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Santini A, Protti A, Pennati F, Dalla Corte F, Martinetti N, Pugliese L, Picardo G, Chiurazzi C, Ferrari M, Costantini E, Aliverti A, Cecconi M. Effect of decreasing PEEP on hyperinflation and collapse in COVID-19: A computed tomography study. Acta Anaesthesiol Scand 2024; 68:626-634. [PMID: 38425207 DOI: 10.1111/aas.14401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 01/24/2024] [Accepted: 02/11/2024] [Indexed: 03/02/2024]
Abstract
BACKGROUND High positive end-expiratory pressure (PEEP>10 cmH2O) is commonly used in mechanically ventilated hypoxemic patients with COVID-19. However, some epidemiological and physiological studies indirectly suggest that using a lower PEEP may primarily and beneficially decrease lung hyperinflation in this population. Herein we directly quantified the effect of decreasing PEEP from 15 to 10 cmH2O on lung hyperinflation and collapse in mechanically ventilated patients with COVID-19. METHODS Twenty mechanically ventilated patients with COVID-19 underwent a lung computed tomography (CT) at PEEP of 15 and 10 cmH2O. The effect of decreasing PEEP on lung hyperinflation and collapse was directly quantified as the change in the over-aerated (density below -900 HU) and non-aerated (density above -100 HU) lung volumes. The net response to decreasing PEEP was computed as the sum of the change in those two compartments and expressed as the change in the "pathologic" lung volume. If the pathologic lung volume decreased (i.e., hyperinflation decreased more than collapse increased) when PEEP was decreased, the net response was considered positive; otherwise, it was considered negative. RESULTS On average, the ratio of arterial tension to inspiratory fraction of oxygen (PaO2:FiO2) in the overall study population was 137 (119-162) mmHg. In 11 (55%) patients, the net response to decreasing PEEP was positive. Their over-aerated lung volume decreased by 159 (98-186) mL, while the non-aerated lung volume increased by only 58 (31-91) mL. In nine (45%) patients, the net response was negative. Their over-aerated lung volume decreased by 46 (18-72) mL, but their non-aerated lung volume increased by 107 (44-121) mL. CONCLUSION In 20 patients with COVID-19 the net response to decreasing PEEP, as assessed with lung CT, was variable. In approximately half of them it was positive (and possibly beneficial), with a decrease in hyperinflation larger than the increase in collapse.
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Affiliation(s)
- Alessandro Santini
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Francesca Pennati
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Francesca Dalla Corte
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Nicolò Martinetti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Luca Pugliese
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Giorgio Picardo
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Chiara Chiurazzi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Michele Ferrari
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Elena Costantini
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Milan, Italy
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Marini JJ. Detecting end-tidal hyperinflation. Intensive Care Med 2024; 50:752-754. [PMID: 38563895 DOI: 10.1007/s00134-024-07379-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/27/2024] [Indexed: 04/04/2024]
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Gatti S, Rezoagli E, Madotto F, Foti G, Bellani G. A non-invasive continuous and real-time volumetric monitoring in spontaneous breathing subjects based on bioimpedance-ExSpiron®Xi: a validation study in healthy volunteers. J Clin Monit Comput 2024; 38:539-551. [PMID: 38238635 PMCID: PMC10994998 DOI: 10.1007/s10877-023-01107-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 11/10/2023] [Indexed: 04/06/2024]
Abstract
Tidal volume (TV) monitoring breath-by-breath is not available at bedside in non-intubated patients. However, TV monitoring may be useful to evaluate the work of breathing. A non-invasive device based on bioimpedance provides continuous and real-time volumetric tidal estimation during spontaneous breathing. We performed a prospective study in healthy volunteers aimed at evaluating the accuracy, the precision and the trending ability of measurements of ExSpiron®Xi as compared with the gold standard (i.e. spirometry). Further, we explored whether the differences between the 2 devices would be improved by the calibration of ExSpiron®Xi with a pre-determined tidal volume. Analysis accounted for the repeated nature of measurements within each subject. We enrolled 13 healthy volunteers, including 5 men and 8 women. Tidal volume, TV/ideal body weight (IBW) and respiratory rate (RR) measured with spirometer (TVSpirometer) and with ExSpiron®Xi (TVExSpiron) showed a robust correlation, while minute ventilation (MV) showed a weak correlation, in both non/calibrated and calibrated steps. The analysis of the agreement showed that non-calibrated TVExSpiron underestimated TVspirometer, while in the calibrated steps, TVExSpiron overestimated TVspirometer. The calibration procedure did not reduce the average absolute difference (error) between TVSpirometer and TVExSpiron. This happened similarly for TV/IBW and MV, while RR showed high accuracy and precision. The trending ability was excellent for TV, TV/IBW and RR. The concordance rate (CR) was >95% in both calibrated and non-calibrated measurements. The trending ability of minute ventilation was limited. Absolute error for both calibrated and not calibrated values of TV, TV/IBW and MV accounting for repeated measurements was variably associated with BMI, height and smoking status. Conclusions: Non-invasive TV, TV/IBW and RR estimation by ExSpiron®Xi was strongly correlated with tidal ventilation according to the gold standard spirometer technique. This data was not confirmed for MV. The calibration of the device did not improve its performance. Although the accuracy of ExSpiron®Xi was mild and the precision was limited for TV, TV/IBW and MV, the trending ability of the device was strong specifically for TV, TV/IBW and RR. This makes ExSpiron®Xi a non-invasive monitoring system that may detect real-time tidal volume ventilation changes and then suggest the need to better optimize the patient ventilatory support.
