1
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Wennen M, Claassen W, Heunks L. Setting positive end-expiratory pressure: role in diaphragm-protective ventilation. Curr Opin Crit Care 2024; 30:61-68. [PMID: 38085880 DOI: 10.1097/mcc.0000000000001126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
PURPOSE OF REVIEW With mechanical ventilation, positive end-expiratory pressure (PEEP) is applied to improve oxygenation and lung homogeneity. However, PEEP setting has been hypothesized to contribute to critical illness associated diaphragm dysfunction via several mechanisms. Here, we discuss the impact of PEEP on diaphragm function, activity and geometry. RECENT FINDINGS PEEP affects diaphragm geometry: it induces a caudal movement of the diaphragm dome and shortening of the zone of apposition. This results in reduced diaphragm neuromechanical efficiency. After prolonged PEEP application, the zone of apposition adapts by reducing muscle fiber length, so-called longitudinal muscle atrophy. When PEEP is withdrawn, for instance during a spontaneous breathing trial, the shortened diaphragm muscle fibers may over-stretch which may lead to (additional) diaphragm myotrauma. Furthermore, PEEP may either increase or decrease respiratory drive and resulting respiratory effort, probably depending on lung recruitability. Finally, the level of PEEP can also influence diaphragm activity in the expiratory phase, which may be an additional mechanism for diaphragm myotrauma. SUMMARY Setting PEEP could play an important role in both lung and diaphragm protective ventilation. Both high and low PEEP levels could potentially introduce or exacerbate diaphragm myotrauma. Today, the impact of PEEP setting on diaphragm structure and function is in its infancy, and clinical implications are largely unknown.
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Affiliation(s)
- Myrte Wennen
- Department of Intensive Care, Erasmus Medical Center, Rotterdam
| | - Wout Claassen
- Department of Physiology, Amsterdam UMC, location VUmc, Amsterdam
| | - Leo Heunks
- Department of Intensive Care, Erasmus Medical Center, Rotterdam
- Department of intensive care medicine, Radboud University Medical Center, Nijmegen, The Netherlands
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2
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Luo XY, He X, Zhou YM, Zhou JF, Chen GQ, Li HL, Yang YL, Zhang L, Zhou JX. Ineffective Effort in Patients With Acute Brain Injury Undergoing Invasive Mechanical Ventilation. Respir Care 2023; 68:1202-1212. [PMID: 36997326 PMCID: PMC10468166 DOI: 10.4187/respcare.10596] [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: 09/27/2022] [Accepted: 03/26/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND Ineffective effort (IE) is a frequent patient-ventilator asynchrony in invasive mechanical ventilation. This study aimed to investigate the incidence of IE and to explore its relationship with respiratory drive in subjects with acute brain injury undergoing invasive mechanical ventilation. METHODS We retrospectively analyzed a clinical database that assessed patient-ventilator asynchrony in subjects with acute brain injury. IE was identified based on airway pressure, flow, and esophageal pressure waveforms collected at 15-min intervals 4 times daily. At the end of each data set recording, airway-occlusion pressure (P0.1) was determined by the airway occlusion test. IE index was calculated to indicate the severity of IE. The incidence of IE in different types of brain injuries as well as its relationship with P0.1 was determined. RESULTS We analyzed 852 data sets of 71 subjects with P0.1 measured and undergoing mechanical ventilation for at least 3 d after enrollment. IE was detected in 688 (80.8%) data sets, with a median index of 2.2% (interquartile range 0.4-13.1). Severe IE (IE index ≥ 10%) was detected in 246 (28.9%) data sets. The post craniotomy for brain tumor and the stroke groups had higher median IE index and lower P0.1 compared with the traumatic brain injury group (2.6% [0.7-9.7] vs 2.7% [0.3-21] vs 1.2% [0.1-8.5], P = .002; 1.4 [1-2] cm H2O vs 1.5 [1-2.2] cm H2O vs 1.8 [1.1-2.8] cm H2O, P = .001). Low respiratory drive (P0.1 < 1.14 cm H2O) was independently associated with severe IE in the expiratory phase (IEE) even after adjusting for confounding factors by logistic regression analysis (odds ratio 5.18 [95% CI 2.69-10], P < .001). CONCLUSIONS IE was very common in subjects with acute brain injury. Low respiratory drive was independently associated with severe IEE.
