerebral perfusion pressure, mean arterial pressure, and mean flow velocity in the middle cerebral artery by transcranial Doppler were recorded. Dead space was measured and partitioned by volumetric capnography. Results Eighteen brain-injured patients were studied: 7 (39%) had mild and 11 (61%) had moderate ARDS. At inclusion, median [interquartile range] PaO2/FiO2 was 173 [146–213] and median PEEP was 8 cmH2O [5–9]. HH allowed to reduce VT by 120 ml [95% CI: 98–144], VT/kg predicted body weight by 1.8 ml/kg [95% CI: 1.5–2.1], plateau pressure and driving pressure by 3.7 cmH2O [2.9–4.3], without affecting PaCO2, alveolar recruitment, and oxygenation. This was permitted by lower airway (− 84 ml [95% CI: − 79 to − 89]) and total dead space (− 86 ml [95% CI: − 73 to − 98]). Sixteen patients (89%) showed driving pressure equal or lower than 14 cmH2O while on HH, as compared to 7 (39%) and 8 (44%) during HME1 and HME2 (p < 0.001). No changes in mean arterial pressure, cerebral perfusion pressure, intracranial pressure, and middle cerebral artery mean flow velocity were documented during HH. Conclusion The dead space reduction provided by HH allows to safely reduce VT without modifying PaCO2 nor cerebral perfusion. This permits to provide a wider proportion of brain-injured ARDS patients with less injurious ventilation.
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Affiliation(s)
- Sara Pitoni
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Sonia D'Arrigo
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Domenico Luca Grieco
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Francesco Antonio Idone
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Maria Teresa Santantonio
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Pierluigi Di Giannatale
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia, Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Via dei Vestini, 66100, Chieti, Italy
| | - Alessandro Ferrieri
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia, Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Via dei Vestini, 66100, Chieti, Italy
| | - Daniele Natalini
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Davide Eleuteri
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Bjorn Jonson
- Clinical Physiology, Skane University Hospital, 221 85, Lund, Sweden
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico A. Gemelli IRCCS, Rome, Italy
| | - Salvatore Maurizio Maggiore
- Department of Medical, Oral and Biotechnological Sciences, School of Medicine and Health Sciences, Section of Anesthesia, Analgesia, Perioperative and Intensive Care, SS. Annunziata Hospital, Gabriele d'Annunzio University of Chieti-Pescara, Via dei Vestini, 66100, Chieti, Italy.
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Gattinoni L, Marini JJ, Quintel M. Recruiting the Acutely Injured Lung: How and Why? Am J Respir Crit Care Med 2020; 201:130-132. [PMID: 31661307 PMCID: PMC6961753 DOI: 10.1164/rccm.201910-2005ed] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, Emergency and Intensive Care MedicineUniversity of GöttingenGöttingen, Germanyand
| | - John J Marini
- Regions Hospital and University of MinnesotaSt. Paul, Minnesota
| | - Michael Quintel
- Department of Anesthesiology, Emergency and Intensive Care MedicineUniversity of GöttingenGöttingen, Germanyand
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Transpulmonary thermodilution detects rapid and reversible increases in lung water induced by positive end-expiratory pressure in acute respiratory distress syndrome. Ann Intensive Care 2020; 10:28. [PMID: 32124129 PMCID: PMC7052093 DOI: 10.1186/s13613-020-0644-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 02/21/2020] [Indexed: 01/22/2023] Open
Abstract
PURPOSE It has been suggested that, by recruiting lung regions and enlarging the distribution volume of the cold indicator, increasing the positive end-expiratory pressure (PEEP) may lead to an artefactual overestimation of extravascular lung water (EVLW) by transpulmonary thermodilution (TPTD). METHODS In 60 ARDS patients, we measured EVLW (PiCCO2 device) at a PEEP level set to reach a plateau pressure of 30 cmH2O (HighPEEPstart) and 15 and 45 min after decreasing PEEP to 5 cmH2O (LowPEEP15' and LowPEEP45', respectively). Then, we increased PEEP back to the baseline level (HighPEEPend). Between HighPEEPstart and LowPEEP15', we estimated the degree of lung derecruitment either by measuring changes in the compliance of the respiratory system (Crs) in the whole population, or by measuring the lung derecruited volume in 30 patients. We defined patients with a large derecruitment from the other ones as patients in whom the Crs changes and the measured derecruited volume were larger than the median of these variables observed in the whole population. RESULTS Reducing PEEP from HighPEEPstart (14 ± 2 cmH2O) to LowPEEP15' significantly decreased EVLW from 20 ± 4 to 18 ± 4 mL/kg, central venous pressure (CVP) from 15 ± 4 to 12 ± 4 mmHg, the arterial oxygen tension over inspired oxygen fraction (PaO2/FiO2) ratio from 184 ± 76 to 150 ± 69 mmHg and lung volume