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Georgopoulos D, Bolaki M, Stamatopoulou V, Akoumianaki E. Respiratory drive: a journey from health to disease. J Intensive Care 2024; 12:15. [PMID: 38650047 DOI: 10.1186/s40560-024-00731-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 04/12/2024] [Indexed: 04/25/2024] Open
Abstract
Respiratory drive is defined as the intensity of respiratory centers output during the breath and is primarily affected by cortical and chemical feedback mechanisms. During the involuntary act of breathing, chemical feedback, primarily mediated through CO2, is the main determinant of respiratory drive. Respiratory drive travels through neural pathways to respiratory muscles, which execute the breathing process and generate inspiratory flow (inspiratory flow-generation pathway). In a healthy state, inspiratory flow-generation pathway is intact, and thus respiratory drive is satisfied by the rate of volume increase, expressed by mean inspiratory flow, which in turn determines tidal volume. In this review, we will explain the pathophysiology of altered respiratory drive by analyzing the respiratory centers response to arterial partial pressure of CO2 (PaCO2) changes. Both high and low respiratory drive have been associated with several adverse effects in critically ill patients. Hence, it is crucial to understand what alters the respiratory drive. Changes in respiratory drive can be explained by simultaneously considering the (1) ventilatory demands, as dictated by respiratory centers activity to CO2 (brain curve); (2) actual ventilatory response to CO2 (ventilation curve); and (3) metabolic hyperbola. During critical illness, multiple mechanisms affect the brain and ventilation curves, as well as metabolic hyperbola, leading to considerable alterations in respiratory drive. In critically ill patients the inspiratory flow-generation pathway is invariably compromised at various levels. Consequently, mean inspiratory flow and tidal volume do not correspond to respiratory drive, and at a given PaCO2, the actual ventilation is less than ventilatory demands, creating a dissociation between brain and ventilation curves. Since the metabolic hyperbola is one of the two variables that determine PaCO2 (the other being the ventilation curve), its upward or downward movements increase or decrease respiratory drive, respectively. Mechanical ventilation indirectly influences respiratory drive by modifying PaCO2 levels through alterations in various parameters of the ventilation curve and metabolic hyperbola. Understanding the diverse factors that modulate respiratory drive at the bedside could enhance clinical assessment and the management of both the patient and the ventilator.
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Affiliation(s)
| | - Maria Bolaki
- Department of Intensive Care Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Vaia Stamatopoulou
- Department of Pulmonary Medicine, University Hospital of Heraklion, Heraklion , Crete, Greece
| | - Evangelia Akoumianaki
- Medical School, University of Crete, Heraklion, Crete, Greece
- Department of Intensive Care Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
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Muttini S, Jona Falco J, Cuevas Cairo I, Umbrello M. A High Respiratory Drive Is Associated with Weaning Failure in Patients with COVID-19-Associated Acute Respiratory Distress Syndrome: The Role of the Electrical Activity of the Diaphragm. J Clin Med 2024; 13:1120. [PMID: 38398433 PMCID: PMC10889278 DOI: 10.3390/jcm13041120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/01/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Mechanical ventilation is the main supportive treatment of severe cases of COVID-19-associated ARDS (C-ARDS). Weaning failure is common and associated with worse outcomes. We investigated the role of respiratory drive, assessed by monitoring the electrical activity of the diaphragm (EAdi), as a predictor of weaning failure. METHODS Consecutive, mechanically ventilated patients admitted to the ICU for C-ARDS with difficult weaning were enrolled. Blood gas, ventilator, and respiratory mechanic parameters, as well as EAdi, were recorded at the time of placement of EAdi catheter, and then after 1, 2, 3, 7, and 10 days, and compared between patients with weaning success and weaning failure. RESULTS Twenty patients were enrolled: age 66 (60-69); 85% males; PaO2/FiO2 at admission 148 (126-177) mmHg. Thirteen subjects (65%) were classified as having a successful weaning. A younger age (OR(95%CI): 0.02 (0.01-0.11) per year), a higher PaO2/FiO2 ratio (OR(95%CI): 1.10 (1.01-1.21) per mmHg), and a lower EAdi (OR(95%CI): 0.16 (0.08-0.34) per μV) were associated with weaning success. CONCLUSION In critically ill patients with moderate-severe C-ARDS and difficult weaning from mechanical ventilation, a successful weaning was associated with a lower age, a higher oxygenation, and a lower respiratory drive, as assessed at the bedside via EAdi monitoring.
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Affiliation(s)
- Stefano Muttini
- Neuroscience Intensive Care Unit, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, 20151 Milano, Italy; (S.M.); (J.J.F.)
| | - Jacopo Jona Falco
- Neuroscience Intensive Care Unit, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, 20151 Milano, Italy; (S.M.); (J.J.F.)
| | - Ilmari Cuevas Cairo
- Department of Anaesthesia and Intensive Care Unit, San Carlo Borromeo Hospital, ASST Santi Paolo e Carlo, 20151 Milano, Italy;
| | - Michele Umbrello
- Department of Intensive care and Anaesthesia, Ospedale Civile di Legnano, ASST Ovest Milanese, 20025 Legnano, Italy
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Wang WZ, Ying LJ, Liu WD, Zhang P, Li SF. Findings of ventilator-measured P0.1 in assessing respiratory drive in patients with severe ARDS. Technol Health Care 2024; 32:719-726. [PMID: 37393453 DOI: 10.3233/thc-230096] [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: 07/03/2023]
Abstract
BACKGROUND Providers should adjust the depth of sedation to promote lung-protective ventilation in patients with severe ARDS. This recommendation was based on the assumption that the depth of sedation could be used to assess respiratory drive. OBJECTIVE To assess the association between respiratory drive and sedation in patients with severe ARDS by using ventilator-measured P0.1 and RASS score. METHODS Loss of spontaneous breathing was observed within 48 h of mechanical ventilation in patients with severe ARDS, and spontaneous breathing returned after 48 hours. P0.1 was measured by ventilator every 12 ± 2 hours, and the RASS score was measured synchronously. RESULTS The RASS score was moderately correlated with P0.1 (R𝑆𝑝𝑒𝑎𝑟𝑚𝑎𝑛, 0.570; 95% CI, 0.475 to 0.637; p= 0.00). However, only patients with a RASS score of -5 were considered to have no excessive respiratory drive, but there was a risk for loss of spontaneous breathing. A P0.1 exceeding 3.5 cm H2O in patients with other RASS scores indicated an increase in respiratory drive. CONCLUSION RASS score has little clinical significance in evaluating respiratory drive in severe ARDS. P0.1 should be evaluated by ventilator when adjusting the depth of sedation to promote lung-protective ventilation.
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Lin L, Wang P, Zheng H, Zhong Z, Zhuansun Y, Yang Z, Chen R. RESPIRATORY MECHANICS AND NEURAL RESPIRATORY DRIVE OF UNTREATED GASPING DURING CARDIAC ARREST IN A PORCINE MODEL. Shock 2023; 59:948-954. [PMID: 37018832 DOI: 10.1097/shk.0000000000002127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
ABSTRACT Introduction: Although the effects on hemodynamics of gasping during cardiac arrest (CA) have received a lot of attention, less is known about the respiratory mechanics and physiology of respiration in gasping. This study aimed to investigate the respiratory mechanics and neural respiratory drive of gasping during CA in a porcine model. Method: Pigs weighing 34.9 ± 5.7 kg were anesthetized intravenously. Ventricular fibrillation (VF) was electrically induced and untreated for 10 min. Mechanical ventilation (MV) was ceased immediately after the onset of VF. Hemodynamic and respiratory parameters, pressure signals, diaphragmatic electromyogram data, and blood gas analysis data were recorded. Results: Gasping was observed in all the animals at a significantly lower rate (2-5 gaps/min), with higher tidal volume ( VT ; 0.62 ± 0.19 L, P < 0.01), and with lower expired minute volume (2.51 ± 1.49 L/min, P < 0.001) in comparison with the baseline. The total respiratory cycle time and the expiratory time tended to be lengthened. Statistically significant elevations in transdiaphragmatic pressure, the pressure-time product of diaphragmatic pressure, and the mean of root mean square diaphragmatic electromyogram values (RMSmean) were observed ( P < 0.05, P < 0.05, and P < 0.001, respectively); however, VT /RMSmean and transdiaphragmatic pressure/RMSmean were reduced at all time points. The partial pressure of oxygen showed a continuous decline after VF to reach statistical significance in the 10th minute (9.46 ± 0.96 kPa, P < 0.001), whereas the partial pressure of carbon dioxide tended to first rise and then fall. Conclusions: Gasping during CA was characterized by high VT , extremely low frequency, and prolonged expiratory time, which may improve hypercapnia. During gasping, increased work of breathing and insufficient neuromechanical efficacy of neural respiratory drive suggested the necessity of MV and appropriate management strategies for MV during resuscitation after CA.