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Affiliation(s)
- Stefano Gatti
- Department of Emergency and Intensive Care, Terapia Intensiva e Semintensiva adulti e Pediatrica, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | - Emanuele Rezoagli
- Department of Emergency and Intensive Care, Terapia Intensiva e Semintensiva adulti e Pediatrica, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Fabiana Madotto
- Department of Area Emergenza Urgenza, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Foti
- Department of Emergency and Intensive Care, Terapia Intensiva e Semintensiva adulti e Pediatrica, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Giacomo Bellani
- Centre for Medical Sciences - CISMed, University of Trento, Trento, Italy.
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento Largo Medaglie d'Oro, Trento, Italy.
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Kummer RL, Marini JJ. The Respiratory Mechanics of COVID-19 Acute Respiratory Distress Syndrome-Lessons Learned? J Clin Med 2024; 13:1833. [PMID: 38610598 PMCID: PMC11012401 DOI: 10.3390/jcm13071833] [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: 01/31/2024] [Revised: 03/13/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a well-defined clinical entity characterized by the acute onset of diffuse pulmonary injury and hypoxemia not explained by fluid overload. The COVID-19 pandemic brought about an unprecedented volume of patients with ARDS and challenged our understanding and clinical approach to treatment of this clinical syndrome. Unique to COVID-19 ARDS is the disruption and dysregulation of the pulmonary vascular compartment caused by the SARS-CoV-2 virus, which is a significant cause of hypoxemia in these patients. As a result, gas exchange does not necessarily correlate with respiratory system compliance and mechanics in COVID-19 ARDS as it does with other etiologies. The purpose of this review is to relate the mechanics of COVID-19 ARDS to its underlying pathophysiologic mechanisms and outline the lessons we have learned in the management of this clinic syndrome.
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Affiliation(s)
- Rebecca L. Kummer
- Department of Pulmonary and Critical Care Medicine, University of Minnesota School of Medicine, Minneapolis, MN 55455, USA
| | - John J. Marini
- Department of Pulmonary and Critical Care Medicine, Regions Hospital, St. Paul, MN 55101, USA
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Rezoagli E, Bastia L. Obesity Enhances the Gravity Effect on the Respiratory System: The Importance of Monitoring Lung Mechanics. Chest 2024; 165:475-477. [PMID: 38461004 DOI: 10.1016/j.chest.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 03/11/2024] Open
Affiliation(s)
- Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy.
| | - Luca Bastia
- Anesthesia and Intensive Care Unit, AUSL Romagna, M. Bufalini Hospital, Cesena, Italy
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Moncomble E, Tuffet S, Boujelben M, Gendreau S, Labedade P, Haudebourg AF, Dessap AM, Carteaux G. Paradoxical Response to Standardized Chest Loading May Unveil Occult Overdistension During Protective Ventilation. Am J Respir Crit Care Med 2024; 209:221-223. [PMID: 37956248 DOI: 10.1164/rccm.202309-1579le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 11/10/2023] [Indexed: 11/15/2023] Open
Affiliation(s)
- Elsa Moncomble
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France
- Université Paris Est-Créteil, Groupe de Recherche Clinique CARMAS, Créteil, France
| | - Samuel Tuffet
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France
- Université Paris Est-Créteil, Groupe de Recherche Clinique CARMAS, Créteil, France
- Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, France
| | - Mohamed Boujelben
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France
- Université Paris Est-Créteil, Groupe de Recherche Clinique CARMAS, Créteil, France
- Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, France
| | - Ségolène Gendreau
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France
- Université Paris Est-Créteil, Groupe de Recherche Clinique CARMAS, Créteil, France
| | - Pascale Labedade
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France
- Université Paris Est-Créteil, Groupe de Recherche Clinique CARMAS, Créteil, France
- Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, France
| | - Anne-Fleur Haudebourg
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France
- Université Paris Est-Créteil, Groupe de Recherche Clinique CARMAS, Créteil, France
| | - Armand Mekontso Dessap
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France
- Université Paris Est-Créteil, Groupe de Recherche Clinique CARMAS, Créteil, France
| | - Guillaume Carteaux
- Assistance Publique-Hôpitaux de Paris, CHU Henri Mondor, Créteil, France
- Université Paris Est-Créteil, Groupe de Recherche Clinique CARMAS, Créteil, France
- Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, France
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Thornton LT, Marini JJ. Optimized ventilation power to avoid VILI. J Intensive Care 2023; 11:57. [PMID: 37986109 PMCID: PMC10658809 DOI: 10.1186/s40560-023-00706-y] [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: 10/23/2023] [Accepted: 11/09/2023] [Indexed: 11/22/2023] Open
Abstract
The effort to minimize VILI risk must be multi-pronged. The need to adequately ventilate, a key determinant of hazardous power, is reduced by judicious permissive hypercapnia, reduction of innate oxygen demand, and by prone body positioning that promotes both efficient pulmonary gas exchange and homogenous distributions of local stress. Modifiable ventilator-related determinants of lung protection include reductions of tidal volume, plateau pressure, driving pressure, PEEP, inspiratory flow amplitude and profile (using longer inspiration to expiration ratios), and ventilation frequency. Underappreciated conditional cofactors of importance to modulate the impact of local specific power may include lower vascular pressures and blood flows. Employed together, these measures modulate ventilation power with the intent to avoid VILI while achieving clinically acceptable targets for pulmonary gas exchange.