by 144 [68-420] mL. The EVLW decrease was similar in "large derecruiters" and the other patients. When PEEP was re-increased to HighPEEPend, CVP, PaO2/FiO2 and EVLW significantly re-increased. At linear mixed effect model, EVLW changes were significantly determined only by changes in PEEP and CVP (p < 0.001 and p = 0.03, respectively, n = 60). When the same analysis was performed by estimating recruitment according to lung volume changes (n = 30), CVP remained significantly associated to the changes in EVLW (p < 0.001). CONCLUSIONS In ARDS patients, changing the PEEP level induced parallel, small and reversible changes in EVLW. These changes were not due to an artefact of the TPTD technique and were likely due to the PEEP-induced changes in CVP, which is the backward pressure of the lung lymphatic drainage. Trial registration ID RCB: 2015-A01654-45. Registered 23 October 2015.
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Chen L, Del Sorbo L, Grieco DL, Junhasavasdikul D, Rittayamai N, Soliman I, Sklar MC, Rauseo M, Ferguson ND, Fan E, Richard JCM, Brochard L. Potential for Lung Recruitment Estimated by the Recruitment-to-Inflation Ratio in Acute Respiratory Distress Syndrome. A Clinical Trial. Am J Respir Crit Care Med 2020; 201:178-187. [DOI: 10.1164/rccm.201902-0334oc] [Citation(s) in RCA: 121] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Lu Chen
- Keenan Research Centre and Li Ka Shing Institute, Department of Critical Care, St. Michael’s Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, and
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Lorenzo Del Sorbo
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology and Critical Care Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Domenico L. Grieco
- Istituto di Anestesia e Rianimazione, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Nuttapol Rittayamai
- Division of Respiratory Diseases and Tuberculosis, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ibrahim Soliman
- Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Michael C. Sklar
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
| | - Michela Rauseo
- Anestesia e Rianimazione, Ospedali Riuniti di Foggia, Foggia, Italy; and
| | - Niall D. Ferguson
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology and Critical Care Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | - Eddy Fan
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology and Critical Care Medicine, Toronto General Hospital, Toronto, Ontario, Canada
| | | | - Laurent Brochard
- Keenan Research Centre and Li Ka Shing Institute, Department of Critical Care, St. Michael’s Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, and
- Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
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Abstract
BACKGROUND Airway closure causes lack of communication between proximal airways and alveoli, making tidal inflation start only after a critical airway opening pressure is overcome. The authors conducted a matched cohort study to report the existence of this phenomenon among obese patients undergoing general anesthesia. METHODS Within the procedures of a clinical trial during gynecological surgery, obese patients underwent respiratory/lung mechanics and lung volume assessment both before and after pneumoperitoneum, in the supine and Trendelenburg positions, respectively. Among patients included in this study, those exhibiting airway closure were compared to a control group of subjects enrolled in the same trial and matched in 1:1 ratio according to body mass index. RESULTS Eleven of 50 patients (22%) showed airway closure after intubation, with a median (interquartile range) airway opening pressure of 9 cm H2O (6 to 12). With pneumoperitoneum, airway opening pressure increased up to 21 cm H2O (19 to 28) and end-expiratory lung volume remained unchanged (1,294 ml [1,154 to 1,363] vs. 1,160 ml [1,118 to 1,256], P = 0.155), because end-expiratory alveolar pressure increased consistently with airway opening pressure and counterbalanced pneumoperitoneum-induced increases in end-expiratory esophageal pressure (16 cm H2O [15 to 19] vs. 27 cm H2O [23 to 30], P = 0.005). Conversely, matched control subjects experienced a statistically significant greater reduction in end-expiratory lung volume due to pneumoperitoneum (1,113 ml [1,040 to 1,577] vs. 1,000 ml [821 to 1,061], P = 0.006). With airway closure, static/dynamic mechanics failed to measure actual lung/respiratory mechanics. When patients with airway closure underwent pressure-controlled ventilation, no tidal volume was inflated until inspiratory pressure overcame airway opening pressure. CONCLUSIONS In obese patients, complete airway closure is frequent during anesthesia and is worsened by Trendelenburg pneumoperitoneum, which increases airway opening pressure and alveolar pressure: besides preventing alveolar derecruitment, this yields misinterpretation of respiratory mechanics and generates a pressure threshold to inflate the lung that can reach high values, spreading concerns on the safety of pressure-controlled modes in this setting.
