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Ball L, Talmor D, Pelosi P. Transpulmonary pressure monitoring in critically ill patients: pros and cons. Crit Care 2024; 28:177. [PMID: 38796447 PMCID: PMC11127359 DOI: 10.1186/s13054-024-04950-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/10/2024] [Indexed: 05/28/2024] Open
Abstract
The use of transpulmonary pressure monitoring based on measurement of esophageal pressure has contributed importantly to the personalization of mechanical ventilation based on respiratory pathophysiology in critically ill patients. However, esophageal pressure monitoring is still underused in the clinical practice. This technique allows partitioning of the respiratory mechanics between the lungs and the chest wall, provides information on lung recruitment and risk of barotrauma, and helps titrating mechanical ventilation settings in patients with respiratory failure. In assisted ventilation modes and during non-invasive respiratory support, esophageal pressure monitoring provides important information on the inspiratory effort and work of breathing. Nonetheless, several controversies persist on technical aspects, interpretation and clinical decision-making based on values derived from this monitoring technique. The aim of this review is to summarize the physiological bases of esophageal pressure monitoring, discussing the pros and cons of its clinical applications and different interpretations in critically ill patients undergoing invasive and non-invasive respiratory support.
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Affiliation(s)
- Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy.
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy.
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
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2
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Somhorst P, Mousa A, Jonkman AH. Setting positive end-expiratory pressure: the use of esophageal pressure measurements. Curr Opin Crit Care 2024; 30:28-34. [PMID: 38062927 PMCID: PMC10763716 DOI: 10.1097/mcc.0000000000001120] [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] [Indexed: 01/03/2024]
Abstract
PURPOSE OF REVIEW To summarize the key concepts, physiological rationale and clinical evidence for titrating positive end-expiratory pressure (PEEP) using transpulmonary pressure ( PL ) derived from esophageal manometry, and describe considerations to facilitate bedside implementation. RECENT FINDINGS The goal of an esophageal pressure-based PEEP setting is to have sufficient PL at end-expiration to keep (part of) the lung open at the end of expiration. Although randomized studies (EPVent-1 and EPVent-2) have not yet proven a clinical benefit of this approach, a recent posthoc analysis of EPVent-2 revealed a potential benefit in patients with lower APACHE II score and when PEEP setting resulted in end-expiratory PL values close to 0 ± 2 cmH 2 O instead of higher or more negative values. Technological advances have made esophageal pressure monitoring easier to implement at the bedside, but challenges regarding obtaining reliable measurements should be acknowledged. SUMMARY Esophageal pressure monitoring has the potential to individualize the PEEP settings. Future studies are needed to evaluate the clinical benefit of such approach.
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Affiliation(s)
- Peter Somhorst
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Amne Mousa
- Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam, The Netherlands
| | - Annemijn H. Jonkman
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
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3
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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: 2] [Impact Index Per Article: 2.0] [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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Stroh JN, Smith BJ, Sottile PD, Hripcsak G, Albers DJ. Hypothesis-driven modeling of the human lung-ventilator system: A characterization tool for Acute Respiratory Distress Syndrome research. J Biomed Inform 2023; 137:104275. [PMID: 36572279 PMCID: PMC9788853 DOI: 10.1016/j.jbi.2022.104275] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 11/21/2022] [Accepted: 12/14/2022] [Indexed: 12/25/2022]
Abstract
Mechanical ventilation is an essential tool in the management of Acute Respiratory Distress Syndrome (ARDS), but it exposes patients to the risk of ventilator-induced lung injury (VILI). The human lung-ventilator system (LVS) involves the interaction of complex anatomy with a mechanical apparatus, which limits the ability of process-based models to provide individualized clinical support. This work proposes a hypothesis-driven strategy for LVS modeling in which robust personalization is achieved using a pre-defined parameter basis in a non-physiological model. Model inversion, here via windowed data assimilation, forges observed waveforms into interpretable parameter values that characterize the data rather than quantifying physiological processes. Accurate, model-based inference on human-ventilator data indicates model flexibility and utility over a variety of breath types, including those from dyssynchronous LVSs. Estimated parameters generate static characterizations of the data that are 50%-70% more accurate than breath-wise single-compartment model estimates. They also retain sufficient information to distinguish between the types of breath they represent. However, the fidelity and interpretability of model characterizations are tied to parameter definitions and model resolution. These additional factors must be considered in conjunction with the objectives of specific applications, such as identifying and tracking the development of human VILI.
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Affiliation(s)
- J N Stroh
- Department of Biomedical Informatics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Bioengineering, University of Colorado, Denver-Anschutz Medical Campus, Aurora, CO, USA.
| | - Bradford J Smith
- Department of Bioengineering, University of Colorado, Denver-Anschutz Medical Campus, Aurora, CO, USA; Section of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | - David J Albers
- Department of Biomedical Informatics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA; Department of Bioengineering, University of Colorado, Denver-Anschutz Medical Campus, Aurora, CO, USA; Department of Biomedical Informatics, Columbia University, New York, NY, USA; Section of Informatics and Data Science, Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO, USA
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5
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Grivans C, Stenqvist O. Gas distribution by EIT during PEEP inflation: PEEP response and optimal PEEP with lowest trans-pulmonary driving pressure can be determined without esophageal pressure during a rapid PEEP trial in patients with acute respiratory failure. Physiol Meas 2022; 43. [PMID: 36007512 DOI: 10.1088/1361-6579/ac8ccc] [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: 04/29/2022] [Accepted: 08/25/2022] [Indexed: 02/07/2023]
Abstract
Objective. Protective ventilation should be based onlungmechanics and transpulmonary driving pressure (ΔPTP), as this 'hits' the lung directly.Approach. The change in end-expiratory lung volume (ΔEELV) is determined by the size of the PEEP step and the elastic properties of the lung (EL), ΔEELV/ΔPEEP. Consequently, EL can be determined as ΔPEEP/ΔEELV. By calibration of tidal inspiratory impedance change with ventilator inspiratory tidal volume, end-expiratory lung impedance changes were converted to volume changes and lung P/V curves were obtained during a PEEP trial in ten patients with acute respiratory failure. The PEEP level where ΔPTP was lowest (optimal PEEP) was determined as the steepest point of the lung P/V curve.Main results. Over-all EL ranged between 7.0-23.2 cmH2O/L. Optimal PEEP was 12.9 cmH2O (10-16) with ΔPTP of 4.1 cmH2O (2.8-7.6). Patients with highest EL were PEEP non-responders, where EL increased in non-dependent and dependent lung at high PEEP, indicating over-distension in all lung. Patients with lower EL were PEEP responders with decreasing EL in dependent lung when increasing PEEP.Significance. PEEP non-responders could be identified by regional lung P/V curves derived from ventilator calibrated EIT. Optimal PEEP could be determined from the equation for the lung P/V curve.
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Affiliation(s)
| | - Ola Stenqvist
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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Advances in Ventilator Management for Patients with Acute Respiratory Distress Syndrome. Clin Chest Med 2022; 43:499-509. [PMID: 36116817 PMCID: PMC9477439 DOI: 10.1016/j.ccm.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The ventilatory care of patients with acute respiratory distress syndrome (ARDS) is evolving as our understanding of physiologic mechanisms of respiratory failure improves. Despite several decades of research, the mortality rate for ARDS remains high. Over the years, we continue to expand strategies to identify and mitigate ventilator-induced lung injury. This now includes a greater understanding of the benefits and harms associated with spontaneous breathing.
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İnci K, Boyacı N, Kara İ, Gürsel G. Assessment of different computing methods of inspiratory transpulmonary pressure in patients with multiple mechanical problems. J Clin Monit Comput 2021; 36:1173-1180. [PMID: 34480238 PMCID: PMC8415196 DOI: 10.1007/s10877-021-00751-8] [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: 04/13/2021] [Accepted: 08/24/2021] [Indexed: 11/15/2022]
Abstract
While plateau airway pressure alone is an unreliable estimate of lung overdistension inspiratory transpulmonary pressure (PL) is an important parameter to reflect it in patients with ARDS and there is no concensus about which computation method should be used to calculate it. Recent studies suggest that different formulas may lead to different tidal volume and PEEP settings. The aim of this study is to compare 3 different inspiratory PL measurement method; direct measurement (PLD), elastance derived (PLE) and release derived (PLR) methods in patients with multiple mechanical abnormalities. 34 patients were included in this prospective observational study. Measurements were obtained during volume controlled mechanical ventilation in sedated and paralyzed patients. During the study day airway and eosephageal pressures, flow, tidal volume were measured and elastance, inspiratory PLE, PLD and PLR were calculated. Mean age of the patients was 67 ± 15 years and APACHE II score was 27 ± 7. Most frequent diagnosis of the patients were pneumonia (71%), COPD exacerbation(56%), pleural effusion (55%) and heart failure(50%). Mean plateau pressure of the patients was 22 ± 5 cmH2O and mean respiratory system elastance was 36.7 ± 13 cmH2O/L. EL/ERS% was 0.75 ± 0.35%. Mean expiratory transpulmonary pressure was 0.54 ± 7.7 cmH2O (min: − 21, max: 12). Mean PLE (18 ± 9 H2O) was significantly higher than PLD (13 ± 9 cmH2O) and PLR methods (11 ± 9 cmH2O). There was a good aggreement and there was no bias between the measurements in Bland–Altman analysis. The estimated bias was similar between the PLD and PLE (− 3.12 ± 11 cmH2O) and PLE and PLR (3.9 ± 10.9 cmH2O) measurements. Our results suggest that standardization of calculation method of inspiratory PL is necessary before using it routinely to estimate alveolar overdistension.
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Affiliation(s)
- Kamil İnci
- Critical Care Training Programme, Division of Critical Care, Department of Internal Medicine, School of Medicine, Gazi University, Ankara, Turkey
| | - Nazlıhan Boyacı
- Critical Care Training Programme, Division of Critical Care, Department of Internal Medicine, School of Medicine, Gazi University, Ankara, Turkey
| | - İskender Kara
- Critical Care Training Programme, Division of Critical Care, Department of Anaesthesiology, School of Medicine, Gazi University, Ankara, Turkey.
| | - Gül Gürsel
- Critical Care Training Programme, Department of Pulmonary Critical Care Medicine, School of Medicine, Gazi University, Ankara, Turkey
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Scaramuzzo G, Spadaro S, Spinelli E, Waldmann AD, Bohm SH, Ottaviani I, Montanaro F, Gamberini L, Marangoni E, Mauri T, Volta CA. Calculation of Transpulmonary Pressure From Regional Ventilation Displayed by Electrical Impedance Tomography in Acute Respiratory Distress Syndrome. Front Physiol 2021; 12:693736. [PMID: 34349666 PMCID: PMC8327175 DOI: 10.3389/fphys.2021.693736] [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] [Received: 04/11/2021] [Accepted: 06/14/2021] [Indexed: 01/21/2023] Open
Abstract
Transpulmonary driving pressure (DPL) corresponds to the cyclical stress imposed on the lung parenchyma during tidal breathing and, therefore, can be used to assess the risk of ventilator-induced lung injury (VILI). Its measurement at the bedside requires the use of esophageal pressure (Peso), which is sometimes technically challenging. Recently, it has been demonstrated how in an animal model of ARDS, the transpulmonary pressure (PL) measured with Peso calculated with the absolute values method (PL = Paw—Peso) is equivalent to the transpulmonary pressure directly measured using pleural sensors in the central-dependent part of the lung. We hypothesized that, since the PL derived from Peso reflects the regional behavior of the lung, it could exist a relationship between regional parameters measured by electrical impedance tomography (EIT) and driving PL (DPL). Moreover, we explored if, by integrating airways pressure data and EIT data, it could be possible to estimate non-invasively DPL and consequently lung elastance (EL) and elastance-derived inspiratory PL (PI). We analyzed 59 measurements from 20 patients with ARDS. There was a significant intra-patient correlation between EIT derived regional compliance in regions of interest (ROI1) (r = 0.5, p = 0.001), ROI2 (r = −0.68, p < 0.001), and ROI3 (r = −0.4, p = 0.002), and DPL. A multiple linear regression successfully predicted DPL based on respiratory system elastance (Ers), ideal body weight (IBW), roi1%, roi2%, and roi3% (R2 = 0.84, p < 0.001). The corresponding Bland-Altmann analysis showed a bias of −1.4e-007 cmH2O and limits of agreement (LoA) of −2.4–2.4 cmH2O. EL and PI calculated using EIT showed good agreement (R2 = 0.89, p < 0.001 and R2 = 0.75, p < 0.001) with the esophageal derived correspondent variables. In conclusion, DPL has a good correlation with EIT-derived parameters in the central lung. DPL, PI, and EL can be estimated with good accuracy non-invasively combining information coming from EIT and airway pressure.
