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Bouillon A, Vanwulpen M, Tackaert T, Cornelis R, Hachimi-Idrissi S. Explorative study on lower inflection point dynamics during cardiopulmonary resuscitation: Potential implications for airway management. Resuscitation 2024; 200:110242. [PMID: 38759718 DOI: 10.1016/j.resuscitation.2024.110242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 05/19/2024]
Abstract
INTRODUCTION In patients undergoing cardiopulmonary resuscitation (CPR) after an Out-of-Hospital Cardiac Arrest (OHCA), intrathoracic airway closure can impede ventilation, adversely affecting patient outcomes. This explorative study investigates the evolution of intrathoracic airway closure by analyzing the lower inflection point (LIP) during the inspiration phase of CPR, aiming to identify the potential thresholds for alveolar recruitment. METHODS AND MATERIALS Eleven OHCA patients undergoing CPR with endotracheal intubation and manual bag ventilation were included. Flow and pressure measurements were obtained using Sensirion SFM3200AW and Wika CPT2500 sensors attached to the endotracheal tube, connected to a Surface Go Tablet for data collection. Flow data was analyzed in Microsoft Excel, while pressure data was processed using the Wika USBsoft2500 application. Analysis focused on the inspiration phase of the first 6-8 breaths, with an additional 2 breaths recorded and analyzed at the end of CPR. RESULTS Across the cohort, the median tidal volume was 870.00 milliliter (mL), average flow was 31.90 standard liters per minute (slm), and average pressure was 17.21 cmH2O. The calculated average LIP was 31.47 cmH2O. Most cases (72.7%) exhibited a negative trajectory in LIP evolution during CPR, with 2 cases (18.2%) showing a positive trajectory and 1 case remaining inconclusive. The average LIP in the first 8 breaths was significantly higher than in the last 2 breaths (p = 0.018). No significant correlation was found between average LIP and return of spontaneous circulation (ROSC), compression depth, frequency, or end-tidal CO2 (EtCO2). However, a significant negative correlation was observed between the average LIP of the last 2 breaths and CPR duration (p = 0.023). VALIDATION LIP calculation in low-flow ventilations using the novel mathematical method yielded values consistent with those reported in the literature. DISCUSSION/CONCLUSION These explorative data demonstrate a predominantly negative trajectory in LIP evolution during CPR, suggesting potential challenges in maintaining airway patency. Limitations include a small sample size and sensor recording issues. Further research is warranted to explore the evolution of LIP and its implications for personalized ventilation strategies in CPR.
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Affiliation(s)
- Arthur Bouillon
- Faculty of Medicine and Health Sciences, Ghent University, Sint-Pietersnieuwstraat 25, Ghent, Belgium.
| | - Maxim Vanwulpen
- Faculty of Medicine and Health Sciences, Ghent University, Sint-Pietersnieuwstraat 25, Ghent, Belgium; Department of Emergency Medicine, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium
| | - Thomas Tackaert
- Faculty of Medicine and Health Sciences, Ghent University, Sint-Pietersnieuwstraat 25, Ghent, Belgium
| | - Ruben Cornelis
- Faculty of Medicine and Health Sciences, Ghent University, Sint-Pietersnieuwstraat 25, Ghent, Belgium
| | - Said Hachimi-Idrissi
- Faculty of Medicine and Health Sciences, Ghent University, Sint-Pietersnieuwstraat 25, Ghent, Belgium; Department of Emergency Medicine, Ghent University Hospital, Corneel Heymanslaan 10, Ghent, Belgium; Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, 1090 Brussels, Belgium
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Ernest EE, Bhattacharjee S, Baidya DK, Anand RK, Ray BR, Bansal VK, Subramaniam R, Maitra S. Effect of incremental PEEP titration on postoperative pulmonary complications in patients undergoing emergency laparotomy: a randomized controlled trial. J Clin Monit Comput 2024; 38:445-454. [PMID: 37968546 DOI: 10.1007/s10877-023-01091-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 10/08/2023] [Indexed: 11/17/2023]
Abstract
Postoperative pulmonary complications (PPC) has a significant negative impact and are associated with increased length of hospital stay and cost of care. Emergency surgery is a well-established risk factor for PPC. Previous studies reported that personalized positive end-expiratory pressure (PEEP) might reduce postoperative atelectasis and postoperative pulmonary complications. N = 168 adult patients undergoing major emergency laparotomy under general anesthesia were recruited in this study. A minimum driving pressure based incremental PEEP titration was compared to a fixed PEEP of 5 cmH2O. The primary outcome was PPC up to postoperative day 7. The mean (standard deviation) of the recruited patients was 41.7(16.1)y, and 48.8% (82 of 168 patients) were female. The risk of PPC at postoperative day 7 was similar in both the study groups [Relative risk (RR) (95% Confidence interval, CI) 0.81 (0.58, 1.13); p = 0.25]. In addition, the incidence of intraoperative hypotension [p = 0.75], oxygen-free days at day 28 [p = 0.27], duration of postoperative hospital stay [p = 0.50], length of postoperative intensive care unit stay [p = 0.28], and in-hospital mortality [p = 0.38] were similar in two groups. Incidence of PPC was not reduced with the use of an individualized PEEP strategy based on lowest driving pressure. However, the incidence of hypotension and bradycardia was also not increased with titrated PEEP.Trial Registration: www.ctri.nic.in ; CTRI/2020/12/029765.
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Affiliation(s)
- Emmanuel Easterson Ernest
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, Room No: 5013, Teaching Block, Ansari Nagar, New Delhi, 110019, India
| | - Sulagna Bhattacharjee
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, Room No: 5013, Teaching Block, Ansari Nagar, New Delhi, 110019, India
| | - Dalim K Baidya
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, Room No: 5013, Teaching Block, Ansari Nagar, New Delhi, 110019, India
| | - Rahul K Anand
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, Room No: 5013, Teaching Block, Ansari Nagar, New Delhi, 110019, India
| | - Bikash R Ray
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, Room No: 5013, Teaching Block, Ansari Nagar, New Delhi, 110019, India
| | - Virinder K Bansal
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
| | - Rajeshwari Subramaniam
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, Room No: 5013, Teaching Block, Ansari Nagar, New Delhi, 110019, India
| | - Souvik Maitra
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, Room No: 5013, Teaching Block, Ansari Nagar, New Delhi, 110019, India.