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Affiliation(s)
- Lin Lin
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou
| | - Pengfei Wang
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou
| | | | - Zheye Zhong
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou
| | - Yongxun Zhuansun
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou
| | - Zhengfei Yang
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou
| | - Rui Chen
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou
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Shimatani T, Kyogoku M, Ito Y, Takeuchi M, Khemani RG. Fundamental concepts and the latest evidence for esophageal pressure monitoring. J Intensive Care 2023; 11:22. [PMID: 37217973 DOI: 10.1186/s40560-023-00671-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 05/16/2023] [Indexed: 05/24/2023] Open
Abstract
Transpulmonary pressure is an essential physiologic concept as it reflects the true pressure across the alveoli, and is a more precise marker for lung stress. To calculate transpulmonary pressure, one needs an estimate of both alveolar pressure and pleural pressure. Airway pressure during conditions of no flow is the most widely accepted surrogate for alveolar pressure, while esophageal pressure remains the most widely measured surrogate marker for pleural pressure. This review will cover important concepts and clinical applications for esophageal manometry, with a particular focus on how to use the information from esophageal manometry to adjust or titrate ventilator support. The most widely used method for measuring esophageal pressure uses an esophageal balloon catheter, although these measurements can be affected by the volume of air in the balloon. Therefore, when using balloon catheters, it is important to calibrate the balloon to ensure the most appropriate volume of air, and we discuss several methods which have been proposed for balloon calibration. In addition, esophageal balloon catheters only estimate the pleural pressure over a certain area within the thoracic cavity, which has resulted in a debate regarding how to interpret these measurements. We discuss both direct and elastance-based methods to estimate transpulmonary pressure, and how they may be applied for clinical practice. Finally, we discuss a number of applications for esophageal manometry and review many of the clinical studies published to date which have used esophageal pressure. These include the use of esophageal pressure to assess lung and chest wall compliance individually which can provide individualized information for patients with acute respiratory failure in terms of setting PEEP, or limiting inspiratory pressure. In addition, esophageal pressure has been used to estimate effort of breathing which has application for ventilator weaning, detection of upper airway obstruction after extubation, and detection of patient and mechanical ventilator asynchrony.
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Affiliation(s)
- Tatsutoshi Shimatani
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima-shi, Hiroshima, Japan.
- Department of Critical Care Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Miyako Kyogoku
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Osaka, Izumi, Japan
- Department of Critical Care Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yukie Ito
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Osaka, Izumi, Japan
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Osaka, Izumi, Japan
- Department of Critical Care Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Robinder G Khemani
- Pediatric ICU, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd., CA, Los Angeles, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, 1975, USA
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Rodrigues A, Telias I, Damiani LF, Brochard L. Reverse Triggering during Controlled Ventilation: From Physiology to Clinical Management. Am J Respir Crit Care Med 2023; 207:533-543. [PMID: 36470240 DOI: 10.1164/rccm.202208-1477ci] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Reverse triggering dyssynchrony is a frequent phenomenon recently recognized in sedated critically ill patients under controlled ventilation. It occurs in at least 30-55% of these patients and often occurs in the transition from fully passive to assisted mechanical ventilation. During reverse triggering, patient inspiratory efforts start after the passive insufflation by mechanical breaths. The most often referred mechanism is the entrainment of the patient's intrinsic respiratory rhythm from the brainstem respiratory centers to periodic mechanical insufflations from the ventilator. However, reverse triggering might also occur because of local reflexes without involving the respiratory rhythm generator in the brainstem. Reverse triggering is observed during the acute phase of the disease, when patients may be susceptible to potential deleterious consequences of injurious or asynchronous efforts. Diagnosing reverse triggering might be challenging and can easily be missed. Inspection of ventilator waveforms or more sophisticated methods, such as the electrical activity of the diaphragm or esophageal pressure, can be used for diagnosis. The occurrence of reverse triggering might have clinical consequences. On the basis of physiological data, reverse triggering might be beneficial or injurious for the diaphragm and the lung, depending on the magnitude of the inspiratory effort. Reverse triggering can cause breath-stacking and loss of protective lung ventilation when triggering a second cycle. Little is known about how to manage patients with reverse triggering; however, available evidence can guide management on the basis of physiological principles.
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Affiliation(s)
- Antenor Rodrigues
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - Irene Telias
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada; and
| | - L Felipe Damiani
- Departamento Ciencias de la Salud, Carrera de Kinesiología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Laurent Brochard
- Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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Zhang H, Liu Z, Shu H, Yu Y, Yang X, Li R, Xu J, Zou X, Shang Y. Prone positioning in ARDS patients supported with VV ECMO, what we should explore? J Intensive Care 2022; 10:46. [PMID: 36195935 PMCID: PMC9531855 DOI: 10.1186/s40560-022-00640-5] [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: 07/20/2022] [Accepted: 09/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background Acute respiratory distress syndrome (ARDS), a prevalent cause of admittance to intensive care units, is associated with high mortality. Prone positioning has been proven to improve the outcomes of moderate to severe ARDS patients owing to its physiological effects. Venovenous extracorporeal membrane oxygenation (VV ECMO) will be considered in patients with severe hypoxemia. However, for patients with severe hypoxemia supported with VV ECMO, the potential effects and optimal strategies of prone positioning remain unclear. This review aimed to present these controversial questions and highlight directions for future research. Main body The clinically significant benefit of prone positioning and early VV ECMO alone was confirmed in patients with severe ARDS. However, a number of questions regarding the combination of VV ECMO and prone positioning remain unanswered. We discussed the potential effects of prone positioning on gas exchange, respiratory mechanics, hemodynamics, and outcomes. Strategies to achieve optimal outcomes, including indications, timing, duration, and frequency of prone positioning, as well as the management of respiratory drive during prone positioning sessions in ARDS patients receiving VV ECMO, are challenging and controversial. Additionally, whether and how to implement prone positioning according to ARDS phenotypes should be evaluated. Lung morphology monitored by computed tomography, lung ultrasound, or electrical impedance tomography might be a potential indication to make an individualized plan for prone positioning therapy in patients supported with VV ECMO. Conclusion For patients with ARDS supported with VV ECMO, the potential effects of prone positioning have yet to be clarified. Ensuring an optimal strategy, especially an individualized plan for prone positioning therapy during VV ECMO, is particularly challenging and requires further research.
