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Positive end-expiratory pressure individualization guided by continuous end-expiratory lung volume monitoring during laparoscopic surgery. J Clin Monit Comput 2021; 36:1557-1567. [PMID: 34966951 DOI: 10.1007/s10877-021-00800-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/24/2021] [Indexed: 10/19/2022]
Abstract
To determine whether end-expiratory lung volume measured with volumetric capnography (EELVCO2) can individualize positive end-expiratory pressure (PEEP) setting during laparoscopic surgery. We studied patients undergoing laparoscopic surgery subjected to Fowler (F-group; n = 20) or Trendelenburg (T-group; n = 20) positions. EELVCO2 was measured at 0° supine (baseline), during capnoperitoneum (CP) at 0° supine, during CP with Fowler (head up + 20°) or Trendelenburg (head down - 30°) positions and after CP back to 0° supine. PEEP was adjusted to preserve baseline EELVCO2 during and after CP. Baseline EELVCO2 was statistically similar to predicted FRC in both groups. At supine and CP, EELVCO2 decreased from baseline values in F-group [median and IQR 2079 (768) to 1545 (725) mL; p = 0.0001] and in T-group [2164 (789) to 1870 (940) mL; p = 0.0001]. Change in body position maintained EELVCO2 unchanged in both groups. PEEP adjustments from 5.6 (1.1) to 10.0 (2.5) cmH2O in the F-group (p = 0.0001) and from 5.6 (0.9) to 10.0 (2.6) cmH2O in T-group (p = 0.0001) were necessary to reach baseline EELVCO2 values. EELVCO2 increased close to baseline with PEEP in the F-group [1984 (600) mL; p = 0.073] and in the T-group [2175 (703) mL; p = 0.167]. After capnoperitoneum and back to 0° supine, PEEP needed to maintain EELVCO2 was similar to baseline PEEP in F-group [5.9 (1.8) cmH2O; p = 0.179] but slightly higher in the T-group [6.5 (2.2) cmH2O; p = 0.006]. Those new PEEP values gave EELVCO2 similar to baseline in the F-group [2039 (980) mL; p = 0.370] and in the T-group [2150 (715) mL; p = 0.881]. Breath-by-breath noninvasive EELVCO2 detected changes in lung volume induced by capnoperitoneum and body position and was useful to individualize the level of PEEP during laparoscopy.Trial registry: Clinicaltrials.gov NCT03693352. Protocol started 1st October 2018.
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Mazzinari G, Serpa Neto A, Hemmes SNT, Hedenstierna G, Jaber S, Hiesmayr M, Hollmann MW, Mills GH, Vidal Melo MF, Pearse RM, Putensen C, Schmid W, Severgnini P, Wrigge H, Cambronero OD, Ball L, de Abreu MG, Pelosi P, Schultz MJ. The Association of Intraoperative driving pressure with postoperative pulmonary complications in open versus closed abdominal surgery patients - a posthoc propensity score-weighted cohort analysis of the LAS VEGAS study. BMC Anesthesiol 2021; 21:84. [PMID: 33740885 PMCID: PMC7977277 DOI: 10.1186/s12871-021-01268-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 01/25/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND It is uncertain whether the association of the intraoperative driving pressure (ΔP) with postoperative pulmonary complications (PPCs) depends on the surgical approach during abdominal surgery. Our primary objective was to determine and compare the association of time-weighted average ΔP (ΔPTW) with PPCs. We also tested the association of ΔPTW with intraoperative adverse events. METHODS Posthoc retrospective propensity score-weighted cohort analysis of patients undergoing open or closed abdominal surgery in the 'Local ASsessment of Ventilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study, that included patients in 146 hospitals across 29 countries. The primary endpoint was a composite of PPCs. The secondary endpoint was a composite of intraoperative adverse events. RESULTS The analysis included 1128 and 906 patients undergoing open or closed abdominal surgery, respectively. The PPC rate was 5%. ΔP was lower in open abdominal surgery patients, but ΔPTW was not different between groups. The association of ΔPTW with PPCs was significant in both groups and had a higher risk ratio in closed compared to open abdominal surgery patients (1.11 [95%CI 1.10 to 1.20], P < 0.001 versus 1.05 [95%CI 1.05 to 1.05], P < 0.001; risk difference 0.05 [95%CI 0.04 to 0.06], P < 0.001). The association of ΔPTW with intraoperative adverse events was also significant in both groups but had higher odds ratio in closed compared to open abdominal surgery patients (1.13 [95%CI 1.12- to 1.14], P < 0.001 versus 1.07 [95%CI 1.05 to 1.10], P < 0.001; risk difference 0.05 [95%CI 0.030.07], P < 0.001). CONCLUSIONS ΔP is associated with PPC and intraoperative adverse events in abdominal surgery, both in open and closed abdominal surgery. TRIAL REGISTRATION LAS VEGAS was registered at clinicaltrials.gov (trial identifier NCT01601223 ).