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Keleher E, Iftikhar H, Schulz LF, McCanny P, Austin D, Stewart A, O'Regan W, Hallbäck M, Wallin M, Aneman A. Capnodynamic monitoring of lung volume and pulmonary blood flow during alveolar recruitment: a prospective observational study in postoperative cardiac patients. J Clin Monit Comput 2023; 37:1463-1472. [PMID: 37243954 DOI: 10.1007/s10877-023-01033-1] [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: 10/26/2022] [Accepted: 05/08/2023] [Indexed: 05/29/2023]
Abstract
Alveolar recruitment manoeuvres may mitigate ventilation and perfusion mismatch after cardiac surgery. Monitoring the efficacy of recruitment manoeuvres should provide concurrent information on pulmonary and cardiac changes. This study in postoperative cardiac patients applied capnodynamic monitoring of changes in end-expiratory lung volume and effective pulmonary blood flow. Alveolar recruitment was performed by incremental increases in positive end-expiratory pressure (PEEP) to a maximum of 15 cmH2O from a baseline of 5 cmH2O over 30 min. The change in systemic oxygen delivery index after the recruitment manoeuvre was used to identify responders (> 10% increase) with all other changes (≤ 10%) denoting non-responders. Mixed factor ANOVA using Bonferroni correction for multiple comparisons was used to denote significant changes (p < 0.05) reported as mean differences and 95% CI. Changes in end-expiratory lung volume and effective pulmonary blood flow were correlated using Pearson's regression. Twenty-seven (42%) of 64 patients were responders increasing oxygen delivery index by 172 (95% CI 61-2984) mL min-1 m-2 (p < 0.001). End-expiratory lung volume increased by 549 (95% CI 220-1116) mL (p = 0.042) in responders associated with an increase in effective pulmonary blood flow of 1140 (95% CI 435-2146) mL min-1 (p = 0.012) compared to non-responders. A positive correlation (r = 0.79, 95% CI 0.5-0.90, p < 0.001) between increased end-expiratory lung volume and effective pulmonary blood flow was only observed in responders. Changes in oxygen delivery index after lung recruitment were correlated to changes in end-expiratory lung volume (r = 0.39, 95% CI 0.16-0.59, p = 0.002) and effective pulmonary blood flow (r = 0.60, 95% CI 0.41-0.74, p < 0.001). Capnodynamic monitoring of end-expiratory lung volume and effective pulmonary blood flow early in postoperative cardiac patients identified a characteristic parallel increase in both lung volume and perfusion after the recruitment manoeuvre in patients with a significant increase in oxygen delivery.Trial registration This study was registered on ClinicalTrials.gov (NCT05082168, 18th of October 2021).
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Affiliation(s)
- E Keleher
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - H Iftikhar
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - L F Schulz
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, NSW, Australia
| | - P McCanny
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, NSW, Australia
| | - D Austin
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, NSW, Australia
| | - A Stewart
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, NSW, Australia
| | - W O'Regan
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, NSW, Australia
| | | | - M Wallin
- Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - A Aneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, NSW, Australia.
- Southwestern Clinical School, University of New South Wales, Sydney, NSW, Australia.
- Ingham Institute for Applied Medical Research, Sydney, NSW, Australia.
- Intensive Care Unit, Liverpool Hospital, Locked Bag 7103, Liverpool BC, NSW, 1871, Australia.
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Choi JY, Al-Saedy MA, Carlson B. Positive end-expiratory pressure and postoperative complications in patients with obesity: a review and meta-analysis. Obesity (Silver Spring) 2023; 31:955-964. [PMID: 36855005 DOI: 10.1002/oby.23675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 10/25/2022] [Accepted: 11/15/2022] [Indexed: 03/02/2023]
Abstract
OBJECTIVE In patients with obesity, use of positive end-expiratory pressure (PEEP) > 5 cm H2 O (centimeters of water) has been shown to prevent intraoperative atelectasis. This study compares the rate of postoperative pulmonary complications (PPCs) associated with PEEP > 5 cm H2 O and PEEP ≤ 5 cm H2 O in patients with obesity who underwent surgery under general anesthesia with mechanical ventilation. METHODS This study searched Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) using the terms "PEEP," "anesthesia," and "ventilation." Cochrane ReviewManager (RevMan) version 5 was used for data analysis. The primary outcome was a composite of PPCs, including atelectasis, pneumonia, pneumothorax, and acute respiratory failure. RESULTS The initial search identified 903 titles and abstracts, and 4 randomized controlled trials were included for analysis. We included a total of 2116 participants from four randomized controlled trials that compared PEEP ≤ 5 cm H2 O with PEEP > 5 cm H2 O in adult patients with obesity. There was no statistically significant difference in PPCs between the PEEP ≤ 5 cm H2 O and PEEP > 5 cm H2 O groups (risk ratio = 2.21, 95% CI: 0.41-11.83; p = 0.35). However, a significant heterogeneity was found within included studies (I2 = 53%). CONCLUSIONS It is unclear whether PEEP > 5 cm H2 O improves the postoperative clinical outcome in patients with obesity, which is in contrast to previously established evidence that it reduces atelectasis in patients with obesity.
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Affiliation(s)
- Jae Y Choi
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, USA
| | - Miriam A Al-Saedy
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, USA
| | - Brian Carlson
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, USA
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Broberg E, Pierre L, Fakhro M, Malmsjö M, Lindstedt S, Hyllén S. Releasing high positive end-expiratory pressure to a low level generates a pronounced increase in particle flow from the airways. Intensive Care Med Exp 2023; 11:12. [PMID: 36929361 PMCID: PMC10020405 DOI: 10.1186/s40635-023-00498-3] [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: 06/09/2022] [Accepted: 02/04/2023] [Indexed: 03/18/2023] Open
Abstract
OBJECTIVES Detecting particle flow from the airways by a non-invasive analyzing technique might serve as an additional tool to monitor mechanical ventilation. In the present study, we used a customized particles in exhaled air (PExA) technique, which is an optical particle counter for the monitoring of particle flow in exhaled air. We studied particle flow while increasing and releasing positive end-expiratory pressure (PEEP). The aim of this study was to investigate the impact of different levels of PEEP on particle flow in exhaled air in an experimental setting. We hypothesized that gradually increasing PEEP will reduce the particle flow from the airways and releasing PEEP from a high level to a low level will result in increased particle flow. METHODS Five fully anesthetized domestic pigs received a gradual increase of PEEP from 5 cmH2O to a maximum of 25 cmH2O during volume-controlled ventilation. The particle count along with vital parameters and ventilator settings were collected continuously and measurements were taken after every increase in PEEP. The particle sizes measured were between 0.41 µm and 4.55 µm. RESULTS A significant increase in particle count was seen going from all levels of PEEP to release of PEEP. At a PEEP level of 15 cmH2O, there was a median particle count of 282 (154-710) compared to release of PEEP to a level of 5 cmH2O which led to a median particle count of 3754 (2437-10,606) (p < 0.009). A decrease in blood pressure was seen from baseline to all levels of PEEP and significantly so at a PEEP level of 20 cmH2O. CONCLUSIONS In the present study, a significant increase in particle count was seen on releasing PEEP back to baseline compared to all levels of PEEP, while no changes were seen when gradually increasing PEEP. These findings further explore the significance of changes in particle flow and their part in pathophysiological processes within the lung.