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Affiliation(s)
- Xu-Ying Luo
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuan He
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi-Min Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Fang Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guang-Qiang Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hong-Liang Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China.
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3
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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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4
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Yarnell CJ, Johnson A, Dam T, Jonkman A, Liu K, Wunsch H, Brochard L, Celi LA, De Grooth HJ, Elbers P, Mehta S, Munshi L, Fowler RA, Sung L, Tomlinson G. Do Thresholds for Invasive Ventilation in Hypoxemic Respiratory Failure Exist? A Cohort Study. Am J Respir Crit Care Med 2023; 207:271-282. [PMID: 36150166 DOI: 10.1164/rccm.202206-1092oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Rationale: Invasive ventilation is a significant event for patients with respiratory failure. Physiologic thresholds standardize the use of invasive ventilation in clinical trials, but it is unknown whether thresholds prompt invasive ventilation in clinical practice. Objectives: To measure, in patients with hypoxemic respiratory failure, the probability of invasive ventilation within 3 hours after meeting physiologic thresholds. Methods: We studied patients admitted to intensive care receiving FiO2 of 0.4 or more via nonrebreather mask, noninvasive positive pressure ventilation, or high-flow nasal cannula, using data from the Medical Information Mart for Intensive Care (MIMIC)-IV database (2008-2019) and the Amsterdam University Medical Centers Database (AmsterdamUMCdb) (2003-2016). We evaluated 17 thresholds, including the ratio of arterial to inspired oxygen, the ratio of saturation to inspired oxygen ratio, composite scores, and criteria from randomized trials. We report the probability of invasive ventilation within 3 hours of meeting each threshold and its association with covariates using odds ratios (ORs) and 95% credible intervals (CrIs). Measurements and Main Results: We studied 4,726 patients (3,365 from MIMIC, 1,361 from AmsterdamUMCdb). Invasive ventilation occurred in 28% (1,320). In MIMIC, the highest probability of invasive ventilation within 3 hours of meeting a threshold was 20%, after meeting prespecified neurologic or respiratory criteria while on vasopressors, and 19%, after a ratio of arterial to inspired oxygen of <80 mm Hg. In AmsterdamUMCdb, the highest probability was 34%, after vasopressor initiation, and 25%, after a ratio of saturation to inspired oxygen of <90. The probability after meeting the threshold from randomized trials was 9% (MIMIC) and 13% (AmsterdamUMCdb). In MIMIC, a race/ethnicity of Black (OR, 0.75; 95% CrI, 0.57-0.96) or Asian (OR, 0.6; 95% CrI, 0.35-0.95) compared with White was associated with decreased probability of invasive ventilation after meeting a threshold. Conclusions: The probability of invasive ventilation within 3 hours of meeting physiologic thresholds was low and associated with patient race/ethnicity.
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Affiliation(s)
- Christopher J Yarnell
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management and Evaluation, and.,Division of Respirology
| | | | - Tariq Dam
- Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Annemijn Jonkman
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Kuan Liu
- Institute of Health Policy, Management and Evaluation, and
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management and Evaluation, and.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine.,Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Leo Anthony Celi
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Biostatistics, T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts; and
| | - Harm-Jan De Grooth
- Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Paul Elbers
- Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology
| | - Robert A Fowler
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management and Evaluation, and.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Haematology/Oncology.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Lillian Sung
- Institute of Health Policy, Management and Evaluation, and.,Division of Haematology/Oncology
| | - George Tomlinson
- Institute of Health Policy, Management and Evaluation, and.,Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
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5
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Kassis EB, Beitler JR, Talmor D. Lung-protective sedation: moving toward a new paradigm of precision sedation. Intensive Care Med 2023; 49:91-94. [PMID: 36239747 DOI: 10.1007/s00134-022-06901-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/24/2022] [Indexed: 01/24/2023]
Affiliation(s)
- Elias Baedorf Kassis
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 375 Longwood Ave, MASCO Building, Boston, MA, 02215, USA.
