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Marini JJ, Gattinoni L. Improving lung compliance by external compression of the chest wall. Crit Care 2021; 25:264. [PMID: 34321060 PMCID: PMC8318320 DOI: 10.1186/s13054-021-03700-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/21/2021] [Indexed: 11/10/2022] Open
Abstract
As exemplified by prone positioning, regional variations of lung and chest wall properties provide possibilities for modifying transpulmonary pressures and suggest that clinical interventions related to the judicious application of external pressure may yield benefit. Recent observations made in late-phase patients with severe ARDS caused by COVID-19 (C-ARDS) have revealed unexpected mechanical responses to local chest wall compressions over the sternum and abdomen in the supine position that challenge the clinician's assumptions and conventional bedside approaches to lung protection. These findings appear to open avenues for mechanism-defining research investigation with possible therapeutic implications for all forms and stages of ARDS.
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Affiliation(s)
- John J Marini
- Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, 640 Jackson St., Minneapolis/St. Paul, Minnesota, 55101, USA.
| | - Luciano Gattinoni
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Medical University of Göttingen, Göttingen, Germany
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2
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Natalini G, Buizza B, Granato A, Aniballi E, Pisani L, Ciabatti G, Lippolis V, Rosano A, Latronico N, Grasso S, Antonelli M, Bernardini A. Non-invasive assessment of respiratory muscle activity during pressure support ventilation: accuracy of end-inspiration occlusion and least square fitting methods. J Clin Monit Comput 2020; 35:913-921. [PMID: 32617847 PMCID: PMC7330529 DOI: 10.1007/s10877-020-00552-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 06/26/2020] [Indexed: 12/01/2022]
Abstract
Pressure support ventilation (PSV) should be titrated considering the pressure developed by the respiratory muscles (Pmusc) to prevent under- and over-assistance. The esophageal pressure (Pes) is the clinical gold standard for Pmusc assessment, but its use is limited by alleged invasiveness and complexity. The least square fitting method and the end-inspiratory occlusion method have been proposed as non-invasive alternatives for Pmusc assessment. The aims of this study were: (1) to compare the accuracy of Pmusc estimation using the end-inspiration occlusion (Pmusc,index) and the least square fitting (Pmusc,lsf) against the reference method based on Pes; (2) to test the accuracy of Pmusc,lsf and of Pmusc,index to detect overassistance, defined as Pmusc ≤ 1 cmH2O. We studied 18 patients at three different PSV levels. At each PSV level, Pmusc, Pmusc,lsf, Pmusc,index were calculated on the same breaths. Differences among Pmusc, Pmusc,lsf, Pmusc,index were analyzed with linear mixed effects models. Bias and agreement were assessed by Bland-Altman analysis for repeated measures. The ability of Pmusc,lsf and Pmusc,index to detect overassistance was assessed by the area under the receiver operating characteristics curve. Positive and negative predictive values were calculated using cutoff values that maximized the sum of sensitivity and specificity. At each PSV level, Pmusc,lsf was not different from Pmusc (p = 0.96), whereas Pmusc,index was significantly lower than Pmusc. The bias between Pmusc and Pmusc,lsf was zero, whereas Pmusc,index systematically underestimated Pmusc of 6 cmH2O. The limits of agreement between Pmusc and Pmusc,lsf and between Pmusc and Pmusc,index were ± 12 cmH2O across bias. Both Pmusc,lsf ≤ 4 cmH2O and Pmusc,index ≤ 1 cmH2O had excellent negative predictive value [0.98 (95% CI 0.94-1) and 0.96 (95% CI 0.91-0.99), respectively)] to identify over-assistance. The inspiratory effort during PSV could not be accurately estimated by the least square fitting or end-inspiratory occlusion method because the limits of agreement were far above the signal size. These non-invasive approaches, however, could be used to screen patients at risk for absent or minimal respiratory muscles activation to prevent the ventilator-induced diaphragmatic dysfunction.