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Affiliation(s)
- Guido Mazzinari
- grid.84393.350000 0001 0360 9602Research Group in Perioperative Medicine, Hospital Universitario y Politécnico la Fe, Avinguda de Fernando Abril Martorell 106, 46026 Valencia, Spain ,grid.84393.350000 0001 0360 9602Department of Anesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Ary Serpa Neto
- grid.413562.70000 0001 0385 1941Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil ,grid.11899.380000 0004 1937 0722Cardio-Pulmonary Department, Pulmonary Division, Faculdade de Medicina, Instituto do Coração, Hospital das Clinicas HCFMUSP, Universidade de Sao Paulo, Sao Paulo, Brazil ,grid.5650.60000000404654431Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - Sabrine N. T. Hemmes
- grid.5650.60000000404654431Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - Goran Hedenstierna
- grid.8993.b0000 0004 1936 9457Department of Medical Sciences, Clinical Physiology, Uppsala University, Uppsala, Sweden
| | - Samir Jaber
- grid.121334.60000 0001 2097 0141PhyMedExp, INSERM U1046, CNRS UMR 9214, University of Montpellier, Montpellier, France
| | - Michael Hiesmayr
- grid.22937.3d0000 0000 9259 8492Division Cardiac, Thoracic, Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Markus W. Hollmann
- grid.5650.60000000404654431Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands
| | - Gary H. Mills
- grid.11835.3e0000 0004 1936 9262Operating Services, Critical Care and Anesthesia, Sheffield Teaching Hospitals, Sheffield and University of Sheffield, Sheffield, UK
| | - Marcos F. Vidal Melo
- grid.32224.350000 0004 0386 9924Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | - Rupert M. Pearse
- grid.4868.20000 0001 2171 1133Queen Mary University of London, London, UK
| | - Christian Putensen
- grid.15090.3d0000 0000 8786 803XDepartment of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Werner Schmid
- grid.22937.3d0000 0000 9259 8492Division Cardiac, Thoracic, Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Paolo Severgnini
- grid.18147.3b0000000121724807Department of Biotechnology and Sciences of Life, ASST- Settelaghi Ospedale di Circolo e Fondazione Macchi, University of Insubria, Varese, Italy
| | - Hermann Wrigge
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Pain Therapy, Bergmannstrost Hospital, Halle, Germany
| | - Oscar Diaz Cambronero
- grid.84393.350000 0001 0360 9602Research Group in Perioperative Medicine, Hospital Universitario y Politécnico la Fe, Avinguda de Fernando Abril Martorell 106, 46026 Valencia, Spain ,grid.84393.350000 0001 0360 9602Department of Anesthesiology, Hospital Universitario y Politécnico la Fe, Valencia, Spain
| | - Lorenzo Ball
- Policlinico San Martino Hospital – IRCCS for Oncology and Neurosciences, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostics, University of Genoa Italy, Genoa, Italy
| | - Marcelo Gama de Abreu
- grid.4488.00000 0001 2111 7257Department of Anesthesiology and Intensive Care Therapy, Pulmonary Engineering Group, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Policlinico San Martino Hospital – IRCCS for Oncology and Neurosciences, Genoa, Italy ,grid.5606.50000 0001 2151 3065Department of Surgical Sciences and Integrated Diagnostics, University of Genoa Italy, Genoa, Italy
| | - Marcus J. Schultz
- grid.5650.60000000404654431Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A), Academic Medical Center, Amsterdam, The Netherlands ,grid.10223.320000 0004 1937 0490Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand ,grid.4991.50000 0004 1936 8948Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Intraabdominal Pressure Targeted Positive End-expiratory Pressure during Laparoscopic Surgery: An Open-label, Nonrandomized, Crossover, Clinical Trial. Anesthesiology 2020; 132:667-677. [PMID: 32011334 DOI: 10.1097/aln.0000000000003146] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pneumoperitoneum for laparoscopic surgery is associated with a rise of driving pressure. The authors aimed to assess the effects of positive end-expiratory