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Affiliation(s)
- Gaetano Scaramuzzo
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Savino Spadaro
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andreas D Waldmann
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Stephan H Bohm
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Irene Ottaviani
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Federica Montanaro
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Lorenzo Gamberini
- Department of Anaesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Elisabetta Marangoni
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplant, University of Milan, Milan, Italy
| | - Carlo Alberto Volta
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
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Chiumello D, Caccioppola A, Pozzi T, Lusardi AC, De Giorgis V, Galanti V, Ferrari E, Coppola S. The assessment of esophageal pressure using different devices: a validation study. Minerva Anestesiol 2020; 86:1047-1056. [DOI: 10.23736/s0375-9393.20.14458-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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10
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Scaramuzzo G, Spadaro S, Dalla Corte F, Waldmann AD, Böhm SH, Ragazzi R, Marangoni E, Grasselli G, Pesenti A, Volta CA, Mauri T. Personalized Positive End-Expiratory Pressure in Acute Respiratory Distress Syndrome: Comparison Between Optimal Distribution of Regional Ventilation and Positive Transpulmonary Pressure. Crit Care Med 2020; 48:1148-1156. [PMID: 32697485 DOI: 10.1097/ccm.0000000000004439] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Different techniques exist to select personalized positive end-expiratory pressure in patients affected by the acute respiratory distress syndrome. The positive end-expiratory transpulmonary pressure strategy aims to counteract dorsal lung collapse, whereas electrical impedance tomography could guide positive end-expiratory pressure selection based on optimal homogeneity of ventilation distribution. We compared the physiologic effects of positive end-expiratory pressure guided by electrical impedance tomography versus transpulmonary pressure in patients affected by acute respiratory distress syndrome. DESIGN Cross-over prospective physiologic study. SETTING Two academic ICUs. PATIENTS Twenty ICU patients affected by acute respiratory distress syndrome undergoing mechanical ventilation. INTERVENTION Patients monitored by an esophageal catheter and a 32-electrode electrical impedance tomography monitor underwent two positive end-expiratory pressure titration trials by randomized cross-over design to find the level of positive end-expiratory pressure associated with: 1) positive end-expiratory transpulmonary pressure (PEEPPL) and 2) proportion of poorly or nonventilated lung units (Silent Spaces) less than or equal to 15% (PEEPEIT). Each positive end-expiratory pressure level was maintained for 20 minutes, and afterward, lung mechanics, gas exchange, and electrical impedance tomography data were collected. MEASUREMENTS AND MAIN RESULTS PEEPEIT and PEEPPL differed in all patients, and there was no correlation between the levels identified by the two methods (Rs = 0.25; p = 0.29). PEEPEIT determined a more homogeneous distribution of ventilation with a lower percentage of dependent Silent Spaces (p = 0.02), whereas PEEPPL was characterized by lower airway-but not transpulmonary-driving pressure (p = 0.04). PEEPEIT was significantly higher than PEEPPL in subjects with extrapulmonary acute respiratory distress syndrome (p = 0.006), whereas the opposite was true for pulmonary acute respiratory distress syndrome (p = 0.03). CONCLUSIONS Personalized positive end-expiratory pressure levels selected by electrical impedance tomography- and transpulmonary pressure-based methods are not correlated at the individual patient level. PEEPPL is associated with lower dynamic stress, whereas PEEPEIT may help to optimize lung recruitment and homogeneity of ventilation. The underlying etiology of acute respiratory distress syndrome could deeply influence results from each method.
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Affiliation(s)
- Gaetano Scaramuzzo
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Ferrara, Italy
| | - Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Ferrara, Italy
| | - Francesca Dalla Corte
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Ferrara, Italy
| | - Andreas D Waldmann
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Stephan H Böhm
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Riccardo Ragazzi
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Ferrara, Italy
| | - Elisabetta Marangoni
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Ferrara, Italy
| | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Carlo Alberto Volta
- Department of Morphology, Surgery and Experimental Medicine, Azienda Ospedaliera-Universitaria Arcispedale Sant'Anna, University of Ferrara, Ferrara, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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11
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Fernandez-Bustamante A, Sprung J, Parker RA, Bartels K, Weingarten TN, Kosour C, Thompson BT, Vidal Melo MF. Individualized PEEP to optimise respiratory mechanics during abdominal surgery: a pilot randomised controlled trial. Br J Anaesth 2020; 125:383-392. [PMID: 32682559 DOI: 10.1016/j.bja.2020.06.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 05/24/2020] [Accepted: 06/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Higher intraoperative driving pressures (ΔP) are associated with increased postoperative pulmonary complications (PPC). We hypothesised that dynamic adjustment of PEEP throughout abdominal surgery reduces ΔP, maintains positive end-expiratory transpulmonary pressures (Ptp_ee) and increases respiratory system static compliance (Crs) with PEEP levels that are variable between and within patients. METHODS In a prospective multicentre pilot study, adults at moderate/high risk for PPC undergoing elective abdominal surgery were randomised to one of three ventilation protocols: (1) PEEP≤2 cm H2O, compared with periodic recruitment manoeuvres followed by individualised PEEP to either optimise respiratory system compliance (PEEPmaxCrs) or maintain positive end-expiratory transpulmonary pressure (PEEPPtp_ee). The composite primary outcome included intraoperative ΔP, Ptp_ee, Crs, and PEEP values (median (interquartile range) and coefficients of variation [CVPEEP]). RESULTS Thirty-seven patients (48.6% female; age range: 47-73 yr) were assigned to control (PEEP≤2 cm H2O; n=13), PEEPmaxCrs (n=16), or PEEPPtp_ee (n=8) groups. The PEEPPtp_ee intervention could not be delivered in two patients. Subjects assigned to PEEPmaxCrs had lower ΔP (median8 cm H2O [7-10]), compared with the control group (12 cm H2O [10-15]; P=0.006). PEEPmaxCrs was also associated with higher Ptp_ee (2.0 cm H2O [-0.7 to 4.5] vs controls: -8.3 cm H2O [-13.0 to -4.0]; P≤0.001) and higher Crs (47.7 ml cm H2O [43.2-68.8] vs controls: 39.0 ml cm H2O [32.9-43.4]; P=0.009). Individualised PEEP (PEEPmaxCrs and PEEPPtp_ee combined) varied widely (median: 10 cm H2O [8-15]; CVPEEP=0.24 [0.14-0.35]), both between, and within, subjects throughout surgery. CONCLUSIONS This pilot study suggests that individualised PEEP management strategies applied during abdominal surgery reduce driving pressure, maintain positive Ptp_ee and increase static compliance. The wide range of PEEP observed suggests that an individualised approach is required to optimise respiratory mechanics during abdominal surgery. CLINICAL TRIAL REGISTRATION NCT02671721.
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Affiliation(s)
- Ana Fernandez-Bustamante
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA; Webb-Waring Center, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Juraj Sprung
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert A Parker
- Department of Medicine, Biostatistics Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Karsten Bartels
- Department of Anesthesiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Carolina Kosour
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcos F Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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12
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Kreyer S, Baker WL, Scaravilli V, Linden K, Belenkiy SM, Necsoiu C, Muders T, Putensen C, Chung KK, Cancio LC, Batchinsky AI. Assessment of spontaneous breathing during pressure controlled ventilation with superimposed spontaneous breathing using respiratory flow signal analysis. J Clin Monit Comput 2020; 35:859-868. [PMID: 32535849 PMCID: PMC7293172 DOI: 10.1007/s10877-020-00545-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 06/06/2020] [Indexed: 11/25/2022]
Abstract
Integrating spontaneous breathing into mechanical ventilation (MV) can speed up liberation from it and reduce its invasiveness. On the other hand, inadequate and asynchronous spontaneous breathing has the potential to aggravate lung injury. During use of airway-pressure-release-ventilation (APRV), the assisted breaths are difficult to measure. We developed an algorithm to differentiate the breaths in a setting of lung injury in spontaneously breathing ewes. We hypothesized that differentiation of breaths into spontaneous, mechanical and assisted is feasible using a specially developed for this purpose algorithm. Ventilation parameters were recorded by software that integrated ventilator output variables. The flow signal, measured by the EVITA® XL (Lübeck, Germany), was measured every 2 ms by a custom Java-based computerized algorithm (Breath-Sep). By integrating the flow signal, tidal volume (VT) of each breath was calculated. By using the flow curve the algorithm separated the different breaths and numbered them for each time point. Breaths were separated into mechanical, assisted and spontaneous. Bland Altman analysis was used to compare parameters. Comparing the values calculated by Breath-Sep with the data from the EVITA® using Bland-Altman analyses showed a mean bias of - 2.85% and 95% limits of agreement from - 25.76 to 20.06% for MVtotal. For respiratory rate (RR) RRset a bias of 0.84% with a SD of 1.21% and 95% limits of agreement from - 1.53 to 3.21% were found. In the cluster analysis of the 25th highest breaths of each group RRtotal was higher using the EVITA®. In the mechanical subgroup the values for RRspont and MVspont the EVITA® showed higher values compared to Breath-Sep. We developed a computerized method for respiratory flow-curve based differentiation of breathing cycle components during mechanical ventilation with superimposed spontaneous breathing. Further studies in humans and optimizing of this technique is necessary to allow for real-time use at the bedside.
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Affiliation(s)
- Stefan Kreyer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany.
