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Chen X, Xiong R, Zhang M, Guan C, Feng L, Yao Z, Li Y, Liu W, Ye M, Li Y, Jiang X, Tang Y, Wang H, Zheng J. Effects of sitting position on ventilation distribution determined by electrical impedance tomography in ventilated ARDS patients. Intensive Crit Care Nurs 2024; 85:103782. [PMID: 39116511 DOI: 10.1016/j.iccn.2024.103782] [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: 04/25/2024] [Revised: 07/17/2024] [Accepted: 07/21/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVE The study aimed to evaluate the improvements in pulmonary ventilation following a sitting position in ventilated ARDS patients using electrical impedance tomography. METHODOLOGY A total of 17 patients with ARDS under mechanical ventilation participated in this study, including 8 with moderate ARDS and 9 with severe ARDS. Each patient was initially placed in the supine position (S1), transitioned to sitting position (SP) for 30 min, and then returned to the supine position (S2). Patients were monitored for each period, with parameters recorded. MAIN OUTCOME MEASURES The primary outcome included the spatial distribution parameters of EIT, regional of interest (ROI), end-expiratory lung impedance (ΔEELI), and parameters of respiratory mechanics. RESULTS Compared to S1, the SP significantly altered the distribution in ROI1 (11.29 ± 4.70 vs 14.88 ± 5.00 %, p = 0.003) and ROI2 (35.59 ± 8.99 vs 44.65 ± 6.97 %, p < 0.001), showing reductions, while ROI3 (39.71 ± 11.49 vs 33.06 ± 6.34 %, p = 0.009), ROI4 (13.35 ± 8.76 vs 7.24 ± 5.23 %, p < 0.001), along with peak inspiratory pressure (29.24 ± 3.96 vs 27.71 ± 4.00 cmH2O, p = 0.036), showed increases. ΔEELI decreased significantly ventrally (168.3 (40.33 - 189.5), p < 0.0001) and increased significantly dorsally (461.7 (297.5 - 683.7), p < 0.0001). The PaO2/FiO2 ratio saw significant improvement in S2 compared to S1 after 30 min in the seated position (108 (73 - 130) vs 96 (57 - 129) mmHg, p = 0.03). CONCLUSIONS The sitting position is associated with enhanced compliance, improved oxygenation, and more homogenous ventilation in patients with ventilated ARDS compared to the supine position. IMPLICATIONS FOR CLINICAL PRACTICE It is important to know the impact of postural changes on patient pulmonary ventilation in order to standardize safe practices in critically ill patients. It may be helpful in the management among ventilated patients.
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Affiliation(s)
- Xiaofeng Chen
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang, PR China
| | - Ruyang Xiong
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang, PR China
| | - Ming Zhang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang, PR China
| | - Chunming Guan
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang, PR China
| | - Liwei Feng
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang, PR China; Department of Intensive Care Medicine, The Arong Banner People's Hospital, Hulunbuir 162750, Inner Mongolia Autonomous Region, PR China
| | - Zhipeng Yao
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang, PR China
| | - Yue Li
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang, PR China
| | - Wenhua Liu
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang, PR China
| | - Ming Ye
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang, PR China
| | - Yunlong Li
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang, PR China
| | - Xuesong Jiang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang, PR China
| | - Yonglin Tang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang, PR China
| | - Hongliang Wang
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang, PR China.
| | - Junbo Zheng
- Department of Intensive Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150081, Heilongjiang, PR China.
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Benites MH, Zapata-Canivilo M, Poblete F, Labbe F, Battiato R, Ferre A, Dreyse J, Bugedo G, Bruhn A, Costa ELV, Retamal J. Physiological and clinical effects of trunk inclination adjustment in patients with respiratory failure: a scoping review and narrative synthesis. Crit Care 2024; 28:228. [PMID: 38982466 PMCID: PMC11232125 DOI: 10.1186/s13054-024-05010-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 06/27/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Adjusting trunk inclination from a semi-recumbent position to a supine-flat position or vice versa in patients with respiratory failure significantly affects numerous aspects of respiratory physiology including respiratory mechanics, oxygenation, end-expiratory lung volume, and ventilatory efficiency. Despite these observed effects, the current clinical evidence regarding this positioning manoeuvre is limited. This study undertakes a scoping review of patients with respiratory failure undergoing mechanical ventilation to assess the effect of trunk inclination on physiological lung parameters. METHODS The PubMed, Cochrane, and Scopus databases were systematically searched from 2003 to 2023. INTERVENTIONS Changes in trunk inclination. MEASUREMENTS Four domains were evaluated in this study: 1) respiratory mechanics, 2) ventilation distribution, 3) oxygenation, and 4) ventilatory efficiency. RESULTS After searching the three databases and removing duplicates, 220 studies were screened. Of these, 37 were assessed in detail, and 13 were included in the final analysis, comprising 274 patients. All selected studies were experimental, and assessed respiratory mechanics, ventilation distribution, oxygenation, and ventilatory efficiency, primarily within 60 min post postural change. CONCLUSION In patients with acute respiratory failure, transitioning from a supine to a semi-recumbent position leads to decreased respiratory system compliance and increased airway driving pressure. Additionally, C-ARDS patients experienced an improvement in ventilatory efficiency, which resulted in lower PaCO2 levels. Improvements in oxygenation were observed in a few patients and only in those who exhibited an increase in EELV upon moving to a semi-recumbent position. Therefore, the trunk inclination angle must be accurately reported in patients with respiratory failure under mechanical ventilation.
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Affiliation(s)
- Martín H Benites
- Unidad de Pacientes Críticos, Clínica Las Condes, Santiago, Chile
- Facultad de Medicina, Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
- Doctorado en Ciencias Médicas, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Fabian Poblete
- Unidad de Pacientes Críticos, Clínica Las Condes, Santiago, Chile
| | - Francisco Labbe
- Unidad de Pacientes Críticos, Clínica Las Condes, Santiago, Chile
| | - Romina Battiato
- Magíster em Bioestadística, Escuela de Salud Pública, Universidad de Chile, Santiago, Chile
| | - Andrés Ferre
- Unidad de Pacientes Críticos, Clínica Las Condes, Santiago, Chile
- Facultad de Medicina, Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
| | - Jorge Dreyse
- Unidad de Pacientes Críticos, Clínica Las Condes, Santiago, Chile
- Facultad de Medicina, Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
| | - Guillermo Bugedo
- Departamento de Medicina Intensiva, Hospital Clínico Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Hospital Clínico Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo L V Costa
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), São Paulo, Brazil
- Hospital Sírio-Libanês, Research and Education Institute, São Paulo, Brazil
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Hospital Clínico Pontificia Universidad Católica de Chile, Santiago, Chile.