pressure (PEEP) on driving pressure at varying intraabdominal pressure levels. It was hypothesized that PEEP attenuates pneumoperitoneum-related rises in driving pressure. METHODS Open-label, nonrandomized, crossover, clinical trial in patients undergoing laparoscopic cholecystectomy. "Targeted PEEP" (2 cm H2O above intraabdominal pressure) was compared with "standard PEEP" (5 cm H2O), with respect to the transpulmonary and respiratory system driving pressure at three predefined intraabdominal pressure levels, and each patient was ventilated with two levels of PEEP at the three intraabdominal pressure levels in the same sequence. The primary outcome was the difference in transpulmonary driving pressure between targeted PEEP and standard PEEP at the three levels of intraabdominal pressure. RESULTS Thirty patients were included and analyzed. Targeted PEEP was 10, 14, and 17 cm H2O at intraabdominal pressure of 8, 12, and 15 mmHg, respectively. Compared to standard PEEP, targeted PEEP resulted in lower median transpulmonary driving pressure at intraabdominal pressure of 8 mmHg (7 [5 to 8] vs. 9 [7 to 11] cm H2O; P = 0.010; difference 2 [95% CI 0.5 to 4 cm H2O]); 12 mmHg (7 [4 to 9] vs.10 [7 to 12] cm H2O; P = 0.002; difference 3 [1 to 5] cm H2O); and 15 mmHg (7 [6 to 9] vs.12 [8 to 15] cm H2O; P < 0.001; difference 4 [2 to 6] cm H2O). The effects of targeted PEEP compared to standard PEEP on respiratory system driving pressure were comparable to the effects on transpulmonary driving pressure, though respiratory system driving pressure was higher than transpulmonary driving pressure at all intraabdominal pressure levels. CONCLUSIONS Transpulmonary driving pressure rises with an increase in intraabdominal pressure, an effect that can be counterbalanced by targeted PEEP. Future studies have to elucidate which combination of PEEP and intraabdominal pressure is best in term of clinical outcomes.
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Positive End-expiratory Pressure and Distribution of Ventilation in Pneumoperitoneum Combined with Steep Trendelenburg Position. Anesthesiology 2020; 132:476-490. [DOI: 10.1097/aln.0000000000003062] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Abstract
Background
Pneumoperitoneum and a steep Trendelenburg position during robot-assisted laparoscopic prostatectomy have been demonstrated to promote a cranial shift of the diaphragm and the formation of atelectasis in the dorsal parts of the lungs. However, neither an impact of higher positive end-expiratory pressure (PEEP) on preserving the ventilation in the dorsal region nor its physiologic effects have been fully examined. The authors hypothesized that PEEP of 15 cm H2O during robot-assisted laparoscopic prostatectomy might maintain ventilation in the dorsal parts and thus improve lung mechanics.
Methods
In this randomized controlled study, 48 patients undergoing robot-assisted laparoscopic prostatectomy were included in the analysis. Patients were assigned to the conventional PEEP (5 cm H2O) group or the high PEEP (15 cm H2O) group. Regional ventilation was monitored using electrical impedance tomography before and after the establishment of pneumoperitoneum and 20° Trendelenburg position during the surgery. The primary endpoint was the regional ventilation in the dorsal parts of the lungs while the secondary endpoints were lung mechanics and postoperative lung function.
Results
Compared to that in the conventional PEEP group, the fraction of regional ventilation in the most dorsal region was significantly higher in the high PEEP group during pneumoperitoneum and Trendelenburg position (mean values at 20 min after taking Trendelenburg position: conventional PEEP, 5.5 ± 3.9%; high PEEP, 9.9 ± 4.7%; difference, –4.5%; 95% CI, –7.4 to –1.6%; P = 0.004). Concurrently, lower driving pressure (conventional PEEP, 14.9 ± 2.5 cm H2O; high PEEP, 11.5 ± 2.8 cm H2O; P < 0.001), higher lung dynamic compliance, and better oxygenation were demonstrated in the high PEEP group. Postoperative lung function did not differ between the groups.