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX, USA.
| | - William L Baker
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX, USA
| | - Vittorio Scaravilli
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX, USA
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milano, MI, Italy
| | - Katharina Linden
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX, USA
- Pediatric Department, University Hospital Bonn, Bonn, Germany
| | - Slava M Belenkiy
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX, USA
- Department of Anesthesiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Corina Necsoiu
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX, USA
| | - Thomas Muders
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Kevin K Chung
- Department of Medicine, Uniformed Services University, Bethesda, MD, USA
| | - Leopoldo C Cancio
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX, USA
| | - Andriy I Batchinsky
- U.S. Army Institute of Surgical Research, JBSA Fort Sam Houston, San Antonio, TX, USA
- The Geneva Foundation, Tacoma, WA, USA
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13
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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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14
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Wang YM, Sun XM, Zhou YM, Chen JR, Cheng KM, Li HL, Yang YL, Zhang L, Zhou JX. Use of Electrical Impedance Tomography (EIT) to Estimate Global and Regional Lung Recruitment Volume (VREC) Induced by Positive End-Expiratory Pressure (PEEP): An Experiment in Pigs with Lung Injury. Med Sci Monit 2020; 26:e922609. [PMID: 32172276 PMCID: PMC7094060 DOI: 10.12659/msm.922609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Electrical impedance tomography (EIT) is a real-time tool used to monitor lung volume change at the bedside, which could be used to measure lung recruitment volume (VREC) for setting positive end-expiratory pressure (PEEP). We assessed and compared the agreement in VREC measurement with the EIT method versus the flow-derived method. Material/Methods In 12 Bama pigs, lung injury was induced by tracheal instillation of hydrochloric acid and verified by an arterial partial pressure of oxygen to inspired oxygen fraction ratio below 200 mmHg. During the end-expiratory occlusion, an airway release maneuver was conduct at 5 and 15 cmH2O of PEEP. VREC was measured by flow-integrated PEEP-induced lung volume change (flow-derived method) and end-expiratory lung impedance change (EIT-derived method). Linear regression and Bland-Altman analysis were used to test the correlation and agreement between these 2 measures. Results Lung injury was successfully induced in all the animals. EIT-derived VREC was significantly correlated with flow-derived VREC (R2=0.650, p=0.002). The bias (the lower and upper limits of agreement) was −19 (−182 to 144) ml. The median (interquartile range) of EIT-derived VREC was 322 (218–469) ml, with 110 (59–142) ml and 194 (157–307) ml in dependent and nondependent lung regions, respectively. Global and regional respiratory system compliance increased significantly at high PEEP compared to those at low PEEP. Conclusions Close correlation and agreement were found between EIT-derived and flow-derived VREC measurements. The advantages of EIT-derived recruitability assessment included the avoidance of ventilation interruption and the ability to provide regional recruitment information.
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Affiliation(s)
- Yu-Mei Wang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (mainland)
| | - Xiu-Mei Sun
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (mainland)
| | - Yi-Min Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (mainland)
| | - Jing-Ran Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (mainland)
| | - Kun-Ming Cheng
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (mainland)
| | - Hong-Liang Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (mainland)
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (mainland)
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (mainland)
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (mainland)
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15
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Pasticci I, Cadringher P, Giosa L, Umbrello M, Formenti P, Macri MM, Busana M, Bonifazi M, Romitti F, Vassalli F, Cressoni M, Quintel M, Chiumello D, Gattinoni L. Determinants of the esophageal-pleural pressure relationship in humans. J Appl Physiol (1985) 2019; 128:78-86. [PMID: 31774352 DOI: 10.1152/japplphysiol.00587.2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Esophageal pressure has been suggested as adequate surrogate of the pleural pressure. We investigate after lung surgery the determinants of the esophageal and intrathoracic pressures and their differences. The esophageal pressure (through esophageal balloon) and the intrathoracic/pleural pressure (through the chest tube on the surgery side) were measured after surgery in 28 patients immediately after lobectomy or wedge resection. Measurements were made in the nondependent lateral position (without or with ventilation of the operated lung) and in the supine position. In the lateral position with the nondependent lung, collapsed or ventilated, the differences between esophageal and pleural pressure amounted to 4.4 ± 1.6 and 5.1 ± 1.7 cmH2O. In the supine position, the difference amounted to 7.3 ± 2.8 cmH2O. In the supine position, the estimated compressive forces on the mediastinum were 10.5 ± 3.1 cmH2O and on the iso-gravitational pleural plane 3.2 ± 1.8 cmH2O. A simple model describing the roles of chest, lung, and pneumothorax volume matching on the pleural pressure genesis was developed; modeled pleural pressure = 1.0057 × measured pleural pressure + 0.6592 (r2 = 0.8). Whatever the position and the ventilator settings, the esophageal pressure changed in a 1:1 ratio with the changes in pleural pressure. Consequently, chest wall elastance (Ecw) measured by intrathoracic (Ecw = ΔPpl/tidal volume) or esophageal pressure (Ecw = ΔPes/tidal volume) was identical in all the positions we tested. We conclude that esophageal and pleural pressures may be largely different depending on body position (gravitational forces) and lung-chest wall volume matching. Their changes, however, are identical.NEW & NOTEWORTHY Esophageal and pleural pressure changes occur at a 1:1 ratio, fully justifying the use of esophageal pressure to compute the chest wall elastance and the changes in pleural pressure and in lung stress. The absolute value of esophageal and pleural pressures may be largely different, depending on the body position (gravitational forces) and the lung-chest wall volume matching. Therefore, the absolute value of esophageal pressure should not be used as a surrogate of pleural pressure.
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Affiliation(s)
- Iacopo Pasticci
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Paolo Cadringher
- Dipartimento Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Giosa
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Michele Umbrello
- SC Anestesia e Rianimazione, ASST Santi Paolo e Carlo, Ospedale San Paolo - Polo Universitario, Milan, Italy
| | - Paolo Formenti
- SC Anestesia e Rianimazione, ASST Santi Paolo e Carlo, Ospedale San Paolo - Polo Universitario, Milan, Italy
| | - Matteo M Macri
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Mattia Busana
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Matteo Bonifazi
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Federica Romitti
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Francesco Vassalli
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Massimo Cressoni
- Dipartimento di Scienze della Salute, Università degli Studi di Milano Bicocca, Milan, Italy
| | - Michael Quintel
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - Davide Chiumello
- SC Anestesia e Rianimazione, ASST Santi Paolo e Carlo, Ospedale San Paolo - Polo Universitario, Milan, Italy
| | - Luciano Gattinoni
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
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16
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Yoshida T, Amato MBP, Grieco DL, Chen L, Lima CAS, Roldan R, Morais CCA, Gomes S, Costa ELV, Cardoso PFG, Charbonney E, Richard JCM, Brochard L, Kavanagh BP. Esophageal Manometry and Regional Transpulmonary Pressure in Lung Injury. Am J Respir Crit Care Med 2019; 197:1018-1026. [PMID: 29323931 DOI: 10.1164/rccm.201709-1806oc] [Citation(s) in RCA: 138] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Esophageal manometry is the clinically available method to estimate pleural pressure, thus enabling calculation of transpulmonary pressure (Pl). However, many concerns make it uncertain in which lung region esophageal manometry reflects local Pl. OBJECTIVES To determine the accuracy of esophageal pressure (Pes) and in which regions esophageal manometry reflects pleural pressure (Ppl) and Pl; to assess whether lung stress in nondependent regions can be estimated at end-inspiration from Pl. METHODS In lung-injured pigs (n = 6) and human cadavers (n = 3), Pes was measured across a range of positive end-expiratory pressure, together with directly measured Ppl in nondependent and dependent pleural regions. All measurements were obtained with minimal nonstressed volumes in the pleural sensors and esophageal balloons. Expiratory and inspiratory Pl was calculated by subtracting local Ppl or Pes from airway pressure; inspiratory Pl was also estimated by subtracting Ppl (calculated from chest wall and respiratory system elastance) from the airway plateau pressure. MEASUREMENTS AND MAIN RESULTS In pigs and human cadavers, expiratory and inspiratory Pl using Pes closely reflected values in dependent to middle lung (adjacent to the esophagus). Inspiratory Pl estimated from elastance ratio reflected the directly measured nondependent values. CONCLUSIONS These data support the use of esophageal manometry in acute respiratory distress syndrome. Assuming correct calibration, expiratory Pl derived from Pes reflects Pl in dependent to middle lung, where atelectasis usually predominates; inspiratory Pl estimated from elastance ratio may indicate the highest level of lung stress in nondependent "baby" lung, where it is vulnerable to ventilator-induced lung injury.
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Affiliation(s)
- Takeshi Yoshida
- 1 Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,2 Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, and.,3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Domenico Luca Grieco
- 1 Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,2 Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, and.,5 Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione "Policlinico universitario A. Gemelli," Rome, Italy.,6 Cardiac Arrest and Ventilation International Association for Research, Laboratoire d'anatomie, Université du Québec à Trois-Rivières et Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, Canada
| | - Lu Chen
- 1 Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,2 Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, and
| | | | - Rollin Roldan
- 4 Divisao de Pneumologia and.,7 Unidad de Cuidados Intensivos, Hospital Rebagliati, Lima, Perú
| | | | | | | | - Paulo F G Cardoso
- 8 Disciplina de Cirurgia Torácica, Instituto do Coração, Hospital das Clinicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Emmanuel Charbonney
- 6 Cardiac Arrest and Ventilation International Association for Research, Laboratoire d'anatomie, Université du Québec à Trois-Rivières et Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, Canada.,9 Centre de Recherche de l'Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada; and
| | - Jean-Christophe M Richard
- 6 Cardiac Arrest and Ventilation International Association for Research, Laboratoire d'anatomie, Université du Québec à Trois-Rivières et Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, Canada.,10 Department of Pre-Hospital and Emergency Medicine, General Hospital of Annecy, Annecy, France
| | - Laurent Brochard
- 1 Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,6 Cardiac Arrest and Ventilation International Association for Research, Laboratoire d'anatomie, Université du Québec à Trois-Rivières et Centre Intégré Universitaire de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec, Trois-Rivières, Canada
| | - Brian P Kavanagh
- 2 Translational Medicine, Departments of Critical Care Medicine and Anesthesia, Hospital for Sick Children, and.,3 Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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17
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Sklar MC, Goligher EC. Strategies to Adjust Positive End-Expiratory Pressure in Patients With ARDS. JAMA 2019; 322:580-582. [PMID: 31408130 DOI: 10.1001/jama.2019.7880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Michael C Sklar
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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18
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Bitker L, Costes N, Le Bars D, Lavenne F, Orkisz M, Hernandez Hoyos M, Benzerdjeb N, Devouassoux M, Richard JC. Noninvasive quantification of macrophagic lung recruitment during experimental ventilation-induced lung injury. J Appl Physiol (1985) 2019; 127:546-558. [PMID: 31169472 DOI: 10.1152/japplphysiol.00825.2018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Macrophagic lung infiltration is pivotal in the development of lung biotrauma because of ventilation-induced lung injury (VILI). We assessed the performance of [11C](R)-PK11195, a positron emission tomography (PET) radiotracer binding the translocator protein, to quantify macrophage lung recruitment during experimental VILI. Pigs (n = 6) were mechanically ventilated under general anesthesia, using protective ventilation settings (baseline). Experimental VILI was performed by titrating tidal volume to reach a transpulmonary end-inspiratory pressure (∆PL) of 35-40 cmH2O. We acquired PET/computed tomography (CT) lung images at baseline and after 4 h of VILI. Lung macrophages were quantified in vivo by the standardized uptake value (SUV) of [11C](R)-PK11195 measured in PET on the whole lung and in six lung regions and ex vivo on lung pathology at the end of experiment. Lung mechanics were extracted from CT images to assess their association with the PET signal. ∆PL increased from 9 ± 1 cmH2O under protective ventilation, to 36 ± 6 cmH2O during experimental VILI. Compared with baseline, whole-lung [11C](R)-PK11195 SUV significantly increased from 1.8 ± 0.5 to 2.9 ± 0.5 after experimental VILI. Regional [11C](R)-PK11195 SUV was positively associated with the magnitude of macrophage recruitment in pathology (P = 0.03). Compared with baseline, whole-lung CT-derived dynamic strain and tidal hyperinflation increased significantly after experimental VILI, from 0.6 ± 0 to 2.0 ± 0.4, and 1 ± 1 to 43 ± 19%, respectively. On multivariate analysis, both were significantly associated with regional [11C](R)-PK11195 SUV. [11C](R)-PK11195 lung uptake (a proxy of lung inflammation) was increased by experimental VILI and was associated with the magnitude of dynamic strain and tidal hyperinflation.NEW & NOTEWORTHY We assessed the performance of [11C](R)-PK11195, a translocator protein-specific positron emission tomography (PET) radiotracer, to quantify macrophage lung recruitment during experimental ventilation-induced lung injury (VILI). In this proof-of-concept study, we showed that the in vivo quantification of [11C](R)-PK11195 lung uptake in PET reflected the magnitude of macrophage lung recruitment after VILI. Furthermore, increased [11C](R)-PK11195 lung uptake was associated with harmful levels of dynamic strain and tidal hyperinflation applied to the lungs.