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Loosen G, Taboada D, Ortmann E, Martinez G. How Would I Treat My Own Chronic Thromboembolic Pulmonary Hypertension in the Perioperative Period? J Cardiothorac Vasc Anesth 2024; 38:884-894. [PMID: 37716891 DOI: 10.1053/j.jvca.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/04/2023] [Accepted: 07/14/2023] [Indexed: 09/18/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) results from an incomplete resolution of acute pulmonary embolism, leading to occlusive organized thrombi, vascular remodeling, and associated microvasculopathy with pulmonary hypertension (PH). A definitive CTEPH diagnosis requires PH confirmation by right-heart catheterization and evidence of chronic thromboembolic pulmonary disease on imaging studies. Surgical removal of the organized fibrotic material by pulmonary endarterectomy (PEA) under deep hypothermic circulatory arrest represents the treatment of choice. One-third of patients with CTEPH are not deemed suitable for surgical treatment, and medical therapy or interventional balloon pulmonary angioplasty presents alternative treatment options. Pulmonary endarterectomy in patients with technically operable disease significantly improves symptoms, functional capacity, hemodynamics, and quality of life. Perioperative mortality is <2.5% in expert centers where a CTEPH multidisciplinary team optimizes patient selection and ensures the best preoperative optimization according to individualized risk assessment. Despite adequate pulmonary artery clearance, patients might be prone to perioperative complications, such as right ventricular maladaptation, airway bleeding, or pulmonary reperfusion injury. These complications can be treated conventionally, but extracorporeal membrane oxygenation has been included in their management recently. Patients with residual PH post-PEA should be considered for medical or percutaneous interventional therapy.
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Affiliation(s)
- Gregor Loosen
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
| | - Dolores Taboada
- Pulmonary Vascular Diseases Unit, Cambridge National Pulmonary Hypertension Service, Royal Papworth Hospital NHS, Department of Cardiothoracic Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Erik Ortmann
- Department of Anesthesiology, Schuechtermann-Heart-Centre, Bad Rothenfelde, Germany
| | - Guillermo Martinez
- Pulmonary Vascular Diseases Unit, Cambridge National Pulmonary Hypertension Service, Royal Papworth Hospital NHS, Department of Cardiothoracic Anesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom.
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Boesing C, Krebs J, Conrad AM, Otto M, Beck G, Thiel M, Rocco PRM, Luecke T, Schaefer L. Effects of prone positioning on lung mechanical power components in patients with acute respiratory distress syndrome: a physiologic study. Crit Care 2024; 28:82. [PMID: 38491457 PMCID: PMC10941550 DOI: 10.1186/s13054-024-04867-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 03/10/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Prone positioning (PP) homogenizes ventilation distribution and may limit ventilator-induced lung injury (VILI) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The static and dynamic components of ventilation that may cause VILI have been aggregated in mechanical power, considered a unifying driver of VILI. PP may affect mechanical power components differently due to changes in respiratory mechanics; however, the effects of PP on lung mechanical power components are unclear. This study aimed to compare the following parameters during supine positioning (SP) and PP: lung total elastic power and its components (elastic static power and elastic dynamic power) and these variables normalized to end-expiratory lung volume (EELV). METHODS This prospective physiologic study included 55 patients with moderate to severe ARDS. Lung total elastic power and its static and dynamic components were compared during SP and PP using an esophageal pressure-guided ventilation strategy. In SP, the esophageal pressure-guided ventilation strategy was further compared with an oxygenation-guided ventilation strategy defined as baseline SP. The primary endpoint was the effect of PP on lung total elastic power non-normalized and normalized to EELV. Secondary endpoints were the effects of PP and ventilation strategies on lung elastic static and dynamic power components non-normalized and normalized to EELV, respiratory mechanics, gas exchange, and hemodynamic parameters. RESULTS Lung total elastic power (median [interquartile range]) was lower during PP compared with SP (6.7 [4.9-10.6] versus 11.0 [6.6-14.8] J/min; P < 0.001) non-normalized and normalized to EELV (3.2 [2.1-5.0] versus 5.3 [3.3-7.5] J/min/L; P < 0.001). Comparing PP with SP, transpulmonary pressures and EELV did not significantly differ despite lower positive end-expiratory pressure and plateau airway pressure, thereby reducing non-normalized and normalized lung elastic static power in PP. PP improved gas exchange, cardiac output, and increased oxygen delivery compared with SP. CONCLUSIONS In patients with moderate to severe ARDS, PP reduced lung total elastic and elastic static power compared with SP regardless of EELV normalization because comparable transpulmonary pressures and EELV were achieved at lower airway pressures. This resulted in improved gas exchange, hemodynamics, and oxygen delivery. TRIAL REGISTRATION German Clinical Trials Register (DRKS00017449). Registered June 27, 2019. https://drks.de/search/en/trial/DRKS00017449.
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Affiliation(s)
- Christoph Boesing
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Joerg Krebs
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Alice Marguerite Conrad
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Matthias Otto
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Grietje Beck
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Manfred Thiel
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, Brazil
| | - Thomas Luecke
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Laura Schaefer
- Department of Anesthesiology and Critical Care Medicine, University Medical Center Mannheim, Medical Faculty Mannheim of the University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
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Bihari S, Wiersema UF. Changes in Respiratory Mechanics With Trunk Inclination Differs Between Patients With ARDS With and Without Obesity. Chest 2024; 165:583-589. [PMID: 37832782 DOI: 10.1016/j.chest.2023.09.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 09/27/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Studies investigating the effect of trunk inclination on respiratory mechanics in mechanically ventilated patients with ARDS have reported postural differences in partition respiratory mechanics. Compared with more upright positions, the supine-flat position provided lower lung and chest wall elastance, allowing reduced driving pressures and end-inspiratory transpulmonary pressure. However, the effect of trunk inclination on respiratory mechanics in patients with obesity and ARDS is uncertain. RESEARCH QUESTION Does the effect of change in posture on partition respiratory mechanics differ between patients with ARDS with and without obesity? STUDY DESIGN AND METHODS In this single-center study, patients with ARDS with and without obesity were randomized into two 15-minute steps in which trunk inclination was changed from semi-recumbent (40° head up) to supine-flat (0°), or vice versa. At the end of each step partition respiratory mechanics, airway opening pressure and arterial blood gases were measured. Paired t test was used to examine respiratory mechanics and blood gas variables in each group. RESULTS Forty consecutive patients were enrolled. Twenty were obese (BMI, 38.4 [34.5-42.3]), and 20 were non-obese (BMI, 26.6 [25.2-28.5]). In the patients with obesity, lung and chest wall elastance, driving pressure, inspiratory transpulmonary pressure, Paco2, and ventilatory ratio were lower supine than semi-recumbent (P < .001). Airways resistance was greater supine (P = .006). In the patients without obesity, only chest wall elastance was lower in supine vs semi-recumbent (P < .001). INTERPRETATION In mechanically ventilated patients with ARDS and obesity, supine posture provided lower lung and chest wall elastance, and better CO2 clearance, than the semi-recumbent posture. CLINICAL TRIAL REGISTRATION This study was registered with Australian New Zealand Clinical Trials Registry (ACTRN12623000794606).
