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Grivans C, Stenqvist O. Gas distribution by EIT during PEEP inflation: PEEP response and optimal PEEP with lowest trans-pulmonary driving pressure can be determined without esophageal pressure during a rapid PEEP trial in patients with acute respiratory failure. Physiol Meas 2022; 43. [PMID: 36007512 DOI: 10.1088/1361-6579/ac8ccc] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/25/2022] [Indexed: 02/07/2023]
Abstract
Objective. Protective ventilation should be based onlungmechanics and transpulmonary driving pressure (ΔPTP), as this 'hits' the lung directly.Approach. The change in end-expiratory lung volume (ΔEELV) is determined by the size of the PEEP step and the elastic properties of the lung (EL), ΔEELV/ΔPEEP. Consequently, EL can be determined as ΔPEEP/ΔEELV. By calibration of tidal inspiratory impedance change with ventilator inspiratory tidal volume, end-expiratory lung impedance changes were converted to volume changes and lung P/V curves were obtained during a PEEP trial in ten patients with acute respiratory failure. The PEEP level where ΔPTP was lowest (optimal PEEP) was determined as the steepest point of the lung P/V curve.Main results. Over-all EL ranged between 7.0-23.2 cmH2O/L. Optimal PEEP was 12.9 cmH2O (10-16) with ΔPTP of 4.1 cmH2O (2.8-7.6). Patients with highest EL were PEEP non-responders, where EL increased in non-dependent and dependent lung at high PEEP, indicating over-distension in all lung. Patients with lower EL were PEEP responders with decreasing EL in dependent lung when increasing PEEP.Significance. PEEP non-responders could be identified by regional lung P/V curves derived from ventilator calibrated EIT. Optimal PEEP could be determined from the equation for the lung P/V curve.
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Affiliation(s)
| | - Ola Stenqvist
- Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
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2
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Yueyi J, Jing T, Lianbing G. A structured narrative review of clinical and experimental studies of the use of different positive end-expiratory pressure levels during thoracic surgery. THE CLINICAL RESPIRATORY JOURNAL 2022; 16:717-731. [PMID: 36181340 PMCID: PMC9629996 DOI: 10.1111/crj.13545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/03/2022] [Accepted: 09/12/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This study aimed to present a review on the general effects of different positive end-expiratory pressure (PEEP) levels during thoracic surgery by qualitatively categorizing the effects into detrimental, beneficial, and inconclusive. DATA SOURCE Literature search of Pubmed, CNKI, and Wanfang was made to find relative articles about PEEP levels during thoracic surgery. We used the following keywords as one-lung ventilation, PEEP, and thoracic surgery. RESULTS We divide the non-individualized PEEP value into five grades, that is, less than 5, 5, 5-10, 10, and more than 10 cmH2 O, among which 5 cmH2 O is the most commonly used in clinic at present to maintain alveolar dilatation and reduce the shunt fraction and the occurrence of atelectasis, whereas individualized PEEP, adjusted by test titration or imaging method to adapt to patients' personal characteristics, can effectively ameliorate intraoperative oxygenation and obtain optimal pulmonary compliance and better indexes relating to respiratory mechanics. CONCLUSIONS Available data suggest that PEEP might play an important role in one-lung ventilation, the understanding of which will help in exploring a simple and economical method to set the appropriate PEEP level.