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Affiliation(s)
- Lauren T Thornton
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis/St Paul, MN, USA
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis/St Paul, MN, USA.
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Bastia L, Amendolagine L, Pozzi F, Carenini S, Cipolla C, Curto F, Bellani G, Fumagalli R, Chieregato A. Reliability of Respiratory System Compliance Calculation During Assisted Mechanical Ventilation: A Retrospective Study. Crit Care Med 2023; 51:e201-e205. [PMID: 37326475 DOI: 10.1097/ccm.0000000000005964] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVES To compare respiratory system compliance (C rs ) calculation during controlled mechanical ventilation (MV) and, subsequently, during assisted MV. DESIGN This is a single-center, retrospective, observational study. SETTING This study was conducted on patients admitted to Neuro-ICU of Niguarda Hospital (tertiary referral hospital). PATIENTS We analyzed every patient greater than or equal to 18 years old having a C rs measurement in controlled and in assisted MV within 60 minutes. Plateau pressure (P plat ) was considered reliable if it was deemed visually stable for at least 2 seconds. INTERVENTIONS Inspiratory pause was incorporated to detect P plat in controlled and assisted MV. Calculation of C rs and driving pressure were achieved. MEASUREMENTS AND MAIN RESULTS A total of 101 patients were studied. An acceptable agreement was found (Bland-Altman plot bias -3.9, level of agreement upper 21.6, lower -29.6). C rs in assisted MV was 64.1 (52.6-79.3) and in controlled MV it was 61.2 (50-71.2) mL/cm H 2o ( p = 0.006). No statistical difference was found in C rs (assisted vs controlled MV) when peak pressure was lower than P plat nor when peak pressure was higher than P plat . CONCLUSIONS A P plat visually stable for at least 2 seconds leads to reliable C rs calculation during assisted MV.
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Affiliation(s)
- Luca Bastia
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | - Federico Pozzi
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano Carenini
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Cristiana Cipolla
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Curto
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giacomo Bellani
- Centre for Medical Sciences-CISMed, University of Trento, Trento, Italy
- Department of Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS Trento, Trento, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Anesthesia and Intensive Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Arturo Chieregato
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Marrazzo F, Spina S, Zadek F, Forlini C, Bassi G, Giudici R, Bellani G, Fumagalli R, Langer T. PEEP Titration Is Markedly Affected by Trunk Inclination in Mechanically Ventilated Patients with COVID-19 ARDS: A Physiologic, Cross-Over Study. J Clin Med 2023; 12:3914. [PMID: 37373608 PMCID: PMC10299565 DOI: 10.3390/jcm12123914] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/04/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Changing trunk inclination affects lung function in patients with ARDS. However, its impacts on PEEP titration remain unknown. The primary aim of this study was to assess, in mechanically ventilated patients with COVID-19 ARDS, the effects of trunk inclination on PEEP titration. The secondary aim was to compare respiratory mechanics and gas exchange in the semi-recumbent (40° head-of-the-bed) and supine-flat (0°) positions following PEEP titration. METHODS Twelve patients were positioned both at 40° and 0° trunk inclination (randomized order). The PEEP associated with the best compromise between overdistension and collapse guided by Electrical Impedance Tomography (PEEPEIT) was set. After 30 min of controlled mechanical ventilation, data regarding respiratory mechanics, gas exchange, and EIT parameters were collected. The same procedure was repeated for the other trunk inclination. RESULTS PEEPEIT was lower in the semi-recumbent than in the supine-flat position (8 ± 2 vs. 13 ± 2 cmH2O, p < 0.001). A semi-recumbent position with optimized PEEP resulted in higher PaO2:FiO2 (141 ± 46 vs. 196 ± 99, p = 0.02) and a lower global inhomogeneity index (46 ± 10 vs. 53 ± 11, p = 0.008). After 30 min of observation, a loss of aeration (measured by EIT) was observed only in the supine-flat position (-153 ± 162 vs. 27 ± 203 mL, p = 0.007). CONCLUSIONS A semi-recumbent position is associated with lower PEEPEIT and results in better oxygenation, less derecruitment, and more homogenous ventilation compared to the supine-flat position.
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Affiliation(s)
- Francesco Marrazzo
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Stefano Spina
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Francesco Zadek
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (F.Z.); (G.B.)
| | - Clarissa Forlini
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Gabriele Bassi
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Riccardo Giudici
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (F.Z.); (G.B.)