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Affiliation(s)
- Laurent Bitker
- Service de Médecine Intensive et Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, CREATIS Unité Mixte de Recherche 5220, U1206, Villeurbanne, France.,Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France
| | | | - Didier Le Bars
- Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France.,CERMEP - Imagerie du Vivant, Bron, France
| | | | - Maciej Orkisz
- Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, CREATIS Unité Mixte de Recherche 5220, U1206, Villeurbanne, France.,Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France
| | - Marcela Hernandez Hoyos
- Systems and Computing Engineering Department, School of Engineering, Universidad de los Andes, Bogota, Colombia
| | - Nazim Benzerdjeb
- Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France.,Centre d'Anatomie et Cytologie Pathologique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Mojgan Devouassoux
- Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France.,Centre d'Anatomie et Cytologie Pathologique, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Jean-Christophe Richard
- Service de Médecine Intensive et Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France.,Univ Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, UJM-Saint Etienne, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, CREATIS Unité Mixte de Recherche 5220, U1206, Villeurbanne, France.,Université Lyon 1 Claude Bernard, Université de Lyon, Lyon, France
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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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20
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Williams EC, Motta-Ribeiro GC, Vidal Melo MF. Driving Pressure and Transpulmonary Pressure: How Do We Guide Safe Mechanical Ventilation? Anesthesiology 2019; 131:155-163. [PMID: 31094753 PMCID: PMC6639048 DOI: 10.1097/aln.0000000000002731] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The physiological concept, pathophysiological implications and clinical relevance and application of driving pressure and transpulmonary pressure to prevent ventilator-induced lung injury are discussed.
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Affiliation(s)
- Elizabeth C Williams
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts. Current Affiliation: Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland (E.C.W.)
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21
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Kaku S, Nguyen CD, Htet NN, Tutera D, Barr J, Paintal HS, Kuschner WG. Acute Respiratory Distress Syndrome: Etiology, Pathogenesis, and Summary on Management. J Intensive Care Med 2019; 35:723-737. [DOI: 10.1177/0885066619855021] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The acute respiratory distress syndrome (ARDS) has multiple causes and is characterized by acute lung inflammation and increased pulmonary vascular permeability, leading to hypoxemic respiratory failure and bilateral pulmonary radiographic opacities. The acute respiratory distress syndrome is associated with substantial morbidity and mortality, and effective treatment strategies are limited. This review presents the current state of the literature regarding the etiology, pathogenesis, and management strategies for ARDS.
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Affiliation(s)
- Shawn Kaku
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Christopher D. Nguyen
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Natalie N. Htet
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Authors have contributed equally
| | - Dominic Tutera
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Juliana Barr
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Harman S. Paintal
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| | - Ware G. Kuschner
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
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22
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Abstract
PURPOSE OF REVIEW Esophageal manometry has shown its usefulness to estimate transpulmonary pressure, that is lung stress, and the intensity of spontaneous effort in patients with acute respiratory distress syndrome. However, clinical uptake of esophageal manometry in ICU is still low. Thus, the purpose of review is to describe technical tips to adequately measure esophageal pressure at the bedside, and then update the most important clinical applications of esophageal manometry in ICU. RECENT FINDINGS Each esophageal balloon has its own nonstressed volume and it should be calibrated properly to measure pleural pressure accurately: transpulmonary pressure calculated on absolute esophageal pressure reflects values in the lung regions adjacent to the esophageal balloon (i.e. dependent to middle lung). Inspiratory transpulmonary pressure calculated from airway plateau pressure and the chest wall to respiratory system elastance ratio reasonably reflects lung stress in the nondependent 'baby' lung, at highest risk of hyperinflation. Also esophageal pressure can be used to detect and minimize patient self-inflicted lung injury. SUMMARY Esophageal manometry is not a complicated technique. There is a large potential to improve clinical outcome in patients with acute respiratory distress syndrome, acting as an early detector of risk of lung injury from mechanical ventilation and vigorous spontaneous effort.
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23
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The Acute Respiratory Distress Syndrome: Diagnosis and Management. PRACTICAL TRENDS IN ANESTHESIA AND INTENSIVE CARE 2018 2019. [PMCID: PMC7122583 DOI: 10.1007/978-3-319-94189-9_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by a new acute onset of hypoxemia secondary to a pulmonary edema of non-cardiogenic origin, bilateral lung opacities and reduction in respiratory system compliance after an insult direct or indirect to lungs. Its first description was in 1970s, and then several shared definitions tried to describe this clinical entity; the last one, known as Berlin definition, brought an improvement in predictive ability for mortality. In the present chapter, the diagnostic workup of the syndrome will be presented with particular attention to microbiological investigations which represent a milestone in the diagnostic process and to imaging techniques such as CT scan and lung ultrasound. Despite the treatment is mainly based on supportive strategies, attention should be applied to assure adequate respiratory gas exchange while minimizing the risk of ventilator-induced lung injury (VILI) onset. Therefore will be described several therapeutic approaches to ARDS, including noninvasive mechanical ventilation (NIMV), high-flow nasal cannulas (HFNC) and invasive ventilation with particular emphasis to risks and benefits of mechanical ventilation, PEEP optimization and lung protective ventilation strategies. Rescue techniques, such as permissive hypercapnia, prone positioning, neuromuscular blockade, inhaled vasodilators, corticosteroids, recruitment maneuvers and extracorporeal life support, will also be reviewed. Finally, the chapter will deal with the mechanical ventilation weaning process with particular emphasis on extrapulmonary factors such as neurologic, diaphragmatic or cardiovascular alterations which can lead to weaning failure.
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24
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Rauseo M, Mirabella L, Grasso S, Cotoia A, Spadaro S, D'Antini D, Valentino F, Tullo L, Loizzi D, Sollitto F, Cinnella G. Peep titration based on the open lung approach during one lung ventilation in thoracic surgery: a physiological study. BMC Anesthesiol 2018; 18:156. [PMID: 30382819 PMCID: PMC6211445 DOI: 10.1186/s12871-018-0624-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 10/19/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND During thoracic surgery in lateral decubitus, one lung ventilation (OLV) may impair respiratory mechanics and gas exchange. We tested a strategy based on an open lung approach (OLA) consisting in lung recruitment immediately followed by a decremental positive-end expiratory pressure (PEEP) titration to the best respiratory system compliance (CRS) and separately quantified the elastic properties of the lung and the chest wall. Our hypothesis was that this approach would improve gas exchange. Further, we were interested in documenting the impact of the OLA on partitioned respiratory system mechanics. METHODS In thirteen patients undergoing upper left lobectomy we studied lung and chest wall mechanics, transpulmonary pressure (PL), respiratory system and transpulmonary driving pressure (ΔPRS and ΔPL), gas exchange and hemodynamics at two time-points (a) during OLV at zero end-expiratory pressure (OLVpre-OLA) and (b) after the application of the open-lung strategy (OLVpost-OLA). RESULTS The external PEEP selected through the OLA was 6 ± 0.8 cmH2O. As compared to OLVpre-OLA, the PaO2/FiO2 ratio went from 205 ± 73 to 313 ± 86 (p = .05) and CL increased from 56 ± 18 ml/cmH2O to 71 ± 12 ml/cmH2O (p = .0013), without changes in CCW. Both ΔPRS and ΔPL decreased from 9.2 ± 0.4 cmH2O to 6.8 ± 0.6 cmH2O and from 8.1 ± 0.5 cmH2O to 5.7 ± 0.5 cmH2O, (p = .001 and p = .015 vs OLVpre-OLA), respectively. Hemodynamic parameters remained stable throughout the study period. CONCLUSIONS In our patients, the OLA strategy performed during OLV improved oxygenation and increased CL and had no clinically significant hemodynamic effects. Although our study was not specifically designed to study ΔPRS and ΔPL, we observed a parallel reduction of both after the OLA. TRIAL REGISTRATION TRN: ClinicalTrials.gov , NCT03435523 , retrospectively registered, Feb 14 2018.
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Affiliation(s)
- Michela Rauseo
- Department of Anesthesia and Intensive care, University of Foggia, Viale Pinto, 1-71100, Foggia, Italy. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| | - Lucia Mirabella
- Department of Anesthesia and Intensive care, University of Foggia, Viale Pinto, 1-71100, Foggia, Italy
| | - Salvatore Grasso
- Department of Anesthesia and Intensive care, University of Bari, Bari, Italy
| | - Antonella Cotoia
- Department of Anesthesia and Intensive care, University of Foggia, Viale Pinto, 1-71100, Foggia, Italy
| | - Savino Spadaro
- Department of Anesthesia and Intensive care, University of Ferrara, Ferrara, Italy
| | - Davide D'Antini
- Department of Anesthesia and Intensive care, University of Foggia, Viale Pinto, 1-71100, Foggia, Italy
| | - Franca Valentino
- Department of Anesthesia and Intensive care, University of Foggia, Viale Pinto, 1-71100, Foggia, Italy
| | - Livio Tullo
- Department of Anesthesia and Intensive care, University of Foggia, Viale Pinto, 1-71100, Foggia, Italy
| | - Domenico Loizzi
- Department of Thoracic Surgery, University of Foggia, Foggia, Italy
| | | | - Gilda Cinnella
- Department of Anesthesia and Intensive care, University of Foggia, Viale Pinto, 1-71100, Foggia, Italy
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25
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Baedorf Kassis E, Loring SH, Talmor D. Should we titrate peep based on end-expiratory transpulmonary pressure?-yes. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:390. [PMID: 30460264 DOI: 10.21037/atm.2018.06.35] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Ventilator management of patients with acute respiratory distress syndrome (ARDS) has been characterized by implementation of basic physiology principles by minimizing harmful distending pressures and preventing lung derecruitment. Such strategies have led to significant improvements in outcomes. Positive end expiratory pressure (PEEP) is an important part of a lung protective strategy but there is no standardized method to set PEEP level. With widely varying types of lung injury, body habitus and pulmonary mechanics, the use of esophageal manometry has become important for personalization and optimization of mechanical ventilation in patients with ARDS. Esophageal manometry estimates pleural pressures, and can be used to differentiate the chest wall and lung (transpulmonary) contributions to the total respiratory system mechanics. Elevated pleural pressures may result in negative transpulmonary pressures at end expiration, leading to lung collapse. Measuring the esophageal pressures and adjusting PEEP to make transpulmonary pressures positive can decrease atelectasis, derecruitment of lung, and cyclical opening and closing of airways and alveoli, thus optimizing lung mechanics and oxygenation. Although there is some spatial and positional artifact, esophageal pressures in numerous animal and human studies in healthy, obese and critically ill patients appear to be a good estimate for the "effective" pleural pressure. Multiple studies have illustrated the benefit of using esophageal pressures to titrate PEEP in patients with obesity and with ARDS. Esophageal pressure monitoring provides a window into the unique physiology of a patient and helps improve clinical decision making at the bedside.