| | - Jeremy R Beitler
- Columbia Respiratory Critical Care Trials Group, Columbia University College of Physicians and Surgeons and New York-Presbyterian Hospital, New York, NY, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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6
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Saavedra SN, Barisich PVS, Maldonado JBP, Lumini RB, Gómez-González A, Gallardo A. Asynchronies during invasive mechanical ventilation: narrative review and update. Acute Crit Care 2022; 37:491-501. [DOI: 10.4266/acc.2022.01158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/20/2022] [Indexed: 12/05/2022] Open
Abstract
Invasive mechanical ventilation is a frequent therapy in critically ill patients in critical care units. To achieve favorable outcomes, patient and ventilator interaction must be adequate. However, many clinical situations could attempt against this principle and generate a mismatch between these two actors. These asynchronies can lead the patient to worst outcomes; because of that is vital to recognize and treat these entities as soon as possible. Early detection and recognition of the different asynchronies could favor the reduction of the days of mechanical ventilation, the days of hospital stay, and in intensive care and improve clinical results.
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7
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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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8
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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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9
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Maslove DM, Sibley S, Boyd JG, Goligher EC, Munshi L, Bogoch II, Rochwerg B. Complications of Critical COVID-19: Diagnostic and Therapeutic Considerations for the Mechanically Ventilated Patient. Chest 2022; 161:989-998. [PMID: 34655568 PMCID: PMC8511547 DOI: 10.1016/j.chest.2021.10.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 09/04/2021] [Accepted: 10/06/2021] [Indexed: 01/31/2023] Open
Abstract
Patients admitted to the ICU with critical COVID-19 often require prolonged periods of mechanical ventilation. Difficulty weaning, lack of progress, and clinical deterioration are commonly encountered. These conditions should prompt a thorough evaluation for persistent or untreated manifestations of COVID-19, as well as complications from COVID-19 and its various treatments. Inflammation may persist and lead to fibroproliferative changes in the lungs. Infectious complications may arise including bacterial superinfection in the earlier stages of disease. Use of immunosuppressants may lead to the dissemination of latent infections, and to opportunistic infections. Venous thromboembolic disease is common, as are certain neurologic manifestations of COVID-19 including delirium and stroke. High levels of ventilatory support may lead to ventilator-induced injury to the lungs and diaphragm. We present diagnostic and therapeutic considerations for the mechanically ventilated patient with COVID-19 who shows persistent or worsening signs of critical illness, and we offer an approach to treating this complex but common scenario.
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Affiliation(s)
- David M. Maslove
- Department of Critical Care Medicine, Queen’s University, Kingston, ON, Canada,Kingston Health Sciences Centre, Kingston, ON, Canada,CORRESPONDENCE TO: David M. Maslove, MD
| | - Stephanie Sibley
- Department of Critical Care Medicine, Queen’s University, Kingston, ON, Canada,Kingston Health Sciences Centre, Kingston, ON, Canada
| | - J. Gordon Boyd
- Department of Critical Care Medicine, Queen’s University, Kingston, ON, Canada,Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Ewan C. Goligher
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada,University Health Network, Toronto, ON, Canada
| | - Laveena Munshi
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada,Sinai Health System, Toronto, ON, Canada
| | - Isaac I. Bogoch
- University Health Network, Toronto, ON, Canada,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada,Juravinski Hospital, Hamilton, ON, Canada
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10
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Somhorst P, Gommers D, Endeman H. Advanced respiratory monitoring in mechanically ventilated patients with coronavirus disease 2019-associated acute respiratory distress syndrome. Curr Opin Crit Care 2022; 28:66-73. [PMID: 34772836 PMCID: PMC8711301 DOI: 10.1097/mcc.0000000000000905] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
PURPOSE OF REVIEW To summarize the current knowledge about the application of advanced monitoring techniques in coronavirus disease 2019 (COVID-19). RECENT FINDINGS Due to the heterogeneity between patients, management of COVID-19 requires daily monitoring of and/or aeration and inspiratory effort. Electrical impedance tomography can be used to optimize positive end-expiratory pressure, monitor the response to changes in treatment or body position and assess pulmonary perfusion and ventilation/perfusion matching. Lung ultrasound is more readily available and can be used to measure and monitor recruitment, provide an indication of diaphragm function and pulmonary perfusion disturbances. Esophageal pressure measurements enable the calculation of the transpulmonary pressure and inspiratory effort in order to prevent excessive stress on the lung. While esophageal pressure measurements are the golden standard in determining inspiratory effort, alternatives like P0.1, negative pressure swing during a single airway occlusion and change in central venous pressure are more readily available and capable of diagnosing extreme inspiratory efforts. SUMMARY Although there is little data on the effectiveness of advanced monitoring techniques in COVID-19, regular monitoring should be a central part of the management of COVID-19-related acute respiratory distress syndrome (C-ARDS).