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Constantin JM, Jabaudon M, Lefrant JY, Jaber S, Quenot JP, Langeron O, Ferrandière M, Grelon F, Seguin P, Ichai C, Veber B, Souweine B, Uberti T, Lasocki S, Legay F, Leone M, Eisenmann N, Dahyot-Fizelier C, Dupont H, Asehnoune K, Sossou A, Chanques G, Muller L, Bazin JE, Monsel A, Borao L, Garcier JM, Rouby JJ, Pereira B, Futier E, Sophie C, Thomas G, Renaud G, Camille V, Russel C, Bernard C, Raiko B, Alexandre L, Nathanael E, Laurent M, Pablo M, Caroline B, Saber B, Claire R, Fouad B, Moussa C, Marion M, Matthieu C, Julie C, Audrey DJ, Auguste D, Pascal A, Thomas L, Yoann L, Antoine R, Raphael C, Caroline B, Anne-Charlotte T, Mathilde B, Benjamin C, Edouard L, Pierre-Marie B, Charlotte A, Laurent Z, Emmanuelle H, Garry D, Calypso M, Herve D, Benoit V, Jean-Christophe O, Hervé Q, Thomas R, Julien CC, Marinne LC, Fabien G, Mona A, Frank P, Jerome M, Serge M, Nanadougmar H. Personalised mechanical ventilation tailored to lung morphology versus low positive end-expiratory pressure for patients with acute respiratory distress syndrome in France (the LIVE study): a multicentre, single-blind, randomised controlled trial. THE LANCET RESPIRATORY MEDICINE 2019; 7:870-880. [DOI: 10.1016/s2213-2600(19)30138-9] [Citation(s) in RCA: 194] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/08/2019] [Accepted: 03/11/2019] [Indexed: 12/29/2022]
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Gallagher JJ. Mechanical Ventilator Modes. Crit Care Nurse 2019; 38:74-76. [PMID: 30275066 DOI: 10.4037/ccn2018101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- John J Gallagher
- John J. Gallagher is a trauma program manager and clinical nurse specialist in the Division of Trauma, Surgical Critical Care and Emergency Surgery at Penn Presbyterian Medical Center in Philadelphia, Pennsylvania.