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Affiliation(s)
- Jiang Yueyi
- The Affiliated Cancer Hospital of Nanjing Medical UniversityNanjingChina
| | - Tan Jing
- Department of AnesthesiologyJiangsu Cancer HospitalNanjingChina
| | - Gu Lianbing
- The Affiliated Cancer Hospital of Nanjing Medical UniversityNanjingChina,Department of AnesthesiologyJiangsu Cancer HospitalNanjingChina
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3
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Suleiman A, Costa E, Santer P, Tartler TM, Wachtendorf LJ, Teja B, Chen G, Baedorf-Kassis E, Nagrebetsky A, Vidal Melo MF, Eikermann M, Schaefer MS. Association between intraoperative tidal volume and postoperative respiratory complications is dependent on respiratory elastance: a retrospective, multicentre cohort study. Br J Anaesth 2022; 129:263-272. [PMID: 35690489 PMCID: PMC9837741 DOI: 10.1016/j.bja.2022.05.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 02/18/2022] [Accepted: 05/05/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The impact of high vs low intraoperative tidal volumes on postoperative respiratory complications remains unclear. We hypothesised that the effect of intraoperative tidal volume on postoperative respiratory complications is dependent on respiratory system elastance. METHODS We retrospectively recorded tidal volume (Vt; ml kg-1 ideal body weight [IBW]) in patients undergoing elective, non-cardiothoracic surgery from hospital registry data. The primary outcome was respiratory failure (requiring reintubation within 7 days of surgery, desaturation after extubation, or both). The primary exposure was defined as the interaction between Vt and standardised respiratory system elastance (driving pressure divided by Vt; cm H2O/[ml kg-1]). Multivariable logistic regression models, with and without interaction terms (which categorised Vt as low [Vt ≤8 ml kg-1] or high [Vt >8 ml kg-1]), were adjusted for potential confounders. Additional analyses included path mediation analysis and fractional polynomial modelling. RESULTS Overall, 10 821/197 474 (5.5%) patients sustained postoperative respiratory complications. Higher Vt was associated with greater risk of postoperative respiratory complications (adjusted odds ratio=1.42 per ml kg-1; 95% confidence interval [CI], 1.35-1.50]; P<0.001). This association was modified by respiratory system elastance (P<0.001); in patients with low compliance (<42.4 ml cm H2O-1), higher Vt was associated with greater risk of postoperative respiratory complications (adjusted risk difference=0.3% [95% CI, 0.0-0.5] at 41.2 ml cm H2O-1 compliance, compared with 5.8% [95% CI, 3.8-7.8] at 14 ml cm H2O-1 compliance). This association was absent when compliance exceeded 41.2 ml cm H2O-1. Adverse effects associated with high Vt were entirely mediated by driving pressures (P<0.001). CONCLUSIONS The association of harm with higher tidal volumes during intraoperative mechanical ventilation is modified by respiratory system elastance. These data suggest that respiratory elastance should inform the design of perioperative trials testing intraoperative ventilatory strategies.
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Affiliation(s)
- Aiman Suleiman
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Boston, MA, USA,Center for Anaesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Centre, Boston, MA, USA,Department of Anaesthesia and Intensive Care, Faculty of Medicine, University of Jordan, Amman, Jordan
| | - Eduardo Costa
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil,Research and Education Institute, Hospital Sírio-Libanes, Sao Paulo, Brazil
| | - Peter Santer
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Tim M. Tartler
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Boston, MA, USA,Center for Anaesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Luca J. Wachtendorf
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Boston, MA, USA,Center for Anaesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Centre, Boston, MA, USA,Department of Anaesthesiology, Montefiore Medical Centre and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Bijan Teja
- Department of Anaesthesiology and Pain Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Guanqing Chen
- Center for Anaesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Elias Baedorf-Kassis
- Department of Pulmonary, Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Centre, Boston, MA, USA
| | - Alexander Nagrebetsky
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Marcos F. Vidal Melo
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY, USA,Corresponding authors.
| | - Matthias Eikermann
- Department of Anaesthesiology, Montefiore Medical Centre and Albert Einstein College of Medicine, Bronx, NY, USA,Klinik für Anästhesiologie und Intensivmedizin, Universität Duisburg-Essen, Essen, Germany
| | - Maximilian S. Schaefer
- Department of Anaesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Boston, MA, USA,Center for Anaesthesia Research Excellence (CARE), Beth Israel Deaconess Medical Centre, Boston, MA, USA,Department of Anaesthesiology, Düsseldorf University Hospital, Dusseldorf, Germany,Corresponding authors.