- Department of Anesthesia and Intensive Care 1, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy
| | - Roberto Fumagalli
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (F.Z.); (G.B.)
| | - Thomas Langer
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (F.Z.); (G.B.)
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10
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Rezoagli E, Bastia L, Brochard L, Bellani G. Physical manoeuvres in patients with ARDS and low compliance: bedside approaches to detect lung hyperinflation and optimise mechanical ventilation. Eur Respir J 2023; 61:61/5/2202169. [PMID: 37208034 DOI: 10.1183/13993003.02169-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/30/2023] [Indexed: 05/21/2023]
Affiliation(s)
- Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Co-first authors
| | - Luca Bastia
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Co-first authors
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
- Co-senior authors
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Co-senior authors
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11
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Rezoagli E, Chen L, Bellani G. Editorial: Lung monitoring in respiratory failure. Front Med (Lausanne) 2023; 10:1155898. [PMID: 36926322 PMCID: PMC10013969 DOI: 10.3389/fmed.2023.1155898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/14/2023] [Indexed: 03/08/2023] Open
Affiliation(s)
- Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, Terapia intensiva e Semintensiva adulti e pediatrica, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Gerardo dei Tintori, Monza, Italy
| | - Lu Chen
- Keenan Research Centre, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, Terapia intensiva e Semintensiva adulti e pediatrica, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) San Gerardo dei Tintori, Monza, Italy
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12
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Selickman J, Marini JJ. Chest wall loading in the ICU: pushes, weights, and positions. Ann Intensive Care 2022; 12:103. [PMID: 36346532 PMCID: PMC9640797 DOI: 10.1186/s13613-022-01076-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
Clinicians monitor mechanical ventilatory support using airway pressures—primarily the plateau and driving pressure, which are considered by many to determine the safety of the applied tidal volume. These airway pressures are influenced not only by the ventilator prescription, but also by the mechanical properties of the respiratory system, which consists of the series-coupled lung and chest wall. Actively limiting chest wall expansion through external compression of the rib cage or abdomen is seldom performed in the ICU. Recent literature describing the respiratory mechanics of patients with late-stage, unresolving, ARDS, however, has raised awareness of the potential diagnostic (and perhaps therapeutic) value of this unfamiliar and somewhat counterintuitive practice. In these patients, interventions that reduce resting lung volume, such as loading the chest wall through application of external weights or manual pressure, or placing the torso in a more horizontal position, have unexpectedly improved tidal compliance of the lung and integrated respiratory system by reducing previously undetected end-tidal hyperinflation. In this interpretive review, we first describe underappreciated lung and chest wall interactions that are clinically relevant to both normal individuals and to the acutely ill who receive ventilatory support. We then apply these physiologic principles, in addition to published clinical observation, to illustrate the utility of chest wall modification for the purposes of detecting end-tidal hyperinflation in everyday practice.
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Affiliation(s)
- John Selickman
- grid.17635.360000000419368657Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN USA ,grid.415858.50000 0001 0087 6510Department of Critical Care Medicine, Regions Hospital, MS 11203B, 640 Jackson St., St. Paul, MN 55101-2595 USA
| | - John J. Marini
- grid.17635.360000000419368657Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN USA ,grid.415858.50000 0001 0087 6510Department of Critical Care Medicine, Regions Hospital, MS 11203B, 640 Jackson St., St. Paul, MN 55101-2595 USA
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Abstract
OBJECTIVES Head-elevated body positioning, a default clinical practice, predictably increases end-expiratory transpulmonary pressure and aerated lung volume. In acute respiratory distress syndrome (ARDS), however, the net effect of such vertical inclination on tidal mechanics depends upon whether lung recruitment or overdistension predominates. We hypothesized that in moderate to severe ARDS, bed inclination toward vertical unloads the chest wall but adversely affects overall respiratory system compliance (C rs ). DESIGN Prospective physiologic study. SETTING Two medical ICUs in the United States. PATIENTS Seventeen patients with ARDS, predominantly moderate to severe. INTERVENTION Patients were ventilated passively by volume control. We measured airway pressures at baseline (noninclined) and following bed inclination toward vertical by an additional 15°. At baseline and following inclination, we manually loaded the chest wall to determine if C rs increased or paradoxically declined, suggestive of end-tidal overdistension. MEASUREMENTS AND MAIN RESULTS Inclination resulted in a higher plateau pressure (supineΔ: 2.8 ± 3.3 cm H 2 O [ p = 0.01]; proneΔ: 3.3 ± 2.5 cm H 2 O [ p = 0.004]), higher driving pressure (supineΔ: 2.9 ± 3.3 cm H 2 O [ p = 0.01]; proneΔ: 3.3 ± 2.8 cm H 2 O [ p = 0.007]), and lower C rs (supine Δ: 3.4 ± 3.7 mL/cm H 2 O [ p = 0.01]; proneΔ: 3.1 ± 3.2 mL/cm H 2 O [ p = 0.02]). Following inclination, manual loading of the chest wall restored C rs and driving pressure to baseline (preinclination) values. CONCLUSIONS In advanced ARDS, bed inclination toward vertical adversely affects C rs and therefore affects the numerical values for plateau and driving tidal pressures commonly targeted in lung protective strategies. These changes are fully reversed with manual loading of the chest wall, suggestive of end-tidal overdistension in the upright position. Body inclination should be considered a modifiable determinant of transpulmonary pressure and lung protection, directionally similar to tidal volume and positive end-expiratory pressure.