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Bergez M, Fritsch N, Tran-Van D, Saghi T, Bounkim T, Gentile A, Labadie P, Fontaine B, Ouattara A, Rozé H. PEEP titration in moderate to severe ARDS: plateau versus transpulmonary pressure. Ann Intensive Care 2019; 9:81. [PMID: 31312921 PMCID: PMC6635540 DOI: 10.1186/s13613-019-0554-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Accepted: 06/24/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Although lung protection with low tidal volume and limited plateau pressure (Pplat) improves survival in acute respiratory distress syndrome patients (ARDS), the best way to set positive end-expiratory pressure (PEEP) is still debated. METHODS This study aimed to compare two strategies using individual PEEP based on a maximum Pplat (28-30 cmH2O, the Express group) or on keeping end-expiratory transpulmonary pressure positive (0-5 cmH2O, PLexpi group). We estimated alveolar recruitment (Vrec), end-expiratory lung volume and alveolar distension based on elastance-related end-inspiratory transpulmonary pressure (PL,EL). RESULTS Nineteen patients with moderate to severe ARDS (PaO2/FiO2 < 150 mmHg) were included with a baseline PEEP of 7.0 ± 1.8 cmH2O and a PaO2/FiO2 of 91.2 ± 31.2 mmHg. PEEP and oxygenation increased significantly from baseline with both protocols; PEEP Express group was 14.2 ± 3.6 cmH2O versus 16.7 ± 5.9 cmH2O in PLexpi group. No patient had the same PEEP with the two protocols. Vrec was higher with the latter protocol (299 [0 to 875] vs. 222 [47 to 483] ml, p = 0.049) and correlated with improved oxygenation (R2 = 0.45, p = 0.002). Two and seven patients in the Express and PL,expi groups, respectively, had PL,EL > 25 cmH2O. CONCLUSIONS There is a great heterogeneity of PLexpi when Pplat is used to titrate PEEP but with limited risk of over-distension. A PEEP titration for a moderate positive level of PLexpi might slightly improve alveolar recruitment and oxygenation but increases the risk of over-distension in one-third of patients.
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Affiliation(s)
- Marie Bergez
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - Nicolas Fritsch
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - David Tran-Van
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - Tahar Saghi
- Intensive Care Unit, North Bordeaux Aquitaine Clinic, Bordeaux, France
| | - Tan Bounkim
- Medical and Surgical Intensive Care, Saint Joseph Saint Luc Teaching Hospital, Lyon, France
| | - Ariane Gentile
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - Philippe Labadie
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - Bruno Fontaine
- Anaesthesia and Intensive Care Unit, Robert Picque Military Teaching Hospital, Villenave d'Ornon, France
| | - Alexandre Ouattara
- Magellan Medico-Surgical Center, South Department of Anaesthesia and Critical Care, CHU Bordeaux, 33000, Bordeaux, France.,Biology of Cardiovascular Diseases, INSERM, UMR 1034, Univ. Bordeaux, 33600, Pessac, France
| | - Hadrien Rozé
- Magellan Medico-Surgical Center, South Department of Anaesthesia and Critical Care, CHU Bordeaux, 33000, Bordeaux, France.
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Gattinoni L, Giosa L, Bonifazi M, Pasticci I, Busana M, Macri M, Romitti F, Vassalli F, Quintel M. Targeting transpulmonary pressure to prevent ventilator-induced lung injury. Expert Rev Respir Med 2019; 13:737-746. [PMID: 31274034 DOI: 10.1080/17476348.2019.1638767] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Introduction: Transpulmonary pressure (PL) is the pressure distending the lung. This pressure equals the stress which develops into the parenchyma at each insufflation and it depends, for a given airway pressure, on the relationship between the lung and the chest wall elastance: a given stress is associated to a given strain, therefor PL is strictly related to ventilator-induced lung injury (VILI). Insufficient knowledge and increased workload account for its limited use in the clinical setting: indeed, the current recommendations for protective ventilation still rely only on the pressures applied to the respiratory system in total (Plateau pressure), without a direct measurement of the real lung stress. Areas covered: We reviewed the significance, the assessment, the application and the limits of transpulmonary pressure in the clinical setting. Expert opinion: Transpulmonary pressure represents a physiologically sound safety limit for mechanical ventilation that should be measured and targeted at least in the most severe ARDS patients. Targeting transpulmonary pressure means 'personalizing' the ventilatory settings.