Conclusions
Application of a PEEP of 15 cm H2O resulted in more homogeneous ventilation and favorable physiologic effects during robot-assisted laparoscopic prostatectomy but did not improve postoperative lung function.
Editor’s Perspective
What We Already Know about This Topic
What This Article Tells Us That Is New
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Noninvasive Assessment of Intra-Abdominal Pressure Using Ultrasound-Guided Tonometry: A Proof-of-Concept Study. Shock 2019; 50:684-688. [PMID: 29251669 DOI: 10.1097/shk.0000000000001085] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Intra-abdominal hypertension jeopardizes abdominal organ perfusion and venous return. Contemporary recognition of elevated intra-abdominal pressure (IAP) plays a crucial role in reducing mortality and morbidity. We evaluated ultrasound-guided tonometry in this context hypothesizing that the vertical chamber diameter of this device inversely correlates with IAP. METHODS IAP was increased in six 5 mmHg steps to 40 mmHg by instillation of normal saline into the peritoneal cavity of eight anesthetized pigs. Liver and renal blood flows (ultrasound transit time), intravesical, intraperitoneal, and end-inspiratory plateau pressures were recorded. For ultrasound-based assessment of IAP (ultrasound-guided tonometry), a pressure-transducing, compressible chamber was fixed at the tip of a linear ultrasound probe, and the system was applied on the abdominal wall using different predetermined levels of external pressure. At each IAP level (reference: intravesical pressure), two investigators measured the vertical diameter of this chamber. RESULTS All abdominal flows decreased (by 39%-58%), and end-inspiratory plateau pressure increased from 15 mbar (14-17 mbar) to 38 mbar (33-42 mbar) (median, range) with increasing IAP (all P < 0.01). Vertical chamber diameter decreased from 14.9 (14.6-15.2) mm to12.8 (12.4-13.4) mm with increasing IAP. Coefficients of variations between and within observers regarding change of the vertical tonometry chamber diameter were small (all <4%), and the results were independent of the externally applied pressure level on the ultrasound probe. Correlation of IAP and vertical pressure chamber distance was highly significant (r = -1, P = 0.0004). Ultrasound-guided tonometry could discriminate between normal (baseline) pressure and 15 mmHg, between 15 and 25 mmHg) and between 25 and 40 mmHg IAP (all P ≤ 0.18). Similar results were obtained for end-inspiratory plateau pressures. CONCLUSIONS In our model, values obtained by ultrasound-guided tonometry correlated significantly with IAPs. The method was able to discriminate between normal, moderately, and markedly increased IAP values.
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Norisue Y, Ashworth L, Naito T, Kataoka J, Takeuchi M, Usami S, Takada J, Fujitani S. Impact of physician education and availability of parameters regarding esophageal pressure and transpulmonary pressure on clinical decisions involving ventilator management. J Crit Care 2017; 41:112-118. [PMID: 28514715 DOI: 10.1016/j.jcrc.2017.04.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 04/09/2017] [Accepted: 04/13/2017] [Indexed: 11/16/2022]
Abstract
PURPOSE This study investigated the effects of physician education and the availability of Peso and PL data on physicians' decisions regarding ventilator management during specific simulated clinical conditions. MATERIALS AND METHODS The study was a prospective, before-after study using a case scenario-based questionnaire and a case simulator device comprising an Avea ventilator and an artificial lung and esophagus, which was connected to a Series 1101 Electronic Breathing Simulator. The 99 physicians participating in the study were provided with five simulated cases with on-time ventilator graphics without Peso and PL and completed a questionnaire on decisions they would make regarding ventilator management of the cases. Then, after receiving instruction on Peso and PL, they were given the same cases along with ventilator graphics that included Peso and PL. RESULTS After receiving instruction and data on Peso and PL, statistically significant numbers of physicians changed their answers regarding ventilator management decisions in all five cases. CONCLUSIONS Providing education and data for Peso and PL had a significant effect on physician decisions regarding ventilator management in simulated cases. The use of case scenario-based education with simulator devices for physicians may hasten worldwide understanding and clinical application of Peso and PL.