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Affiliation(s)
- Hongling Zhang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.,Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, 237000, China
| | - Zhengdong Liu
- Department of Intensive Care Unit, Affiliated Lu'an Hospital, Anhui Medical University, Lu'an, 237000, China
| | - Huaqing Shu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yuan Yu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiaobo Yang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Ruiting Li
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jiqian Xu
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Xiaojing Zou
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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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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9
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Survival Prediction in Patients with Hypertensive Chronic Kidney Disease in Intensive Care Unit: A Retrospective Analysis Based on the MIMIC-III Database. J Immunol Res 2022; 2022:3377030. [PMID: 35600047 PMCID: PMC9119756 DOI: 10.1155/2022/3377030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/26/2022] [Indexed: 11/30/2022] Open
Abstract
Objective Disease prediction is crucial to treatment success. The aim of this study was to accurately and explicably predict, based on the first laboratory measurements, medications, and demographic information, the risk of death in patients with hypertensive chronic kidney disease within 1 and 3 years after admission to the Intensive Care Unit (ICU). Methods Patients with hypertensive chronic kidney disease who had been registered in the Medical Information Mart for Intensive Care (MIMIC-III) database of critical care medicine were set as the subject of study, which was randomly divided into a training set and a validation set in a ratio of 7 : 3. Univariate Cox regression analysis and stepwise Cox regression analysis were applied in the training set to identify the predictive factors of prognosis of patients with hypertensive chronic kidney disease in ICU, and the predictive nomogram based on Cox regression model was constructed. We internally validated the model in the training set and externally validated that in the validation model. The efficacy was assessed primarily through area under the receiver operating characteristic (ROC) curve, clinical decision curves, and calibration curves. Results A total of 1762 patients with hypertensive chronic kidney disease were finally included. During the 3-year follow-up, 667 patients (37.85%) died, with a median follow-up time of 220 days (1-1090). The data set were randomly divided into a training set (n = 1231) and a validation set (n = 531). It was identified in the training set that insurance, albumin, alkaline phosphatase, the mean corpuscular hemoglobin concentration, mean corpuscular volume, history of coronary angiogram, hyperlipemia, medication of digoxin, acute renal failure, and history of renal surgery were the most relevant features. Taking 1 year and 3 years as the cut-off points, the AUC of participants were 0.736 and 0.744, respectively, in the internal validation and were 0.775 and 0.769, respectively, in the external validation, suggesting that the model is of favorable predictive efficacy. Conclusion We trained and validated a model using data from a large multicenter cohort, which has considerable predictive performance on an individual scale and could be used to improve treatment strategies.
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Ríos-Castro F, González-Seguel F, Molina J. Respiratory drive, inspiratory effort, and work of breathing: review of definitions and non-invasive monitoring tools for intensive care ventilators during pandemic times. Medwave 2022; 22:e8724. [DOI: 10.5867/medwave.2022.03.002550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 04/28/2022] [Indexed: 11/27/2022] Open
Abstract
Technological advances in mechanical ventilation have been essential to increasing the survival rate in intensive care units. Usually, patients needing mechanical ventilation use controlled ventilation to override the patient’s respiratory muscles and favor lung protection. Weaning from mechanical ventilation implies a transition towards spontaneous breathing, mainly using assisted mechanical ventilation. In this transition, the challenge for clinicians is to avoid under and over assistance and minimize excessive respiratory effort and iatrogenic diaphragmatic and lung damage. Esophageal balloon monitoring allows objective measurements of respiratory muscle activity in real time, but there are still limitations to its routine application in intensive care unit patients using mechanical ventilation. Like the esophageal balloon, respiratory muscle electromyography and diaphragmatic ultrasound are minimally invasive tools requiring specific training that monitor respiratory muscle activity. Particularly during the coronavirus disease pandemic, non invasive tools available on mechanical ventilators to monitor respiratory drive, inspiratory effort, and work of breathing have been extended to individualize mechanical ventilation based on patient’s needs. This review aims to identify the conceptual definitions of respiratory drive, inspiratory effort, and work of breathing and to identify non invasive maneuvers available on intensive care ventilators to measure these parameters. The literature highlights that although respiratory drive, inspiratory effort, and work of breathing are intuitive concepts, even distinguished authors disagree on their definitions.
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Beretta E, Romanò F, Sancini G, Grotberg JB, Nieman GF, Miserocchi G. Pulmonary Interstitial Matrix and Lung Fluid Balance From Normal to the Acutely Injured Lung. Front Physiol 2021; 12:781874. [PMID: 34987415 PMCID: PMC8720972 DOI: 10.3389/fphys.2021.781874] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 11/02/2021] [Indexed: 01/17/2023] Open
Abstract
This review analyses the mechanisms by which lung fluid balance is strictly controlled in the air-blood barrier (ABB). Relatively large trans-endothelial and trans-epithelial Starling pressure gradients result in a minimal flow across the ABB thanks to low microvascular permeability aided by the macromolecular structure of the interstitial matrix. These edema safety factors are lost when the integrity of the interstitial matrix is damaged. The result is that small Starling pressure gradients, acting on a progressively expanding alveolar barrier with high permeability, generate a high transvascular flow that causes alveolar flooding in minutes. We modeled the trans-endothelial and trans-epithelial Starling pressure gradients under control conditions, as well as under increasing alveolar pressure (Palv) conditions of up to 25 cmH2O. We referred to the wet-to-dry weight (W/D) ratio, a specific index of lung water balance, to be correlated with the functional state of the interstitial structure. W/D averages ∼5 in control and might increase by up to ∼9 in severe edema, corresponding to ∼70% loss in the integrity of the native matrix. Factors buffering edemagenic conditions include: (i) an interstitial capacity for fluid accumulation located in the thick portion of ABB, (ii) the increase in interstitial pressure due to water binding by hyaluronan (the "safety factor" opposing the filtration gradient), and (iii) increased lymphatic flow. Inflammatory factors causing lung tissue damage include those of bacterial/viral and those of sterile nature. Production of reactive oxygen species (ROS) during hypoxia or hyperoxia, or excessive parenchymal stress/strain [lung overdistension caused by patient self-induced lung injury (P-SILI)] can all cause excessive inflammation. We discuss the heterogeneity of intrapulmonary distribution of W/D ratios. A W/D ∼6.5 has been identified as being critical for the transition to severe edema formation. Increasing Palv for W/D > 6.5, both trans-endothelial and trans-epithelial gradients favor filtration leading to alveolar flooding. Neither CT scan nor ultrasound can identify this initial level of lung fluid balance perturbation. A suggestion is put forward to identify a non-invasive tool to detect the earliest stages of perturbation of lung fluid balance before the condition becomes life-threatening.
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Affiliation(s)
- Egidio Beretta
- Department of Medicine and Surgery, School of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - Francesco Romanò
- Univ. Lille, CNRS, ONERA, Arts et Métiers, Centrale Lille, FRE 2017-LMFL-Laboratoire de Mécanique des Fluides de Lille – Kampé de Fériet, Lille, France
| | - Giulio Sancini
- Department of Medicine and Surgery, School of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Monza, Italy
| | - James B. Grotberg
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, United States
| | - Gary F. Nieman
- Department of Surgery, State University of New York Upstate Medical University, Syracuse, NY, United States
| | - Giuseppe Miserocchi
- Department of Medicine and Surgery, School of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Monza, Italy
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Wang SY, Liang HW, Lu GS, Jiang ZJ, Zhang BZ, Deng QX, Sun QW, Lin ZM, Chen Q, Yang C, Xu YD, Sang L. Effect of sequential high-flow nasal cannula oxygen therapy and non-invasive positive-pressure ventilation in patients with difficult weaning from mechanical ventilation after extubation on respiratory mechanics. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1251. [PMID: 34532388 PMCID: PMC8421953 DOI: 10.21037/atm-21-3408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/05/2021] [Indexed: 11/25/2022]
Abstract
Background Patients with difficult weaning who undergo mechanical ventilation are more likely to be at risk of reintubation and the sequential use of oxygen therapy after extubation is a concern for clinicians. Therefore, the aim of the present study was to compare the effects of transnasal high-flow nasal cannula (HFNC) oxygen therapy and non-invasive positive-pressure ventilation (NIV) on respiratory mechanics in patients with difficult weaning. Methods The present study was a single-center, retrospective, observational study. Twenty-nine patients with difficult weaning off invasive mechanical ventilation from the Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, from December 2018 to April 2021, were included. Within 48 h after extubation, alternate respiratory support with HFNC and NIV was provided. Relevant indicators were recorded after each support mode had been maintained for at least 60 min. These included esophageal pressure (Pes), gastric pressure (Pga), transdiaphragmatic pressure (Pdi), pressure-time product of Pes (PTPes), pressure-time product of Pga (PTPga), pressure-time product of Pdi (PTPdi), ratio of the PTPdi to the PTPes (PTPdi/PTPes), and ratio of the Pes to the Pdi (Pes/Pdi), diaphragmatic electromyogram (EMGdi), percentage of esophageal pressure coefficient of variation (CVes%),diaphragmatic electromyogram coefficient of variation (CVEMG),inspiratory time (Ti), expiratory time (Te) and respiratory cycle time (Ttot). Results Of the 29 patients included, 22 were males and 7 were females [age: 63.97±15.34 years, Acute Physiological and Chronic Health Estimation II (APACHE II) score: 18.00±5.63]. The CVes% and the Pes/Pdi were significantly higher in patients with NIV than HFNC using 40 L/min, CVes%: 9 (−6, 20) vs. −7 (−23, 6) and Pes/Pdi: 0.17 (−0.1, 0.53), vs. −0.12 (−0.43, 0.08) (P<0.05). The remaining indicators were not statistically different. Conclusions The sequential NIV and HFNC can be tolerated in patients with such difficult weaning off mechanical ventilation after extubation, and more patients tend to choose HFNC subjectively. Compared with HFNC, NIV reduces the work of adjunctive respiratory muscle, but the patient’s Pes dispersion is high when NIV is used, and it is necessary to pay attention to patient–ventilator coordination in clinical practice. We recommend alternating HFNC and NIV during the sequential respiratory therapy after extubation.