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4
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Andrews P, Shiber J, Madden M, Nieman GF, Camporota L, Habashi NM. Myths and Misconceptions of Airway Pressure Release Ventilation: Getting Past the Noise and on to the Signal. Front Physiol 2022; 13:928562. [PMID: 35957991 PMCID: PMC9358044 DOI: 10.3389/fphys.2022.928562] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/21/2022] [Indexed: 12/16/2022] Open
Abstract
In the pursuit of science, competitive ideas and debate are necessary means to attain knowledge and expose our ignorance. To quote Murray Gell-Mann (1969 Nobel Prize laureate in Physics): “Scientific orthodoxy kills truth”. In mechanical ventilation, the goal is to provide the best approach to support patients with respiratory failure until the underlying disease resolves, while minimizing iatrogenic damage. This compromise characterizes the philosophy behind the concept of “lung protective” ventilation. Unfortunately, inadequacies of the current conceptual model–that focuses exclusively on a nominal value of low tidal volume and promotes shrinking of the “baby lung” - is reflected in the high mortality rate of patients with moderate and severe acute respiratory distress syndrome. These data call for exploration and investigation of competitive models evaluated thoroughly through a scientific process. Airway Pressure Release Ventilation (APRV) is one of the most studied yet controversial modes of mechanical ventilation that shows promise in experimental and clinical data. Over the last 3 decades APRV has evolved from a rescue strategy to a preemptive lung injury prevention approach with potential to stabilize the lung and restore alveolar homogeneity. However, several obstacles have so far impeded the evaluation of APRV’s clinical efficacy in large, randomized trials. For instance, there is no universally accepted standardized method of setting APRV and thus, it is not established whether its effects on clinical outcomes are due to the ventilator mode per se or the method applied. In addition, one distinctive issue that hinders proper scientific evaluation of APRV is the ubiquitous presence of myths and misconceptions repeatedly presented in the literature. In this review we discuss some of these misleading notions and present data to advance scientific discourse around the uses and misuses of APRV in the current literature.
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Affiliation(s)
- Penny Andrews
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
- *Correspondence: Penny Andrews,
| | - Joseph Shiber
- University of Florida College of Medicine, Jacksonville, FL, United States
| | - Maria Madden
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Gary F. Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Luigi Camporota
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, United Kingdom
| | - Nader M. Habashi
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
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5
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Protective positive end-expiratory pressure and tidal volume adapted to lung compliance determined by a rapid positive end-expiratory pressure-step procedure in the operating theatre: a post hoc analysis. Br J Anaesth 2022; 128:e284-e286. [DOI: 10.1016/j.bja.2022.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/30/2021] [Accepted: 01/12/2022] [Indexed: 11/22/2022] Open
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6
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Araos J, Lacitignola L, de Monte V, Stabile M, Porter I, Hurtado DE, Perez A, Crovace A, Grasso S, Martin-Flores M, Staffieri F. Evaluation of Lung Aeration and Respiratory System Mechanics in Obese Dogs Ventilated With Tidal Volumes Based on Ideal vs. Current Body Weight. Front Vet Sci 2021; 8:704863. [PMID: 34660755 PMCID: PMC8517180 DOI: 10.3389/fvets.2021.704863] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/06/2021] [Indexed: 11/23/2022] Open
Abstract
We describe the respiratory mechanics and lung aeration in anesthetized obese dogs ventilated with tidal volumes (VT) based on ideal (VTi) vs. current (VTc) body weight. Six dogs with body condition scores ≥ 8/9 were included. End-expiratory respiratory mechanics and end-expiratory CT-scan were obtained at baseline for each dog. Thereafter, dogs were ventilated with VT 15 ml kg−1 based on VTi and VTc, applied randomly. Respiratory mechanics and CT-scan were repeated at end-inspiration during VTi and VTc. Data analyzed with linear mixed models and reported as mean ± SD or median [range]. Statistical significance p < 0.05. The elastance of the lung, chest wall and respiratory system indexed by ideal body weight (IBW) were positively correlated with body fat percentage, whereas the functional residual capacity indexed by IBW was negatively correlated with body fat percentage. At end-expiration, aeration (%) was: hyperaeration 0.03 [0.00–3.35], normoaeration 69.7 [44.6–82.2], hypoaeration 29.3 [13.6–49.4] and nonaeration (1.06% [0.37–6.02]). Next to the diaphragm, normoaeration dropped to 12 ± 11% and hypoaeration increased to 90 ± 8%. No differences in aeration between groups were found at end-inspiration. Airway driving pressure (cm H2O) was higher (p = 0.002) during VTc (9.8 ± 0.7) compared with VTi (7.6 ± 0.4). Lung strain was higher (p = 0.014) during VTc (55 ± 21%) than VTi (38 ± 10%). The stress index was higher (p = 0.012) during VTc (SI = 1.07 [0.14]) compared with VTi (SI = 0.93 [0.18]). This study indicates that body fat percentage influences the magnitude of lung, chest wall, and total respiratory system elastance and resistance, as well as functional residual capacity. Further, these results indicate that obese dogs have extensive areas of hypoaerated lungs, especially in caudodorsal regions. Finally, lung strain and airway driving pressure, surrogates of lung deformation, are higher during VTc than during VTi, suggesting that in obese anesthetized dogs, ventilation protocols based on IBW may be advantageous.