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Affiliation(s)
- Shailesh Bihari
- Department of ICCU, Flinders Medical Centre, Bedford Park, SA, Australia; College of Medicine and Public Health, Flinders University, Bedford Park, SA, Australia.
| | - Ubbo F Wiersema
- Department of ICCU, Flinders Medical Centre, Bedford Park, SA, Australia
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Rosén J, Frykholm P, Jonsson Fagerlund M, Pellegrini M, Campoccia Jalde F, von Oelreich E, Fors D. Lung impedance changes during awake prone positioning in COVID-19. A non-randomized cross-over study. PLoS One 2024; 19:e0299199. [PMID: 38381730 PMCID: PMC10880988 DOI: 10.1371/journal.pone.0299199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 02/01/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND The effects of awake prone positioning (APP) on respiratory mechanics in patients with COVID-19 are not well characterized. The aim of this study was to investigate changes of global and regional lung volumes during APP compared with the supine position using electrical lung impedance tomography (EIT) in patients with hypoxemic respiratory failure due to COVID-19. MATERIALS AND METHODS This exploratory non-randomized cross-over study was conducted at two university hospitals in Sweden between January and May 2021. Patients admitted to the intensive care unit with confirmed COVID-19, an arterial cannula in place, a PaO2/FiO2 ratio <26.6 kPa (<200 mmHg) and high-flow nasal oxygen or non-invasive ventilation were eligible for inclusion. EIT-data were recorded at supine baseline, at 30 and 60 minutes after APP-initiation, and 30 minutes after supine repositioning. The primary outcomes were changes in global and regional tidal impedance variation (TIV), center of ventilation (CoV), global and regional delta end-expiratory lung-impedance (dEELI) and global inhomogeneity (GI) index at the end of APP compared with supine baseline. Data were reported as median (IQR). RESULTS All patients (n = 10) were male and age was 64 (47-73) years. There were no changes in global or regional TIV, CoV or GI-index during the intervention. dEELI increased from supine reference value 0 to 1.51 (0.32-3.62) 60 minutes after APP (median difference 1.51 (95% CI 0.19-5.16), p = 0.04) and returned to near baseline values after supine repositioning. Seven patients (70%) showed an increase >0.20 in dEELI during APP. The other EIT-variables did not change during APP compared with baseline. CONCLUSION Awake prone positioning was associated with a transient lung recruiting effect without changes in ventilation distribution measured with EIT in patients with hypoxemic respiratory failure due to COVID-19.
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Affiliation(s)
- Jacob Rosén
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
| | - Peter Frykholm
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
| | - Malin Jonsson Fagerlund
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
| | - Mariangela Pellegrini
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
| | - Francesca Campoccia Jalde
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
- Section of Thoracic Anesthesiology and Intensive Care, Department of Molecular Medicine and Surgery, Karolinska Institutet, Solna, Sweden
| | - Erik von Oelreich
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
| | - Diddi Fors
- Department of Surgical Sciences, Anaesthesiology and Intensive Care Medicine, Uppsala University, Uppsala, Sweden
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Duhem H, Terzi N, Segond N, Bellier A, Sanchez C, Louis B, Debaty G, Guérin C. Effect of automated head-thorax elevation during chest compressions on lung ventilation: a model study. Sci Rep 2023; 13:20393. [PMID: 37989865 PMCID: PMC10663599 DOI: 10.1038/s41598-023-47727-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 11/17/2023] [Indexed: 11/23/2023] Open
Abstract
Our goal was to investigate the effects of head-thorax elevation (HUP) during chest compressions (CC) on lung ventilation. A prospective study was performed on seven human cadavers. Chest was automatically compressed-decompressed in flat position and during progressive HUP from 18 to 35°. Lung ventilation was measured with electrical impedance tomography. In each cadaver, 5 sequences were randomly performed: one without CC at positive end-expiratory pressure (PEEP) 0cmH2O, 3 s with CC at PEEP0, 5 or 10cmH2O and 1 with CC and an impedance threshold device at PEEP0cmH2O. The minimal-to-maximal change in impedance (VTEIT in arbitrary unit a.u.) and the minimal impedance in every breathing cycle (EELI) the) were compared between flat, 18°, and 35° in each sequence by a mixed-effects model. Values are expressed as median (1st-3rd quartiles). With CC, between flat, 18° and 35° VTEIT decreased at each level of PEEP. It was 12416a.u. (10,689; 14,442), 11,239 (7667; 13,292), and 6457 (4631; 9516), respectively, at PEEP0. The same was true with the impedance threshold device. EELI/VTEIT significantly decreased from - 0.30 (- 0.40; - 0.15) before to - 1.13 (- 1.70; - 0.61) after the CC (P = 0.009). With HUP lung ventilation decreased with CC as compared to flat position. CC are associated with decreased in EELI.
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Affiliation(s)
- Hélène Duhem
- SAMU 38, Centre Hospitalier Universitaire Grenoble Alpes, 38043, Grenoble, France
- Université de Grenoble-Alpes/CNRS, UMR 5525Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, 38000, Grenoble, France
| | - Nicolas Terzi
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, 38043, Grenoble, France
| | - Nicolas Segond
- SAMU 38, Centre Hospitalier Universitaire Grenoble Alpes, 38043, Grenoble, France
- Université de Grenoble-Alpes/CNRS, UMR 5525Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, 38000, Grenoble, France
| | - Alexandre Bellier
- Université de Grenoble-Alpes/CNRS, UMR 5525Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, 38000, Grenoble, France
| | - Caroline Sanchez
- Université de Grenoble-Alpes/CNRS, UMR 5525Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, 38000, Grenoble, France
| | - Bruno Louis
- Institut Mondor de Recherches Biomédicales INSERM-UPEC UMR 955 Eq13 - CNRS EMR 7000, 8 rue du Général Sarrail, 94010, Créteil, France
| | - Guillaume Debaty
- SAMU 38, Centre Hospitalier Universitaire Grenoble Alpes, 38043, Grenoble, France.