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Affiliation(s)
- Luciano Gattinoni
- a Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen , Göttingen , Germany
| | - Lorenzo Giosa
- a Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen , Göttingen , Germany
| | - Matteo Bonifazi
- a Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen , Göttingen , Germany
| | - Iacopo Pasticci
- a Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen , Göttingen , Germany
| | - Mattia Busana
- a Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen , Göttingen , Germany
| | - Matteo Macri
- a Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen , Göttingen , Germany
| | - Federica Romitti
- a Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen , Göttingen , Germany
| | - Francesco Vassalli
- a Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen , Göttingen , Germany
| | - Michael Quintel
- a Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Göttingen , Göttingen , Germany
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Araos JD, Lacitignola L, Stripoli T, Grasso S, Crovace A, Staffieri F. Effects of positive end-expiratory pressure alone or an open-lung approach on recruited lung volumes and respiratory mechanics of mechanically ventilated horses. Vet Anaesth Analg 2019; 46:780-788. [PMID: 31477474 DOI: 10.1016/j.vaa.2019.04.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Revised: 03/29/2019] [Accepted: 04/24/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate the effects of positive end-expiratory pressure (PEEP) alone and PEEP preceded by lung recruitment manoeuvre (LRM) on lung volumes and respiratory system mechanics in healthy horses undergoing general anaesthesia. STUDY DESIGN Controlled, prospective clinical study. ANIMALS A group of 15 horses undergoing arthroscopy. METHODS Following anaesthetic induction, initial ventilatory settings were: tidal volume 15 mL kg-1, inspiratory:expiratory ratio 1:2, respiratory rate to maintain end-tidal CO2 between 5.3-6.6 kPa (40-50 mmHg). The following settings were implemented sequentially: zero PEEP (ZEEP); PEEP 10 cmH2O (PEEP); LRM (50 cmH2O for 20 seconds) followed by 10 cmH2O of PEEP (LRM + PEEP). Static compliance (Cst), driving pressure, delta end-expiratory (ΔEELV) and recruited lung volumes (RLV) were obtained 30 minutes after initiating each ventilatory strategy. Data were analyzed with paired t test or analysis of variance followed by Tukey's post hoc test. Data are shown as mean ± standard deviation; p < 0.05 was considered significant. RESULTS PEEP induced ΔEELV of 6.68 ± 3.36 mL kg-1; ΔEELV during LRM + PEEP was 14.28 ± 5.59 mL kg-1 (p < 0.0001). The RLV was greater during the LRM + PEEP phase (12.30 ± 5.85 mL kg-1) than during PEEP (4.47 ± 3.97 mL kg-1; p < 0.0001). The Cst was unchanged from ZEEP to PEEP (0.75 ± 0.21 and 0.85 ± 0.22 mL cmH2O-1 kg-1, respectively, p = 0.36) but increased using LRM + PEEP (1.11 ± 0.25 mL cmH2O-1 kg-1, p = 0.0004). Driving pressure was lower during LRM + PEEP than during PEEP and ZEEP (16 ± 2, 19 ± 2 and 21 ± 4 cmH2O, respectively, p < 0.0001). CONCLUSIONS AND CLINICAL RELEVANCE Unlike PEEP alone, PEEP preceded by LRM increased RLV and Cst and reduced driving pressure in horses under anaesthesia.
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Affiliation(s)
- Joaquin D Araos
- Centre Hospitalier Universitaire Veterinaire, Faculte de Medecine Veterinaire, Universite de Montreal, Québec, Canada
| | - Luca Lacitignola
- Surgery Unit, Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantation D.E.O.T., "Aldo Moro" University of Bari, Bari, Italy
| | - Tania Stripoli
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation (D.E.O.T.), "Aldo Moro" University of Bari, Bari, Italy
| | - Salvatore Grasso
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation (D.E.O.T.), "Aldo Moro" University of Bari, Bari, Italy
| | - Antonio Crovace
- Surgery Unit, Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantation D.E.O.T., "Aldo Moro" University of Bari, Bari, Italy
| | - Francesco Staffieri
- Surgery Unit, Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantation D.E.O.T., "Aldo Moro" University of Bari, Bari, Italy.