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Affiliation(s)
- Shi-Ya Wang
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Han-Wen Liang
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Guang-Sheng Lu
- Department of Critical Care Medicine, First People's Hospital of Zhaoqing, Zhaoqing, China
| | - Zhen-Jie Jiang
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Bao-Zhu Zhang
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qiu-Xue Deng
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Qing-Wen Sun
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zhi-Min Lin
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Guangzhou Laboratory, Guangzhou, China
| | - Qiang Chen
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Chun Yang
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yuan-Da Xu
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Guangzhou Laboratory, Guangzhou, China
| | - Ling Sang
- National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China.,Guangzhou Laboratory, Guangzhou, China
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13
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Albaiceta GM, Brochard L, Dos Santos CC, Fernández R, Georgopoulos D, Girard T, Jubran A, López-Aguilar J, Mancebo J, Pelosi P, Skrobik Y, Thille AW, Wilcox ME, Blanch L. The central nervous system during lung injury and mechanical ventilation: a narrative review. Br J Anaesth 2021; 127:648-659. [PMID: 34340836 DOI: 10.1016/j.bja.2021.05.038] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/03/2021] [Accepted: 05/24/2021] [Indexed: 11/26/2022] Open
Abstract
Mechanical ventilation induces a number of systemic responses for which the brain plays an essential role. During the last decade, substantial evidence has emerged showing that the brain modifies pulmonary responses to physical and biological stimuli by various mechanisms, including the modulation of neuroinflammatory reflexes and the onset of abnormal breathing patterns. Afferent signals and circulating factors from injured peripheral tissues, including the lung, can induce neuronal reprogramming, potentially contributing to neurocognitive dysfunction and psychological alterations seen in critically ill patients. These impairments are ubiquitous in the presence of positive pressure ventilation. This narrative review summarises current evidence of lung-brain crosstalk in patients receiving mechanical ventilation and describes the clinical implications of this crosstalk. Further, it proposes directions for future research ranging from identifying mechanisms of multiorgan failure to mitigating long-term sequelae after critical illness.
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Affiliation(s)
- Guillermo M Albaiceta
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Oviedo, Spain; Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain; Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Claudia C Dos Santos
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Rafael Fernández
- Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Critical Care Department, Althaia Xarxa Assistencial Universitaria de Manresa, Universitat Internacional de Catalunya, Manresa, Spain
| | - Dimitris Georgopoulos
- Intensive Care Medicine Department, University Hospital of Heraklion, School of Medicine, University of Crete, Heraklion, Crete, Greece
| | - Timothy Girard
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Amal Jubran
- Division of Pulmonary and Critical Care Medicine, Hines VA Hospital, Hines, IL, USA; Loyola University of Chicago, Stritch School of Medicine, Maywood, IL, USA
| | - Josefina López-Aguilar
- Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Jordi Mancebo
- Servei Medicina Intensiva, University Hospital Sant Pau, Barcelona, Spain
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Yoanna Skrobik
- Department of Medicine, McGill University, Regroupement de Soins Critiques Respiratoires, Réseau de Soins Respiratoires FRQS, Montreal, QC, Canada
| | - Arnaud W Thille
- CHU de Poitiers, Médecine Intensive Réanimation, Poitiers, France; INSERM CIC 1402 ALIVE, Université de Poitiers, Poitiers, France
| | - Mary E Wilcox
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Division of Respirology (Critical Care Medicine), University Health Network, Toronto, ON, Canada
| | - Lluis Blanch
- Centro de Investigación Biomédica en Red-Enfermedades Respiratorias (CIBER)-Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain; Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
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14
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Neuromuscular Blockers in Acute Respiratory Distress Syndrome: Flat Dose or Not. Are We Missing the Point? Crit Care Med 2021; 48:e438. [PMID: 32301792 DOI: 10.1097/ccm.0000000000004280] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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15
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Reis AMD, Midega TD, Deliberato RO, Johnson AE, Bulgarelli L, Correa TD, Celi LA, Pelosi P, Gama De Abreu M, Schultz MJ, Serpa Neto A. Effect of spontaneous breathing on ventilator-free days in critically ill patients-an analysis of patients in a large observational cohort. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:783. [PMID: 34268396 PMCID: PMC8246163 DOI: 10.21037/atm-20-7901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/22/2021] [Indexed: 11/06/2022]
Abstract
Background Mechanical ventilation can injure lung tissue and respiratory muscles. The aim of the present study is to assess the effect of the amount of spontaneous breathing during mechanical ventilation on patient outcomes. Methods This is an analysis of the database of the ‘Medical Information Mart for Intensive Care (MIMIC)’-III, considering intensive care units (ICUs) of the Beth Israel Deaconess Medical Center (BIDMC), Boston, MA. Adult patients who received invasive ventilation for at least 48 hours were included. Patients were categorized according to the amount of spontaneous breathing, i.e., ≥50% (‘high spontaneous breathing’) and <50% (‘low spontaneous breathing’) of time during first 48 hours of ventilation. The primary outcome was the number of ventilator-free days. Results In total, the analysis included 3,380 patients; 70.2% were classified as ‘high spontaneous breathing’, and 29.8% as ‘low spontaneous breathing’. Patients in the ‘high spontaneous breathing’ group were older, had more comorbidities, and lower severity scores. In adjusted analysis, the amount of spontaneous breathing was not associated with the number of ventilator-free days [20.0 (0.0–24.2) vs. 19.0 (0.0–23.7) in high vs. low; absolute difference, 0.54 (95% CI, –0.10 to 1.19); P=0.101]. However, ‘high spontaneous breathing' was associated with shorter duration of ventilation in survivors [6.5 (3.6 to 12.2) vs. 7.6 (4.1 to 13.9); absolute difference, –0.91 (95% CI, −1.80 to −0.02); P=0.046]. Conclusions In patients surviving and receiving ventilation for at least 48 hours, the amount of spontaneous breathing during this period was not associated with an increased number of ventilator-free days.
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Affiliation(s)
- Aline Mela Dos Reis
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Thais Dias Midega
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Rodrigo Octavio Deliberato
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Big Data Analytics Group, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Alistair Ew Johnson
- Laboratory for Computational Physiology, Institute for Medical Engineering & Science, MIT, Cambridge, MA, USA
| | - Lucas Bulgarelli
- Big Data Analytics Group, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Laboratory for Computational Physiology, Institute for Medical Engineering & Science, MIT, Cambridge, MA, USA
| | - Thiago Domingos Correa
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Leo Anthony Celi
- Laboratory for Computational Physiology, Institute for Medical Engineering & Science, MIT, Cambridge, MA, USA.,Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Paolo Pelosi
- IRCCS San Martino Policlinico Hospital, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Marcelo Gama De Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - Marcus J Schultz
- Department of Intensive Care & 'Laboratory of Experimental Intensive Care and Anesthesiology' (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Intensive Care & 'Laboratory of Experimental Intensive Care and Anesthesiology' (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.,Data Analytics Research & Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Melbourne, Australia
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16
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Abstract
PURPOSE OF REVIEW There is increased awareness that derangements of respiratory drive and inspiratory effort are frequent and can result in lung and diaphragm injury together with dyspnea and sleep disturbances. This review aims to describe available techniques to monitor drive and effort. RECENT FINDINGS Measuring drive and effort is necessary to quantify risk and implement strategies to minimize lung and the diaphragm injury by modifying sedation and ventilation. Evidence on the efficacy of such strategies is yet to be elucidated, but physiological and epidemiological data support the need to avoid injurious patterns of breathing effort.Some techniques have been used in research for decades (e.g., esophageal pressure or airway occlusion pressure), evidence on their practical utility is growing, and technical advances have eased implementation. More novel techniques (e.g., electrical activity of the diaphragm and ultrasound) are being investigated providing new insights on their use and interpretation. SUMMARY Available techniques provide reliable measures of the intensity and timing of drive and effort. Simple, noninvasive techniques might be implemented in most patients and the more invasive or time-consuming in more complex patients at higher risk. We encourage clinicians to become familiar with technical details and physiological rationale of each for optimal implementation.