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Affiliation(s)
- Peter Somhorst
- Department of Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
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11
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Kallet RH, Phillips JS, Summers TJ, Burns G, Pangilinan L, Carothers L, Mangalindan ER, Lipnick MS. Expiratory Pause Maneuver to Assess Inspiratory Muscle Pressure During Assisted Mechanical Ventilation: A Bench Study. Respir Care 2021; 66:1649-1656. [PMID: 34493608 PMCID: PMC9993533 DOI: 10.4187/respcare.09047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The generation of excessive inspiratory muscle pressure (Pmus) during assisted mechanical ventilation in patients with respiratory failure may result in acute respiratory muscle injury and/or fatigue, and exacerbate ventilator-induced lung injury. A readily available noninvasive surrogate measure of Pmus may help in titrating both mechanical ventilation and sedation to minimize these risks. This bench study explored the feasibility and accuracy of using a ventilator's expiratory pause hold function to measure Pmus across multiple operators. METHODS A standardized technique for executing a brief (<1 s) expiratory pause maneuver was used to measure the airway occlusion pressure change (Δ Paw) by using 3 simulated Pmus (Δ Pmus: 5, 10, 15 cm H2O) under (1) pressure support ventilation (0, 10, 15 cm H2O), (2) volume and pressure-regulated volume ventilation, (3) flow and pressure-triggering, and (4) varying levels of PEEP and pressure-rise time. Individual and grouped measurements were made by 4-7 clinicians on 3 different ventilators. The concordance between occlusion Δ Paw and Δ Pmus was arbitrarily set at ≤ 2 cm H2O. Data were evaluated by using analysis of variance and the Tukey-Kramer posttest. Correlation was assessed by using the Pearson R test; bias and precision were assessed by using the Bland-Altman method. Alpha was set at 0.05. RESULTS Grouped expiratory pause maneuver measurements of occlusion Δ Paw across simulated Δ Pmus, mode and level of ventilatory support showed reasonable concordance, regardless of the ventilator used. Occlusion Δ Paw accuracy frequently decreased by ∼3 cm H2O when both pressure support ventilation and Δ Pmus reached 15 cm H2O. Expiratory pause maneuver accuracy was not affected by trigger mechanism and/or sensitivity, PEEP, or the post-trigger pressurization rate. In general, only small differences in Δ Paw occurred among the individual operators. CONCLUSIONS The expiratory pause maneuver generally provided reproducible, stable approximations of Δ Pmus across ventilators and ventilator settings, and a range of simulated effort. Technique standardization produced relatively consistent results across multiple operators. The expiratory pause maneuver seemed feasible for general use in monitoring inspiratory effort during assisted mechanical ventilation.