- Université de Grenoble-Alpes/CNRS, UMR 5525Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, 38000, Grenoble, France.
| | - Claude Guérin
- Institut Mondor de Recherches Biomédicales INSERM-UPEC UMR 955 Eq13 - CNRS EMR 7000, 8 rue du Général Sarrail, 94010, Créteil, France
- Faculté de médecine Lyon Est, Université de Lyon, 8 avenue Rockefeller, 69373, Lyon cedex 08, France
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Benites MH, Torres D, Poblete F, Labbe F, Bachmann MC, Regueira TE, Soto L, Ferre A, Dreyse J, Retamal J. Effects of changes in trunk inclination on ventilatory efficiency in ARDS patients: quasi-experimental study. Intensive Care Med Exp 2023; 11:65. [PMID: 37755538 PMCID: PMC10533449 DOI: 10.1186/s40635-023-00550-2] [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: 04/12/2023] [Accepted: 09/12/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Trunk inclination from semirecumbent head-upright to supine-flat positioning reduces driving pressure and increases respiratory system compliance in patients with acute respiratory distress syndrome (ARDS). These effects are associated with an improved ventilatory ratio and reduction in the partial pressure of carbon dioxide (PaCO2). However, these physiological effects have not been completely studied, and their mechanisms have not yet been elucidated. Therefore, this study aimed to evaluate the effects of a change in trunk inclination from semirecumbent (45°) to supine-flat (10°) on physiological dead space and ventilation distribution in different lung regions. RESULTS Twenty-two ARDS patients on pressure-controlled ventilation underwent three 60-min steps in which trunk inclination was changed from 45° (baseline) to 10° (intervention) and back to 45° (control) in the last step. Tunk inclination from a semirecumbent (45°) to a supine-flat (10°) position resulted in a higher tidal volume [371 (± 76) vs. 433 (± 84) mL (P < 0.001)] and respiratory system compliance [34 (± 10) to 41 (± 12) mL/cmH2O (P < 0.001)]. The CO2 exhaled per minute improved from 191 mL/min (± 34) to 227 mL/min (± 38) (P < 0.001). Accordingly, Bohr's dead space ratio decreased from 0.49 (± 0.07) to 0.41 (± 0.06) (p < 0.001), and PaCO2 decreased from 43 (± 5) to 36 (± 4) mmHg (p < 0.001). In addition, the impedance ratio, which divides the ventilation activity of the ventral region by the dorsal region ventilation activity in tidal images, dropped from 1.27 (0.83-1.78) to 0.86 (0.51-1.33) (p < 0.001). These results, calculated from functional EIT images, indicated further ventilation activity in the dorsal lung regions. These effects rapidly reversed once the patient was repositioned at 45°. CONCLUSIONS A change in trunk inclination from a semirecumbent (45 degrees) to a supine-flat position (10 degrees) improved Bohr's dead space ratio and reduced PaCO2 in patients with ARDS. This effect is associated with an increase in tidal volume and respiratory system compliance, along with further favourable impedance ventilation distribution toward the dorsal lung regions. This study highlights the importance of considering trunk inclination as a modifiable determinant of physiological parameters. The angle of trunk inclination is essential information that must be reported in ARDS patients.
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Affiliation(s)
- Martín H Benites
- Unidad de Pacientes Críticos, Clínica Las Condes, Estoril 450, Santiago, Chile
- Departamento de Epidemiología y Estudios en Salud, Magíster en Epidemiología, Universidad de los Andes, Monseñor Álvaro del Portillo 12455, Santiago, Chile
- Estudiante del Programa Doctorado en Ciencias Médicas, Escuela de Medicina, Pontificia Universidad Católica de Chile, Av. Libertador Bernardo O'Higgins 340, Santiago, Chile
- Facultad de Medicina, Escuela de Medicina, Universidad Finis Terrae, Av. Pedro de Valdivia 1509, Santiago, Chile
| | - David Torres
- Departamento de Epidemiología y Estudios en Salud, Magíster en Epidemiología, Universidad de los Andes, Monseñor Álvaro del Portillo 12455, Santiago, Chile
| | - Fabian Poblete
- Unidad de Pacientes Críticos, Clínica Las Condes, Estoril 450, Santiago, Chile
| | - Francisco Labbe
- Unidad de Pacientes Críticos, Clínica Las Condes, Estoril 450, Santiago, Chile
| | - María C Bachmann
- Estudiante del Programa Doctorado en Ciencias Médicas, Escuela de Medicina, Pontificia Universidad Católica de Chile, Av. Libertador Bernardo O'Higgins 340, Santiago, Chile
- Departamento de Medicina Intensiva, Hospital Clínico Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, Chile
| | - Tomas E Regueira
- Unidad de Pacientes Críticos, Clínica Santa María, Bellavista 415, Santiago, Chile
| | - Leonardo Soto
- Facultad de Medicina, Escuela de Medicina, Universidad Finis Terrae, Av. Pedro de Valdivia 1509, Santiago, Chile
- Unidad de Pacientes Críticos, Clínica Santa María, Bellavista 415, Santiago, Chile
| | - Andrés Ferre
- Unidad de Pacientes Críticos, Clínica Las Condes, Estoril 450, Santiago, Chile
- Facultad de Medicina, Escuela de Medicina, Universidad Finis Terrae, Av. Pedro de Valdivia 1509, Santiago, Chile
| | - Jorge Dreyse
- Unidad de Pacientes Críticos, Clínica Las Condes, Estoril 450, Santiago, Chile
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Hospital Clínico Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, Chile.