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Affiliation(s)
- Joaquin Araos
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Luca Lacitignola
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantation D.E.O.T., "Aldo Moro" University of Bari, Bari, Italy
| | - Valentina de Monte
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantation D.E.O.T., "Aldo Moro" University of Bari, Bari, Italy
| | - Marzia Stabile
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantation D.E.O.T., "Aldo Moro" University of Bari, Bari, Italy
| | - Ian Porter
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Daniel E Hurtado
- Department of Structural and Geotechnical Engineering, School of Engineering, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Millennium Nucleus for Cardiovascular Magnetic Resonance, Santiago, Chile
| | - Agustín Perez
- Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Antonio Crovace
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantation D.E.O.T., "Aldo Moro" University of Bari, Bari, Italy
| | - Salvatore Grasso
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation D.E.O.T., "Aldo Moro" University of Bari, Bari, Italy
| | - Manuel Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Francesco Staffieri
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantation D.E.O.T., "Aldo Moro" University of Bari, Bari, Italy
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7
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Lee JH, Kang P, Song IS, Ji SH, Lee HC, Jang YE, Kim EH, Kim HS, Kim JT. Determining optimal positive end-expiratory pressure and tidal volume in children by intratidal compliance: a prospective observational study. Br J Anaesth 2021; 128:214-221. [PMID: 34686309 DOI: 10.1016/j.bja.2021.09.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/30/2021] [Accepted: 09/10/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Limited data exist regarding optimal intraoperative ventilation strategies for the paediatric population. This study aimed to determine the optimal combination of PEEP and tidal volume (VT) based on intratidal compliance profiles in healthy young children undergoing general anaesthesia. METHODS During anaesthesia, infants (1 month-1 yr), toddlers (1-3 yr), and children (3-6 yr) were assigned serially to four ventilator settings: PEEP 8 cm H2O/VT 8 ml kg-1 (PEEP8/VT8), PEEP 10 cm H2O/VT 5 ml kg-1 (PEEP10/VT5), PEEP 10 cm H2O/VT 8 ml kg-1 (PEEP10/VT8), and PEEP 12 cm H2O/VT 5 ml kg-1 (PEEP12/VT5). The primary outcome was intratidal compliance profile, classified at each ventilator setting as horizontal (indicative of optimal alveolar ventilatory conditions), increasing, decreasing, or combinations of increasing/decreasing/horizontal compliance. Secondary outcomes were peak inspiratory, plateau, and driving pressures. RESULTS Intratidal compliance was measured in 15 infants, 13 toddlers, and 15 children (15/43 [35%] females). A horizontal compliance profile was most frequently observed with PEEP10/VT5 (60.5%), compared with PEEP10/VT8, PEEP8/VT8, and PEEP12/VT5 (23.3-34.9%; P<0.001). Decreasing compliance profiles were most frequent when VT increased to 8 ml kg-1, PEEP increased to 12 cm H2O, or both. Plateau airway pressures were lower at PEEP8/VT8 (16.9 cm H2O [2.2]) and PEEP10/VT5 (16.7 cm H2O [1.7]), compared with PEEP10/VT8 (19.5 cm H2O [2.1]) and PEEP12/VT5 (19.0 cm H2O [2.0]; P<0.001). Driving pressure was lowest with PEEP10/VT5 (4.6 cm H2O), compared with other combinations (7.0 cm H2O [2.0]-9.5 cm H2O [2.1]; P<0.001). CONCLUSIONS VT 5 ml kg-1 combined with 10 cm H2O PEEP may reduce atelectasis and overdistension, and minimise driving pressure in the majority of mechanically ventilated children <6 yr. The effect of these PEEP and VT settings on postoperative pulmonary complications in children undergoing surgery requires further study. CLINICAL TRIAL REGISTRATION NCT04633720.