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Affiliation(s)
| | | | | | | | | | | | | | - Michael S Lipnick
- Critical Care Division, Department of Anesthesia and Perioperative Care, University of California, San Francisco at Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California
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12
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Grieco DL, Maggiore SM, Roca O, Spinelli E, Patel BK, Thille AW, Barbas CSV, de Acilu MG, Cutuli SL, Bongiovanni F, Amato M, Frat JP, Mauri T, Kress JP, Mancebo J, Antonelli M. Non-invasive ventilatory support and high-flow nasal oxygen as first-line treatment of acute hypoxemic respiratory failure and ARDS. Intensive Care Med 2021; 47:851-866. [PMID: 34232336 PMCID: PMC8261815 DOI: 10.1007/s00134-021-06459-2] [Citation(s) in RCA: 87] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 06/09/2021] [Indexed: 12/21/2022]
Abstract
The role of non-invasive respiratory support (high-flow nasal oxygen and noninvasive ventilation) in the management of acute hypoxemic respiratory failure and acute respiratory distress syndrome is debated. The oxygenation improvement coupled with lung and diaphragm protection produced by non-invasive support may help to avoid endotracheal intubation, which prevents the complications of sedation and invasive mechanical ventilation. However, spontaneous breathing in patients with lung injury carries the risk that vigorous inspiratory effort, combined or not with mechanical increases in inspiratory airway pressure, produces high transpulmonary pressure swings and local lung overstretch. This ultimately results in additional lung damage (patient self-inflicted lung injury), so that patients intubated after a trial of noninvasive support are burdened by increased mortality. Reducing inspiratory effort by high-flow nasal oxygen or delivery of sustained positive end-expiratory pressure through the helmet interface may reduce these risks. In this physiology-to-bedside review, we provide an updated overview about the role of noninvasive respiratory support strategies as early treatment of hypoxemic respiratory failure in the intensive care unit. Noninvasive strategies appear safe and effective in mild-to-moderate hypoxemia (PaO2/FiO2 > 150 mmHg), while they can yield delayed intubation with increased mortality in a significant proportion of moderate-to-severe (PaO2/FiO2 ≤ 150 mmHg) cases. High-flow nasal oxygen and helmet noninvasive ventilation represent the most promising techniques for first-line treatment of severe patients. However, no conclusive evidence allows to recommend a single approach over the others in case of moderate-to-severe hypoxemia. During any treatment, strict physiological monitoring remains of paramount importance to promptly detect the need for endotracheal intubation and not delay protective ventilation.
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Affiliation(s)
- Domenico Luca Grieco
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. .,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy.
| | - Salvatore Maurizio Maggiore
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy.,University Department of Innovative Technologies in Medicine and Dentistry, Gabriele D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - Oriol Roca
- Servei de Medicina Intensiva, Hospital Universitari Vall D'Hebron, Institut de Recerca Vall D'Hebron, Barcelona, Spain.,Ciber Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Maggiore Policlinico Hospital, Milan, Italy
| | - Bhakti K Patel
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Arnaud W Thille
- Centre Hospitalier Universitaire (CHU) de Poitiers, Médecine Intensive Réanimation, Poitiers, France.,Centre D'Investigation Clinique 1402, ALIVE, INSERM, Université de Poitiers, Poitiers, France
| | - Carmen Sílvia V Barbas
- Division of Pulmonary and Critical Care, University of São Paulo, São Paulo, Brazil.,Intensive Care Unit, Albert Einstein Hospital, São Paulo, Brazil
| | - Marina Garcia de Acilu
- Servei de Medicina Intensiva, Hospital Universitari Vall D'Hebron, Institut de Recerca Vall D'Hebron, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Salvatore Lucio Cutuli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Filippo Bongiovanni
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
| | - Marcelo Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Jean-Pierre Frat
- Centre Hospitalier Universitaire (CHU) de Poitiers, Médecine Intensive Réanimation, Poitiers, France.,Centre D'Investigation Clinique 1402, ALIVE, INSERM, Université de Poitiers, Poitiers, France
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Maggiore Policlinico Hospital, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - John P Kress
- Department of Anesthesia, Critical Care and Emergency, Foundation IRCCS Ca' Granda Maggiore Policlinico Hospital, Milan, Italy
| | - Jordi Mancebo
- Servei de Medicina Intensiva, Hospital Universitari de La Santa Creu I Sant Pau, Barcelona, Spain
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, L.go F. Vito, 00168, Rome, Italy
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13
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Carteaux G, Parfait M, Combet M, Haudebourg AF, Tuffet S, Mekontso Dessap A. Patient-Self Inflicted Lung Injury: A Practical Review. J Clin Med 2021; 10:jcm10122738. [PMID: 34205783 PMCID: PMC8234933 DOI: 10.3390/jcm10122738] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/15/2021] [Accepted: 06/19/2021] [Indexed: 12/14/2022] Open
Abstract
Patients with severe lung injury usually have a high respiratory drive, resulting in intense inspiratory effort that may even worsen lung damage by several mechanisms gathered under the name “patient-self inflicted lung injury” (P-SILI). Even though no clinical study has yet demonstrated that a ventilatory strategy to limit the risk of P-SILI can improve the outcome, the concept of P-SILI relies on sound physiological reasoning, an accumulation of clinical observations and some consistent experimental data. In this review, we detail the main pathophysiological mechanisms by which the patient’s respiratory effort could become deleterious: excessive transpulmonary pressure resulting in over-distension; inhomogeneous distribution of transpulmonary pressure variations across the lung leading to cyclic opening/closing of nondependent regions and pendelluft phenomenon; increase in the transvascular pressure favoring the aggravation of pulmonary edema. We also describe potentially harmful patient-ventilator interactions. Finally, we discuss in a practical way how to detect in the clinical setting situations at risk for P-SILI and to what extent this recognition can help personalize the treatment strategy.