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Affiliation(s)
- Elias Baedorf Kassis
- Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center and Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen H Loring
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
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26
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Mojoli F, Torriglia F, Orlando A, Bianchi I, Arisi E, Pozzi M. Technical aspects of bedside respiratory monitoring of transpulmonary pressure. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:377. [PMID: 30460251 DOI: 10.21037/atm.2018.08.37] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Transpulmonary pressure, that is the difference between airway pressure (Paw) and pleural pressure, is considered one of the most important parameters to know in order to set a safe mechanical ventilation in acute respiratory distress syndrome (ARDS) patients but also in critically ill obese patients, in abdominal pathologies or in pathologies affecting the chest wall itself. Transpulmonary pressure should rely on the assessment of intrathoracic pleural pressure. Esophageal pressure (Pes) is considered the best surrogate of pleural pressure in critically ill patients, but concerns about its reliability exist. The aim of this article is to describe the technique of Pes measurement in mechanically ventilated patients: the catheter insertion, the proper balloon placement and filling, the validation test and specific procedures to remove the main artifacts will be discussed.
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Affiliation(s)
- Francesco Mojoli
- Anesthesia, Intensive Care and Pain Therapy, University of Pavia, Pavia, Italy.,Anesthesia and Intensive Care, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Francesca Torriglia
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Anita Orlando
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
| | - Isabella Bianchi
- Anesthesia, Intensive Care and Pain Therapy, University of Pavia, Pavia, Italy
| | - Eric Arisi
- Anesthesia, Intensive Care and Pain Therapy, University of Pavia, Pavia, Italy
| | - Marco Pozzi
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico S. Matteo, Pavia, Italy
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27
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Umbrello M, Chiumello D. Interpretation of the transpulmonary pressure in the critically ill patient. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:383. [PMID: 30460257 DOI: 10.21037/atm.2018.05.31] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Mechanical ventilation is a life-saving procedure, which takes over the function of the respiratory muscles while buying time for healing to take place. However, it can also promote or worsen lung injury, so that careful monitoring of respiratory mechanics is suggested to titrate the level of support and avoid injurious pressures and volumes to develop. Standard monitoring includes flow, volume and airway pressure (Paw). However, Paw represents the pressure acting on the respiratory system as a whole, and does not allow to differentiate the part of pressure that is spent di distend the chest wall. Moreover, if spontaneous breathing efforts are allowed, the Paw is the sum of that applied by the ventilator and that generated by the patient. As a consequence, monitoring of Paw has significant shortcomings. Assessment of esophageal pressure (Pes), as a surrogate for pleural pressure (Ppl), may allow the clinicians to discriminate between the elastic behaviour of the lung and the chest wall, and to calculate the degree of spontaneous respiratory effort. In the present review, the characteristics and limitations of airway and transpulmonary pressure monitoring will be presented; we will highlight the different assumptions underlying the various methods for measuring transpulmonary pressure (i.e., the elastance-derived and the release-derived method, and the direct measurement), as well as the potential application of transpulmonary pressure assessment during both controlled and spontaneous/assisted mechanical ventilation in critically ill patients.
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Affiliation(s)
- Michele Umbrello
- UOC Anestesia e Rianimazione, Ospedale San Paolo - ASST Santi Paolo e Carlo, Milano, Italy
| | - Davide Chiumello
- UOC Anestesia e Rianimazione, Ospedale San Paolo - ASST Santi Paolo e Carlo, Milano, Italy.,Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milano, Italy
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28
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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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29
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Marini JJ. Should we titrate positive end-expiratory pressure based on an end-expiratory transpulmonary pressure? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:391. [PMID: 30460265 DOI: 10.21037/atm.2018.08.22] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Arguments continue to swirl regarding the need for and best method of positive end-expiratory pressure (PEEP) titration. An appropriately conducted decremental method that uses modest peak pressures for the recruiting maneuver (RM), a lung protective tidal excursion, relatively small PEEP increments and appropriate timing intervals is currently the most logical and attractive option, particularly when the esophageal balloon pressure (Pes) is used to calculate transpulmonary driving pressures relevant to the lung. The setting of PEEP by the Pes-guided end-expiratory pressure at the 'polarity transition' point of the transmural end-expiratory pressure is quite relevant to the locale of the esophageal balloon catheter. Its desirability, however, is limited by its tendency to encourage PEEP levels that are higher than most other PEEP titration methods. These Pes-set PEEP values promote higher mean airway pressures and are likely to be unnecessary when small tidal driving pressures are in use. Because high airway pressures increase global lung stress and risk hemodynamic compromise, the Pes-determined PEEP would seem associated with a relatively high hazard to benefit ratio for many patients.
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Affiliation(s)
- John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN, USA
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30
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Silva PL, Gama de Abreu M. Regional distribution of transpulmonary pressure. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:385. [PMID: 30460259 DOI: 10.21037/atm.2018.10.03] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The pressure across the lung, so-called transpulmonary pressure (PL), represents the main force acting toward to provide lung movement. During mechanical ventilation, PL is provided by respiratory system pressurization, using specific ventilator setting settled by the operator, such as: tidal volume (VT), positive end-expiratory pressure (PEEP), respiratory rate (RR), and inspiratory airway flow. Once PL is developed throughout the lungs, its distribution is heterogeneous, being explained by the elastic properties of the lungs and pleural pressure gradient. There are different methods of PL calculation, each one with importance and some limitations. Among the most known, it can be quoted: (I) direct measurement of PL; (II) elastance derived method at end-inspiration of PL; (III) transpulmonary driving pressure. Recent studies using pleural sensors in large animal models as also in human cadaver have added new and important information about PL heterogeneous distribution across the lungs. Due to this heterogeneous distribution, lung damage could happen in specific areas of the lung. In addition, it is widely accepted that high PL can cause lung damage, however the way it is delivered, whether it's compressible or tensile, may also further damage despite the values of PL achieved. According to heterogeneous distribution of PL across the lungs, the interstitium and lymphatic vessels may also interplay to disseminate lung inflammation toward peripheral organs through thoracic lymph tracts. Thus, it is conceivable that juxta-diaphragmatic area associated strong efforts leading to high values of PL may be a source of dissemination of inflammatory cells, large molecules, and plasma contents able to perpetuate inflammation in distal organs.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
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31
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Chen H, Chen K, Xu JQ, Zhang YR, Yu RG, Zhou JX. Intracranial pressure responsiveness to positive end-expiratory pressure is influenced by chest wall elastance: a physiological study in patients with aneurysmal subarachnoid hemorrhage. BMC Neurol 2018; 18:124. [PMID: 30143022 PMCID: PMC6108121 DOI: 10.1186/s12883-018-1132-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 08/20/2018] [Indexed: 12/18/2022] Open
Abstract
Background Respiratory system elastance (ERS) is an important determinant of the responsiveness of intracranial pressure (ICP) to positive end-expiratory pressure (PEEP). However, lung elastance (EL) and chest wall elastance (ECW) were not differentiated in previous studies. We tested the hypothesis that patients with high ECW or a high ECW/ERS ratio have greater ICP responsiveness to PEEP. Methods An esophageal balloon catheter was placed to measure esophageal pressure. PEEP was increased from 5 to 15 cmH2O. Airway pressure and esophageal pressure were measured and EL, ECW and ERS were calculated at the two PEEP levels. Patients were classified into either an ICP responder group or a non-responder group based on whether the change of ICP after PEEP adjustment was greater than or less than the median of the overall study population. Results The magnitude of the increase in esophageal pressure (median [interquartile range]) at end-expiratory occlusion was significantly increased in the responder group compared with that in the non-responder group (4.1 [2.7–4.1] versus 2.7 [0.0–2.7] cmH2O, p = 0.033) after PEEP adjustment. ECW and the ECW/ERS ratio were significantly higher in ICP responders than in non-responders at both low PEEP (p = 0.021 and 0.017) and high PEEP (p = 0.011 and 0.025) levels. No significant differences in ERS and EL were noted between the two groups at both PEEP levels. Conclusions Patients with greater ICP responsiveness to increased PEEP exhibit higher ECW and a higher ECW/ERS ratio, suggesting the importance of ECW monitoring. Electronic supplementary material The online version of this article (10.1186/s12883-018-1132-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Han Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No 6, Tiantan Xili, Dongcheng District, Beijing, China.,Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Kai Chen
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Jing-Qing Xu
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Ying-Rui Zhang
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Rong-Guo Yu
- Surgical Intensive Care Unit, Fujian Provincial Clinical College, Fujian Medical University, Fuzhou, Fujian, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, No 6, Tiantan Xili, Dongcheng District, Beijing, China.
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Sun XM, Chen GQ, Huang HW, He X, Yang YL, Shi ZH, Xu M, Zhou JX. Use of esophageal balloon pressure-volume curve analysis to determine esophageal wall elastance and calibrate raw esophageal pressure: a bench experiment and clinical study. BMC Anesthesiol 2018; 18:21. [PMID: 29444644 PMCID: PMC5813414 DOI: 10.1186/s12871-018-0488-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 02/08/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Accurate measurement of esophageal pressure (Pes) depends on proper filling of the balloon. Esophageal wall elastance (Ees) may also influence the measurement. We examined the estimation of balloon-surrounding elastance in a bench model and investigated a simplified calibrating procedure of Pes in a balloon with relatively small volume. METHODS The Cooper balloon catheter (geometric volume of 2.8 ml) was used in the present study. The balloon was progressively inflated in different gas-tight glass chambers with different inner volumes. Chamber elastance was measured by the fitting of chamber pressure and balloon volume. Balloon pressure-volume (P-V) curves were obtained, and the slope of the intermediate linear section was defined as the estimated chamber elastance. Balloon volume tests were also performed in 40 patients under controlled ventilation. The slope of the intermediate linear section on the end-expiratory esophageal P-V curve was calculated as the Ees. The balloon volume with the largest Pes tidal swing was defined as the best volume. Pressure generated by the esophageal wall during balloon inflation (Pew) was estimated as the product of Ees and best volume. Because the clinical intermediate linear section enclosed filling volume of 0.6 to 1.4 ml in each of the patient, we simplified the estimation of Ees by only using parameters at these two filling volumes. RESULTS In the bench experiment, bias (lower and upper limits of agreement) was 0.5 (0.2 to 0.8) cmH2O/ml between the estimated and measured chamber elastance. The intermediate linear section on the clinical and bench P-V curves resembled each other. Median (interquartile range) Ees was 3.3 (2.5-4.1) cmH2O/ml. Clinical best volume was 1.0 (0.8-1.2) ml and ranged from 0.6 to 1.4 ml. Estimated Pew at the best volume was 2.8 (2.5-3.5) cmH2O with a maximum value of 5.2 cmH2O. Compared with the conventional method, bias (lower and upper limits of agreement) of Ees estimated by the simple method was - 0.1 (- 0.7 to 0.6) cmH2O/ml. CONCLUSIONS The slope of the intermediate linear section on the balloon P-V curve correlated with the balloon-surrounding elastance. The estimation of Ees and calibration of Pes were feasible for a small-volume-balloon. TRIAL REGISTRATION Identifier NCT02976844 . Retrospectively registered on 29 November 2016.