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9
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Marrazzo F, Spina S, Zadek F, Forlini C, Bassi G, Giudici R, Bellani G, Fumagalli R, Langer T. PEEP Titration Is Markedly Affected by Trunk Inclination in Mechanically Ventilated Patients with COVID-19 ARDS: A Physiologic, Cross-Over Study. J Clin Med 2023; 12:3914. [PMID: 37373608 PMCID: PMC10299565 DOI: 10.3390/jcm12123914] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/04/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Changing trunk inclination affects lung function in patients with ARDS. However, its impacts on PEEP titration remain unknown. The primary aim of this study was to assess, in mechanically ventilated patients with COVID-19 ARDS, the effects of trunk inclination on PEEP titration. The secondary aim was to compare respiratory mechanics and gas exchange in the semi-recumbent (40° head-of-the-bed) and supine-flat (0°) positions following PEEP titration. METHODS Twelve patients were positioned both at 40° and 0° trunk inclination (randomized order). The PEEP associated with the best compromise between overdistension and collapse guided by Electrical Impedance Tomography (PEEPEIT) was set. After 30 min of controlled mechanical ventilation, data regarding respiratory mechanics, gas exchange, and EIT parameters were collected. The same procedure was repeated for the other trunk inclination. RESULTS PEEPEIT was lower in the semi-recumbent than in the supine-flat position (8 ± 2 vs. 13 ± 2 cmH2O, p < 0.001). A semi-recumbent position with optimized PEEP resulted in higher PaO2:FiO2 (141 ± 46 vs. 196 ± 99, p = 0.02) and a lower global inhomogeneity index (46 ± 10 vs. 53 ± 11, p = 0.008). After 30 min of observation, a loss of aeration (measured by EIT) was observed only in the supine-flat position (-153 ± 162 vs. 27 ± 203 mL, p = 0.007). CONCLUSIONS A semi-recumbent position is associated with lower PEEPEIT and results in better oxygenation, less derecruitment, and more homogenous ventilation compared to the supine-flat position.
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Affiliation(s)
- Francesco Marrazzo
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Stefano Spina
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Francesco Zadek
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (F.Z.); (G.B.)
| | - Clarissa Forlini
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Gabriele Bassi
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Riccardo Giudici
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (F.Z.); (G.B.)
- Department of Anesthesia and Intensive Care 1, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy
| | - Roberto Fumagalli
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (F.Z.); (G.B.)
| | - Thomas Langer
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (F.Z.); (G.B.)
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10
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Selickman J, Tawfik P, Crooke PS, Dries DJ, Shelver J, Gattinoni L, Marini JJ. Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP. Crit Care 2022; 26:201. [PMID: 35791021 PMCID: PMC9255488 DOI: 10.1186/s13054-022-04073-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/24/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Chest wall loading has been shown to paradoxically improve respiratory system compliance (CRS) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The most likely, albeit unconfirmed, mechanism is relief of end-tidal overdistension in ‘baby lungs’ of low-capacity. The purpose of this study was to define how small changes of tidal volume (VT) and positive end-expiratory pressure (PEEP) affect CRS (and its associated airway pressures) in patients with ARDS who demonstrate a paradoxical response to chest wall loading. We hypothesized that small reductions of VT or PEEP would alleviate overdistension and favorably affect CRS and conversely, that small increases of VT or PEEP would worsen CRS.
Methods
Prospective, multi-center physiologic study of seventeen patients with moderate to severe ARDS who demonstrated paradoxical responses to chest wall loading. All patients received mechanical ventilation in volume control mode and were passively ventilated. Airway pressures were measured before and after decreasing/increasing VT by 1 ml/kg predicted body weight and decreasing/increasing PEEP by 2.5 cmH2O.
Results
Decreasing either VT or PEEP improved CRS in all patients. Driving pressure (DP) decreased by a mean of 4.9 cmH2O (supine) and by 4.3 cmH2O (prone) after decreasing VT, and by a mean of 2.9 cmH2O (supine) and 2.2 cmH2O (prone) after decreasing PEEP. CRS increased by a mean of 3.1 ml/cmH2O (supine) and by 2.5 ml/cmH2O (prone) after decreasing VT. CRS increased by a mean of 5.2 ml/cmH2O (supine) and 3.6 ml/cmH2O (prone) after decreasing PEEP (P < 0.01 for all). Small increments of either VT or PEEP worsened CRS in the majority of patients.
Conclusion
Patients with a paradoxical response to chest wall loading demonstrate uniform improvement in both DP and CRS following a reduction in either VT or PEEP, findings in keeping with prior evidence suggesting its presence is a sign of end-tidal overdistension. The presence of ‘paradox’ should prompt re-evaluation of modifiable determinants of end-tidal overdistension, including VT, PEEP, and body position.
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11
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Selickman J, Marini JJ. Chest wall loading in the ICU: pushes, weights, and positions. Ann Intensive Care 2022; 12:103. [PMID: 36346532 PMCID: PMC9640797 DOI: 10.1186/s13613-022-01076-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
Clinicians monitor mechanical ventilatory support using airway pressures—primarily the plateau and driving pressure, which are considered by many to determine the safety of the applied tidal volume. These airway pressures are influenced not only by the ventilator prescription, but also by the mechanical properties of the respiratory system, which consists of the series-coupled lung and chest wall. Actively limiting chest wall expansion through external compression of the rib cage or abdomen is seldom performed in the ICU. Recent literature describing the respiratory mechanics of patients with late-stage, unresolving, ARDS, however, has raised awareness of the potential diagnostic (and perhaps therapeutic) value of this unfamiliar and somewhat counterintuitive practice. In these patients, interventions that reduce resting lung volume, such as loading the chest wall through application of external weights or manual pressure, or placing the torso in a more horizontal position, have unexpectedly improved tidal compliance of the lung and integrated respiratory system by reducing previously undetected end-tidal hyperinflation. In this interpretive review, we first describe underappreciated lung and chest wall interactions that are clinically relevant to both normal individuals and to the acutely ill who receive ventilatory support. We then apply these physiologic principles, in addition to published clinical observation, to illustrate the utility of chest wall modification for the purposes of detecting end-tidal hyperinflation in everyday practice.