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Effects of increasing PEEP on lung stress and strain in children with and without ARDS. Intensive Care Med 2019; 45:1315-1317. [PMID: 31214743 DOI: 10.1007/s00134-019-05667-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2019] [Indexed: 01/01/2023]
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Morton SE, Knopp JL, Chase JG, Docherty P, Howe SL, Möller K, Shaw GM, Tawhai M. Optimising mechanical ventilation through model-based methods and automation. ANNUAL REVIEWS IN CONTROL 2019; 48:369-382. [PMID: 36911536 PMCID: PMC9985488 DOI: 10.1016/j.arcontrol.2019.05.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 04/09/2019] [Accepted: 05/01/2019] [Indexed: 06/11/2023]
Abstract
Mechanical ventilation (MV) is a core life-support therapy for patients suffering from respiratory failure or acute respiratory distress syndrome (ARDS). Respiratory failure is a secondary outcome of a range of injuries and diseases, and results in almost half of all intensive care unit (ICU) patients receiving some form of MV. Funding the increasing demand for ICU is a major issue and MV, in particular, can double the cost per day due to significant patient variability, over-sedation, and the large amount of clinician time required for patient management. Reducing cost in this area requires both a decrease in the average duration of MV by improving care, and a reduction in clinical workload. Both could be achieved by safely automating all or part of MV care via model-based dynamic systems modelling and control methods are ideally suited to address these problems. This paper presents common lung models, and provides a vision for a more automated future and explores predictive capacity of some current models. This vision includes the use of model-based methods to gain real-time insight to patient condition, improve safety through the forward prediction of outcomes to changes in MV, and develop virtual patients for in-silico design and testing of clinical protocols. Finally, the use of dynamic systems models and system identification to guide therapy for improved personalised control of oxygenation and MV therapy in the ICU will be considered. Such methods are a major part of the future of medicine, which includes greater personalisation and predictive capacity to both optimise care and reduce costs. This review thus presents the state of the art in how dynamic systems and control methods can be applied to transform this core area of ICU medicine.
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Affiliation(s)
- Sophie E Morton
- Department of Mechanical Engineering, University of Canterbury, New Zealand
| | - Jennifer L Knopp
- Department of Mechanical Engineering, University of Canterbury, New Zealand
| | - J Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, New Zealand
| | - Paul Docherty
- Department of Mechanical Engineering, University of Canterbury, New Zealand
| | - Sarah L Howe
- Department of Mechanical Engineering, University of Canterbury, New Zealand
| | - Knut Möller
- Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
| | - Geoffrey M Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch, New Zealand
| | - Merryn Tawhai
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
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47
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Predictive Virtual Patient Modelling of Mechanical Ventilation: Impact of Recruitment Function. Ann Biomed Eng 2019; 47:1626-1641. [PMID: 30927170 DOI: 10.1007/s10439-019-02253-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/22/2019] [Indexed: 10/27/2022]
Abstract
Mechanical ventilation is a life-support therapy for intensive care patients suffering from respiratory failure. To reduce the current rate of ventilator-induced lung injury requires ventilator settings that are patient-, time-, and disease-specific. A common lung protective strategy is to optimise the level of positive end-expiratory pressure (PEEP) through a recruitment manoeuvre to prevent alveolar collapse at the end of expiration and to improve gas exchange through recruitment of additional alveoli. However, this process can subject parts of the lung to excessively high pressures or volumes. This research significantly extends and more robustly validates a previously developed pulmonary mechanics model to predict lung mechanics throughout recruitment manoeuvres. In particular, the process of recruitment is more thoroughly investigated and the impact of the inclusion of expiratory data when estimating peak inspiratory pressure is assessed. Data from the McREM trial and CURE pilot trial were used to test model predictive capability and assumptions. For PEEP changes of up to and including 14 cmH2O, the parabolic model was shown to improve peak inspiratory pressure prediction resulting in less than 10% absolute error in the CURE cohort and 16% in the McREM cohort. The parabolic model also better captured expiratory mechanics than the exponential model for both cohorts.