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Affiliation(s)
- Xiu-Mei Sun
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Address: No 6, Tiantan Xili, Dongcheng district, Beijing, 100050, China
| | - Guang-Qiang Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Address: No 6, Tiantan Xili, Dongcheng district, Beijing, 100050, China
| | - Hua-Wei Huang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Address: No 6, Tiantan Xili, Dongcheng district, Beijing, 100050, China
| | - Xuan He
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Address: No 6, Tiantan Xili, Dongcheng district, Beijing, 100050, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Address: No 6, Tiantan Xili, Dongcheng district, Beijing, 100050, China
| | - Zhong-Hua Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Address: No 6, Tiantan Xili, Dongcheng district, Beijing, 100050, China
| | - Ming Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Address: No 6, Tiantan Xili, Dongcheng district, Beijing, 100050, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Address: No 6, Tiantan Xili, Dongcheng district, Beijing, 100050, China.
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Godet T, Jabaudon M, Blondonnet R, Tremblay A, Audard J, Rieu B, Pereira B, Garcier JM, Futier E, Constantin JM. High frequency percussive ventilation increases alveolar recruitment in early acute respiratory distress syndrome: an experimental, physiological and CT scan study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:3. [PMID: 29325586 PMCID: PMC5763966 DOI: 10.1186/s13054-017-1924-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 12/13/2017] [Indexed: 01/27/2023]
Abstract
Background High frequency percussive ventilation (HFPV) combines diffusive (high frequency mini-bursts) and convective ventilation patterns. Benefits include enhanced oxygenation and hemodynamics, and alveolar recruitment, while providing hypothetic lung-protective ventilation. No study has investigated HFPV-induced changes in lung aeration in patients with early acute respiratory distress syndrome (ARDS). Methods Eight patients with early non-focal ARDS were enrolled and five swine with early non-focal ARDS were studied in prospective computed tomography (CT) scan and animal studies, in a university-hospital tertiary ICU and an animal laboratory. Patients were optimized under conventional “open-lung” ventilation. Lung CT was performed using an end-expiratory hold (Conv) to assess lung morphology. HFPV was applied for 1 hour to all patients before new CT scans were performed with end-expiratory (HFPV EE) and end-inspiratory (HFPV EI) holds. Lung volumes were determined after software analysis. At specified time points, blood gases and hemodynamic data were collected. Recruitment was defined as a change in non-aerated lung volumes between Conv, HFPV EE and HFPV EI. The main objective was to verify whether HFPV increases alveolar recruitment without lung hyperinflation. Correlation between pleural, upper airways and HFPV-derived pressures was assessed in an ARDS swine-based model. Results One-hour HFPV significantly improved oxygenation and hemodynamics. Lung recruitment significantly rose by 12.0% (8.5–18.0%), P = 0.05 (Conv-HFPV EE) and 12.5% (9.3–16.8%), P = 0.003 (Conv-HFPV EI). Hyperinflation tended to increase by 2.0% (0.5–2.5%), P = 0.89 (Conv-HFPV EE) and 3.0% (2.5–4.0%), P = 0.27 (Conv-HFPV EI). HFPV hyperinflation correlated with hyperinflated and normally-aerated lung volumes at baseline: r = 0.79, P = 0.05 and r = 0.79, P = 0.05, respectively (Conv-HFPV EE); and only hyperinflated lung volumes at baseline: r = 0.88, P = 0.01 (Conv-HFPV EI). HFPV CT-determined tidal volumes reached 5.7 (1.1–8.1) mL.kg-1 of ideal body weight (IBW). Correlations between pleural and HFPV-monitored pressures were acceptable and end-inspiratory pleural pressures remained below 25cmH20. Conclusions HFPV improves alveolar recruitment, gas exchanges and hemodynamics of patients with early non-focal ARDS without relevant hyperinflation. HFPV-derived pressures correlate with corresponding pleural or upper airways pressures. Trial registration ClinicalTrials.gov, NCT02510105. Registered on 1 June 2015. The trial was retrospectively registered. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1924-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas Godet
- Departement de Médecine Périopératoire (MPO), Hôpital Estaing, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 place Lucie Aubrac, Clermont-Ferrand, F-63003, France.,Université Clermont Auvergne, Laboratoire Universitaire GReD, UMR/CNRS 6293, INSERM U1103, Clermont-Ferrand, F-63003, France
| | - Matthieu Jabaudon
- Departement de Médecine Périopératoire (MPO), Hôpital Estaing, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 place Lucie Aubrac, Clermont-Ferrand, F-63003, France.,Université Clermont Auvergne, Laboratoire Universitaire GReD, UMR/CNRS 6293, INSERM U1103, Clermont-Ferrand, F-63003, France
| | - Raïko Blondonnet
- Departement de Médecine Périopératoire (MPO), Hôpital Estaing, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 place Lucie Aubrac, Clermont-Ferrand, F-63003, France.,Université Clermont Auvergne, Laboratoire Universitaire GReD, UMR/CNRS 6293, INSERM U1103, Clermont-Ferrand, F-63003, France
| | - Aymeric Tremblay
- Département d'Anesthésie et de Réanimation, Centre Hospitalier Universitaire (CHU) Saint-Etienne, Saint-Etienne, F-42000, France
| | - Jules Audard
- Departement de Médecine Périopératoire (MPO), Hôpital Estaing, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 place Lucie Aubrac, Clermont-Ferrand, F-63003, France.,Université Clermont Auvergne, Laboratoire Universitaire GReD, UMR/CNRS 6293, INSERM U1103, Clermont-Ferrand, F-63003, France
| | - Benjamin Rieu
- Departement de Médecine Périopératoire (MPO), Hôpital Estaing, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 place Lucie Aubrac, Clermont-Ferrand, F-63003, France
| | - Bruno Pereira
- Délégation à la Recherche Clinique et à l'Innovation (DRCI), Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Clermont-Ferrand, F-63000, France
| | - Jean-Marc Garcier
- Département de Radiologie, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, Clermont-Ferrand, F-63003, France
| | - Emmanuel Futier
- Departement de Médecine Périopératoire (MPO), Hôpital Estaing, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 place Lucie Aubrac, Clermont-Ferrand, F-63003, France.,Université Clermont Auvergne, Laboratoire Universitaire GReD, UMR/CNRS 6293, INSERM U1103, Clermont-Ferrand, F-63003, France
| | - Jean-Michel Constantin
- Departement de Médecine Périopératoire (MPO), Hôpital Estaing, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 1 place Lucie Aubrac, Clermont-Ferrand, F-63003, France. .,Université Clermont Auvergne, Laboratoire Universitaire GReD, UMR/CNRS 6293, INSERM U1103, Clermont-Ferrand, F-63003, France.
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Gattinoni L, Cressoni M, Chiumello D, Marini JJ. Transpulmonary Pressure Meaning: Babel or Conceptual Evolution? Am J Respir Crit Care Med 2017; 195:1404-1405. [PMID: 28504598 DOI: 10.1164/rccm.201612-2467le] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | - Davide Chiumello
- 2 Università degli Studi di Milano Milan, Italy.,3 Azienda Socio Sanitaria Territoriale Santi Paolo e Carlo Milan, Italy and
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35
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Esophageal pressure: research or clinical tool? Med Klin Intensivmed Notfmed 2017; 113:13-20. [PMID: 29134245 DOI: 10.1007/s00063-017-0372-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 10/09/2017] [Indexed: 10/18/2022]
Abstract
Esophageal manometry has traditionally been utilized for respiratory physiology research, but clinicians have recently found numerous applications within the intensive care unit. Esophageal pressure (PEs) is a surrogate for pleural pressures (PPl), and the difference between airway pressure (PAO) and PEs provides a good estimate for the pressure across the lung also known as the transpulmonary pressure (PL). Differentiating the effects of mechanical ventilation and spontaneous breathing on the respiratory system, chest wall, and across the lung allows for improved personalization in clinical decision making. Measuring PL in acute respiratory distress syndrome (ARDS) may help set positive end expiratory pressure (PEEP) to prevent derecruitment and atelectrauma, while assuring peak pressures do not cause over distension during tidal breathing and recruitment maneuvers. Monitoring PEs allows improved insight into patient-ventilator interactions and may help in decisions to adjust sedation and paralytics to correct dyssynchrony. Intrinsic PEEP (auto-PEEP) may be monitored using esophageal manometry, which may also improve patient comfort and synchrony with the ventilator. Finally, during weaning, PEs may be used to better predict weaning success and allow for rapid intervention during failure. Improved consistency in definition and terminology and further outcomes research is needed to encourage more widespread adoption; however, with clear clinical benefit and increased ease of use, it appears time to reintroduce basic physiology into personalized ventilator management in the intensive care unit.
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Hotz JC, Sodetani CT, Van Steenbergen J, Khemani RG, Deakers TW, Newth CJ. Measurements Obtained From Esophageal Balloon Catheters Are Affected by the Esophageal Balloon Filling Volume in Children With ARDS. Respir Care 2017; 63:177-186. [PMID: 29089460 DOI: 10.4187/respcare.05685] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Esophageal balloon inflation volume may affect the accuracy of transpulmo-nary pressure estimates in adults, but the effect is unknown in pediatrics. Using a combination bench and human study, we sought to determine a range of optimal filling volumes for esophageal balloon catheters and to derive a technique to inflate catheters to yield the most accurate estimates of pleural pressure. METHODS In the laboratory study, we evaluated 4 pediatric and adult esophageal balloon catheters, a liquid-filled catheter, and a micro-tip catheter, both with and without a model esophagus. We compared the measured esophageal pressure for each type of catheter within a pressurized chamber. Esophageal balloon catheters were also tested by manipulating the esophageal balloon inflation volume, and we attempted to derive a filling-volume technique that would assure accuracy. We then tested the feasibility of this technique in 5 mechanically ventilated pediatric subjects with ARDS. RESULTS In the laboratory study, smaller inflation volumes underestimated the chamber pressure at higher chamber pressures, and larger inflation volumes overestimated the chamber pressure at lower chamber pressures. Using an optimal filling-volume technique resulted in a mean total error that ranged from -0.53 to -0.10 cm H2O. The optimal filling-volume values for the pediatric catheters were 0.2-0.6 mL, and 0.4-0.8 mL for the adult catheters. When correctly positioned and calibrated, the micro-tip transducer and liquid-filled catheters were within ± 1 cm H2O of chamber pressure for all ranges of pressure. In the clinical study, high variability in measured esophageal pressure and subsequent transpulmonary pressure during exhalation and during inhalation was observed within the manufacturer's recommended esophageal balloon inflation ranges. CONCLUSIONS Manufacturer-recommended esophageal balloon inflation ranges do not assure accuracy. Individual titration of esophageal balloon volume may improve accuracy. Better esophageal catheters are needed to provide reliable esophageal pressure measurements in children.