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Affiliation(s)
- Giuseppe Natalini
- Department of Intensive Care and Anesthesiology, Fondazione Poliambulanza, Brescia, Italy
| | - Barbara Buizza
- Department of Intensive Care and Anesthesiology, University of Brescia, Brescia, Italy
| | - Anna Granato
- Department of Intensive Care and Anesthesiology, Fondazione Poliambulanza, Brescia, Italy.,Department of Intensive Care and Anesthesiology, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy
| | - Eros Aniballi
- Department of Intensive Care and Anesthesiology, Fondazione Poliambulanza, Brescia, Italy.,Department of Intensive Care and Anesthesiology, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy
| | - Luigi Pisani
- Department of Intensive Care and Anesthesiology, Fondazione Poliambulanza, Brescia, Italy.,Department of Intensive Care, Amsterdam University Medical Centers - Location AMC, Amsterdam, Netherlands
| | - Gianni Ciabatti
- Department of Anesthesiology and Intensive Care, Neurointensive Care Unit, Azienda Ospedaliera Universitaria Careggi, Firenze, Italy.
| | - Valeria Lippolis
- Department of Intensive Care and Anesthesiology, Fondazione Poliambulanza, Brescia, Italy.,Department of Emergency and Organ Transplants (DETO), Anesthesiology and Intensive Care, Università Degli Studi Di Bari "Aldo Moro", Bari, Italy
| | - Antonio Rosano
- Department of Intensive Care and Anesthesiology, Fondazione Poliambulanza, Brescia, Italy
| | - Nicola Latronico
- Department of Intensive Care and Anesthesiology, University of Brescia, Brescia, Italy.,Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Salvatore Grasso
- Department of Emergency and Organ Transplants (DETO), Anesthesiology and Intensive Care, Università Degli Studi Di Bari "Aldo Moro", Bari, Italy
| | - Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Fondazione Policlinico Universitario A.Gemelli IRCCS, Roma, Italy.,Catholic University of Sacred Heart, Roma, Italy
| | - Achille Bernardini
- Department of Intensive Care and Anesthesiology, Fondazione Poliambulanza, Brescia, Italy
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Schaefer MS, Serpa Neto A, Pelosi P, Gama de Abreu M, Kienbaum P, Schultz MJ, Meyer-Treschan TA. Temporal Changes in Ventilator Settings in Patients With Uninjured Lungs: A Systematic Review. Anesth Analg 2020; 129:129-140. [PMID: 30222649 DOI: 10.1213/ane.0000000000003758] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In patients with uninjured lungs, increasing evidence indicates that tidal volume (VT) reduction improves outcomes in the intensive care unit (ICU) and in the operating room (OR). However, the degree to which this evidence has translated to clinical changes in ventilator settings for patients with uninjured lungs is unknown. To clarify whether ventilator settings have changed, we searched MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science for publications on invasive ventilation in ICUs or ORs, excluding those on patients <18 years of age or those with >25% of patients with acute respiratory distress syndrome (ARDS). Our primary end point was temporal change in VT over time. Secondary end points were changes in maximum airway pressure, mean airway pressure, positive end-expiratory pressure, inspiratory oxygen fraction, development of ARDS (ICU studies only), and postoperative pulmonary complications (OR studies only) determined using correlation analysis and linear regression. We identified 96 ICU and 96 OR studies comprising 130,316 patients from 1975 to 2014 and observed that in the ICU, VT size decreased annually by 0.16 mL/kg (-0.19 to -0.12 mL/kg) (P < .001), while positive end-expiratory pressure increased by an average of 0.1 mbar/y (0.02-0.17 mbar/y) (P = .017). In the OR, VT size decreased by 0.09 mL/kg per year (-0.14 to -0.04 mL/kg per year) (P < .001). The change in VTs leveled off in 1995. Other intraoperative ventilator settings did not change in the study period. Incidences of ARDS (ICU studies) and postoperative pulmonary complications (OR studies) also did not change over time. We found that, during a 39-year period, from 1975 to 2014, VTs in clinical studies on mechanical ventilation have decreased significantly in the ICU and in the OR.