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Affiliation(s)
- John Selickman
- grid.17635.360000000419368657Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN USA ,grid.415858.50000 0001 0087 6510Department of Critical Care Medicine, Regions Hospital, MS 11203B, 640 Jackson St., St. Paul, MN 55101-2595 USA
| | - John J. Marini
- grid.17635.360000000419368657Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN USA ,grid.415858.50000 0001 0087 6510Department of Critical Care Medicine, Regions Hospital, MS 11203B, 640 Jackson St., St. Paul, MN 55101-2595 USA
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12
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Abstract
OBJECTIVES Head-elevated body positioning, a default clinical practice, predictably increases end-expiratory transpulmonary pressure and aerated lung volume. In acute respiratory distress syndrome (ARDS), however, the net effect of such vertical inclination on tidal mechanics depends upon whether lung recruitment or overdistension predominates. We hypothesized that in moderate to severe ARDS, bed inclination toward vertical unloads the chest wall but adversely affects overall respiratory system compliance (C rs ). DESIGN Prospective physiologic study. SETTING Two medical ICUs in the United States. PATIENTS Seventeen patients with ARDS, predominantly moderate to severe. INTERVENTION Patients were ventilated passively by volume control. We measured airway pressures at baseline (noninclined) and following bed inclination toward vertical by an additional 15°. At baseline and following inclination, we manually loaded the chest wall to determine if C rs increased or paradoxically declined, suggestive of end-tidal overdistension. MEASUREMENTS AND MAIN RESULTS Inclination resulted in a higher plateau pressure (supineΔ: 2.8 ± 3.3 cm H 2 O [ p = 0.01]; proneΔ: 3.3 ± 2.5 cm H 2 O [ p = 0.004]), higher driving pressure (supineΔ: 2.9 ± 3.3 cm H 2 O [ p = 0.01]; proneΔ: 3.3 ± 2.8 cm H 2 O [ p = 0.007]), and lower C rs (supine Δ: 3.4 ± 3.7 mL/cm H 2 O [ p = 0.01]; proneΔ: 3.1 ± 3.2 mL/cm H 2 O [ p = 0.02]). Following inclination, manual loading of the chest wall restored C rs and driving pressure to baseline (preinclination) values. CONCLUSIONS In advanced ARDS, bed inclination toward vertical adversely affects C rs and therefore affects the numerical values for plateau and driving tidal pressures commonly targeted in lung protective strategies. These changes are fully reversed with manual loading of the chest wall, suggestive of end-tidal overdistension in the upright position. Body inclination should be considered a modifiable determinant of transpulmonary pressure and lung protection, directionally similar to tidal volume and positive end-expiratory pressure.
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13
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Marrazzo F, Spina S, Fumagalli R, Langer T. Reply to Oppersma et al.. Am J Respir Crit Care Med 2022; 206:799-800. [PMID: 35653706 PMCID: PMC9799101 DOI: 10.1164/rccm.202205-0987le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
| | - Stefano Spina
- ASST Grande Ospedale Metropolitano NiguardaMilan, Italy
| | - Roberto Fumagalli
- ASST Grande Ospedale Metropolitano NiguardaMilan, Italy,University of Milan-BicoccaMilan, Italy
| | - Thomas Langer
- ASST Grande Ospedale Metropolitano NiguardaMilan, Italy,University of Milan-BicoccaMilan, Italy,Corresponding author (e-mail: )
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14
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Selickman J, Tawfik P, Crooke PS, Dries DJ, Shelver J, Gattinoni L, Marini JJ. Paradoxical response to chest wall loading predicts a favorable mechanical response to reduction in tidal volume or PEEP. Crit Care 2022. [PMID: 35791021 DOI: 10.1186/s13054-022-04073-] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND Chest wall loading has been shown to paradoxically improve respiratory system compliance (CRS) in patients with moderate to severe acute respiratory distress syndrome (ARDS). The most likely, albeit unconfirmed, mechanism is relief of end-tidal overdistension in 'baby lungs' of low-capacity. The purpose of this study was to define how small changes of tidal volume (VT) and positive end-expiratory pressure (PEEP) affect CRS (and its associated airway pressures) in patients with ARDS who demonstrate a paradoxical response to chest wall loading. We hypothesized that small reductions of VT or PEEP would alleviate overdistension and favorably affect CRS and conversely, that small increases of VT or PEEP would worsen CRS. METHODS Prospective, multi-center physiologic study of seventeen patients with moderate to severe ARDS who demonstrated paradoxical responses to chest wall loading. All patients received mechanical ventilation in volume control mode and were passively ventilated. Airway pressures were measured before and after decreasing/increasing VT by 1 ml/kg predicted body weight and decreasing/increasing PEEP by 2.5 cmH2O. RESULTS Decreasing either VT or PEEP improved CRS in all patients. Driving pressure (DP) decreased by a mean of 4.9 cmH2O (supine) and by 4.3 cmH2O (prone) after decreasing VT, and by a mean of 2.9 cmH2O (supine) and 2.2 cmH2O (prone) after decreasing PEEP. CRS increased by a mean of 3.1 ml/cmH2O (supine) and by 2.5 ml/cmH2O (prone) after decreasing VT. CRS increased by a mean of 5.2 ml/cmH2O (supine) and 3.6 ml/cmH2O (prone) after decreasing PEEP (P < 0.01 for all). Small increments of either VT or PEEP worsened CRS in the majority of patients. CONCLUSION Patients with a paradoxical response to chest wall loading demonstrate uniform improvement in both DP and CRS following a reduction in either VT or PEEP, findings in keeping with prior evidence suggesting its presence is a sign of end-tidal overdistension. The presence of 'paradox' should prompt re-evaluation of modifiable determinants of end-tidal overdistension, including VT, PEEP, and body position.
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Affiliation(s)
- John Selickman
- Department of Pulmonary and Critical Care Medicine, University of Minnesota School of Medicine, 640 Jackson Street, Mail Stop 11203B, MinneapolisSt. Paul, MN, 55101, USA.