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Affiliation(s)
- Ellen Broberg
- Department of Clinical Sciences, Lund University, Lund, Sweden. .,Department of Cardiothoracic Anaesthesia and Intensive Care, Skåne University Hospital, Entrégatan 8, Level 8, 22241, Lund, Sweden.
| | - Leif Pierre
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Cardiothoracic Anaesthesia and Intensive Care, Skåne University Hospital, Entrégatan 8, Level 8, 22241, Lund, Sweden
| | - Mohammed Fakhro
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | - Malin Malmsjö
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Ophthalmology, Skåne University Hospital, Lund, Sweden
| | - Sandra Lindstedt
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden.,Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
| | - Snejana Hyllén
- Department of Clinical Sciences, Lund University, Lund, Sweden.,Department of Cardiothoracic Anaesthesia and Intensive Care, Skåne University Hospital, Entrégatan 8, Level 8, 22241, Lund, Sweden
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Razwanul Haque S, Sudan Saha S, Maruf Hossain AKM, Hasanur Rahman Sohag M, Rabbi Shafi F, Ranjan Sarkar S, Rahman T. Cost-effective and power-efficient portable turbine-based emergency ventilator. HARDWAREX 2022; 12:e00350. [PMID: 36110160 PMCID: PMC9468466 DOI: 10.1016/j.ohx.2022.e00350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 08/10/2022] [Accepted: 08/20/2022] [Indexed: 06/15/2023]
Abstract
Ventilators have always been common in medical scenarios but are very expensive to procure or develop. One of the main reasons for these is the components that are being used are expensive and require precise instrumentation, research, and development. This paper attempts to mitigate that problem by proposing a novel way to rapidly develop a portable ventilator that uses common 3D printing technology and off-the-shelf components. This turbine and valve-based ventilator feature most of the modes that are commonly used by healthcare professionals. A unique servo-based pressure release mechanism has been designed that makes the system around 36 times more efficient than solenoid-based systems. Reliability and efficiency have been increased further through the use of a novel positive end-expiratory pressure (PEEP) valve that does not contain any electromechanical component. Effective algorithms such as feed-forward and proportional-integral-derivative (PID) controllers were used alongside the unique 'Sensor data filtration methodology'. The system also provides an interactive graphical user interface (GUI) via an android application that can be installed on any readily found tabs while the firmware manages the breathing detection algorithm using a flow meter and pressure sensor. This modular and portable ventilator also features a replaceable battery and holds the ability to run on solar power. This energy-efficient low-noise system can run for 5 to 6 h at a stretch without needing to be connected to the main's supply.
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Renz M, Müllejans L, Riedel J, Mohnke K, Rissel R, Ziebart A, Duenges B, Hartmann EK, Ruemmler R. High PEEP Levels during CPR Improve Ventilation without Deleterious Haemodynamic Effects in Pigs. J Clin Med 2022; 11:jcm11164921. [PMID: 36013161 PMCID: PMC9410261 DOI: 10.3390/jcm11164921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/17/2022] [Accepted: 08/18/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Invasive ventilation during cardiopulmonary resuscitation (CPR) is very complex due to unique thoracic pressure conditions. Current guidelines do not provide specific recommendations for ventilation during ongoing chest compressions regarding positive end-expiratory pressure (PEEP). This trial examines the cardiopulmonary effects of PEEP application during CPR. Methods: Forty-two German landrace pigs were anaesthetised, instrumented, and randomised into six intervention groups. Three PEEP levels (0, 8, and 16 mbar) were compared in high standard and ultralow tidal volume ventilation. After the induction of ventricular fibrillation, mechanical chest compressions and ventilation were initiated and maintained for thirty minutes. Blood gases, ventilation/perfusion ratio, and electrical impedance tomography loops were taken repeatedly. Ventilation pressures and haemodynamic parameters were measured continuously. Postmortem lung tissue damage was assessed using the diffuse alveolar damage (DAD) score. Statistical analyses were performed using SPSS, and p values <0.05 were considered significant. Results: The driving pressure (Pdrive) showed significantly lower values when using PEEP 16 mbar than when using PEEP 8 mbar (p = 0.045) or PEEP 0 mbar (p < 0.001) when adjusted for the ventilation mode. Substantially increased overall lung damage was detected in the PEEP 0 mbar group (vs. PEEP 8 mbar, p = 0.038; vs. PEEP 16 mbar, p = 0.009). No significant differences in mean arterial pressure could be detected. Conclusion: The use of PEEP during CPR seems beneficial because it optimises ventilation pressures and reduces lung damage without significantly compromising blood pressure. Further studies are needed to examine long-term effects in resuscitated animals.
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Boules ME, Laz NI, Elberry AA, Hussein RRS, Abdelrahim MEA. Effect of pressures and type of ventilation on aerosol delivery to chronic obstructive pulmonary disease patients. BENI-SUEF UNIVERSITY JOURNAL OF BASIC AND APPLIED SCIENCES 2022; 11:57. [PMID: 35441078 PMCID: PMC9010937 DOI: 10.1186/s43088-022-00234-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 03/29/2022] [Indexed: 11/23/2022] Open
Abstract
Background Continuous Positive Airway Pressure (CPAP), BiPhasic Positive Airway Pressure (BiPAP), and high flow nasal cannula (HFNC) show some evidence to have efficacy in COVID-19 patients. Delivery during noninvasive mechanical ventilation (NIV) or HFNC gives faster and more enhanced clinical effects than when aerosols are given without assisted breath. The present work aimed to compare the effect of BiPhasic Positive Airway Pressure (BiPAP) mode at two different pressures; low BiPAP (Inspiratory Positive Airway Pressure (IPAP)/Expiratory Positive Airway Pressure (EPAP) of 10/5 cm water) and high BiPAP (IPAP/EPAP of 20/5 cm water), with HFNC system on pulmonary and systemic drug delivery of salbutamol. On the first day of the experiment, all patients received 2500 μg salbutamol using Aerogen Solo vibrating mesh nebulizer. Urine samples 30 min post-dose and cumulative urinary salbutamol during the next 24 h were collected on the next day. On the third day, the ex-vivo filter was inserted before the patient to collect the delivered dose to the patient of the 2500 μg salbutamol. Salbutamol was quantified using high-performance liquid chromatography (HPLC). Results Low-pressure BiPAP showed the highest amount delivered to the lung after 30 min followed by HFNC then high-pressure BiPAP. But the significant difference was only observed between low and high-pressure BiPAP modes (p = 0.012). Low-pressure BiPAP showed the highest delivered systemic delivery amount followed by HFNC then high-pressure BiPAP. Low-pressure BiPAP was significantly higher than HFNC (p = 0.017) and high-pressure BiPAP (p = 0.008). No significant difference was reported between HFNC and high-pressure BiPAP. The ex-vivo filter was the greatest in the case of low-pressure BiPAP followed by HFNC then high-pressure BiPAP. Low-pressure BiPAP was significantly higher than HFNC (p = 0.033) and high-pressure BiPAP (p = 0.008). Also, no significant difference was found between HFNC and high-pressure BiPAP. Conclusions Our results of pulmonary, systemic, and ex-vivo drug delivery were found to be consistent. The low BiPAP delivered the highest amount followed by the HFNC then the high BiPAP with the least amount. However, no significant difference was found between HFNC and high BiPAP.
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Nair PR, Ramachandran R, Trikha A, Anand RK, Rewari V. Effect of positive end expiratory pressure on atelectasis in patients undergoing major upper abdominal surgery under general anaesthesia: A lung ultrasonography study. J Perioper Pract 2022; 33:99-106. [PMID: 35322693 DOI: 10.1177/17504589211045218] [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: 11/17/2022]
Abstract
Postoperative pulmonary complications vary in major upper abdominal surgery. The objective of this study was to assess the effect of positive end expiratory pressure on the incidence of atelectasis in patients undergoing major upper abdominal surgery under general anaesthesia using lung ultrasound. The patients were randomised into receiving either no positive end expiratory pressure (Group I) or positive end expiratory pressure of 5cm H2O (Group II). Lung ultrasound was performed at various time points - baseline, 10 minutes, 2 hours after induction, during closure of skin and 30 minutes post extubation. The lung aeration as assessed by Total Modified Lung Ultrasound Score was worse in the Group I as compared to the Group II at 2 hours post induction. Driving pressure in Group II was significantly reduced compared to Group I. Application of positive end expiratory pressure, as minimal as 5cm H2O, as a single intervention, helps in significantly reducing the Total Modified Lung Ultrasound Score after a duration of more than 2 hours and also attaining low driving pressures during intraoperative mechanical ventilation.