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17
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Brosnahan SB, Jonkman AH, Kugler MC, Munger JS, Kaufman DA. COVID-19 and Respiratory System Disorders: Current Knowledge, Future Clinical and Translational Research Questions. Arterioscler Thromb Vasc Biol 2020; 40:2586-2597. [PMID: 32960072 PMCID: PMC7571846 DOI: 10.1161/atvbaha.120.314515] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The severe acute respiratory syndrome coronavirus-2 emerged as a serious human pathogen in late 2019, causing the disease coronavirus disease 2019 (COVID-19). The most common clinical presentation of severe COVID-19 is acute respiratory failure consistent with the acute respiratory distress syndrome. Airway, lung parenchymal, pulmonary vascular, and respiratory neuromuscular disorders all feature in COVID-19. This article reviews what is known about the effects of severe acute respiratory syndrome coronavirus-2 infection on different parts of the respiratory system, clues to understanding the underlying biology of respiratory disease, and highlights current and future translation and clinical research questions.
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Affiliation(s)
- Shari B Brosnahan
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU School of Medicine (S.B.B., M.C.K., J.S.M., D.A.K.)
| | - Annemijn H Jonkman
- Keenan Centre for Biomedical Research, Critical Care Department, St. Michael's Hospital, Toronto, Canada (A.H.J.).,Department of Intensive Care Medicine, Amsterdam UMC, location VUmc, Amsterdam, the Netherlands (A.H.J.)
| | - Matthias C Kugler
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU School of Medicine (S.B.B., M.C.K., J.S.M., D.A.K.)
| | - John S Munger
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU School of Medicine (S.B.B., M.C.K., J.S.M., D.A.K.)
| | - David A Kaufman
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, NYU School of Medicine (S.B.B., M.C.K., J.S.M., D.A.K.)
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18
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Telias I, Junhasavasdikul D, Rittayamai N, Piquilloud L, Chen L, Ferguson ND, Goligher EC, Brochard L. Airway Occlusion Pressure As an Estimate of Respiratory Drive and Inspiratory Effort during Assisted Ventilation. Am J Respir Crit Care Med 2020; 201:1086-1098. [PMID: 32097569 DOI: 10.1164/rccm.201907-1425oc] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Rationale: Monitoring and controlling respiratory drive and effort may help to minimize lung and diaphragm injury. Airway occlusion pressure (P0.1) is a noninvasive measure of respiratory drive.Objectives: To determine 1) the validity of "ventilator" P0.1 (P0.1vent) displayed on the screen as a measure of drive, 2) the ability of P0.1 to detect potentially injurious levels of effort, and 3) how P0.1vent displayed by different ventilators compares to a "reference" P0.1 (P0.1ref) measured from airway pressure recording during an occlusion.Methods: Analysis of three studies in patients, one in healthy subjects, under assisted ventilation, and a bench study with six ventilators. P0.1vent was validated against measures of drive (electrical activity of the diaphragm and muscular pressure over time) and P0.1ref. Performance of P0.1ref and P0.1vent to detect predefined potentially injurious effort was tested using derivation and validation datasets using esophageal pressure-time product as the reference standard.Measurements and Main Results: P0.1vent correlated well with measures of drive and with the esophageal pressure-time product (within-subjects R2 = 0.8). P0.1ref >3.5 cm H2O was 80% sensitive and 77% specific for detecting high effort (≥200 cm H2O ⋅ s ⋅ min-1); P0.1ref ≤1.0 cm H2O was 100% sensitive and 92% specific for low effort (≤50 cm H2O ⋅ s ⋅ min-1). The area under the receiver operating characteristics curve for P0.1vent to detect potentially high and low effort were 0.81 and 0.92, respectively. Bench experiments showed a low mean bias for P0.1vent compared with P0.1ref for most ventilators but precision varied; in patients, precision was lower. Ventilators estimating P0.1vent without occlusions could underestimate P0.1ref.Conclusions: P0.1 is a reliable bedside tool to assess respiratory drive and detect potentially injurious inspiratory effort.
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Affiliation(s)
- Irene Telias
- Interdepartmental Division of Critical Care Medicine and.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Detajin Junhasavasdikul
- Interdepartmental Division of Critical Care Medicine and.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Department of Medicine, Faculty of Medicine Ramathibodi Hospital and
| | - Nuttapol Rittayamai
- Interdepartmental Division of Critical Care Medicine and.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Lise Piquilloud
- Adult Intensive Care and Burn Unit, University Hospital and University of Lausanne, Lausanne, Switzerland; and
| | - Lu Chen
- Interdepartmental Division of Critical Care Medicine and.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine and.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine and.,Division of Respirology, Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada.,Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine and.,Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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Jonkman AH, Rauseo M, Carteaux G, Telias I, Sklar MC, Heunks L, Brochard LJ. Proportional modes of ventilation: technology to assist physiology. Intensive Care Med 2020; 46:2301-2313. [PMID: 32780167 PMCID: PMC7417783 DOI: 10.1007/s00134-020-06206-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 07/30/2020] [Indexed: 01/17/2023]
Abstract
Proportional modes of ventilation assist the patient by adapting to his/her effort, which contrasts with all other modes. The two proportional modes are referred to as neurally adjusted ventilatory assist (NAVA) and proportional assist ventilation with load-adjustable gain factors (PAV+): they deliver inspiratory assist in proportion to the patient’s effort, and hence directly respond to changes in ventilatory needs. Due to their working principles, NAVA and PAV+ have the ability to provide self-adjusted lung and diaphragm-protective ventilation. As these proportional modes differ from ‘classical’ modes such as pressure support ventilation (PSV), setting the inspiratory assist level is often puzzling for clinicians at the bedside as it is not based on usual parameters such as tidal volumes and PaCO2 targets. This paper provides an in-depth overview of the working principles of NAVA and PAV+ and the physiological differences with PSV. Understanding these differences is fundamental for applying any assisted mode at the bedside. We review different methods for setting inspiratory assist during NAVA and PAV+ , and (future) indices for monitoring of patient effort. Last, differences with automated modes are mentioned.
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Affiliation(s)
- Annemijn H Jonkman
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Michela Rauseo
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Guillaume Carteaux
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, F-94010, France.,Groupe de Recherche Clinique CARMAS, Université Paris Est-Créteil, Créteil, F-94010, France.,Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, F-94010, France
| | - Irene Telias
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Michael C Sklar
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Leo Heunks
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Laurent J Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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20
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Lilitsis E, Stamatopoulou V, Andrianakis E, Petraki A, Antonogiannaki EM, Georgopoulos D, Vaporidi K, Kondili E. Inspiratory effort and breathing pattern change in response to varying the assist level: A physiological study. Respir Physiol Neurobiol 2020; 280:103474. [PMID: 32531441 PMCID: PMC7283104 DOI: 10.1016/j.resp.2020.103474] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 10/25/2022]
Abstract
AIM To describe the response of breathing pattern and inspiratory effort upon changes in assist level and to assesss if changes in respiratory rate may indicate changes in respiratory muscle effort. METHODS Prospective study of 82 patients ventilated on proportional assist ventilation (PAV+). At three levels of assist (20 %-50 %-80 %), patients' inspiratory effort and breathing pattern were evaluated using a validated prototype monitor. RESULTS Independent of the assist level, a wide range of respiratory rates (16-35br/min) was observed when patients' effort was within the accepted range. Changing the assist level resulted in paired changes in inspiratory effort and rate of the same tendency (increase or decrease) in all but four patients. Increasing the level in assist resulted in a 31 % (8-44 %) decrease in inspiratory effort and a 10 % (0-18 %) decrease in respiratory rate. The change in respiratory rate upon the change in assist correlated modestly with the change in the effort (R = 0.5). CONCLUSION Changing assist level results in changes in both respiratory rate and effort in the same direction, with change in effort being greater than that of respiratory rate. Yet, neither the magnitude of respiratory rate change nor the resulting absolute value may reliably predict the level of effort after a change in assist.