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Affiliation(s)
- Maximilian S Schaefer
- From the Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Program of Post-Graduation, Innovation and Research, Faculdade de Medicina do ABC, Santo Andre, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) for Oncology, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Peter Kienbaum
- From the Department of Anesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Marcus J Schultz
- Department of Intensive Care, Academic Medical Center, University of Amsterdam, the Netherlands
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Koutsoukou A, Pecchiari M. Expiratory flow-limitation in mechanically ventilated patients: A risk for ventilator-induced lung injury? World J Crit Care Med 2019; 8:1-8. [PMID: 30697515 PMCID: PMC6347666 DOI: 10.5492/wjccm.v8.i1.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/24/2018] [Accepted: 10/17/2018] [Indexed: 02/06/2023] Open
Abstract
Expiratory flow limitation (EFL), that is the inability of expiratory flow to increase in spite of an increase of the driving pressure, is a common and unrecognized occurrence during mechanical ventilation in a variety of intensive care unit conditions. Recent evidence suggests that the presence of EFL is associated with an increase in mortality, at least in acute respiratory distress syndrome (ARDS) patients, and in pulmonary complications in patients undergoing surgery. EFL is a major cause of intrinsic positive end-expiratory pressure (PEEPi), which in ARDS patients is heterogeneously distributed, with a consequent increase of ventilation/perfusion mismatch and reduction of arterial oxygenation. Airway collapse is frequently concomitant to the presence of EFL. When airways close and reopen during tidal ventilation, abnormally high stresses are generated that can damage the bronchiolar epithelium and uncouple small airways from the alveolar septa, possibly generating the small airways abnormalities detected at autopsy in ARDS. Finally, the high stresses and airway distortion generated downstream the choke points may contribute to parenchymal injury, but this possibility is still unproven. PEEP application can abolish EFL, decrease PEEPi heterogeneity, and limit recruitment/derecruitment. Whether increasing PEEP up to EFL disappearance is a useful criterion for PEEP titration can only be determined by future studies.
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Affiliation(s)
- Antonia Koutsoukou
- ICU, 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens Medical School, Athens 11527, Greece
| | - Matteo Pecchiari
- Dipartimento di Fisiopatologia e dei Trapianti, Università degli Studi di Milano, Milan 20133, Italy
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Junhasavasdikul D, Telias I, Grieco DL, Chen L, Gutierrez CM, Piraino T, Brochard L. Expiratory Flow Limitation During Mechanical Ventilation. Chest 2018; 154:948-962. [PMID: 29432712 DOI: 10.1016/j.chest.2018.01.046] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 01/27/2018] [Accepted: 01/30/2018] [Indexed: 12/13/2022] Open
Abstract
Expiratory flow limitation (EFL) is present when the flow cannot rise despite an increase in the expiratory driving pressure. The mechanisms of EFL are debated but are believed to be related to the collapsibility of small airways. In patients who are mechanically ventilated, EFL can exist during tidal ventilation, representing an extreme situation in which lung volume cannot decrease, regardless of the expiratory driving forces. It is a key factor for the generation of auto- or intrinsic positive end-expiratory pressure (PEEP) and requires specific management such as positioning and adjustment of external PEEP. EFL can be responsible for causing dyspnea and patient-ventilator dyssynchrony, and it is influenced by the fluid status of the patient. EFL frequently affects patients with COPD, obesity, and heart failure, as well as patients with ARDS, especially at low PEEP. EFL is, however, most often unrecognized in the clinical setting despite being associated with complications of mechanical ventilation and poor outcomes such as postoperative pulmonary complications, extubation failure, and possibly airway injury in ARDS. Therefore, prompt recognition might help the management of patients being mechanically ventilated who have EFL and could potentially influence outcome. EFL can be suspected by using different means, and this review summarizes the methods to specifically detect EFL during mechanical ventilation.
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Affiliation(s)
- Detajin Junhasavasdikul
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Irene Telias
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Domenico Luca Grieco
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione "Policlinico Universitario A. Gemelli," Rome, Italy
| | - Lu Chen
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada
| | - Cinta Millan Gutierrez
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Thomas Piraino
- Department of Respiratory Therapy, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.