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Affiliation(s)
- Parvathy Ramachandran Nair
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Rashmi Ramachandran
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Anjan Trikha
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Rahul Kumar Anand
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Vimi Rewari
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi 110029, India
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Hemodynamic variations in arterial wave reflection associated with the application of increasing levels of PEEP in healthy subjects. Sci Rep 2022; 12:3335. [PMID: 35228629 PMCID: PMC8885708 DOI: 10.1038/s41598-022-07410-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 02/16/2022] [Indexed: 11/16/2022] Open
Abstract
Positive end-expiratory pressure (PEEP) may affect arterial wave propagation and reflection, thus influencing ventricular loading conditions. The aim of the study was to investigate the hemodynamic variations in arterial wave reflection (i.e., wave reflection time, augmentation index, left ventricular ejection time, diastolic time, SEVR) associated with the application of increasing levels of PEEP in healthy subjects. We conducted a prospective observational study. Study population was selected from students and staff. Pulse contour wave analysis was performed from the right carotid artery during stepwise increase in PEEP levels (from 0 cmH2O, 5 cmH20, 10 cmH2O) with applanation tonometry. Sixty-two healthy volunteers were recruited. There were no significant changes in heart rate, augmentation index (AIx), left ventricular ejection time, Diastolic time (DT) among all of the different steps. A significant increase of time to the inflection point (Ti) was observed during all steps of the study. Diastolic area under the curve (AUC) divided by systolic-AUC (SEVR) increased from baseline to PEEP = 5 cmH2O, and from baseline to PEEP = 10 cmH2O. AIx and Ti were significantly correlated (directly) at the baseline and during PEEP = 10 cmH2O. Ti and DT were significantly correlated at the baseline and during PEEP = 5 cmH2O. In our preliminary results, low levels of PEEP played a role in the interaction between the heart and the vascular system, apparently mediated by a prolongation of the diastolic phase and a reduction in the systolic work of the heart. Clinical trials registration number: NCT03294928, 19/09/2017.
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Fridman SE, Di Giampietro P, Sensoli A, Beleffi M, Bucce C, Salvatore V, Giostra F, Gianstefani A. Prediction of Conventional Oxygen Therapy Failure in COVID-19 Patients With Acute Respiratory Failure by Assessing Serum Lactate Concentration, PaO2/FiO2 Ratio, and Body Temperature. Cureus 2022; 14:e21987. [PMID: 35155050 PMCID: PMC8820760 DOI: 10.7759/cureus.21987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 12/13/2022] Open
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Calero Rodriguez A, Oostrom H, Grauw J. Long‐term mechanical ventilation of an 8‐week‐old dog with idiopathic polyradiculoneuritis. VETERINARY RECORD CASE REPORTS 2022. [DOI: 10.1002/vrc2.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Abraham Calero Rodriguez
- Department of Equine Sciences Faculty of Veterinary Medicine University of Utrecht Utrecht The Netherlands
| | - Hugo Oostrom
- Department of Equine Sciences Faculty of Veterinary Medicine University of Utrecht Utrecht The Netherlands
| | - Janny Grauw
- Department of Equine Sciences Faculty of Veterinary Medicine University of Utrecht Utrecht The Netherlands
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Depta F, Torok P, Reeves V, Gentile M. Programmed Multi-Level Ventilation: A Strategy for Ventilating Non-Homogenous Lungs. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2021; 14:277-285. [PMID: 34584466 PMCID: PMC8464363 DOI: 10.2147/mder.s329352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/30/2021] [Indexed: 12/16/2022] Open
Abstract
Mechanical ventilation (MV) has been an integral method used in ICU care for decades. MV is typically viewed as a life-supporting intervention. However, it can also contribute to lung injury through stress and strain, as evidenced by ventilator-induced lung injury (VILI), even in previously healthy lungs. The negative impact may be worsened when significant lung non-homogeneity is present, eg. ALI and ARDS. Protective lung strategies to minimize VILI are to use low tidal volumes (Vt 4–6 mL/kg/PBW), plateau pressures (Pplat) <30 cmH2O and relatively high positive end-expiratory pressures (PEEP). Yet, use of constantly high PEEP levels is well recognized to result in hemodynamic compromise of the right ventricle, increased stress and strain through high mechanical energy impact on the lung and overdistension of relatively healthy lung tissue. Taking these issues into consideration, a different approach to mechanical ventilation was developed specifically for patients with non-homogeneity. This review focuses on a feature called programmed multi-level ventilation (PMLV). It is not a ventilation mode per se, but rather a form of extension that adjusts and modifies any ventilation mode (eg PCV,PSV, VCV, SIMV, etc.). PMLV is based on measured time constants (Tau) of the whole respiratory system, including artificial airways, breathing circuits, humidification devices and mechanical ventilator. Using a physiology-based approach presents a method to ventilate non-homogenous lungs through cyclic changes of different PEEP levels; recruitment takes place in lung areas with long time constants but protects relatively healthy lung areas from overdistension thus minimizing excessive mechanical power to the lung tissue.
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Affiliation(s)
- Filip Depta
- Department of Critical Care, East Slovak Institute of Cardiovascular Diseases, Košice, Slovakia.,Pavol Jozef Šafárik University, Košice, Slovakia
| | - Pavol Torok
- Department of Critical Care, East Slovak Institute of Cardiovascular Diseases, Košice, Slovakia.,Pavol Jozef Šafárik University, Košice, Slovakia
| | - Veldon Reeves
- Department of Administration and Medical Affairs, IPM Chirana Inc, Durham, NC, USA
| | - Michael Gentile
- Department of Administration and Medical Affairs, IPM Chirana Inc, Durham, NC, USA
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Ossai CI, Wickramasinghe N. Intelligent decision support with machine learning for efficient management of mechanical ventilation in the intensive care unit - A critical overview. Int J Med Inform 2021; 150:104469. [PMID: 33906020 DOI: 10.1016/j.ijmedinf.2021.104469] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 04/16/2021] [Accepted: 04/18/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Effective management of Mechanical Ventilation (MV) is vital for reducing morbidity, mortality, and cost of healthcare. OBJECTIVE This study aims to synthesize evidence for effective MV management through Intelligent decision support (IDS) with Machine Learning (ML). METHOD Databases that include EBSCO, IEEEXplore, Google Scholar, SCOPUS, and the Web of Science were systematically searched to identify studies on IDS for effective MV management regarding Tidal Volume (TV), asynchrony, weaning, and other outcomes such as the risk of Prolonged Mechanical ventilation (PMV). The quality of the articles identified was assessed with a modified Joanna Briggs Institute (JBI) critical appraisal checklist for cross-sessional research. RESULTS A total of 26 articles were identified for the study that has IDS for TV (n = 2, 7.8 %), asynchrony (n = 9, 34.6 %), weaning (n = 12, 46.2 %), and others (n = 3, 11.5 %). It was affirmed that implementing IDS in MV management will enhance seamless ICU patient management following the utilization of various Machine Learning (ML) algorithms in decision support. The studies relied on (n = 14) ML algorithms to predict the TV, asynchrony, weaning, risk of PMV and Positive End-Expiratory Pressure (PEEP) changes of 11-20262 ICU patients records with model inputs ranging from (n = 1) for timeseries analysis of TV to (n = 47) for weaning prediction. CONCLUSIONS The small data size, poor study design, and result reporting, with the heterogeneity of techniques used in the various studies, hampered the development of a unified approach for managing MV efficiency in TV monitoring, asynchrony, and weaning predictions. Notwithstanding, the ensemble model was able to predict TV, asynchrony, and weaning to a higher accuracy than the other algorithms.