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Affiliation(s)
- Emmanouil Lilitsis
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Vaia Stamatopoulou
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Eleftherios Andrianakis
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Adamantia Petraki
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Elvira-Markela Antonogiannaki
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Dimitrios Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece
| | - Eumorfia Kondili
- Department of Intensive Care Medicine, University Hospital of Heraklion and School of Medicine, University of Crete, Voutes, 71110, Heraklion, Crete, Greece.
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Jonkman AH, de Vries HJ, Heunks LMA. Physiology of the Respiratory Drive in ICU Patients: Implications for Diagnosis and Treatment. Crit Care 2020; 24:104. [PMID: 32204710 PMCID: PMC7092542 DOI: 10.1186/s13054-020-2776-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Annemijn H Jonkman
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Heder J de Vries
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Leo M A Heunks
- Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Sciences Research Institute, Amsterdam UMC, Amsterdam, The Netherlands.
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Abstract
PURPOSE OF REVIEW Diaphragm dysfunction is common in mechanically ventilated patients and predisposes them to prolonged ventilator dependence and poor clinical outcomes. Mechanical ventilation is a major cause of diaphragm dysfunction in these patients, raising the possibility that diaphragm dysfunction might be prevented if mechanical ventilation can be optimized to avoid diaphragm injury - a concept referred to as diaphragm-protective ventilation. This review surveys the evidence supporting the concept of diaphragm-protective ventilation and introduces potential routes and challenges to pursuing this strategy. RECENT FINDINGS Mechanical ventilation can cause diaphragm injury (myotrauma) by a variety of mechanisms. An understanding of these various mechanisms raises the possibility of a new approach to ventilatory management, a diaphragm-protective ventilation strategy. Deranged inspiratory effort is the main mediator of diaphragmatic myotrauma; titrating ventilation to maintain an optimal level of inspiratory effort may help to limit diaphragm dysfunction and accelerate liberation of mechanical ventilation. SUMMARY Mechanical ventilation can cause diaphragm injury and weakness. A novel diaphragm-protective ventilation strategy, avoiding the harmful effects of both excessive and insufficient inspiratory effort, has the potential to substantially improve outcomes for patients.
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Vaporidi K, Akoumianaki E, Telias I, Goligher EC, Brochard L, Georgopoulos D. Respiratory Drive in Critically Ill Patients. Pathophysiology and Clinical Implications. Am J Respir Crit Care Med 2020; 201:20-32. [DOI: 10.1164/rccm.201903-0596so] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School University of Crete, Heraklion, Greece
| | - Evangelia Akoumianaki
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School University of Crete, Heraklion, Greece
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Center and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University Health Network, Toronto, Ontario, Canada; and
- Toronto General Hospital Research Institute, Toronto, Ontario, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Keenan Research Center and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Dimitris Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School University of Crete, Heraklion, Greece
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Spontaneous Breathing in Early Acute Respiratory Distress Syndrome: Insights From the Large Observational Study to UNderstand the Global Impact of Severe Acute Respiratory FailurE Study. Crit Care Med 2019; 47:229-238. [PMID: 30379668 PMCID: PMC6336491 DOI: 10.1097/ccm.0000000000003519] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Supplemental Digital Content is available in the text. Objectives: To describe the characteristics and outcomes of patients with acute respiratory distress syndrome with or without spontaneous breathing and to investigate whether the effects of spontaneous breathing on outcome depend on acute respiratory distress syndrome severity. Design: Planned secondary analysis of a prospective, observational, multicentre cohort study. Setting: International sample of 459 ICUs from 50 countries. Patients: Patients with acute respiratory distress syndrome and at least 2 days of invasive mechanical ventilation and available data for the mode of mechanical ventilation and respiratory rate for the 2 first days. Interventions: Analysis of patients with and without spontaneous breathing, defined by the mode of mechanical ventilation and by actual respiratory rate compared with set respiratory rate during the first 48 hours of mechanical ventilation. Measurements and Main Results: Spontaneous breathing was present in 67% of patients with mild acute respiratory distress syndrome, 58% of patients with moderate acute respiratory distress syndrome, and 46% of patients with severe acute respiratory distress syndrome. Patients with spontaneous breathing were older and had lower acute respiratory distress syndrome severity, Sequential Organ Failure Assessment scores, ICU and hospital mortality, and were less likely to be diagnosed with acute respiratory distress syndrome by clinicians. In adjusted analysis, spontaneous breathing during the first 2 days was not associated with an effect on ICU or hospital mortality (33% vs 37%; odds ratio, 1.18 [0.92–1.51]; p = 0.19 and 37% vs 41%; odds ratio, 1.18 [0.93–1.50]; p = 0.196, respectively ). Spontaneous breathing was associated with increased ventilator-free days (13 [0–22] vs 8 [0–20]; p = 0.014) and shorter duration of ICU stay (11 [6–20] vs 12 [7–22]; p = 0.04). Conclusions: Spontaneous breathing is common in patients with acute respiratory distress syndrome during the first 48 hours of mechanical ventilation. Spontaneous breathing is not associated with worse outcomes and may hasten liberation from the ventilator and from ICU. Although these results support the use of spontaneous breathing in patients with acute respiratory distress syndrome independent of acute respiratory distress syndrome severity, the use of controlled ventilation indicates a bias toward use in patients with higher disease severity. In addition, because the lack of reliable data on inspiratory effort in our study, prospective studies incorporating the magnitude of inspiratory effort and adjusting for all potential severity confounders are required.
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25
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Rackley CR, MacIntyre NR. Low Tidal Volumes for Everyone? Chest 2019; 156:783-791. [DOI: 10.1016/j.chest.2019.06.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/13/2019] [Accepted: 06/06/2019] [Indexed: 01/03/2023] Open
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Beloncle F, Piquilloud L, Olivier PY, Vuillermoz A, Yvin E, Mercat A, Richard JC. Accuracy of P0.1 measurements performed by ICU ventilators: a bench study. Ann Intensive Care 2019; 9:104. [PMID: 31520230 PMCID: PMC6744533 DOI: 10.1186/s13613-019-0576-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 09/05/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Occlusion pressure at 100 ms (P0.1), defined as the negative pressure measured 100 ms after the initiation of an inspiratory effort performed against a closed respiratory circuit, has been shown to be well correlated with central respiratory drive and respiratory effort. Automated P0.1 measurement is available on modern ventilators. However, the reliability of this measurement has never been studied. This bench study aimed at assessing the accuracy of P0.1 measurements automatically performed by different ICU ventilators. METHODS Five ventilators set in pressure support mode were tested using a two-chamber test lung model simulating spontaneous breathing. P0.1 automatically displayed on the ventilator screen (P0.1vent) was recorded at three levels of simulated inspiratory effort corresponding to P0.1 of 2.5, 5 and 10 cm H2O measured directly at the test lung and considered as the reference values of P0.1 (P0.1ref). The pressure drop after 100 ms was measured offline on the airway pressure-time curves recorded during the automated P0.1 measurements (P0.1aw). P0.1vent was compared to P0.1ref and to P0.1aw. To assess the potential impact of the circuit length, P0.1 were also measured with circuits of different lengths (P0.1circuit). RESULTS Variations of P0.1vent correlated well with variations of P0.1ref. Overall, P0.1vent underestimated P0.1ref except for the Löwenstein® ventilator at P0.1ref 2.5 cm H2O and for the Getinge group® ventilator at P0.1ref 10 cm H2O. The agreement between P0.1vent and P0.1ref assessed with the Bland-Altman method gave a mean bias of - 1.3 cm H2O (limits of agreement: 1 and - 3.7 cm H2O). Analysis of airway pressure-time and flow-time curves showed that all the tested ventilators except the Getinge group® ventilator performed an occlusion of at least 100 ms to measure P0.1. The agreement between P0.1vent and P0.1aw assessed with the Bland-Altman method gave a mean bias of 0.5 cm H2O (limits of agreement: 2.4 and - 1.4 cm H2O). The circuit's length impacted P0.1 measurements' values. A longer circuit was associated with lower P0.1circuit values. CONCLUSION P0.1vent relative changes are well correlated to P0.1ref changes in all the tested ventilators. Accuracy of absolute values of P0.1vent varies according to the ventilator model. Overall, P0.1vent underestimates P0.1ref. The length of the circuit may partially explain P0.1vent underestimation.