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Affiliation(s)
- Ji-Hyun Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Pyoyoon Kang
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - In Sun Song
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Sang-Hwan Ji
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyung-Chul Lee
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Young-Eun Jang
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun-Hee Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee-Soo Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Jin-Tae Kim
- Department of Anaesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Department of Anaesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea.
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8
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Definition and clinical evaluation of a recruiting airway pressure based on the specific lung elastance in anesthetized dogs. Vet Anaesth Analg 2021; 48:484-492. [PMID: 33926822 DOI: 10.1016/j.vaa.2021.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To determine the specific lung elastance (SEL) in anesthetized dogs and to evaluate the efficacy of a SEL-based recruiting airway pressure (RPaw) at improving global and regional lung aeration. STUDY DESIGN Retrospective and prospective clinical study. ANIMALS A total of 28 adult dogs were included in the retrospective study and six adult dogs in the prospective study. METHODS Retrospective study: SEL and SEL-based RPaw were determined using previously published data. In mechanically ventilated dogs undergoing thoracic computed tomography (CT), SEL was calculated as ΔPL/(VT/EELV), where ΔPL is the driving transpulmonary pressure, VT is the tidal volume and EELV is the end-expiratory lung volume. The ratio of lung to respiratory system elastance (EL/Ers) was determined. SEL and EL/Ers were used to calculate the SEL-based RPaw. Prospective study: dogs underwent thoracic CT at end-expiration and at end-inspiration using the SEL-based RPaw, and global and regional aeration was determined. For analysis of regional aeration, lungs were divided into cranial, intermediate and caudal regions. Regional compliance was also calculated. A p value <0.05 was considered significant. RESULTS The SEL and EL/Ers were 12.7 ± 3.1 cmH2O and 0.54 ± 0.07, respectively. The SEL-based RPaw was 29.1 ± 7.6 cmH2O. In the prospective study, the RPaw was 28.2 ± 1.3 cmH2O. During RPaw, hyperinflation increased (p = 0.0003) whereas poorly aerated (p < 0.0001) and nonaerated (p = 0.01) tissue decreased. Normally aerated tissue did not change (p = 0.265). Regional compliance was higher in the intermediate (p = 0.0003) and caudal (p = 0.034) regions compared with the cranial region. Aeration did not differ between regions (p > 0.05). CONCLUSIONS AND CLINICAL RELEVANCE An SEL-based RPaw reduces poorly and nonaerated lung tissue in anesthetized dogs. In nonsurgical anesthetized dogs, an RPaw near 30 cmH2O is effective at improving lung aeration.