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14
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Bedside Detection of End-Tidal Hyperinflation in Acute Respiratory Distress Syndrome. Ann Am Thorac Soc 2022; 19:1791-1795. [PMID: 35849421 DOI: 10.1513/annalsats.202205-460ps] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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15
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Umbrello M, Lassola S, Sanna A, Pace R, Magnoni S, Miori S. Chest wall loading during supine and prone position in patients with COVID-19 ARDS: effects on respiratory mechanics and gas exchange. Crit Care 2022; 26:277. [PMID: 36100903 PMCID: PMC9470071 DOI: 10.1186/s13054-022-04141-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 08/08/2022] [Indexed: 11/25/2022] Open
Abstract
Background Recent reports of patients with severe, late-stage COVID-19 ARDS with reduced respiratory system compliance described paradoxical decreases in plateau pressure and increases in respiratory system compliance in response to anterior chest wall loading. We aimed to assess the effect of chest wall loading during supine and prone position in ill patients with COVID-19-related ARDS and to investigate the effect of a low or normal baseline respiratory system compliance on the findings. Methods This is a single-center, prospective, cohort study in the intensive care unit of a COVID-19 referral center. Consecutive mechanically ventilated, critically ill patients with COVID-19-related ARDS were enrolled and classified as higher (≥ 40 ml/cmH2O) or lower respiratory system compliance (< 40 ml/cmH2O). The study included four steps, each lasting 6 h: Step 1, supine position, Step 2, 10-kg continuous chest wall compression (supine + weight), Step 3, prone position, Step 4, 10-kg continuous chest wall compression (prone + weight). The mechanical properties of the respiratory system, gas exchange and alveolar dead space were measured at the end of each step. Results Totally, 40 patients were enrolled. In the whole cohort, neither oxygenation nor respiratory system compliance changed between supine and supine + weight; both increased during prone positioning and were unaffected by chest wall loading in the prone position. Alveolar dead space was unchanged during all the steps. In 16 patients with reduced compliance, PaO2/FiO2 significantly increased from supine to supine + weight and further with prone and prone + weight (107 ± 15.4 vs. 120 ± 18.5 vs. 146 ± 27.0 vs. 159 ± 30.4, respectively; p < 0.001); alveolar dead space decreased from both supine and prone position after chest wall loading, and respiratory system compliance significantly increased from supine to supine + weight and from prone to prone + weight (23.9 ± 3.5 vs. 30.9 ± 5.7 and 31.1 ± 5.7 vs. 37.8 ± 8.7 ml/cmH2O, p < 0.001). The improvement was higher the lower the baseline compliance. Conclusions Unlike prone positioning, chest wall loading had no effects on respiratory system compliance, gas exchange or alveolar dead space in an unselected cohort of critically ill patients with C-ARDS. Only patients with a low respiratory system compliance experienced an improvement, with a higher response the lower the baseline compliance. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04141-7.
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16
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Kodamanchili S. Author\'s Response to Trendelenburg Ventilation in Acute Respiratory Distress Syndrome: Should We Do More than Proning? Indian J Crit Care Med 2022; 26:978-979. [PMID: 36042758 PMCID: PMC9363802 DOI: 10.5005/jp-journals-10071-24294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Kodamanchili S. Author's Response to Trendelenburg Ventilation in Acute Respiratory Distress Syndrome: Should We Do More than Proning? Indian J Crit Care Med 2022;26(8):978–979.
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Affiliation(s)
- Saiteja Kodamanchili
- Department of Anesthesia and Critical Care Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
- Saiteja Kodamanchili, Department of Anesthesia and Critical Care Medicine, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India, Phone: +91 9491758129, e-mail:
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17
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Datta PK, Kundu R. Trendelenburg in Acute Respiratory Distress Syndrome: Should We Do More than Proning? Indian J Crit Care Med 2022; 26:976-977. [PMID: 36042767 PMCID: PMC9363798 DOI: 10.5005/jp-journals-10071-24275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
How to cite this article: Datta PK, Kundu R. Trendelenburg in Acute Respiratory Distress Syndrome: Should We Do More than Proning? Indian J Crit Care Med 2022;26(8):976–977.