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Natalini G, Tuzzo D, Rosano A, Testa M, Grazioli M, Pennestrì V, Amodeo G, Berruto F, Fiorillo M, Peratoner A, Tinnirello A, Filippini M, Marsilia PF, Minelli C, Bernardini A. Effect of external PEEP in patients under controlled mechanical ventilation with an auto-PEEP of 5 cmH2O or higher. Ann Intensive Care 2016; 6:53. [PMID: 27306887 PMCID: PMC4909663 DOI: 10.1186/s13613-016-0158-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Accepted: 06/05/2016] [Indexed: 12/16/2022] Open
Abstract
Background In some patients with auto-positive end-expiratory pressure (auto-PEEP), application of PEEP lower than auto-PEEP maintains a constant total PEEP, therefore reducing the inspiratory threshold load without detrimental cardiovascular or respiratory effects. We refer to these patients as “complete PEEP-absorbers.” Conversely, adverse effects of PEEP application could occur in patients with auto-PEEP when the total PEEP rises as a consequence. From a pathophysiological perspective, all subjects with flow limitation are expected to be “complete PEEP-absorbers,” whereas PEEP should increase total PEEP in all other patients. This study aimed to empirically assess the extent to which flow limitation alone explains a “complete PEEP-absorber” behavior (i.e., absence of further hyperinflation with PEEP), and to identify other factors associated with it. Methods One hundred patients with auto-PEEP of at least 5 cmH2O at zero end-expiratory pressure (ZEEP) during controlled mechanical ventilation were enrolled. Total PEEP (i.e., end-expiratory plateau pressure) was measured both at ZEEP and after applied PEEP equal to 80 % of auto-PEEP measured at ZEEP. All measurements were repeated three times, and the average value was used for analysis. Results Forty-seven percent of the patients suffered from chronic pulmonary disease and 52 % from acute pulmonary disease; 61 % showed flow limitation at ZEEP, assessed by manual compression of the abdomen. The mean total PEEP was 7 ± 2 cmH2O at ZEEP and 9 ± 2 cmH2O after the application of PEEP (p < 0.001). Thirty-three percent of the patients were “complete PEEP-absorbers.” Multiple logistic regression was used to predict the behavior of “complete PEEP-absorber.” The best model included a respiratory rate lower than 20 breaths/min and the presence of flow limitation. The predictive ability of the model was excellent, with an overoptimism-corrected area under the receiver operating characteristics curve of 0.89 (95 % CI 0.80–0.97). Conclusions Expiratory flow limitation was associated with both high and complete “PEEP-absorber” behavior, but setting a relatively high respiratory rate on the ventilator can prevent from observing complete “PEEP-absorption.” Therefore, the effect of PEEP application in patients with auto-PEEP can be accurately predicted at the bedside by measuring the respiratory rate and observing the flow-volume loop during manual compression of the abdomen.
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Affiliation(s)
- Giuseppe Natalini
- Department of Anesthesia and Intensive Care, Fondazione Poliambulanza Hospital, Brescia, Italy.