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Stenqvist O, Persson P, Stahl CA, Lundin S. Monitoring transpulmonary pressure during anaesthesia using the PEEP-step method. Br J Anaesth 2018; 121:1373-1375. [PMID: 30442269 DOI: 10.1016/j.bja.2018.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 10/28/2022] Open
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Morton SE, Dickson J, Chase JG, Docherty P, Desaive T, Howe SL, Shaw GM, Tawhai M. A virtual patient model for mechanical ventilation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2018; 165:77-87. [PMID: 30337083 DOI: 10.1016/j.cmpb.2018.08.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 07/24/2018] [Accepted: 08/08/2018] [Indexed: 06/08/2023]
Abstract
BACKGROUND AND OBJECTIVES Mechanical ventilation (MV) is a primary therapy for patients with acute respiratory failure. However, poorly selected ventilator settings can cause further lung damage due to heterogeneity of healthy and damaged alveoli. Varying positive-end-expiratory-pressure (PEEP) to a point of minimum elastance is a lung protective ventilator strategy. However, even low levels of PEEP can lead to ventilator induced lung injury for individuals with highly inflamed pulmonary tissue. Hence, models that could accurately predict peak inspiratory pressures after changes to PEEP could improve clinician confidence in attempting potentially beneficial treatment strategies. METHODS This study develops and validates a physiologically relevant respiratory model that captures elastance and resistance via basis functions within a well-validated single compartment lung model. The model can be personalised using information available at a low PEEP to predict lung mechanics at a higher PEEP. Proof of concept validation is undertaken with data from four patients and eight recruitment manoeuvre arms. RESULTS Results show low error when predicting upwards over the clinically relevant pressure range, with the model able to predict peak inspiratory pressure with less than 10% error over 90% of the range of PEEP changes up to 12 cmH2O. CONCLUSIONS The results provide an in-silico model-based means of predicting clinically relevant responses to changes in MV therapy, which is the foundation of a first virtual patient for MV.
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Affiliation(s)
- S E Morton
- Department of Mechanical Engineering, University of Canterbury, New Zealand.
| | - J Dickson
- Department of Mechanical Engineering, University of Canterbury, New Zealand.
| | - J G Chase
- Department of Mechanical Engineering, University of Canterbury, New Zealand.
| | - P Docherty
- Department of Mechanical Engineering, University of Canterbury, New Zealand.
| | - T Desaive
- GIGA Cardiovascular Science, University of Liege, Liege, Belgium.
| | - S L Howe
- Department of Mechanical Engineering, University of Canterbury, New Zealand.
| | - G M Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch, New Zealand.
| | - M Tawhai
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand.
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Stenqvist O, Persson P, Lundin S. Can we estimate transpulmonary pressure without an esophageal balloon?-yes. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:392. [PMID: 30460266 DOI: 10.21037/atm.2018.06.05] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A protective ventilation strategy is based on separation of lung and chest wall mechanics and determination of transpulmonary pressure. So far, this has required esophageal pressure measurement, which is cumbersome, rarely used clinically and associated with lack of consensus on the interpretation of measurements. We have developed an alternative method based on a positive end expiratory pressure (PEEP) step procedure where the PEEP-induced change in end-expiratory lung volume is determined by the ventilator pneumotachograph. In pigs, lung healthy patients and acute lung injury (ALI) patients, it has been verified that the determinants of the change in end-expiratory lung volume following a PEEP change are the size of the PEEP step and the elastic properties of the lung, ∆PEEP × Clung. As a consequence, lung compliance can be calculated as the change in end-expiratory lung volume divided by the change in PEEP and esophageal pressure measurements are not needed. When lung compliance is determined in this way, transpulmonary driving pressure can be calculated on a breath-by-breath basis. As the end-expiratory transpulmonary pressure increases as much as PEEP is increased, it is also possible to determine the end-inspiratory transpulmonary pressure at any PEEP level. Thus, the most crucial factors of ventilator induced lung injury can be determined by a simple PEEP step procedure. The measurement procedure can be repeated with short intervals, which makes it possible to follow the course of the lung disease closely. By the PEEP step procedure we may also obtain information (decision support) on the mechanical consequences of changes in PEEP and tidal volume performed to improve oxygenation and/or carbon dioxide removal.
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Affiliation(s)
- Ola Stenqvist
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Persson
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stefan Lundin
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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