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Affiliation(s)
- Priyankar K Datta
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Riddhi Kundu
- Department of Critical Care Medicine, Manipal Hospitals, New Delhi, India
- Riddhi Kundu, Department of Critical Care Medicine, Manipal Hospitals, New Delhi, India, Phone: +91 9650813320, e-mail:
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18
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Rezoagli E, Laffey JG, Bellani G. Monitoring Lung Injury Severity and Ventilation Intensity during Mechanical Ventilation. Semin Respir Crit Care Med 2022; 43:346-368. [PMID: 35896391 DOI: 10.1055/s-0042-1748917] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a severe form of respiratory failure burden by high hospital mortality. No specific pharmacologic treatment is currently available and its ventilatory management is a key strategy to allow reparative and regenerative lung tissue processes. Unfortunately, a poor management of mechanical ventilation can induce ventilation induced lung injury (VILI) caused by physical and biological forces which are at play. Different parameters have been described over the years to assess lung injury severity and facilitate optimization of mechanical ventilation. Indices of lung injury severity include variables related to gas exchange abnormalities, ventilatory setting and respiratory mechanics, ventilation intensity, and the presence of lung hyperinflation versus derecruitment. Recently, specific indexes have been proposed to quantify the stress and the strain released over time using more comprehensive algorithms of calculation such as the mechanical power, and the interaction between driving pressure (DP) and respiratory rate (RR) in the novel DP multiplied by four plus RR [(4 × DP) + RR] index. These new parameters introduce the concept of ventilation intensity as contributing factor of VILI. Ventilation intensity should be taken into account to optimize protective mechanical ventilation strategies, with the aim to reduce intensity to the lowest level required to maintain gas exchange to reduce the potential for VILI. This is further gaining relevance in the current era of phenotyping and enrichment strategies in ARDS.
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Affiliation(s)
- Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy
| | - John G Laffey
- School of Medicine, National University of Ireland, Galway, Ireland.,Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Saolta University Hospital Group, Galway, Ireland.,Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo University Hospital, Monza, Italy
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19
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Protti A, Santini A, Pennati F, Chiurazzi C, Ferrari M, Iapichino GE, Carenzo L, Dalla Corte F, Lanza E, Martinetti N, Aliverti A, Cecconi M. Lung response to prone positioning in mechanically-ventilated patients with COVID-19. Crit Care 2022; 26:127. [PMID: 35526009 PMCID: PMC9076814 DOI: 10.1186/s13054-022-03996-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/23/2022] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Prone positioning improves survival in moderate-to-severe acute respiratory distress syndrome (ARDS) unrelated to the novel coronavirus disease (COVID-19). This benefit is probably mediated by a decrease in alveolar collapse and hyperinflation and a more homogeneous distribution of lung aeration, with fewer harms from mechanical ventilation. In this preliminary physiological study we aimed to verify whether prone positioning causes analogue changes in lung aeration in COVID-19. A positive result would support prone positioning even in this other population. METHODS Fifteen mechanically-ventilated patients with COVID-19 underwent a lung computed tomography in the supine and prone position with a constant positive end-expiratory pressure (PEEP) within three days of endotracheal intubation. Using quantitative analysis, we measured the volume of the non-aerated, poorly-aerated, well-aerated, and over-aerated compartments and the gas-to-tissue ratio of the ten vertical levels of the lung. In addition, we expressed the heterogeneity of lung aeration with the standardized median absolute deviation of the ten vertical gas-to-tissue ratios, with lower values indicating less heterogeneity. RESULTS By the time of the study, PEEP was 12 (10-14) cmH2O and the PaO2:FiO2 107 (84-173) mmHg in the supine position. With prone positioning, the volume of the non-aerated compartment decreased by 82 (26-147) ml, of the poorly-aerated compartment increased by 82 (53-174) ml, of the normally-aerated compartment did not significantly change, and of the over-aerated compartment decreased by 28 (11-186) ml. In eight (53%) patients, the volume of the over-aerated compartment decreased more than the volume of the non-aerated compartment. The gas-to-tissue ratio of the ten vertical levels of the lung decreased by 0.34 (0.25-0.49) ml/g per level in the supine position and by 0.03 (- 0.11 to 0.14) ml/g in the prone position (p < 0.001). The standardized median absolute deviation of the gas-to-tissue ratios of those ten levels decreased in all patients, from 0.55 (0.50-0.71) to 0.20 (0.14-0.27) (p < 0.001). CONCLUSIONS In fifteen patients with COVID-19, prone positioning decreased alveolar collapse, hyperinflation, and homogenized lung aeration. A similar response has been observed in other ARDS, where prone positioning improves outcome. Therefore, our data provide a pathophysiological rationale to support prone positioning even in COVID-19.
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Affiliation(s)
- Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy.