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9
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Lee JH, Ji SH, Lee HC, Jang YE, Kim EH, Kim HS, Kim JT. Evaluation of the intratidal compliance profile at different PEEP levels in children with healthy lungs: a prospective, crossover study. Br J Anaesth 2020; 125:818-825. [DOI: 10.1016/j.bja.2020.06.046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/24/2020] [Accepted: 06/23/2020] [Indexed: 12/21/2022] Open
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10
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Gudmundsson M, Persson P, Perchiazzi G, Lundin S, Rylander C. Transpulmonary driving pressure during mechanical ventilation-validation of a non-invasive measurement method. Acta Anaesthesiol Scand 2020; 64:211-215. [PMID: 31585019 DOI: 10.1111/aas.13482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 08/27/2019] [Accepted: 09/15/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Transpulmonary driving pressure plays an important role in today's understanding of ventilator induced lung injury. We have previously validated a novel non-invasive method based on stepwise increments of PEEP to assess transpulmonary driving pressure in anaesthetised patients with healthy lungs. The aim of this study was to validate the method in patients who were mechanically ventilated for different diagnoses requiring intensive care. METHODS We measured transpulmonary pressure (Ptp) and calculated transpulmonary driving pressure (ΔPtp) in 31 patients undergoing mechanical ventilation in an intensive care unit. Parallel triplicate measurements were performed with the PEEP step method (PtpPSM) and the conventional oesophageal balloon method (Ptpconv). Their agreement was compared using the intraclass correlation coefficient (ICC) and the Bland Altman plot. RESULT The coefficient of variation for the repeated measurements was 4,3 for ΔPtpPSM and 9,2 for ΔPtpconv. The ICC of 0,864 and the Bland Altman plot indicate good agreement between the two methods. CONCLUSION The non-invasive method can be applied in mechanically ventilated patients to measure transpulmonary driving pressure with good repeatability and accuracy comparable to the traditional oesophageal balloon method.
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Affiliation(s)
- Magni Gudmundsson
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Per Persson
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Gaetano Perchiazzi
- Hedenstierna Laboratory, Institute of Medical Sciences Uppsala University Uppsala Sweden
| | - Stefan Lundin
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy University of Gothenburg Gothenburg Sweden
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11
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Affiliation(s)
- Stefan Lundin
- Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Persson
- Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Larsson
- Hedenstierna Laboratory, Uppsala University, Uppsala, Sweden
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12
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Williams EC, Motta-Ribeiro GC, Vidal Melo MF. Driving Pressure and Transpulmonary Pressure: How Do We Guide Safe Mechanical Ventilation? Anesthesiology 2019; 131:155-163. [PMID: 31094753 PMCID: PMC6639048 DOI: 10.1097/aln.0000000000002731] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The physiological concept, pathophysiological implications and clinical relevance and application of driving pressure and transpulmonary pressure to prevent ventilator-induced lung injury are discussed.
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Affiliation(s)
- Elizabeth C Williams
- From the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts. Current Affiliation: Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland (E.C.W.)
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13
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Stenqvist O, Persson P, Stahl CA, Lundin S. Monitoring transpulmonary pressure during anaesthesia using the PEEP-step method. Br J Anaesth 2018; 121:1373-1375. [PMID: 30442269 DOI: 10.1016/j.bja.2018.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 08/28/2018] [Accepted: 08/29/2018] [Indexed: 10/28/2022] Open
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Stenqvist O, Persson P, Lundin S. Can we estimate transpulmonary pressure without an esophageal balloon?-yes. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:392. [PMID: 30460266 DOI: 10.21037/atm.2018.06.05] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A protective ventilation strategy is based on separation of lung and chest wall mechanics and determination of transpulmonary pressure. So far, this has required esophageal pressure measurement, which is cumbersome, rarely used clinically and associated with lack of consensus on the interpretation of measurements. We have developed an alternative method based on a positive end expiratory pressure (PEEP) step procedure where the PEEP-induced change in end-expiratory lung volume is determined by the ventilator pneumotachograph. In pigs, lung healthy patients and acute lung injury (ALI) patients, it has been verified that the determinants of the change in end-expiratory lung volume following a PEEP change are the size of the PEEP step and the elastic properties of the lung, ∆PEEP × Clung. As a consequence, lung compliance can be calculated as the change in end-expiratory lung volume divided by the change in PEEP and esophageal pressure measurements are not needed. When lung compliance is determined in this way, transpulmonary driving pressure can be calculated on a breath-by-breath basis. As the end-expiratory transpulmonary pressure increases as much as PEEP is increased, it is also possible to determine the end-inspiratory transpulmonary pressure at any PEEP level. Thus, the most crucial factors of ventilator induced lung injury can be determined by a simple PEEP step procedure. The measurement procedure can be repeated with short intervals, which makes it possible to follow the course of the lung disease closely. By the PEEP step procedure we may also obtain information (decision support) on the mechanical consequences of changes in PEEP and tidal volume performed to improve oxygenation and/or carbon dioxide removal.