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Affiliation(s)
- Justin C Hotz
- Department of Respiratory Care, Children's Hospital Los Angeles, CA. .,Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, CA
| | - Cary T Sodetani
- Department of Respiratory Care, Children's Hospital Los Angeles, CA
| | | | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, CA.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
| | - Timothy W Deakers
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, CA.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
| | - Christopher J Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, CA.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles
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Abstract
The main goals of assessing respiratory system mechanical function are to evaluate the lung function through a variety of methods and to detect early signs of abnormalities that could affect the patient's outcomes. In ventilated patients, it has become increasingly important to recognize whether respiratory function has improved or deteriorated, whether the ventilator settings match the patient's demand, and whether the selection of ventilator parameters follows a lung-protective strategy. Ventilator graphics, esophageal pressure, intra-abdominal pressure, and electric impedance tomography are some of the best-known monitoring tools to obtain measurements and adequately evaluate the respiratory system mechanical function.
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38
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Ten tips to facilitate understanding and clinical use of esophageal pressure manometry. Intensive Care Med 2017; 44:220-222. [PMID: 28842719 DOI: 10.1007/s00134-017-4906-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 08/09/2017] [Indexed: 10/19/2022]
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Loring SH, Topulos GP, Hubmayr RD. Transpulmonary Pressure: The Importance of Precise Definitions and Limiting Assumptions. Am J Respir Crit Care Med 2017; 194:1452-1457. [PMID: 27606837 DOI: 10.1164/rccm.201512-2448cp] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Recent studies applying the principles of respiratory mechanics to respiratory disease have used inconsistent and mutually exclusive definitions of the term "transpulmonary pressure." By the traditional definition, transpulmonary pressure is the pressure across the whole lung, including the intrapulmonary airways, (i.e., the pressure difference between the opening to the pulmonary airway and the pleural surface). However, more recently transpulmonary pressure has also been defined as the pressure across only the lung tissue (i.e., the pressure difference between the alveolar space and the pleural surface), traditionally known as the "elastic recoil pressure of the lung." Multiple definitions of the same term, and failure to recognize their underlying assumptions, have led to different interpretations of lung physiology and conclusions about appropriate therapy for patients. It is our view that many current controversies in the physiological interpretation of disease are caused by the lack of consistency in the definitions of these common physiological terms. In this article, we discuss the historical uses of these terms and recent misconceptions that may have resulted when these terms were confused. These misconceptions include assertions that normal pleural pressure must be negative (subatmospheric) and that a pressure in the pleural space may not be substantially positive when a subject is relaxed with an open airway. We urge specificity and uniformity when using physiological terms to define the physical state of the lungs, the chest wall, and the integrated respiratory system.
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Affiliation(s)
- Stephen H Loring
- 1 Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - George P Topulos
- 2 Department of Anesthesia, Perioperative and Pain Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts; and
| | - Rolf D Hubmayr
- 3 Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
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Grieco DL, Chen L, Brochard L. Transpulmonary pressure: importance and limits. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:285. [PMID: 28828360 DOI: 10.21037/atm.2017.07.22] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Transpulmonary pressure (PL) is computed as the difference between airway pressure and pleural pressure and separates the pressure delivered to the lung from the one acting on chest wall and abdomen. Pleural pressure is measured as esophageal pressure (PES) through dedicated catheters provided with esophageal balloons. We discuss the role of PL in assessing the effects of mechanical ventilation in patients with acute respiratory distress syndrome (ARDS). In the supine position, directly measured PL represents the pressure acting on the alveoli and airways. Because there is a pressure gradient in the pleural space from the non-dependent to the dependent zones, the pressure in the esophagus probably represents the pressure at a mid-level between sternal and vertebral regions. For this reason, it has been proposed to set the end-expiratory pressure in order to get a positive value of PL. This improves oxygenation and compliance. PL can also be estimated from airway pressure plateau and the ratio of lung to respiratory elastance (elastance-derived method). Some data suggest that this latter calculation may better estimate PL in the nondependent lung zones, at risk for hyperinflation. Elastance-derived PL at end-inspiration (PLend-insp) may be a good surrogate of end-inspiratory lung stress for the "baby lung", at least in non-obese patients. Limiting end-inspiratory PL to 20-25 cmH2O appears physiologically sound to mitigate ventilator-induced lung injury (VILI). Last, lung driving pressure (∆PL) reflects the tidal distending pressure. Changes in PL may also be assessed during assisted breathing to take into account the additive effects of spontaneous breathing and mechanical breaths on lung distension. In summary, despite limitations, assessment of PL allows a deeper understanding of the risk of VILI and may potentially help tailor ventilator settings.
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Affiliation(s)
- Domenico Luca Grieco
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Research Centre and Li Ka Shing Institute, Department of Critical Care, St Michael's Hospital, Toronto, Canada.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, "A. Gemelli" University Hospital, Rome, Italy
| | - Lu Chen
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Research Centre and Li Ka Shing Institute, Department of Critical Care, St Michael's Hospital, Toronto, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Research Centre and Li Ka Shing Institute, Department of Critical Care, St Michael's Hospital, Toronto, Canada
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Loring SH, Topulos GP, Hubmayr RD. Reply: Transpulmonary Pressure Meaning: Babel or Conceptual Evolution? Am J Respir Crit Care Med 2017; 195:1405-1406. [DOI: 10.1164/rccm.201701-0028le] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Stephen H. Loring
- Beth Israel Deaconess Medical CenterBoston, Massachusetts
- Harvard Medical SchoolBoston, Massachusetts
| | - George P. Topulos
- Brigham and Women’s HospitalBoston, Massachusetts
- Harvard Medical SchoolBoston, Massachusetts
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Current Concepts of ARDS: A Narrative Review. Int J Mol Sci 2016; 18:ijms18010064. [PMID: 28036088 PMCID: PMC5297699 DOI: 10.3390/ijms18010064] [Citation(s) in RCA: 85] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Revised: 12/18/2016] [Accepted: 12/23/2016] [Indexed: 01/20/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by the acute onset of pulmonary edema of non-cardiogenic origin, along with bilateral pulmonary infiltrates and reduction in respiratory system compliance. The hallmark of the syndrome is refractory hypoxemia. Despite its first description dates back in the late 1970s, a new definition has recently been proposed. However, the definition remains based on clinical characteristic. In the present review, the diagnostic workup and the pathophysiology of the syndrome will be presented. Therapeutic approaches to ARDS, including lung protective ventilation, prone positioning, neuromuscular blockade, inhaled vasodilators, corticosteroids and recruitment manoeuvres will be reviewed. We will underline how a holistic framework of respiratory and hemodynamic support should be provided to patients with ARDS, aiming to ensure adequate gas exchange by promoting lung recruitment while minimizing the risk of ventilator-induced lung injury. To do so, lung recruitability should be considered, as well as the avoidance of lung overstress by monitoring transpulmonary pressure or airway driving pressure. In the most severe cases, neuromuscular blockade, prone positioning, and extra-corporeal life support (alone or in combination) should be taken into account.
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Guérin C, Papazian L, Reignier J, Ayzac L, Loundou A, Forel JM. Effect of driving pressure on mortality in ARDS patients during lung protective mechanical ventilation in two randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:384. [PMID: 27894328 PMCID: PMC5126997 DOI: 10.1186/s13054-016-1556-2] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/02/2016] [Indexed: 12/15/2022]
Abstract
Background Driving pressure (ΔPrs) across the respiratory system is suggested as the strongest predictor of hospital mortality in patients with acute respiratory distress syndrome (ARDS). We wonder whether this result is related to the range of tidal volume (VT). Therefore, we investigated ΔPrs in two trials in which strict lung-protective mechanical ventilation was applied in ARDS. Our working hypothesis was that ΔPrs is a risk factor for mortality just like compliance (Crs) or plateau pressure (Pplat,rs) of the respiratory system. Methods We performed secondary analysis of data from 787 ARDS patients enrolled in two independent randomized controlled trials evaluating distinct adjunctive techniques while they were ventilated as in the low VT arm of the ARDSnet trial. For this study, we used VT, positive end-expiratory pressure (PEEP), Pplat,rs, Crs, ΔPrs, and respiratory rate recorded 24 hours after randomization, and compared them between survivors and nonsurvivors at day 90. Patients were followed for 90 days after inclusion. Cox proportional hazard modeling was used for mortality at day 90. If colinearity between ΔPrs, Crs, and Pplat,rs was verified, specific Cox models were used for each of them. Results Both trials enrolled 805 patients of whom 787 had day-1 data available, and 533 of these survived. In the univariate analysis, ΔPrs averaged 13.7 ± 3.7 and 12.8 ± 3.7 cmH2O (P = 0.002) in nonsurvivors and survivors, respectively. Colinearity between ΔPrs, Crs and Pplat,rs, which was expected as these variables are mathematically coupled, was statistically significant. Hazard ratios from the Cox models for day-90 mortality were 1.05 (1.02–1.08) (P = 0.005), 1.05 (1.01–1.08) (P = 0.008) and 0.985 (0.972–0.985) (P = 0.029) for ΔPrs, Pplat,rs and Crs, respectively. PEEP and VT were not associated with death in any model. Conclusions When ventilating patients with low VT, ΔPrs is a risk factor for death in ARDS patients, as is Pplat,rs or Crs. As our data originated from trials from which most ARDS patients were excluded due to strict inclusion and exclusion criteria, these findings must be validated in independent observational studies in patients ventilated with a lung protective strategy. Trial registration Clinicaltrials.gov NCT00299650. Registered 6 March 2006 for the Acurasys trial. Clinicaltrials.gov NCT00527813. Registered 10 September 2007 for the Proseva trial. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1556-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Claude Guérin
- Réanimation Médicale Groupement Hospitalier Nord Hospices civils de Lyon, Lyon, France. .,Université de Lyon, 1 69100, Villeurbanne, France. .,Institut Mondor de Recherche Biomédicale, INSERM 955 Equipe 13, Créteil, France.
| | - Laurent Papazian
- Hôpitaux de Marseille Hôpital Nord Réanimation des Détresses Respiratoires et des Infections Sévères, Marseille, 13015, France.,Aix-Marseille University EA 3279 Research Unit Department of Public Health Medecine School University Marseille, Marseille, France.,URMITE UMR CNRS 7278, Marseille, 13005, France
| | | | - Louis Ayzac
- Centre de Coordination et de Lutte Contre les Infections Nosocomiales Sud-Est, Saint-Genis Laval, France
| | - Anderson Loundou
- Aix-Marseille University EA 3279 Research Unit Department of Public Health Medecine School University Marseille, Marseille, France
| | - Jean-Marie Forel
- Hôpitaux de Marseille Department of Research and Innovation Support Unit for clinical research and economic evaluation, Marseille, 13005, France
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The promises and problems of transpulmonary pressure measurements in acute respiratory distress syndrome. Curr Opin Crit Care 2016; 22:7-13. [PMID: 26627536 DOI: 10.1097/mcc.0000000000000268] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The optimal strategy for assessing and preventing ventilator-induced lung injury in the acute respiratory distress syndrome (ARDS) is controversial. Recent investigative efforts have focused on personalizing ventilator settings to individual respiratory mechanics. This review examines the strengths and weaknesses of using transpulmonary pressure measurements to guide ventilator management in ARDS. RECENT FINDINGS Recent clinical studies suggest that adjusting ventilator settings based on transpulmonary pressure measurements is feasible, may improve oxygenation, and reduce ventilator-induced lung injury. SUMMARY The measurement of transpulmonary pressure relies upon esophageal manometry, which requires the acceptance of several assumptions and potential errors. Notably, this includes the ability of localized esophageal pressures to represent global pleural pressure. Recent investigations demonstrated improved oxygenation in ARDS patients when positive end-expiratory pressure was adjusted to target specific end-inspiratory or end-expiratory transpulmonary pressures. However, there are different methods for estimating transpulmonary pressure and different goals for positive end-expiratory pressure titration among recent studies. More research is needed to refine techniques for the estimation and utilization of transpulmonary pressure to guide ventilator settings in ARDS patients.