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Affiliation(s)
- Guillaume Carteaux
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, F-94010 Créteil, France
- Correspondence:
| | - Mélodie Parfait
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
| | - Margot Combet
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
| | - Anne-Fleur Haudebourg
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
| | - Samuel Tuffet
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, F-94010 Créteil, France
| | - Armand Mekontso Dessap
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Service de Médecine Intensive Réanimation, F-94010 Créteil, France; (M.P.); (M.C.); (A.-F.H.); (S.T.); (A.M.D.)
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, F-94010 Créteil, France
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14
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[Patient self-inflicted lung injury (P-SILI) : From pathophysiology to clinical evaluation with differentiated management]. Med Klin Intensivmed Notfmed 2021; 116:614-623. [PMID: 33961061 PMCID: PMC8103432 DOI: 10.1007/s00063-021-00823-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/19/2021] [Accepted: 03/23/2021] [Indexed: 02/08/2023]
Abstract
Die Etablierung der unterstützten Spontanatmung gilt allgemein als eine vorteilhafte und wenig gefährdende Phase der Beatmungstherapie. Allerdings geben neuere Erkenntnisse Hinweise auf eine potenzielle Schädigung durch exzessive Spontanatembemühungen vor allem bei akuter Lungenschädigung. Das Syndrom wird unter dem Begriff „patient self-inflicted lung injury“ zusammengefasst. Ärzte, Pflegepersonen und Atmungstherapeuten sollten für diese Thematik sensibilisiert werden. Parameter, die mittels Ösophagusdruckmessung oder einfacher Manöver am Respirator bestimmt werden können, sind bei der Entscheidung zur Durchführung und zur Überwachung von Spontanatmung auch in den akuten Phasen der Lungenschädigung hilfreich. Weiterhin gibt es im Umgang mit hohem Atemantrieb oder erhöhter Atemanstrengung therapeutische Möglichkeiten, diesen zu begegnen.
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15
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Oto B, Annesi J, Foley RJ. Patient-ventilator dyssynchrony in the intensive care unit: A practical approach to diagnosis and management. Anaesth Intensive Care 2021; 49:86-97. [PMID: 33906464 DOI: 10.1177/0310057x20978981] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patient-ventilator dyssynchrony or asynchrony occurs when, for any parameter of respiration, discordance exists between the patient's spontaneous effort and the ventilator's provided support. If not recognised, it may promote oversedation, prolong the duration of mechanical ventilation, create risk for lung injury, and generally confuse the clinical picture. Seven forms of dyssynchrony are common: (a) ineffective triggering; (b) autotriggering; (c) inadequate flow; (d) too much flow; (e) premature cycling; (f) delayed cycling; and (g) peak pressure apnoea. 'Reverse triggering' also occurs and may mimic premature cycling. Correct diagnosis of these phenomena often permits management by simple ventilator optimisation rather than by less desirable measures.