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Affiliation(s)
- Chinedu I Ossai
- Faculty of Health, Arts and Design, School of Health Sciences, Department of Health and Medical Sciences, Swinburne University, John street Hawthorn, Victoria, 3122, Australia.
| | - Nilmini Wickramasinghe
- Faculty of Health, Arts and Design, School of Health Sciences, Department of Health and Medical Sciences, Swinburne University, John street Hawthorn, Victoria, 3122, Australia; Epworth Healthcare Australia, Australia.
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Siddiqui MA, Pandey S, Azim A, Sinha N, Siddiqui MH. Metabolomics: An emerging potential approach to decipher critical illnesses. Biophys Chem 2020; 267:106462. [PMID: 32911125 PMCID: PMC9986419 DOI: 10.1016/j.bpc.2020.106462] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/18/2020] [Accepted: 08/23/2020] [Indexed: 12/15/2022]
Abstract
Critical illnesses contribute to the maximum morbidity and mortality of hospitalized patients. Acute respiratory distress syndrome (ARDS) and sepsis/septic shock are the two most common acute illnesses associated with intensive care unit (ICU) admission. Once triggered, both have an identical underlying mechanism, portrayed by inflammation and endothelial dysfunction. The diagnosis of ARDS is based on clinical findings, laboratory tests, and radiological imaging. Blood cultures remain the gold standard for the diagnosis of sepsis, with the limitation of time delay and low positive yield. A combination of biomarkers has been proposed to diagnose and prognosticate these acute disorders with strengths and limitations, but still, the gold standard has been elusive to clinicians. In this review article, we illustrate the potential of metabolomics to unravel biomarkers that can be clinically utilized as a rapid prognostic and diagnostic tool associated with specific patient populations (ARDS and sepsis/septic shock) based on the available scientific data.
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Affiliation(s)
- Mohd Adnan Siddiqui
- Centre of Biomedical Research, SGPGIMS Campus, Lucknow 226014, India; Department of Bioengineering, Integral University, Lucknow 226026, India
| | - Swarnima Pandey
- Centre of Biomedical Research, SGPGIMS Campus, Lucknow 226014, India; Department of Zoology, Banaras Hindu University, Banaras 221005, India
| | - Afzal Azim
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Raebareli Road, Lucknow 226014, India.
| | - Neeraj Sinha
- Centre of Biomedical Research, SGPGIMS Campus, Lucknow 226014, India.
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Almeida MR, Horta JGÁ, de Matos NA, de Souza ABF, Castro TDF, Cândido LDS, Andrade MC, Cangussú SD, Costa GDP, Talvani A, Bezerra FS. The effects of different ventilatory modes in female adult rats submitted to mechanical ventilation. Respir Physiol Neurobiol 2020; 284:103583. [PMID: 33202295 DOI: 10.1016/j.resp.2020.103583] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 10/30/2020] [Accepted: 11/11/2020] [Indexed: 12/15/2022]
Abstract
This study aimed to analyze the effects of volume-controlled ventilation (VCV) and pressure-controlled ventilation (PCV) modes in female Wistar rats. 18 Wistar female adult rats were divided into three groups: control (CG), pressure-controlled ventilation (PCVG), and volume-controlled ventilation (VCVG). PCVG and VCVG were submitted to MV for one hour with a tidal volume (TV) of 8 mL/Kg, respiratory rate of 80 breaths/min, and positive end-expiratory pressure of 0 cmH2O. At the end of the experiment, all animals were euthanized. The neutrophils and lymphocytes influx to lung were higher in VCVG and PCVG compared to CG. The activities of superoxide dismutase, catalase and myeloperoxidase were higher in PCVG compared to CG. There was an increase in lipid peroxidation and protein oxidation in PCVG compared to CG. The levels of CCL3 and CCL5 were higher in PCVG compared to CG. In conclusions, the PCV mode promoted structural changes in the lung parenchyma, redox imbalance and inflammation in healthy adult female rats submitted to MV.
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Affiliation(s)
- Matheus Rocha Almeida
- Laboratory of Experimental Pathophysiology (LAFEx), Department of Biological Sciences (DECBI), Institute of Exact and Biological Sciences (ICEB), Federal University of Ouro Preto (UFOP), Brazil
| | - Jacques Gabriel Álvares Horta
- Laboratory of Experimental Pathophysiology (LAFEx), Department of Biological Sciences (DECBI), Institute of Exact and Biological Sciences (ICEB), Federal University of Ouro Preto (UFOP), Brazil; Department of Clinical Medicine/Pediatrics, School of Medicine, Federal University of Ouro Preto (UFOP), Ouro Preto, MG, Brazil
| | - Natália Alves de Matos
- Laboratory of Experimental Pathophysiology (LAFEx), Department of Biological Sciences (DECBI), Institute of Exact and Biological Sciences (ICEB), Federal University of Ouro Preto (UFOP), Brazil
| | - Ana Beatriz Farias de Souza
- Laboratory of Experimental Pathophysiology (LAFEx), Department of Biological Sciences (DECBI), Institute of Exact and Biological Sciences (ICEB), Federal University of Ouro Preto (UFOP), Brazil
| | - Thalles de Freitas Castro
- Laboratory of Experimental Pathophysiology (LAFEx), Department of Biological Sciences (DECBI), Institute of Exact and Biological Sciences (ICEB), Federal University of Ouro Preto (UFOP), Brazil
| | - Leandro da Silva Cândido
- Laboratory of Experimental Pathophysiology (LAFEx), Department of Biological Sciences (DECBI), Institute of Exact and Biological Sciences (ICEB), Federal University of Ouro Preto (UFOP), Brazil
| | - Mônica Campos Andrade
- Laboratory of Experimental Pathophysiology (LAFEx), Department of Biological Sciences (DECBI), Institute of Exact and Biological Sciences (ICEB), Federal University of Ouro Preto (UFOP), Brazil
| | - Sílvia Dantas Cangussú
- Laboratory of Experimental Pathophysiology (LAFEx), Department of Biological Sciences (DECBI), Institute of Exact and Biological Sciences (ICEB), Federal University of Ouro Preto (UFOP), Brazil
| | - Guilherme de Paula Costa
- Laboratory of Immunobiology of Inflammation (LABIIN), Department of Biological Sciences (DECBI), Institute of Exact and Biological Sciences (ICEB), Federal University of Ouro Preto (UFOP), Brazil
| | - André Talvani
- Laboratory of Immunobiology of Inflammation (LABIIN), Department of Biological Sciences (DECBI), Institute of Exact and Biological Sciences (ICEB), Federal University of Ouro Preto (UFOP), Brazil
| | - Frank Silva Bezerra
- Laboratory of Experimental Pathophysiology (LAFEx), Department of Biological Sciences (DECBI), Institute of Exact and Biological Sciences (ICEB), Federal University of Ouro Preto (UFOP), Brazil.