| | - Pierre Tawfik
- Department of Pulmonary and Critical Care Medicine, University of Minnesota School of Medicine, 640 Jackson Street, Mail Stop 11203B, MinneapolisSt. Paul, MN, 55101, USA
| | - Philip S Crooke
- Department of Mathematics, Vanderbilt University, Nashville, TN, USA
| | - David J Dries
- Department of Surgery, Regions Hospital, St Paul, MN, USA
- Department of Surgery, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Jonathan Shelver
- Department of Pulmonary and Critical Care Medicine, Methodist Hospital, St. Louis Park, MN, USA
| | - Luciano Gattinoni
- Department of Anesthesiology, Medical University of Göttingen, University Medical Center Göttingen, Göttingen, Germany
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota School of Medicine, 640 Jackson Street, Mail Stop 11203B, MinneapolisSt. Paul, MN, 55101, USA
- Department of Critical Care Medicine, Regions Hospital, St. Paul, MN, USA
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15
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Marrazzo F, Spina S, Forlini C, Guarnieri M, Giudici R, Bassi G, Bastia L, Bottiroli M, Fumagalli R, Langer T. Effects of Trunk Inclination on Respiratory Mechanics in Patients with COVID-19 Associated ARDS: Let’s Always Report the Angle! Am J Respir Crit Care Med 2022; 205:582-584. [PMID: 34982652 PMCID: PMC8906482 DOI: 10.1164/rccm.202110-2360le] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Francesco Marrazzo
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Stefano Spina
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Clarissa Forlini
- Università degli Studi di Milano-Bicocca, 9305, School of Medicine and Surgery, Monza, Italy
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Marcello Guarnieri
- Università degli Studi di Milano-Bicocca, 9305, School of Medicine and Surgery, Monza, Italy
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Riccardo Giudici
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Gabriele Bassi
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Luca Bastia
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Maurizio Bottiroli
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Roberto Fumagalli
- Università degli Studi di Milano-Bicocca, 9305, School of Medicine and Surgery, Monza, Italy
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Thomas Langer
- Università degli Studi di Milano-Bicocca, 9305, School of Medicine and Surgery, Monza, Italy
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
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16
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Duhem H, Moore JC, Rojas-Salvador C, Salverda B, Lick M, Pepe P, Labarere J, Debaty G, Lurie KG. Improving post-cardiac arrest cerebral perfusion pressure by elevating the head and thorax. Resuscitation 2021; 159:45-53. [PMID: 33385469 DOI: 10.1016/j.resuscitation.2020.12.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/04/2020] [Accepted: 12/15/2020] [Indexed: 01/17/2023]
Abstract
AIM The optimal head and thorax position after return of spontaneous circulation (ROSC) following cardiac arrest (CA) is unknown. This study examined whether head and thorax elevation post-ROSC is beneficial, in a porcine model. METHODS Protocol A: 40 kg anesthetized pigs were positioned flat, after 7.75 min of untreated CA the heart and head were elevated 8 and 12 cm, respectively, above the horizontal plane, automated active compression decompression (ACD) plus impedance threshold device (ITD) CPR was started, and 2 min later the heart and head were elevated 10 and 22 cm, respectively, over 2 min to the highest head up position (HUP). After 30 min of CPR pigs were defibrillated and randomized 10 min later to four 5-min epochs of HUP or flat position. Multiple physiological parameters were measured. In Protocol B, after 6 min of untreated VF, pigs received 6 min of conventional CPR flat, and after ROSC were randomized HUP versus Flat as in Protocol A. The primary endpoint was cerebral perfusion pressure (CerPP). Multivariate analysis-of-variance (MANOVA) for repeated measures was used. Data were reported as mean ± SD. RESULTS In Protocol A, intracranial pressure (ICP) (mmHg) was significantly lower post-ROSC with HUP (9.1 ± 5.5) versus Flat (18.5 ± 5.1) (p < 0.001). Conversely, CerPP was higher with HUP (62.5 ± 19.9) versus Flat (53.2 ± 19.1) (p = 0.004), respectively. Protocol A and B results comparing HUP versus Flat were similar. CONCLUSION Post-ROSC head and thorax elevation in a porcine model of cardiac arrest resulted in higher CerPP and lower ICP values, regardless of VF duration or CPR method. IACUC PROTOCOL NUMBER 19-09.
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Affiliation(s)
- Helene Duhem
- University Grenoble Alps/CNRS/CHU Grenoble Alpes/TIMC-IMAG UMR 5525, Grenoble, France
| | - Johanna C Moore
- Department of Emergency Medicine, Hennepin Healthcare, Minneapolis, MN, USA; Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | | | - Bayert Salverda
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Michael Lick
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA
| | - Paul Pepe
- Dallas County Fire Rescue, Dallas, TX, USA; Palm Beach County Fire Rescue, West Palm Beach, FL and Broward Sheriff's Office, Fire Rescue Department Fort Lauderdale, FL, USA
| | - Jose Labarere
- University Grenoble Alps/CNRS/CHU Grenoble Alpes/TIMC-IMAG UMR 5525, Grenoble, France
| | - Guillaume Debaty
- University Grenoble Alps/CNRS/CHU Grenoble Alpes/TIMC-IMAG UMR 5525, Grenoble, France.
| | - Keith G Lurie
- Hennepin Healthcare Research Institute, Minneapolis, MN, USA; Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, USA
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17
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Ni Z, Wang K, Wang T, Ni Y, Huang W, Zhu P, Fan T, Wang Y, Wang B, Deng J, Qian Z, Liu J, Cai W, Xu S, Du Y, Wang G, Liang Z, Li W, Luo J, Luo F, Liu D. Efficacy of early prone or lateral positioning in patients with severe COVID-19: a single-center prospective cohort. PRECISION CLINICAL MEDICINE 2020; 3:260-271. [PMID: 35960672 PMCID: PMC7543626 DOI: 10.1093/pcmedi/pbaa034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 08/23/2020] [Accepted: 09/15/2020] [Indexed: 02/05/2023] Open
Abstract
Abstract
Background
Position intervention has been shown to improve oxygenation, but its role in non-invasively ventilated patients with severe COVID-19 has not been assessed. The objective of this study was to investigate the efficacy of early position intervention on non-invasively ventilated patients with severe COVID-19.
Methods
This was a single-center, prospective observational study in consecutive patients with severe COVID-19 managed in a provisional ICU at Renmin Hospital of Wuhan University from 31 January to 15 February 2020. Patients with chest CT showing exudation or consolidation in bilateral peripheral and posterior parts of the lungs were included. Early position intervention (prone or lateral) was commenced for > 4 hours daily for 10 days in these patients, while others received standard care.
Results
The baseline parameters were comparable between the position intervention group (n = 17) and the standard care group (n = 35). Position intervention was well-tolerated and increased cumulative adjusted mean difference of SpO2/FiO2 (409, 95% CI 86 to 733) and ROX index (26, 95% CI 9 to 43) with decreased Borg scale (−9, 95% CI −15 to −3) during the first 7 days. It also facilitated absorption of lung lesions and reduced the proportion of patients with high National Early Warning Score 2 (≥ 7) on days 7 and 14, with a trend toward faster clinical improvement. Virus shedding and length of hospital stay were comparable between the two groups.
Conclusions
This study provides the first evidence for improved oxygenation and lung lesion absorption using early position intervention in non-invasively ventilated patients with severe COVID-19, and warrants further randomized trials.