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Affiliation(s)
- Brandon Oto
- Adult Critical Care, UConn Health, Farmington, USA
| | - Janet Annesi
- Respiratory Therapy Department, UConn Health, Farmington, USA
| | - Raymond J Foley
- Division of Pulmonary, Critical Care, and Sleep Medicine, UConn Health, Farmington, USA
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16
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Abstract
PURPOSE OF REVIEW The aim of this study was to review the most recent literature on mechanical ventilation strategies in patients with septic shock. RECENT FINDINGS Indirect clinical trial evidence has refined the use of neuromuscular blocking agents, positive end-expiratory pressure (PEEP) and recruitment manoeuvres in septic shock patients with acute respiratory distress syndrome. Weaning strategies and devices have also been recently evaluated. The role of lung protective ventilation in patients with healthy lungs, while recognized, still needs to be further refined. The possible detrimental effects of spontaneous breathing in patients who develop acute respiratory distress syndrome is increasingly recognized, but clinical trial evidence is still lacking to confirm this hypothesis. A new concept of lung and diaphragm protective is emerging in the critical care literature, but its application will need a complex intervention implementation approach to allow adequate scrutiny of this concept and uptake by clinicians. SUMMARY Many advances in the management of the mechanically ventilated patient with sepsis and septic shock have occurred in recent years, but clinical trial evidence is still necessary to translate new hypotheses to the bedside and find the right balance between benefits and risks of these new strategies.
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17
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Goligher EC, Jonkman AH, Dianti J, Vaporidi K, Beitler JR, Patel BK, Yoshida T, Jaber S, Dres M, Mauri T, Bellani G, Demoule A, Brochard L, Heunks L. Clinical strategies for implementing lung and diaphragm-protective ventilation: avoiding insufficient and excessive effort. Intensive Care Med 2020; 46:2314-2326. [PMID: 33140181 PMCID: PMC7605467 DOI: 10.1007/s00134-020-06288-9] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/08/2020] [Indexed: 12/12/2022]
Abstract
Mechanical ventilation may have adverse effects on both the lung and the diaphragm. Injury to the lung is mediated by excessive mechanical stress and strain, whereas the diaphragm develops atrophy as a consequence of low respiratory effort and injury in case of excessive effort. The lung and diaphragm-protective mechanical ventilation approach aims to protect both organs simultaneously whenever possible. This review summarizes practical strategies for achieving lung and diaphragm-protective targets at the bedside, focusing on inspiratory and expiratory ventilator settings, monitoring of inspiratory effort or respiratory drive, management of dyssynchrony, and sedation considerations. A number of potential future adjunctive strategies including extracorporeal CO2 removal, partial neuromuscular blockade, and neuromuscular stimulation are also discussed. While clinical trials to confirm the benefit of these approaches are awaited, clinicians should become familiar with assessing and managing patients’ respiratory effort, based on existing physiological principles. To protect the lung and the diaphragm, ventilation and sedation might be applied to avoid excessively weak or very strong respiratory efforts and patient-ventilator dysynchrony.
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Affiliation(s)
- Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada.,Toronto General Hospital Research Institute, Toronto, Canada
| | - Annemijn H Jonkman
- Department of Intensive Care, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, Division of Respirology, University Health Network, Toronto, Canada
| | - Katerina Vaporidi
- Department of Intensive Care Medicine, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | - Jeremy R Beitler
- Center for Acute Respiratory Failure, Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Bhakti K Patel
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL, USA
| | - Takeshi Yoshida
- Department of Anesthesiology and Intensive Care Medicine, Osaka University Graduate School of Medicine, Suita, Japan
| | - Samir Jaber
- Critical Care and Anesthesia Department (DAR B), Hôpital Saint-Éloi, CHU de Montpellier, PhyMedExp, Université de Montpellier, Montpellier, France
| | - Martin Dres
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.,Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| | - Tommaso Mauri
- Department of Anesthesiology, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milan-Bicocca, Via Cadore 48, Monza, MB, Italy
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.,Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Keenan Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Leo Heunks
- Department of Intensive Care, Amsterdam UMC, Location VUmc, De Boelelaan 1117, 1081 HV, Amsterdam, the Netherlands.
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