| | - Daniele Tuzzo
- Department of Anesthesia and Intensive Care, Spedali Civili Hospital, Brescia, Italy
| | - Antonio Rosano
- Department of Anesthesia and Intensive Care, Fondazione Poliambulanza Hospital, Brescia, Italy
| | - Marco Testa
- Department of Anesthesia and Intensive Care, SS. Annunziata Hospital, Savigliano, Italy
| | - Michele Grazioli
- Department of Anesthesia and Intensive Care, Fondazione Poliambulanza Hospital, Brescia, Italy
| | - Vincenzo Pennestrì
- Department of Anesthesia and Intensive Care, Misericordia Hospital, Grosseto, Italy
| | - Guido Amodeo
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Naples, Italy
| | - Francesco Berruto
- Department of Anesthesia and Intensive Care, Agnelli Hospital, Pinerolo, Italy
| | - Marialinda Fiorillo
- Department of Anesthesia and Intensive Care, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Alberto Peratoner
- Department of Anesthesia and Intensive Care, Cattinara Hospital, Trieste, Italy
| | - Andrea Tinnirello
- Department of Anesthesia and Intensive Care, Mellino Mellini Hospital, Chiari, Italy
| | - Matteo Filippini
- Department of Anesthesia, Critical Care Medicine and Emergency, University of Brescia at Spedali Civili, Brescia, Italy
| | - Paolo F Marsilia
- Department of Anesthesia and Intensive Care, Cardarelli Hospital, Naples, Italy
| | - Cosetta Minelli
- Respiratory Epidemiology, Occupational Medicine and Public Health, Imperial College, London, UK
| | - Achille Bernardini
- Department of Anesthesia and Intensive Care, Fondazione Poliambulanza Hospital, Brescia, Italy
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Morino A, Shida M, Tanaka M, Sato K, Seko T, Ito S, Ogawa S, Takahashi N. Parameters affecting the tidal volume during expiratory abdominal compression in patients with prolonged tracheostomy mechanical ventilation. J Phys Ther Sci 2015; 27:2167-9. [PMID: 26311947 PMCID: PMC4540842 DOI: 10.1589/jpts.27.2167] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 04/03/2015] [Indexed: 11/24/2022] Open
Abstract
[Purpose] The aim of this study was to clarify physical parameters affecting the tidal
volume during expiratory abdominal compression in patients with prolonged tracheostomy
mechanical ventilation. [Methods] Eighteen patients with prolonged mechanical ventilation
were included in this study. Expiratory abdominal compression was performed on patients
lying in a supine position. The abdomen above the navel was vertically compressed in
synchronization with expiration and released with inspiration. We measured the tidal
volume during expiratory abdominal compression. [Results] The mean tidal volume during
expiratory abdominal compression was higher than that at rest (430.6 ± 127.1 mL vs. 344.0
± 94.3 mL). The tidal volume during expiratory abdominal compression was correlated with
weight, days of ventilator support, dynamic compliance and abdominal expansion. Stepwise
multiple regression analysis revealed that weight (β = 0.499), dynamic compliance (β =
0.387), and abdominal expansion (β = 0.365) were factors contributing to the tidal volume
during expiratory abdominal compression. [Conclusion] Expiratory abdominal compression
increased the tidal volume in patients with prolonged tracheostomy mechanical ventilation.
The tidal volume during expiratory abdominal compression was influenced by each of the
pulmonary conditions and the physical characteristics.
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Affiliation(s)
- Akira Morino
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology, Japan
| | - Masahiro Shida
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology, Japan
| | - Masashi Tanaka
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology, Japan
| | - Kimihiro Sato
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology, Japan
| | - Toshiaki Seko
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology, Japan
| | - Shunsuke Ito
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology, Japan
| | - Shunichi Ogawa
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology, Japan
| | - Naoaki Takahashi
- Department of Physical Therapy, Health Sciences, School of Rehabilitation Sciences, University of Hokkaido, Japan
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Morino A, Shida M, Tanaka M, Sato K, Seko T, Ito S, Ogawa S, Takahashi N. Comparison of changes in tidal volume associated with expiratory rib cage compression and expiratory abdominal compression in patients on prolonged mechanical ventilation. J Phys Ther Sci 2015; 27:2253-6. [PMID: 26311963 PMCID: PMC4540858 DOI: 10.1589/jpts.27.2253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 04/13/2015] [Indexed: 11/24/2022] Open
Abstract
[Purpose] This study was designed to compare and clarify the relationship between
expiratory rib cage compression and expiratory abdominal compression in patients on
prolonged mechanical ventilation, with a focus on tidal volume. [Subjects and Methods] The
subjects were 18 patients on prolonged mechanical ventilation, who had undergone
tracheostomy. Each patient received expiratory rib cage compression and expiratory
abdominal compression; the order of implementation was randomized. Subjects were
positioned in a 30° lateral recumbent position, and a 2-kgf compression was applied. For
expiratory rib cage compression, the rib cage was compressed unilaterally; for expiratory
abdominal compression, the area directly above the navel was compressed. Tidal volume
values were the actual measured values divided by body weight. [Results] Tidal volume
values were as follows: at rest, 7.2 ± 1.7 mL/kg; during expiratory rib cage compression,
8.3 ± 2.1 mL/kg; during expiratory abdominal compression, 9.1 ± 2.2 mL/kg. There was a
significant difference between the tidal volume during expiratory abdominal compression
and that at rest. The tidal volume in expiratory rib cage compression was strongly
correlated with that in expiratory abdominal compression. [Conclusion] These results
indicate that expiratory abdominal compression may be an effective alternative to the
manual breathing assist procedure.