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Affiliation(s)
- Ola Stenqvist
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Persson
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stefan Lundin
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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Grieco D, Anzellotti G, Dell’Anna A, Russo A, Bongiovanni F, Antonelli M. PEEP-induced changes in lung volume to estimate transpulmonary pressure: the role of alveolar recruitment. Br J Anaesth 2018; 121:101-103. [DOI: 10.1016/j.bja.2018.03.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 03/29/2018] [Accepted: 04/01/2018] [Indexed: 10/17/2022] Open
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Grieco DL, Russo A, Romanò B, Anzellotti GM, Ciocchetti P, Torrini F, Barelli R, Eleuteri D, Perilli V, Dell'Anna AM, Bongiovanni F, Sollazzi L, Antonelli M. Lung volumes, respiratory mechanics and dynamic strain during general anaesthesia. Br J Anaesth 2018; 121:1156-1165. [PMID: 30336861 DOI: 10.1016/j.bja.2018.03.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 03/11/2018] [Accepted: 03/28/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Driving pressure (ΔP) represents tidal volume normalised to respiratory system compliance (CRS) and is a novel parameter to target ventilator settings. We conducted a study to determine whether CRS and ΔP reflect aerated lung volume and dynamic strain during general anaesthesia. METHODS Twenty non-obese patients undergoing open abdominal surgery received three PEEP levels (2, 7, or 12 cm H2O) in random order with constant tidal volume ventilation. Respiratory mechanics, lung volumes, and alveolar recruitment were measured to assess end-expiratory aerated volume, which was compared with the patient's individual predicted functional residual capacity in supine position (FRCp). RESULTS CRS was linearly related to aerated volume and ΔP to dynamic strain at PEEP of 2 cm H2O (intraoperative FRC) (r=0.72 and r=0.73, both P<0.001). These relationships were maintained with higher PEEP only when aerated volume did not overcome FRCp (r=0.73, P<0.001; r=0.54, P=0.004), with 100 ml lung volume increases accompanied by 1.8 ml cm H2O-1 (95% confidence interval [1.1-2.5]) increases in CRS. When aerated volume was greater or equal to FRCp (35% of patients at PEEP 2 cm H2O, 55% at PEEP 7 cm H2O, and 75% at PEEP 12 cm H2O), CRS and ΔP were independent from aerated volume and dynamic strain, with CRS weakly but significantly inversely related to alveolar dead space fraction (r=-0.47, P=0.001). PEEP-induced alveolar recruitment yielded higher CRS and reduced ΔP only at aerated volumes below FRCp (P=0.015 and 0.008, respectively). CONCLUSIONS During general anaesthesia, respiratory system compliance and driving pressure reflect aerated lung volume and dynamic strain, respectively, only if aerated volume does not exceed functional residual capacity in supine position, which is a frequent event when PEEP is used in this setting.
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Affiliation(s)
- D L Grieco
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy.
| | - A Russo
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - B Romanò
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - G M Anzellotti
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - P Ciocchetti
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - F Torrini
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - R Barelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - D Eleuteri
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - V Perilli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - A M Dell'Anna
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - F Bongiovanni
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - L Sollazzi
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
| | - M Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli", Rome, Italy
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Shaefi S, Eikermann M. Analysing tidal volumes early after a positive end-expiratory pressure increase: a new way to determine optimal PEEP in the operating theatre? Br J Anaesth 2018; 120:623-626. [PMID: 29576103 DOI: 10.1016/j.bja.2018.01.017] [Citation(s) in RCA: 96] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/01/2018] [Accepted: 01/22/2018] [Indexed: 11/16/2022] Open
Affiliation(s)
- S Shaefi
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - M Eikermann
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.
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