| | - Alessandro Santini
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Francesca Pennati
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Chiara Chiurazzi
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Michele Ferrari
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Giacomo E Iapichino
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Luca Carenzo
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Francesca Dalla Corte
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Ezio Lanza
- Department of Radiology, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Nicolò Martinetti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Department of Anesthesia and Intensive Care Units, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
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20
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Bastia L, Rezoagli E, Guarnieri M, Engelberts D, Forlini C, Marrazzo F, Spina S, Bassi G, Giudici R, Post M, Bellani G, Fumagalli R, Brochard LJ, Langer T. External chest-wall compression in prolonged COVID-19 ARDS with low-compliance: a physiological study. Ann Intensive Care 2022; 12:35. [PMID: 35412161 PMCID: PMC9003155 DOI: 10.1186/s13613-022-01008-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/23/2022] [Indexed: 12/13/2022] Open
Abstract
Background External chest-wall compression (ECC) is sometimes used in ARDS patients despite lack of evidence. It is currently unknown whether this practice has any clinical benefit in patients with COVID-19 ARDS (C-ARDS) characterized by a respiratory system compliance (Crs) < 35 mL/cmH2O. Objectives To test if an ECC with a 5 L-bag in low-compliance C-ARDS can lead to a reduction in driving pressure (DP) and improve gas exchange, and to understand the underlying mechanisms. Methods Eleven patients with low-compliance C-ARDS were enrolled and underwent 4 steps: baseline, ECC for 60 min, ECC discontinuation and PEEP reduction. Respiratory mechanics, gas exchange, hemodynamics and electrical impedance tomography were recorded. Four pigs with acute ARDS were studied with ECC to understand the effect of ECC on pleural pressure gradient using pleural pressure transducers in both non-dependent and dependent lung regions. Results Five minutes of ECC reduced DP from baseline 14.2 ± 1.3 to 12.3 ± 1.3 cmH2O (P < 0.001), explained by an improved lung compliance. Changes in DP by ECC were strongly correlated with changes in DP obtained with PEEP reduction (R2 = 0.82, P < 0.001). The initial benefit of ECC decreased over time (DP = 13.3 ± 1.5 cmH2O at 60 min, P = 0.03 vs. baseline). Gas exchange and hemodynamics were unaffected by ECC. In four pigs with lung injury, ECC led to a decrease in the pleural pressure gradient at end-inspiration [2.2 (1.1–3) vs. 3.0 (2.2–4.1) cmH2O, P = 0.035]. Conclusions In C-ARDS patients with Crs < 35 mL/cmH2O, ECC acutely reduces DP. ECC does not improve oxygenation but it can be used as a simple tool to detect hyperinflation as it improves Crs and reduces Ppl gradient. ECC benefits seem to partially fade over time. ECC produces similar changes compared to PEEP reduction. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01008-6.
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Affiliation(s)
- Luca Bastia
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Emergency and Intensive Care, ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Marcello Guarnieri
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Doreen Engelberts
- Translational Medicine Program, Hospital for Sick Children, Toronto, ON, Canada
| | - Clarissa Forlini
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Francesco Marrazzo
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Stefano Spina
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Gabriele Bassi
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Riccardo Giudici
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Martin Post
- Translational Medicine Program, Hospital for Sick Children, Toronto, ON, Canada
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Emergency and Intensive Care, ASST Monza, San Gerardo Hospital, Monza, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, 209 Victoria Street, Room 4-08, Toronto, ON, M5B 1T8, Canada.
| | - Thomas Langer
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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21
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Marrazzo F, Spina S, Forlini C, Guarnieri M, Giudici R, Bassi G, Bastia L, Bottiroli M, Fumagalli R, Langer T. Effects of Trunk Inclination on Respiratory Mechanics in Patients with COVID-19 Associated ARDS: Let’s Always Report the Angle! Am J Respir Crit Care Med 2022; 205:582-584. [PMID: 34982652 PMCID: PMC8906482 DOI: 10.1164/rccm.202110-2360le] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Francesco Marrazzo
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Stefano Spina
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Clarissa Forlini
- Università degli Studi di Milano-Bicocca, 9305, School of Medicine and Surgery, Monza, Italy
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Marcello Guarnieri
- Università degli Studi di Milano-Bicocca, 9305, School of Medicine and Surgery, Monza, Italy
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Riccardo Giudici
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Gabriele Bassi
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Luca Bastia
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Maurizio Bottiroli
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Roberto Fumagalli
- Università degli Studi di Milano-Bicocca, 9305, School of Medicine and Surgery, Monza, Italy
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
| | - Thomas Langer
- Università degli Studi di Milano-Bicocca, 9305, School of Medicine and Surgery, Monza, Italy
- ASST Grande Ospedale Metropolitano Niguarda, 9338, Department of Anesthesia and Critical Care, Milano, Italy
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Lassola S, Miori S, Sanna A, Pace R, Magnoni S, Vetrugno L, Umbrello M. Effect of chest wall loading during supine and prone position in a critically ill covid-19 patient: a new strategy for ARDS? Crit Care 2021; 25:442. [PMID: 34930393 PMCID: PMC8686100 DOI: 10.1186/s13054-021-03865-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 12/13/2021] [Indexed: 01/16/2023] Open
Affiliation(s)
- Sergio Lassola
- SC Anestesia E Rianimazione 1, Ospedale Santa Chiara, Trento, Italy
| | - Sara Miori
- SC Anestesia E Rianimazione 1, Ospedale Santa Chiara, Trento, Italy.