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Cressoni M, Chiumello D. Transpulmonary pressure during high-frequency oscillation ventilation: Is it the culprit? Ann Intensive Care 2016; 6:86. [PMID: 27620876 PMCID: PMC5020035 DOI: 10.1186/s13613-016-0191-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 08/31/2016] [Indexed: 11/12/2022] Open
Affiliation(s)
- M Cressoni
- Dipartimento di Fisiopatologia Medico Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
| | - Davide Chiumello
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy. .,Dipartimento di Emergenza-Urgenza, ASST Santi Paolo e Carlo, Milan, Italy.
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Guervilly C, Forel JM, Hraiech S, Roch A, Talmor D, Papazian L. Effect of high-frequency oscillatory ventilation on esophageal and transpulmonary pressures in moderate-to-severe acute respiratory distress syndrome. Ann Intensive Care 2016; 6:84. [PMID: 27577052 PMCID: PMC5005229 DOI: 10.1186/s13613-016-0181-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 08/10/2016] [Indexed: 12/02/2022] Open
Abstract
Background High-frequency oscillatory ventilation (HFOV) has not been shown to be beneficial in the management of moderate-to-severe acute respiratory distress syndrome (ARDS). There is uncertainty about the actual pressure applied into the lung during HFOV. We therefore performed a study to compare the transpulmonary pressure (PL) during conventional mechanical ventilation (CMV) and different levels of mean airway pressure (mPaw) during HFOV. Methods This is a prospective randomized crossover study in a university teaching hospital. An esophageal balloon catheter was used to measure esophageal pressures (Pes) at end inspiration and end expiration and to calculate PL. Measurements were taken during ventilation with CMV (CMVpre) after which patients were switched to HFOV with three 1-h different levels of mPaw set at +5, +10 and +15 cm H2O above the mean airway pressure measured during CMV. Patients were thereafter switched back to CMV (CMVpost). Results Ten patients with moderate-to-severe ARDS were included. We demonstrated a linear increase in Pes and PL with the increase in mPaw during HFOV. Contrary to CMV, PL was always positive during HFOV whatever the level of mPaw applied but not associated with improvement in oxygenation. We found significant correlations between mPaw and Pes. Conclusion HFOV with high level of mPaw increases transpulmonary pressures without improvement in oxygenation.
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Affiliation(s)
- Christophe Guervilly
- Aix-Marseille Univ, APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Marseille, France.
| | - Jean-Marie Forel
- Aix-Marseille Univ, APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Marseille, France
| | - Sami Hraiech
- Aix-Marseille Univ, APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Marseille, France
| | - Antoine Roch
- Aix-Marseille Univ, APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Marseille, France.,Service d'Accueil des Urgences, APHM, Hôpital Nord, Marseille, France
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA, USA
| | - Laurent Papazian
- Aix-Marseille Univ, APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Marseille, France
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Formenti P, Umbrello M, Graf J, Adams AB, Dries DJ, Marini JJ. Reliability of transpulmonary pressure-time curve profile to identify tidal recruitment/hyperinflation in experimental unilateral pleural effusion. J Clin Monit Comput 2016; 31:783-791. [PMID: 27438965 DOI: 10.1007/s10877-016-9908-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 07/14/2016] [Indexed: 10/21/2022]
Abstract
The stress index (SI) is a parameter that characterizes the shape of the airway pressure-time profile (P/t). It indicates the slope progression of the curve, reflecting both lung and chest wall properties. The presence of pleural effusion alters the mechanical properties of the respiratory system decreasing transpulmonary pressure (Ptp). We investigated whether the SI computed using Ptp tracing would provide reliable insight into tidal recruitment/overdistention during the tidal cycle in the presence of unilateral effusion. Unilateral pleural effusion was simulated in anesthetized, mechanically ventilated pigs. Respiratory system mechanics and thoracic computed tomography (CT) were studied to assess P/t curve shape and changes in global lung aeration. SI derived from airway pressure (Paw) was compared with that calculated by Ptp under the same conditions. These results were themselves compared with quantitative CT analysis as a gold standard for tidal recruitment/hyperinflation. Despite marked changes in tidal recruitment, mean values of SI computed either from Paw or Ptp were remarkably insensitive to variations of PEEP or condition. After the instillation of effusion, SI indicates a preponderant over-distension effect, not detected by CT. After the increment in PEEP level, the extent of CT-determined tidal recruitment suggest a huge recruitment effect of PEEP as reflected by lung compliance. Both SI in this case were unaffected. We showed that the ability of SI to predict tidal recruitment and overdistension was significantly reduced in a model of altered chest wall-lung relationship, even if the parameter was computed from the Ptp curve profile.
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Affiliation(s)
- P Formenti
- Pulmonary Research Laboratory, Regions Hospital, St Paul, MN, USA. .,Dipartimento di Anestesiologia e Terapia Intensiva, Azienda Opsedaliera San Paolo - Polo Universitario, Univeristà degli Studi di Milano, Via A. Di Rudinì, 8, 20142, Milan, Italy.
| | - M Umbrello
- Dipartimento di Anestesiologia e Terapia Intensiva, Azienda Opsedaliera San Paolo - Polo Universitario, Univeristà degli Studi di Milano, Via A. Di Rudinì, 8, 20142, Milan, Italy
| | - J Graf
- Pulmonary Research Laboratory, Regions Hospital, St Paul, MN, USA.,Departamento de Paciente Critico, Clinica Alemana de Santiago, Facultad de Medicina Clinica Alemana, Universidad del Desarrollo, Vitacura, Santiago, Chile
| | - A B Adams
- Pulmonary Research Laboratory, Regions Hospital, St Paul, MN, USA
| | - D J Dries
- Department of Surgical Services, HealthPartners Medical Group, University of Minnesota, Minneapolis/St. Paul, MN, USA
| | - J J Marini
- Pulmonary Research Laboratory, Regions Hospital, St Paul, MN, USA
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How much esophageal pressure-guided end-expiratory transpulmonary pressure is sufficient to maintain lung recruitment in lavage-induced lung injury? J Trauma Acute Care Surg 2016; 80:302-7. [PMID: 26517781 DOI: 10.1097/ta.0000000000000900] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Because of limitations of the esophageal balloon technique, the value of using esophageal pressure (Pes)-guided end-expiratory transpulmonary pressure (PL-exp) to maintain lung recruitment in adult respiratory distress syndrome is controversial. This study aimed to investigate whether tailoring PL-exp to greater than 0 was enough to maintain lung recruitment. METHODS Ten pigs with severe lavage-induced lung injury were mechanically ventilated in a decremental positive end-expiratory pressure (PEEP) trial that was reduced from 20 to 6 cm H2O after full-lung recruitment. Respiratory mechanics, blood gases, hemodynamic data, and whole-lung computed tomography scans were recorded at each PEEP level. Open-lung PEEP (OL-PEEP) was determined by computed tomography, while Pes-guided PEEP (Pes-PEEP) was to maintain PL-exp greater than 0. RESULTS OL-PEEP was higher than Pes-PEEP, which induced a higher PL-exp at OL-PEEP than at Pes-PEEP (4.6 [1.6] cm H2O vs. 1.2 [0.6] cm H2O, p < 0.001). Compared with OL-PEEP, the nonaerated lung region was significantly increased at Pes-PEEP. Superimposed pressure (SP) of the lung tissue between the esophageal plane and the dorsal level was higher at Pes-PEEP than at OL-PEEP, whereas PL-exp at the dorsal level was lower at Pes-PEEP than at OL-PEEP (-1.5 [0.7] cm H2O vs. 2.5 [1.5] cm H2O, p < 0.001). The SP correlated with PL-exp at the dorsal level and the nonaerated lung region. CONCLUSION In this surfactant-depleted model, maintaining PL-exp just greater than 0 using Pes was unable to maintain lung recruitment; this was partly caused by a lack of compensation for the increased SP between the esophageal plane and the dorsal level.
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Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is characterized by a noncardiogenic pulmonary edema with bilateral chest X-ray opacities and reduction in lung compliance, and the hallmark of the syndrome is hypoxemia refractory to oxygen therapy. Severe hypoxemia (PaO2/FiO2 < 100 mmHg), which defines severe ARDS, can be found in 20-30 % of the patients and is associated with the highest mortality rate. Although the standard supportive treatment remains mechanical ventilation (noninvasive and invasive), possible adjuvant therapies can be considered. We performed an up-to-date clinical review of the possible available strategies for ARDS patients with severe hypoxemia. MAIN RESULTS In summary, in moderate-to-severe ARDS or in the presence of other organ failure, noninvasive ventilatory support presents a high risk of failure: in those cases the risk/benefit of delayed mechanical ventilation should be evaluated carefully. Tailoring mechanical ventilation to the individual patient is fundamental to reduce the risk of ventilation-induced lung injury (VILI): it is mandatory to apply a low tidal volume, while the optimal level of positive end-expiratory pressure should be selected after a stratification of the severity of the disease, also taking into account lung recruitability; monitoring transpulmonary pressure or airway driving pressure can help to avoid lung overstress. Targeting oxygenation of 88-92 % and tolerating a moderate level of hypercapnia are a safe choice. Neuromuscular blocking agents (NMBAs) are useful to maintain patient-ventilation synchrony in the first hours; prone positioning improves oxygenation in most cases and promotes a more homogeneous distribution of ventilation, reducing the risk of VILI; both treatments, also in combination, are associated with an improvement in outcome if applied in the acute phase in the most severe cases. The use of extracorporeal membrane oxygenation (ECMO) in severe ARDS is increasing worldwide, but because of a lack of randomized trials is still considered a rescue therapy. CONCLUSION Severe ARDS patients should receive a holistic framework of respiratory and hemodynamic support aimed to ensure adequate gas exchange while minimizing the risk of VILI, by promoting lung recruitment and setting protective mechanical ventilation. In the most severe cases, NMBAs, prone positioning, and ECMO should be considered.
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Affiliation(s)
- Davide Chiumello
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Via F. Sforza 35, Milan, Italy.
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy.
| | - Matteo Brioni
- Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
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Pulse Pressure Variations in Acute Respiratory Distress Syndrome: "Fifty Shades of Grey". Crit Care Med 2016; 44:452-3. [PMID: 26771794 DOI: 10.1097/ccm.0000000000001529] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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