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Affiliation(s)
- Akira Morino
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Masahiro Shida
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Masashi Tanaka
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Kimihiro Sato
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Toshiaki Seko
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Shunsuke Ito
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Shunichi Ogawa
- Department of Physical Therapy, Hokkaido Chitose Institute of Rehabilitation Technology: 10 Satomi 2-chome, Chitose 066-0055, Japan
| | - Naoaki Takahashi
- Department of Physical Therapy, Health Sciences University of Hokkaido School of Rehabilitation Sciences, Japan
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Perez T, Garcia G, Roche N, Bautin N, Chambellan A, Chaouat A, Court-Fortune I, Delclaux B, Guenard H, Jebrak G, Orvoen-Frija E, Terrioux P. Société de pneumologie de langue française. Recommandation pour la pratique clinique. Prise en charge de la BPCO. Mise à jour 2012. Exploration fonctionnelle respiratoire. Texte long. Rev Mal Respir 2014; 31:263-94. [DOI: 10.1016/j.rmr.2013.11.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Effects of sitting position and applied positive end-expiratory pressure on respiratory mechanics of critically ill obese patients receiving mechanical ventilation*. Crit Care Med 2013; 41:2592-9. [PMID: 23939358 DOI: 10.1097/ccm.0b013e318298637f] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the extent to which sitting position and applied positive end-expiratory pressure improve respiratory mechanics of severely obese patients under mechanical ventilation. DESIGN Prospective cohort study. SETTINGS A 15-bed ICU of a tertiary hospital. PARTICIPANTS Fifteen consecutive critically ill patients with a body mass index (the weight in kilograms divided by the square of the height in meters) above 35 were compared to 15 controls with body mass index less than 30. INTERVENTIONS Respiratory mechanics was first assessed in the supine position, at zero end-expiratory pressure, and then at positive end-expiratory pressure set at the level of auto-positive endexpiratory pressure. Second, all measures were repeated in the sitting position. MEASUREMENTS AND MAIN RESULTS Assessment of respiratory mechanics included plateau pressure, auto-positive end-expiratory pressure, and flow-limited volume during manual compression of the abdomen, expressed as percentage of tidal volume to evaluate expiratory flow limitation. In supine position at zero end-expiratory pressure, all critically ill obese patients demonstrated expiratory flow limitation (flow-limited volume, 59.4% [51.3-81.4%] vs 0% [0-0%] in controls; p < 0.0001) and greater auto-positive end-expiratory pressure (10 [5-12.5] vs 0.7 [0.4-1.25] cm H2O in controls; p < 0.0001). Applied positive end-expiratory pressure reverses expiratory flow limitation (flow-limited volume, 0% [0-21%] vs 59.4% [51-81.4%] at zero end-expiratory pressure; p < 0.001) in almost all the obese patients, without increasing plateau pressure (24 [19-25] vs 22 [18-24] cm H2O at zero end-expiratory pressure; p = 0.94). Sitting position not only reverses partially or completely expiratory flow limitation at zero end-expiratory pressure (flow-limited volume, 0% [0-58%] vs 59.4% [51-81.4%] in supine obese patients; p < 0.001) but also results in a significant drop in auto-positive end-expiratory pressure (1.2 [0.6-4] vs 10 [5-12.5] cm H2O in supine obese patients; p < 0.001) and plateau pressure (15.6 [14-17] vs 22 [18-24] cm H2O in supine obese patients; p < 0.001). CONCLUSIONS In critically ill obese patients under mechanical ventilation, sitting position constantly and significantly relieved expiratory flow limitation and auto-positive end-expiratory pressure resulting in a dramatic drop in alveolar pressures. Combining sitting position and applied positive end-expiratory pressure provides the best strategy.
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