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Affiliation(s)
- Zhong Ni
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Kaige Wang
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Ting Wang
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Yuenan Ni
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Wei Huang
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Ping Zhu
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Tao Fan
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Ye Wang
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Bo Wang
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jun Deng
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou 646000, China
| | - Zhicheng Qian
- Intensive Care Unit, the Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
| | - Jiasheng Liu
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Wenhao Cai
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Shanling Xu
- Critical Care Medicine Department, Sichuan Cancer Hospital, Affiliated Cancer Hospital to University of Electronic Science and Technology of China, Chengdu 610041, China
| | - Yu Du
- Department of Emergency and Critical Care Medicine, West China School of Public Health, West China Fourth Hospital, Sichuan University, Chengdu 610041, China
| | - Gang Wang
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Zongan Liang
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Weimin Li
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Jianfei Luo
- Department of Gastrointestinal Surgery, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Fengming Luo
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Dan Liu
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu 610041, China
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Zhu Q, Huang Z, Ma Q, Wu Z, Kang Y, Zhang M, Gan T, Wang M, Huang F. Supine versus semi-Fowler's positions for tracheal extubation in abdominal surgery-a randomized clinical trial. BMC Anesthesiol 2020; 20:185. [PMID: 32738878 PMCID: PMC7395215 DOI: 10.1186/s12871-020-01108-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 07/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Tracheal extubation is commonly performed in the supine position. However, in patients undergoing abdominal surgery, the supine position increases abdominal wall tension, especially during coughing and deep breathing, which may aggravate pain and lead to abdominal wound dehiscence. The semi-Fowler's position may reduce abdominal wall tension, but its safety and comfort in tracheal extubation have not been reported. We aimed to evaluate the safety and comfort of different extubation positions in patients undergoing abdominal surgery. METHODS We enrolled 141 patients with an American Society of Anesthesiologists grade of I-III who underwent abdominal surgery. All patients were anesthetized with propofol, fentanyl, cisatracurium, and sevoflurane. After surgery, all patients were transferred to the post-anesthesia care unit (PACU). Patients were then randomly put into the semi-Fowler's (n = 70) or supine (n = 71) position while 100% oxygen was administered. The endotracheal tube was removed after the patients opened their eyes and regained consciousness. Vital signs, coughing, and pain and comfort scores before and/or after extubation were recorded until the patients left the PACU. RESULTS In comparison with the supine position, the semi-Fowler's position significantly decreased the wound pain scores at all intervals after extubation (3.51 ± 2.50 vs. 4.58 ± 2.26, 2.23 ± 1.68 vs. 3.11 ± 2.00, 1.81 ± 1.32 vs. 2.59 ± 1.88, P = 0.009, 0.005 and 0.005, respectively), reduced severe coughing (8[11.43%] vs. 21[29.58%], P = 0.008) and bucking after extubation (3[4.29%] vs. 18[25.35%], P < 0.001), and improved the comfort scores 5 min after extubation (6.11 ± 2.30 vs. 5.17 ± 1.78, P = 0.007) and when leaving from post-anesthesia care unit (7.17 ± 2.27 vs. 6.44 ± 1.79, P = 0.034). The incidences of vomiting, emergence agitation, and respiratory complications were of no significant difference. CONCLUSION Tracheal extubation in the semi-Fowler's position is associated with less coughing, sputum suction, and pain, and more comfort, without specific adverse effects when compared to the conventional supine position. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR1900025566 . Registered on 1st September 2019.
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Affiliation(s)
- Qiongfang Zhu
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zheyan Huang
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Qiaomei Ma
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Zehui Wu
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Yubo Kang
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Miaoyin Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Tiantian Gan
- Department of Anesthesiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Minxue Wang
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Rd, Guangzhou, China
| | - Fei Huang
- Department of Anesthesiology, The Third Affiliated Hospital of Sun Yat-sen University, 600 Tianhe Rd, Guangzhou, China.
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Turbil E, Terzi N, Schwebel C, Cour M, Argaud L, Guérin C. Does endo-tracheal tube clamping prevent air leaks and maintain positive end-expiratory pressure during the switching of a ventilator in a patient in an intensive care unit? A bench study. PLoS One 2020; 15:e0230147. [PMID: 32160252 PMCID: PMC7065807 DOI: 10.1371/journal.pone.0230147] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 02/21/2020] [Indexed: 11/18/2022] Open
Abstract
Objectives When patients with acute respiratory distress syndrome are moved out of an intensive care unit, the ventilator often requires changing. This procedure suppresses positive end expiratory pressure and promotes lung derecruitment. Clamping the endotracheal tube may prevent this from occurring. Whether or not such clamping maintains positive end-expiratory pressure has never been investigated. We designed a bench study to explore this further. How the study was done We used the Elysee 350 ventilator in ‘volume controlled’ mode with a positive end-expiratory pressure of 15 cmH2O, connected to an endotracheal tube with an 8 mm internal diameter inserted into a lung model with 40 ml/cmH2O compliance and 10 cmH2O/L/s resistance. We measured airway pressure and flow between the distal end of the endotracheal tube and the lung model. We tested a plastic, a metal, and an Extra Corporeal Membrane Oxygenation clamp, each with an oral/nasal, a nasal, and a reinforced endotracheal tube. We performed an end-expiratory hold then clamped the endotracheal tube and disconnected the ventilator. We measured the change in airway pressure and volume for 30 s following the disconnection of the ventilator. Results Airway pressure decreased thirty seconds after disconnection with all combinations of clamp and endotracheal tube. The largest fall in airway pressure (-17.486 cmH2O/s at 5 s and -18.834 cmH2O/s at 30 s) was observed with the plastic clamp combined with the reinforced endotracheal tube. The smallest decrease in airway pressure (0 cmH2O/s at 5 s and -0.163 cmH2O/s at 30 s) was observed using the Extra Corporeal Membrane Oxygenation clamp with the nasal endotracheal tube. Conclusions Only the Extra Corporeal Membrane Oxygenation clamp was efficient. Even with an Extra Corporeal Membrane Oxygenation clamp, it is important to limit the duration the ventilator is disconnected to a few seconds (ideally 5 s).
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Affiliation(s)
- Emanuele Turbil
- Anesthesiology and Intensive care, Università degli Studi di Sassari, Sassari, Italy
| | - Nicolas Terzi
- Médecine Intensive Réanimation, C.H.U de Grenoble-Alpes, Grenoble, France
- University of Grenoble-Alpes, Grenoble, France
| | - Carole Schwebel
- Médecine Intensive Réanimation, C.H.U de Grenoble-Alpes, Grenoble, France
- University of Grenoble-Alpes, Grenoble, France
| | - Martin Cour
- Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
- University of Lyon, Lyon, France
| | - Laurent Argaud
- Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
- University of Lyon, Lyon, France
| | - Claude Guérin
- Médecine Intensive-Réanimation, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
- University of Lyon, Lyon, France
- INSERM, Créteil, France
- * E-mail:
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