| | - Andrea Sanna
- SC Anestesia E Rianimazione 1, Ospedale Santa Chiara, Trento, Italy
| | - Rocco Pace
- SC Anestesia E Rianimazione 1, Ospedale Santa Chiara, Trento, Italy
| | - Sandra Magnoni
- SC Anestesia E Rianimazione 1, Ospedale Santa Chiara, Trento, Italy
| | - Luigi Vetrugno
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS, Annunziata Hospital, Chieti, Italy.,Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, Chieti, Italy
| | - Michele Umbrello
- SC Anestesia E Rianimazione II, Ospedale San Carlo Borromeo, ASST Santi Paolo e Carlo, Milan, Italy
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Dorsal Push and Abdominal Binding Improve Respiratory Compliance and Driving Pressure in Proned Coronavirus Disease 2019 Acute Respiratory Distress Syndrome. Crit Care Explor 2021; 3:e0593. [PMID: 34841252 PMCID: PMC8613362 DOI: 10.1097/cce.0000000000000593] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
We describe seven proned patients with coronavirus disease 2019-related acute respiratory distress syndrome in whom a paradoxical decrease in driving pressure reversibly occurred during passive, volume-controlled ventilation when compressing the lower back by a sustained "dorsal push." We offer a potential explanation for these unexpected observations and suggest the possible importance of eliciting this response for lung-protective ventilation of similar patients. DESIGN/SETTING Case series at a single teaching hospital affiliated with the University of Minnesota. Measurements were recorded from continuously monitored airway pressure and flow data. PATIENTS Nonconsecutive and nonrandomized sample of coronavirus disease 2019 acute respiratory distress syndrome patients who were already prone and paralyzed for optimized lung protective clinical management while inhaling pure oxygen. INTERVENTIONS Sustained, firm manual pressure applied over the lower back in all patients, followed by abdominal binding in a subset of these. MEASUREMENTS AND MAIN RESULTS Respiratory system driving pressure declined and respiratory system compliance improved in seven patients with the dorsal push maneuver. In a subset of four of these, abdominal binding sustained those improvements over >3 hours. CONCLUSIONS Sustained compressive force applied to the dorsum of the passive and prone patient with severe respiratory failure due to coronavirus disease pneumonia may elicit a paradoxical response characterized by improved compliance and for a given tidal volume, lower plateau, and driving pressures. Such findings, which suggest end-tidal overinflation within the aerated part of the diseased lung despite the already compressed anterior chest wall of prone positioning, complement and extend those observations recently described for the supine position in coronavirus disease 2019 acute respiratory distress syndrome.
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24
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Protti A, Santini A, Pennati F, Chiurazzi C, Cressoni M, Ferrari M, Iapichino GE, Carenzo L, Lanza E, Picardo G, Caironi P, Aliverti A, Cecconi M. Lung response to a higher positive end-expiratory pressure in mechanically ventilated patients with COVID-19. Chest 2021; 161:979-988. [PMID: 34666011 PMCID: PMC8520168 DOI: 10.1016/j.chest.2021.10.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 09/25/2021] [Accepted: 10/06/2021] [Indexed: 01/17/2023] Open
Abstract
Background International guidelines suggest using a higher (> 10 cm H2O) positive end-expiratory pressure (PEEP) in patients with moderate-to-severe ARDS due to COVID-19. However, even if oxygenation generally improves with a higher PEEP, compliance, and Paco2 frequently do not, as if recruitment was small. Research Question Is the potential for lung recruitment small in patients with early ARDS due to COVID-19? Study Design and Methods Forty patients with ARDS due to COVID-19 were studied in the supine position within 3 days of endotracheal intubation. They all underwent a PEEP trial, in which oxygenation, compliance, and Paco2 were measured with 5, 10, and 15 cm H2O of PEEP, and all other ventilatory settings unchanged. Twenty underwent a whole-lung static CT scan at 5 and 45 cm H2O, and the other 20 at 5 and 15 cm H2O of airway pressure. Recruitment and hyperinflation were defined as a decrease in the volume of the non-aerated (density above −100 HU) and an increase in the volume of the over-aerated (density below −900 HU) lung compartments, respectively. Results From 5 to 15 cm H2O, oxygenation improved in 36 (90%) patients but compliance only in 11 (28%) and Paco2 only in 14 (35%). From 5 to 45 cm H2O, recruitment was 351 (161-462) mL and hyperinflation 465 (220-681) mL. From 5 to 15 cm H2O, recruitment was 168 (110-202) mL and hyperinflation 121 (63-270) mL. Hyperinflation variably developed in all patients and exceeded recruitment in more than half of them. Interpretation Patients with early ARDS due to COVID-19, ventilated in the supine position, present with a large potential for lung recruitment. Even so, their compliance and Paco2 do not generally improve with a higher PEEP, possibly because of hyperinflation.
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Affiliation(s)
- Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Anesthesia and Intensive Care Units, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy.
| | - Alessandro Santini
- Department of Anesthesia and Intensive Care Units, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Francesca Pennati
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Chiara Chiurazzi
- Department of Anesthesia and Intensive Care Units, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Massimo Cressoni
- Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Michele Ferrari
- Department of Anesthesia and Intensive Care Units, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Giacomo E Iapichino
- Department of Anesthesia and Intensive Care Units, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Luca Carenzo
- Department of Anesthesia and Intensive Care Units, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Ezio Lanza
- Department of Radiology, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Giorgio Picardo
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Pietro Caironi
- Department of Oncology, University of Turin, Turin, Italy; Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria S. Luigi Gonzaga, Orbassano, Italy
| | - Andrea Aliverti
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, Milan, Italy
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy; Department of Anesthesia and Intensive Care Units, Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
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