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Affiliation(s)
- François Beloncle
- Medical Intensive Care Unit, University Hospital of Angers, UNIV Angers, 4 rue Larrey, 49933, Angers Cedex 9, France.
| | - Lise Piquilloud
- Medical Intensive Care Unit, University Hospital of Angers, UNIV Angers, 4 rue Larrey, 49933, Angers Cedex 9, France.,Adult Intensive Care and Burn Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Pierre-Yves Olivier
- Medical Intensive Care Unit, University Hospital of Angers, UNIV Angers, 4 rue Larrey, 49933, Angers Cedex 9, France.,Intensive Care Unit, General Hospital of Le Mans, Le Mans, France
| | - Alice Vuillermoz
- Medical Intensive Care Unit, University Hospital of Angers, UNIV Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Elise Yvin
- Medical Intensive Care Unit, University Hospital of Angers, UNIV Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Alain Mercat
- Medical Intensive Care Unit, University Hospital of Angers, UNIV Angers, 4 rue Larrey, 49933, Angers Cedex 9, France
| | - Jean-Christophe Richard
- SAMU74, Emergency Department, General Hospital of Annecy, Annecy, France.,INSERM, UMR 1066, Creteil, France
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de Haro C, Ochagavia A, López-Aguilar J, Fernandez-Gonzalo S, Navarra-Ventura G, Magrans R, Montanyà J, Blanch L. Patient-ventilator asynchronies during mechanical ventilation: current knowledge and research priorities. Intensive Care Med Exp 2019; 7:43. [PMID: 31346799 PMCID: PMC6658621 DOI: 10.1186/s40635-019-0234-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 03/07/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mechanical ventilation is common in critically ill patients. This life-saving treatment can cause complications and is also associated with long-term sequelae. Patient-ventilator asynchronies are frequent but underdiagnosed, and they have been associated with worse outcomes. MAIN BODY Asynchronies occur when ventilator assistance does not match the patient's demand. Ventilatory overassistance or underassistance translates to different types of asynchronies with different effects on patients. Underassistance can result in an excessive load on respiratory muscles, air hunger, or lung injury due to excessive tidal volumes. Overassistance can result in lower patient inspiratory drive and can lead to reverse triggering, which can also worsen lung injury. Identifying the type of asynchrony and its causes is crucial for effective treatment. Mechanical ventilation and asynchronies can affect hemodynamics. An increase in intrathoracic pressure during ventilation modifies ventricular preload and afterload of ventricles, thereby affecting cardiac output and hemodynamic status. Ineffective efforts can decrease intrathoracic pressure, but double cycling can increase it. Thus, asynchronies can lower the predictive accuracy of some hemodynamic parameters of fluid responsiveness. New research is also exploring the psychological effects of asynchronies. Anxiety and depression are common in survivors of critical illness long after discharge. Patients on mechanical ventilation feel anxiety, fear, agony, and insecurity, which can worsen in the presence of asynchronies. Asynchronies have been associated with worse overall prognosis, but the direct causal relation between poor patient-ventilator interaction and worse outcomes has yet to be clearly demonstrated. Critical care patients generate huge volumes of data that are vastly underexploited. New monitoring systems can analyze waveforms together with other inputs, helping us to detect, analyze, and even predict asynchronies. Big data approaches promise to help us understand asynchronies better and improve their diagnosis and management. CONCLUSIONS Although our understanding of asynchronies has increased in recent years, many questions remain to be answered. Evolving concepts in asynchronies, lung crosstalk with other organs, and the difficulties of data management make more efforts necessary in this field.
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Affiliation(s)
- Candelaria de Haro
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain. .,CIBERES, Instituto de Salud Carlos III, Madrid, Spain.
| | - Ana Ochagavia
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Josefina López-Aguilar
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | - Sol Fernandez-Gonzalo
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain.,CIBERSAM, Instituto de Salud Carlos III, Madrid, Spain
| | - Guillem Navarra-Ventura
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain
| | - Rudys Magrans
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Lluís Blanch
- Critical Care Center, Hospital Universitari Parc Taulí, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Parc Taulí 1, 08208, Sabadell, Spain.,CIBERES, Instituto de Salud Carlos III, Madrid, Spain
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28
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Double and multiple cycling in mechanical ventilation: Complex events with varying clinical effects. Med Intensiva 2019; 44:449-451. [PMID: 31337498 DOI: 10.1016/j.medin.2019.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 06/17/2019] [Indexed: 11/21/2022]
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Laverdure F, Genty T, Rezaiguia-Delclaux S, Herve P, Stephan F. Ultrasound Assessment of Respiratory Workload With High-Flow Nasal Oxygen Versus Other Noninvasive Methods After Chest Surgery. J Cardiothorac Vasc Anesth 2019; 33:3042-3047. [PMID: 31201041 DOI: 10.1053/j.jvca.2019.05.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/13/2019] [Accepted: 05/15/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To compare the respiratory workload using the diaphragm thickening fraction (DTf) determined by sonography during high-flow nasal oxygen (HFNO), standard oxygen therapy (SOT), and noninvasive bilevel positive airway pressure support (BIPAP) in patients with acute respiratory failure (ARF) after cardiothoracic surgery. DESIGN Prospective controlled clinical trial. SETTING A French 23-bed cardiothoracic surgical intensive care unit. PARTICIPANTS Nonintubated patients with ARF after cardiothoracic surgery or while awaiting lung transplantation. INTERVENTIONS HFNO (50 L/min), SOT via a standard facemask, and BIPAP (pressure support, 4 cmH2O; positive end-expiratory pressure [PEEP], 4 cmH2O), with FIO2 kept constant were successively applied and compared. With BIPAP, pressure support or PEEP increments up to 8 cmH2O were compared with baseline settings. Each measurement was made after stable breathing for 5 minutes. MEASUREMENTS AND MAIN RESULTS Fifty patients aged 60.0 ± 12.2 years were enrolled, including 14 (28%) with obesity. Mean PaO2/FIO2 was 153 ± 55 mmHg. DTf was lower with HFNO and BIPAP than with SOT (respectively 21.2% ± 15.1% v 30.9% ± 21.1% and 17.8% ± 19.1% v 30.9% ± 21.1%, p < 0.001) and was not different with HFNO versus BIPAP (p = 0.22). With BIPAP, increasing pressure support to 8 cmH2O decreased DTf (21.0% ± 14.3% v 28.8% ± 19.8%, p = 0.009), whereas increasing PEEP to 8 cmH2O did not (25.2% ± 17.2% v 28.8% ± 19.8%, p = 0.79). Tidal volume increased to 10.6 ± 3.4 mL/kg with 8 cmH2O pressure support v 8.8 ± 2.7 mL/kg with 4 cmH2O pressure support (p < 0.001). CONCLUSION HFNO provides a comparable respiratory workload decrease compared with BIPAP at lower levels of pressure support and PEEP compared with SOT. Increasing BIPAP pressure support may provide higher levels of assistance but carries a risk of overdistension.