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Crouse SF, Lytle JR, Boutros S, Benton W, Moreno M, McCulloch PC, Lambert BS. Wearable positive end-expiratory pressure valve improves exercise performance. SPORTS MEDICINE AND HEALTH SCIENCE 2020; 2:159-165. [PMID: 35782287 PMCID: PMC9219351 DOI: 10.1016/j.smhs.2020.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/13/2020] [Accepted: 06/19/2020] [Indexed: 11/30/2022] Open
Abstract
We tested a PEEP (4.2 cmH2O) mouthpiece (PMP) on maximal cycling performance in healthy adults. Experiment-1, PMP vs. non-PMP mouthpiece (CON) [n = 9 (5♂), Age = 30 ± 2 yr]; Experiment-2, PMP vs. no mouthpiece (NMP) [n = 10 (7♂), Age = 27 ± 1 yr]. At timepoint 1 in both experiments (mouthpiece condition randomized) subjects performed graded cycling testing (GXT) (Corival® cycle ergometer) to determine V˙O2peak (ml∗kg∗min−1), O2pulse (mlO2∗bt−1), GXT endurance time (GXT-T(s)), and V˙O2(ml∗kg∗min−1)-at-ventilatory-threshold (V˙O2 @VT). At timepoint 2 72 h later, subjects completed a ventilatory-threshold-endurance-ride [VTER(s)] timed to exhaustion at V˙O2 @VT power (W). One week later at timepoints 3 and 4 (time-of-day controlled), subjects repeated testing protocols under the alternate mouthpiece condition. Selected results (paired T-test, p<0.05): Experiment 1 PMP vs. CON, respectively: V˙O2peak = 45.2 ± 2.4 vs. 42.4 ± 2.3 p<0.05; V˙O2@VT = 33.7 ± 2.0 vs. 32.3 ± 1.6; GXT-TTE = 521.7 ± 73.4 vs. 495.3 ± 72.8 (p<0.05); VTER = 846.2 ± 166.0 vs. 743.1 ± 124.7; O2pulse = 24.5 ± 1.4 vs. 23.1 ± 1.3 (p<0.05). Experiment 2 PMP vs. NMP, respectively: V˙O2peak = 43.3 ± 1.6 vs. 41.7 ± 1.6 (p<0.05); V˙O2@VT = 31.1 ± 1.2 vs. 29.1 ± 1.3 (p<0.05); GXT-TTE = 511.7 ± 49.6 vs. 486.4 ± 49.6 (p<0.05); VTER 872.4 ± 134.0 vs. 792.9 ± 122.4; O2pulse = 24.1 ± 0.9 vs. 23.4 ± 0.9 (p<0.05). Results demonstrate that the PMP conferred a significant performance benefit to cyclists completing high intensity cycling exercise.
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Affiliation(s)
- Stephen F. Crouse
- Department of Health and Kinesiology, Texas A&M University, College Station, TX, USA
- Corresponding author. Department of Health and Kinesiology Texas A&M University, 4245 TAMU, College Station, TX, 77843, USA.
| | - Jason R. Lytle
- Department of Health and Kinesiology, Texas A&M University, College Station, TX, USA
| | - Sean Boutros
- My Houston Surgeons, 9230 Katy Freeway, Suite 600, Houston, TX, USA
| | - William Benton
- PEEP Performance, LLC., 96 Siwanoy Blvd, Eastchester, NY, USA
| | - Michael Moreno
- Department of Mechanical Engineering, Texas A&M University, College Station, TX, USA
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The effect of positive end-expiratory pressure on cardiac output and oxygen delivery during cardiopulmonary resuscitation. Intensive Care Med Exp 2020; 8:36. [PMID: 32712733 PMCID: PMC7382317 DOI: 10.1186/s40635-020-00330-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 07/16/2020] [Indexed: 12/11/2022] Open
Abstract
Background Positive end-expiratory pressure (PEEP) is used to optimize oxygenation by preventing alveolar collapse. However, PEEP can potentially decrease cardiac output through cardiopulmonary interactions. The effect of PEEP on cardiac output during cardiopulmonary resuscitation (CPR) is not known. Methods This was a preclinical randomized, controlled, animal study conducted in an animal research facility on 25 Landrace-Yorkshire pigs. After inducing cardiac arrest, CPR was performed with LUCAS 3. During CPR, pigs were ventilated at a PEEP of 0, 5, 10, 15, 20 cmH2O (randomly determined via lottery) for 9 min. Cardiac output, obtained via ultrasound dilution, and PaO2 were measured, and oxygen delivery calculated for each PEEP. Results A mixed-effects repeated-measures analysis of variance was used to compare the baseline value adjusted mean cardiac output, PaO2, and oxygen delivery between PEEP groups. Least significant difference test was used to conduct pairwise comparisons between PEEP groups. To determine optimum PEEP, Gaussian mixture model was applied to the adjusted means of cardiac output and oxygen delivery. Increasing PEEP to 10 and higher resulted in significant declines in cardiac output. A PEEP of 15 and higher resulted in significant declines in oxygen delivery. As PEEP was increased from 0 to 20, PaO2 increased significantly. Gaussian mixture model identified the 0–5 PEEP group as providing optimal cardiac output and oxygen delivery, with PEEP of 5 providing the highest oxygen delivery. Conclusions A PEEP of 0–5 resulted in the optimal oxygen delivery and cardiac output during CPR, with PEEP of 5 resulting in higher oxygen delivery, and a slightly lower, statistically insignificant cardiac output than PEEP of 0.
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19
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Rupp T, Saugy JJ, Bourdillon N, Verges S, Millet GP. Positive expiratory pressure improves arterial and cerebral oxygenation in acute normobaric and hypobaric hypoxia. Am J Physiol Regul Integr Comp Physiol 2019; 317:R754-R762. [PMID: 31530174 DOI: 10.1152/ajpregu.00025.2019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Positive expiratory pressure (PEP) has been shown to limit hypoxia-induced reduction in arterial oxygen saturation, but its effectiveness on systemic and cerebral adaptations, depending on the type of hypoxic exposure [normobaric (NH) versus hypobaric (HH)], remains unknown. Thirteen healthy volunteers completed three randomized sessions consisting of 24-h exposure to either normobaric normoxia (NN), NH (inspiratory oxygen fraction, FiO2 = 13.6%; barometric pressure, BP = 716 mmHg; inspired oxygen partial pressure, PiO2 = 90.9 ± 1.0 mmHg), or HH (3,450 m, FiO2 = 20.9%, BP = 482 mmHg, PiO2 = 91.0 ± 0.6 mmHg). After the 6th and the 22nd hours, participants breathed quietly through a facemask with a 10-cmH2O PEP for 2 × 5 min interspaced with 5 min of free breathing. Arterial (SpO2, pulse oximetry), quadriceps, and cerebral (near-infrared spectroscopy) oxygenation, middle cerebral artery blood velocity (MCAv; transcranial Doppler), ventilation, and cardiovascular responses were recorded continuously. SpO2without PEP was significantly lower in HH (87 ± 4% on average for both time points, P < 0.001) compared with NH (91 ± 3%) and NN (97 ± 1%). PEP breathing did not change SpO2 in NN but increased it similarly in NH and HH (+4.3 ± 2.5 and +4.7 ± 4.1% after 6h; +3.5 ± 2.2 and +4.1 ± 2.9% after 22h, both P < 0.001). Although MCAv was reduced by PEP (in all sessions and at all time points, -6.0 ± 4.2 cm/s on average, P < 0.001), the cerebral oxygenation was significantly improved (P < 0.05) with PEP in both NH and HH, with no difference between conditions. These data indicate that PEP could be an attractive nonpharmacological means to improve arterial and cerebral oxygenation under both normobaric and hypobaric mild hypoxic conditions in healthy participants.