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Affiliation(s)
- Florent Laverdure
- Department of Anesthesiology, Marie Lannelongue Hospital, Le Plessis Robinson, France; Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France.
| | - Thibaut Genty
- Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | | | - Philippe Herve
- Department of Thoracic Surgery, Marie Lannelongue Hospital, Le Plessis Robinson, France
| | - François Stephan
- Intensive Care Unit, Marie Lannelongue Hospital, Le Plessis Robinson, France
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Stripoli T, Spadaro S, Di Mussi R, Volta CA, Trerotoli P, De Carlo F, Iannuzziello R, Sechi F, Pierucci P, Staffieri F, Bruno F, Camporota L, Grasso S. High-flow oxygen therapy in tracheostomized patients at high risk of weaning failure. Ann Intensive Care 2019; 9:4. [PMID: 30617626 PMCID: PMC6323064 DOI: 10.1186/s13613-019-0482-2] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Accepted: 01/02/2019] [Indexed: 12/14/2022] Open
Abstract
Purpose High-flow oxygen therapy delivered through nasal cannulae improves oxygenation and decreases work of breathing in critically ill patients. Little is known of the physiological effects of high-flow oxygen therapy applied to the tracheostomy cannula (T-HF). In this study, we compared the effects of T-HF or conventional low-flow oxygen therapy (conventional O2) on neuro-ventilatory drive, work of breathing, respiratory rate (RR) and gas exchange, in a mixed population of tracheostomized patients at high risk of weaning failure. Methods This was a single-center, unblinded, cross-over study on fourteen patients. After disconnection from the ventilator, each patient received two 1-h periods of T-HF (T-HF1 and T-HF2) alternated with 1 h of conventional O2. The inspiratory oxygen fraction was titrated to achieve an arterial O2 saturation target of 94–98% (88–92% in COPD patients). We recorded neuro-ventilatory drive (electrical diaphragmatic activity, EAdi), work of breathing (inspiratory muscular pressure–time product per breath and per minute, PTPmusc/b and PTPmusc/min, respectively) respiratory rate and arterial blood gases. Results The EAdipeak remained unchanged (mean ± SD) in the T-HF1, conventional O2 and T-HF2 study periods (8.8 ± 4.3 μV vs 8.9 ± 4.8 μV vs 9.0 ± 4.1 μV, respectively, p = 0.99). Similarly, PTPmusc/b and PTPmusc/min, RR and gas exchange remained unchanged. Conclusions In tracheostomized patients at high risk of weaning failure from mechanical ventilation, T-HF did not improve neuro-ventilatory drive, work of breathing, respiratory rate and gas exchange compared with conventional O2 after disconnection from the ventilator. The present findings might suggest that physiological effects of high-flow therapy through tracheostomy substantially differ from nasal high flow.
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Affiliation(s)
- Tania Stripoli
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy
| | - Savino Spadaro
- Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Sezione di Anestesiologia e Terapia Intensiva Universitaria, Università degli studi di Ferrara, Ferrara, Italy
| | - Rosa Di Mussi
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy
| | - Carlo Alberto Volta
- Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Sezione di Anestesiologia e Terapia Intensiva Universitaria, Università degli studi di Ferrara, Ferrara, Italy
| | - Paolo Trerotoli
- Dipartimento di Scienze Biomediche ed Oncologia Umana, Cattedra di Statistica Medica, Università degli Studi Aldo Moro, Bari, Italy
| | - Francesca De Carlo
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy
| | - Rachele Iannuzziello
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy
| | - Fabio Sechi
- Dipartimento di Scienze Chirurgiche e Microchirurgiche, Università degli Studi di Sassari, Sassari, Italy
| | - Paola Pierucci
- Dipartimento di Medicina Respiratoria e del Sonno, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Francesco Staffieri
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Chirurgia Veterinaria, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Francesco Bruno
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, King's College London, London, UK.,Division of Centre of Human Applied Physiological Sciences, King's College London, London, UK
| | - Salvatore Grasso
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Ospedale Policlinico, Piazza Giulio Cesare 11, Bari, Italy.
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Weaning from Mechanical Ventilation in ARDS: Aspects to Think about for Better Understanding, Evaluation, and Management. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5423639. [PMID: 30402484 PMCID: PMC6198583 DOI: 10.1155/2018/5423639] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/22/2018] [Accepted: 08/26/2018] [Indexed: 12/14/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by severe inflammatory response and hypoxemia. The use of mechanical ventilation (MV) for correction of gas exchange can cause worsening of this inflammatory response, called “ventilator-induced lung injury” (VILI). The process of withdrawing mechanical ventilation, referred to as weaning from MV, may cause worsening of lung injury by spontaneous ventilation. Currently, there are few specific studies in patients with ARDS. Herein, we reviewed the main aspects of spontaneous ventilation and also discussed potential methods to predict the failure of weaning in this patient category. We also reviewed new treatments (modes of mechanical ventilation, neuromuscular blocker use, and extracorporeal membrane oxygenation) that could be considered in weaning ARDS patients from MV.
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Di Mussi R, Spadaro S, Stripoli T, Volta CA, Trerotoli P, Pierucci P, Staffieri F, Bruno F, Camporota L, Grasso S. High-flow nasal cannula oxygen therapy decreases postextubation neuroventilatory drive and work of breathing in patients with chronic obstructive pulmonary disease. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:180. [PMID: 30071876 PMCID: PMC6091018 DOI: 10.1186/s13054-018-2107-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 06/22/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The physiological effects of high-flow nasal cannula O2 therapy (HFNC) have been evaluated mainly in patients with hypoxemic respiratory failure. In this study, we compared the effects of HFNC and conventional low-flow O2 therapy on the neuroventilatory drive and work of breathing postextubation in patients with a background of chronic obstructive pulmonary disease (COPD) who had received mechanical ventilation for hypercapnic respiratory failure. METHODS This was a single center, unblinded, cross-over study on 14 postextubation COPD patients who were recovering from an episode of acute hypercapnic respiratory failure of various etiologies. After extubation, each patient received two 1-h periods of HFNC (HFNC1 and HFNC2) alternated with 1 h of conventional low-flow O2 therapy via a face mask. The inspiratory fraction of oxygen was titrated to achieve an arterial O2 saturation target of 88-92%. Gas exchange, breathing pattern, neuroventilatory drive (electrical diaphragmatic activity (EAdi)) and work of breathing (inspiratory trans-diaphragmatic pressure-time product per minute (PTPDI/min)) were recorded. RESULTS EAdi peak increased from a mean (±SD) of 15.4 ± 6.4 to 23.6 ± 10.5 μV switching from HFNC1 to conventional O2, and then returned to 15.2 ± 6.4 μV during HFNC2 (conventional O2: p < 0.05 versus HFNC1 and HFNC2). Similarly, the PTPDI/min increased from 135 ± 60 to 211 ± 70 cmH2O/s/min, and then decreased again during HFNC2 to 132 ± 56 (conventional O2: p < 0.05 versus HFNC1 and HFNC2). CONCLUSIONS In patients with COPD, the application of HFNC postextubation significantly decreased the neuroventilatory drive and work of breathing compared with conventional O2 therapy.
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Affiliation(s)
- Rosa Di Mussi
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy
| | - Savino Spadaro
- Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Sezione di Anestesiologia e Terapia Intensiva Universitaria, Università degli studi di Ferrara, Ferrara, Italy
| | - Tania Stripoli
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy
| | - Carlo Alberto Volta
- Dipartimento di Morfologia, Chirurgia e Medicina Sperimentale, Sezione di Anestesiologia e Terapia Intensiva Universitaria, Università degli studi di Ferrara, Ferrara, Italy
| | - Paolo Trerotoli
- Dipartimento di Scienze Biomediche ed Oncologia Umana, Cattedra di Statistica Medica, Università degli Studi Aldo Moro, Bari, Italy
| | - Paola Pierucci
- Dipartimento di Medicina Respiratoria e del Sonno, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Francesco Staffieri
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Chirurgia Veterinaria, Università degli Studi di Bari "Aldo Moro", Bari, Italy
| | - Francesco Bruno
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, and Division of Centre of Human Applied Physiological Sciences, King's College London, London, UK
| | - Salvatore Grasso
- Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Ospedale Policlinico, Università degli Studi di Bari "Aldo Moro", Piazza Giulio Cesare 11, Bari, Italy.
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