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Affiliation(s)
- Thomas Rupp
- Laboratoire Interuniversitaire de Biologie de la Motricité, Inter-University Laboratory of Human Movement Science, University Savoie Mont Blanc, Chambery, France
| | - Jonas J Saugy
- Institute of Sport Sciences of the University of Lausanne, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Nicolas Bourdillon
- Institute of Sport Sciences of the University of Lausanne, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Samuel Verges
- Hypoxia-pathophysiology 2 Laboratory, Grenoble Alpes University, France.,Unité 1042, INSERM, Grenoble, Grenoble, France
| | - Grégoire P Millet
- Institute of Sport Sciences of the University of Lausanne, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
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Di Bella C, Lacitignola L, Grasso S, Centonze P, Greco A, Ostuni R, Crovace A, Staffieri F. An alveolar recruitment maneuver followed by positive end-expiratory pressure improves lung function in healthy dogs undergoing laparoscopy. Vet Anaesth Analg 2018; 45:618-629. [DOI: 10.1016/j.vaa.2018.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Revised: 01/27/2018] [Accepted: 03/07/2018] [Indexed: 01/16/2023]
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Christensen M, Craft J. The cardio-respiratory effects of intra-abdominal hypertension: Considerations for critical care nursing practice. Intensive Crit Care Nurs 2017; 44:53-58. [PMID: 28600109 DOI: 10.1016/j.iccn.2017.05.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 05/12/2017] [Indexed: 11/28/2022]
Abstract
Intra-abdominal hypertension can be classified as either primary or secondary. Primary intra-abdominal hypertension is often associated through trauma or diseases of the abdominopelvic region such as pancreatitis or abdominal surgery, while secondary intra-abdominal hypertension is the result of extra-abdominal causes such as sepsis or burns. The critically ill patient offers some challenges in monitoring in particular secondary intra-abdominal hypertension because of the effects of fluid resuscitation, the use of inotropes and positive pressure ventilation. Recent work suggests that intensive care unit nurses are often unaware of the secondary effects of intra-abdominal pressure and therefore this is not monitored effectively. Therefore being aware of the cardio-respiratory effects may alert theintensive care nurse nurse to the development of intra-abdominal hypertension. The aim of this paper is to discuss the pathophysiology associated with the cardio-respiratory effects seen with intra-abdominal hypertension in the critically ill. In particular it will discuss how intra-abdominal hypertension can inadvertently be overlooked because of the low flow states that it produces which could be misconstrued as something else. It will also discuss how intra-abdominal hypertension impedes ventilation and respiratory mechanics which can often result in a non-cardiogenic pulmonary oedema. To close, the paper will offer some implications for critical care nursing practice.
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Affiliation(s)
- Martin Christensen
- School of Nursing, Queensland University of Technology, Caboolture Campus, Caboolture, Queensland 4510, Australia.
| | - Judy Craft
- School of Biomedical Sciences, Queensland University of Technology, Caboolture Campus, Caboolture, Queensland 4510, Australia.
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Amado-Rodríguez L, Del Busto C, García-Prieto E, Albaiceta GM. Mechanical ventilation in acute respiratory distress syndrome: The open lung revisited. Med Intensiva 2017; 41:550-558. [PMID: 28238441 DOI: 10.1016/j.medin.2016.12.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 12/26/2016] [Indexed: 02/02/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is still related to high mortality and morbidity rates. Most patients with ARDS will require ventilatory support. This treatment has a direct impact upon patient outcome and is associated to major side effects. In this regard, ventilator-associated lung injury (VALI) is the main concern when this technique is used. The ultimate mechanisms of VALI and its management are under constant evolution. The present review describes the classical mechanisms of VALI and how they have evolved with recent findings from physiopathological and clinical studies, with the aim of analyzing the clinical implications derived from them. Lastly, a series of knowledge-based recommendations are proposed that can be helpful for the ventilator assisted management of ARDS at the patient bedside.
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Affiliation(s)
- L Amado-Rodríguez
- Unidad de Gestión Clínica de Medicina Intensiva, Hospital Valle del Nalón, Langreo, Spain
| | - C Del Busto
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - E García-Prieto
- Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - G M Albaiceta
- Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Oviedo, Spain; Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain.
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Banner MJ, Euliano NR, Grooms D, Daniel Martin A, Al-Rawas N, Gabrielli A. Oxygenation advisor recommends appropriate positive end expiratory pressure and FIO2 settings: retrospective validation study. J Clin Monit Comput 2013; 28:203-10. [PMID: 24136193 DOI: 10.1007/s10877-013-9518-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 10/04/2013] [Indexed: 11/30/2022]
Abstract
A decision support, rule-based oxygenation advisor that provides guidance for setting positive end expiratory pressure (PEEP) and fractional inhaled oxygen concentration (FIO2) for patients with respiratory failure is described. The target oxygenation goal is to achieve and maintain pulse oximeter oxygen saturation (SpO2) ≥ 88 and ≤ 95%, as posited by the Acute Respiratory Distress Syndrome Network, by recommending appropriate combinations of PEEP and FIO2. For patient safety, the oxygenation advisor monitors mean arterial blood pressure (MAP) to ensure it is ≥ 65 mmHg for hemodynamic stability and inspiratory plateau pressure (Pplt) so it is ≤ 30 cm H2O for lung protection. The purpose of this validation study was to compare attending physicians' recommendations to those recommendations of the oxygenation advisor for setting PEEP and FIO2. Adults with respiratory failure (n = 117) receiving ventilatory support were studied. PEEP, FIO2, SpO2, MAP, and Pplt are input variables into the advisor. Recommendations to increase, maintain, or decrease PEEP and FIO2 are the oxygenation advisor's output variables. Physicians' recommendations for setting PEEP and FIO2 were recorded; the oxygenation advisor's recommendations were also recorded for comparison. At all times, ventilator settings were based on recommendations from attending physicians. PEEP ranged from 2 to 22 cm H2O and FIO2 ranged from 0.30 to 0.65. A total of 326 recommendations by the oxygenation advisor and attending physicians were made to increase, maintain, or decrease PEEP and FIO2. There was a very significant relationship (p < 0.0001) between recommendations of the oxygenation advisor and attending physicians for setting PEEP and FIO2. The agreement rate for recommendations by the oxygenation advisor and attending physicians was 92%. The K statistic, a test of the strength of agreement of recommendations between the oxygenation advisor and attending physicians, was 0.82 (p < 0.0001), indicating "almost perfect agreement". Relationships for recommendations made by the oxygenation advisor and attending physicians for setting PEEP and FIO2 were excellent, PEEP: r = 0.98 (p < 0.01), r(2) = 0.96; FIO2: r = 0.91 (p < 0.01), r(2) = 0.83, bias and precision values were negligible. A novel oxygenation advisor provided continuous and automatic recommendations for setting PEEP and FIO2 that were shown to be as good as the clinical judgment of experienced attending physicians. For all patients, the target oxygenation goal was achieved. Concerning patient safety, the oxygenation advisor detected those occasions when MAP and Pplt were in potentially unsafe ranges.
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Affiliation(s)
- Michael J Banner
- Department of Anesthesiology, University of Florida College of Medicine, PO Box 100254, 1600 SW Archer Road, Gainesville, FL, 32610, USA,
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Bang JO, Ha SI, Choi IC. The effect of positive-end expiratory pressure on oxygenation during high frequency jet ventilation and conventional mechanical ventilation in the rabbit model of acute lung injury. Korean J Anesthesiol 2012; 63:346-52. [PMID: 23115688 PMCID: PMC3483494 DOI: 10.4097/kjae.2012.63.4.346] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 07/12/2012] [Accepted: 08/02/2012] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND The use of positive end expiratory pressure (PEEP) in patients with acute lung injury (ALI) improves arterial oxygenation by alleviating pulmonary shunting, helping the respiratory muscles to decrease the work of breathing, decreasing the rate of infiltrated and atelectatic tissues, and increasing functional residual capacity. In a rabbit model of saline lavage-induced ALI, we examined the effects of PEEP on gas exchange, hemodynamics, and oxygenation during high frequency jet ventilation (HFJV), and then compared these parameters with those during conventional mechanical ventilation (CMV). METHODS Twelve rabbits underwent repeated saline lavage to create ALI. The animals were divided in 2 groups: 1) Group CMV (n = 6), and 2) Group HFJV (n = 6). In both groups, we applied 2 levels of PEEP (5 cmH(2)O and 10 cmH(2)O) and then measured the arterial blood gas, mixed venous blood gas, and hemodynamic parameters. RESULTS With administration of PEEP of either 5 cmH(2)O or 10 cmH(2)O, the arterial oxygen content of both groups was increased, although without statistically significant differences between groups. On the contrary, the arterial carbon dioxide content was significantly decreased in the HFJV group, as compared with the CMV group, during the entire experiment. Furthermore, there was significant decreases in mean arterial pressures in both groups with a PEEP of 10 cmH(2)O. CONCLUSIONS The application of PEEP in rabbits with ALI effectively improves oxygenation in either HFJV or CMV.
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Affiliation(s)
- Jae Ouk Bang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Il Ha
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In-Cheol Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Sundaresan A, Chase JG, Hann CE, Shaw GM. Cardiac output estimation using pulmonary mechanics in mechanically ventilated patients. Biomed Eng Online 2010; 9:80. [PMID: 21108836 PMCID: PMC3009970 DOI: 10.1186/1475-925x-9-80] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 11/25/2010] [Indexed: 01/09/2023] Open
Abstract
The application of positive end expiratory pressure (PEEP) in mechanically ventilated (MV) patients with acute respiratory distress syndrome (ARDS) decreases cardiac output (CO). Accurate measurement of CO is highly invasive and is not ideal for all MV critically ill patients. However, the link between the PEEP used in MV, and CO provides an opportunity to assess CO via MV therapy and other existing measurements, creating a CO measure without further invasiveness. This paper examines combining models of diffusion resistance and lung mechanics, to help predict CO changes due to PEEP. The CO estimator uses an initial measurement of pulmonary shunt, and estimations of shunt changes due to PEEP to predict CO at different levels of PEEP. Inputs to the cardiac model are the PV loops from the ventilator, as well as the oxygen saturation values using known respiratory inspired oxygen content. The outputs are estimates of pulmonary shunt and CO changes due to changes in applied PEEP. Data from two published studies are used to assess and initially validate this model. The model shows the effect on oxygenation due to decreased CO and decreased shunt, resulting from increased PEEP. It concludes that there is a trade off on oxygenation parameters. More clinically importantly, the model also examines how the rate of CO drop with increased PEEP can be used as a method to determine optimal PEEP, which may be used to optimise MV therapy with respect to the gas exchange achieved, as well as accounting for the impact on the cardiovascular system and its management.
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Affiliation(s)
- Ashwath Sundaresan
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand.
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Hamaekers A, Borg P, Enk D. The importance of flow and pressure release in emergency jet ventilation devices. Paediatr Anaesth 2009; 19:452-7. [PMID: 19040504 DOI: 10.1111/j.1460-9592.2008.02830.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several self-assembled devices, consisting of a three-way stopcock connected to a high pressure oxygen source, have been proposed for transtracheal jet ventilation in an emergency situation. As a three-way stopcock acts as a 'flow splitter' it will, when connected to a continuous oxygen flow, never ensure total flow and pressure release through its side port. The aim of the present study was to measure the efficacy of flow and pressure release of three previously described self-assembled jet devices and one commercially available tool. METHODS In a laboratory setting simulating an obstructed upper airway the generated pressure at the cannula tip (PACT) during the expiration phase was measured in three self-assembled jet devices consisting of a three-way stopcock with an inner diameter of 2 mm (device A), 2.5 mm (device B), and 3 mm (device C), respectively, and in the Oxygen Flow Modulator (OFM) at oxygen flows of 6, 9, 12, and 15 l min(-1). RESULTS The PACT of device A at on oxygen flow of 15 l min(-1) was 71.1 (+/-0.08) cm H(2)O. At a reduced flow of 9 l min(-1) the PACT of device A was still 25.8 (+/-0.08) cm H2O. In device B and C the PACT was 35.6 (+/-0.04) and 17.6 (+/-0.04) cm H2O, respectively, at an oxygen flow of 15 l.min(-1). In contrast, the PACT in the OFM (five side holes open) was 4.4 (+/-0.02) cm H2O at the same flow. CONCLUSION In case of complete upper airway obstruction the OFM provides sufficient flow and pressure release, whereas the self-assembled jet devices tested are inherently dangerous constructions.
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Affiliation(s)
- Ankie Hamaekers
- Department of Anesthesiology, Maastricht University Medical Centre, PO Box 5800, Maastricht 6202 AZ, The Netherlands.
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Zagli G, Tarantini F, Bonizzoli M, Di Filippo A, Peris A, De Gaudio AR, Geppetti P. Altered pharmacology in the Intensive Care Unit patient. Fundam Clin Pharmacol 2008; 22:493-501. [PMID: 18684127 DOI: 10.1111/j.1472-8206.2008.00623.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Critically ill patients, not infrequently present alterations of physiological parameters that determine the success/failure of therapeutic interventions as well as the final outcome. Sepsis and polytrauma are two of the most common and complex syndromes occurring in Intensive Care Unit (ICU) and affect drug absorption, disposition, metabolism and elimination. Pharmacological management of ICU patients requires consideration of the unique pharmacokinetics associated with these clinical conditions and the likely occurrence of drug interaction. Rational adjustment in drug choice and dosing contributes to the appropriateness of treatment of those patients.
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Affiliation(s)
- Giovanni Zagli
- Department of Critical Care Medicine and Surgery, University of Florence and Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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Effect of pressure support ventilation and positive end expiratory pressure on the rapid shallow breathing index in intensive care unit patients. Intensive Care Med 2007; 34:505-10. [DOI: 10.1007/s00134-007-0939-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2007] [Accepted: 10/31/2007] [Indexed: 10/22/2022]
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