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Affiliation(s)
- Yasuhiro Norisue
- Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan.
| | - Lonny Ashworth
- Department of Respiratory Care, Boise State University, Boise, ID, USA
| | - Takaki Naito
- Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Jun Kataoka
- Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Muneyuki Takeuchi
- Department of Anesthesia and Critical Care Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
| | - Sunao Usami
- Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Junko Takada
- Department of Pulmonary and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Shigeki Fujitani
- Department of Emergency and Critical Care Medicine, St. Marianna University Hospital, Kanagawa, Japan
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Xie J, Jin F, Pan C, Liu S, Liu L, Xu J, Yang Y, Qiu H. The effects of low tidal ventilation on lung strain correlate with respiratory system compliance. Crit Care 2017; 21:23. [PMID: 28159013 PMCID: PMC5291981 DOI: 10.1186/s13054-017-1600-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 01/04/2017] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND The effect of alterations in tidal volume on mortality of acute respiratory distress syndrome (ARDS) is determined by respiratory system compliance. We aimed to investigate the effects of different tidal volumes on lung strain in ARDS patients who had various levels of respiratory system compliance. METHODS Nineteen patients were divided into high (Chigh group) and low (Clow group) respiratory system compliance groups based on their respiratory system compliance values. We defined compliance ≥0.6 ml/(cmH2O/kg) as Chigh and compliance <0.6 ml/(cmH2O/kg) as Clow. End-expiratory lung volumes (EELV) at various tidal volumes were measured by nitrogen wash-in/washout. Lung strain was calculated as the ratio between tidal volume and EELV. The primary outcome was that lung strain is a function of tidal volume in patients with various levels of respiratory system compliance. RESULTS The mean baseline EELV, strain and respiratory system compliance values were 1873 ml, 0.31 and 0.65 ml/(cmH2O/kg), respectively; differences in all of these parameters were statistically significant between the two groups. For all participants, a positive correlation was found between the respiratory system compliance and EELV (R = 0.488, p = 0.034). Driving pressure and strain increased together as the tidal volume increased from 6 ml/kg predicted body weight (PBW) to 12 ml/kg PBW. Compared to the Chigh ARDS patients, the driving pressure was significantly higher in the Clow patients at each tidal volume. Similar effects of lung strain were found for tidal volumes of 6 and 8 ml/kg PBW. The "lung injury" limits for driving pressure and lung strain were much easier to exceed with increases in the tidal volume in Clow patients. CONCLUSIONS Respiratory system compliance affected the relationships between tidal volume and driving pressure and lung strain in ARDS patients. These results showed that increasing tidal volume induced lung injury more easily in patients with low respiratory system compliance. TRIAL REGISTRATION Clinicaltrials.gov identifier NCT01864668 , Registered 21 May 2013.
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Affiliation(s)
- Jianfeng Xie
- Department of Critical Care Medicine, Nanjing ZhongDa Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Gulou District, Nanjing, Jiangsu 210009 China
| | - Fang Jin
- Department of Critical Care Medicine, Nanjing ZhongDa Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Gulou District, Nanjing, Jiangsu 210009 China
| | - Chun Pan
- Department of Critical Care Medicine, Nanjing ZhongDa Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Gulou District, Nanjing, Jiangsu 210009 China
| | - Songqiao Liu
- Department of Critical Care Medicine, Nanjing ZhongDa Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Gulou District, Nanjing, Jiangsu 210009 China
| | - Ling Liu
- Department of Critical Care Medicine, Nanjing ZhongDa Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Gulou District, Nanjing, Jiangsu 210009 China
| | - Jingyuan Xu
- Department of Critical Care Medicine, Nanjing ZhongDa Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Gulou District, Nanjing, Jiangsu 210009 China
| | - Yi Yang
- Department of Critical Care Medicine, Nanjing ZhongDa Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Gulou District, Nanjing, Jiangsu 210009 China
| | - Haibo Qiu
- Department of Critical Care Medicine, Nanjing ZhongDa Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Gulou District, Nanjing, Jiangsu 210009 China
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Kollisch-Singule M, Emr B, Jain SV, Andrews P, Satalin J, Liu J, Porcellio E, Kenyon V, Wang G, Marx W, Gatto LA, Nieman GF, Habashi NM. The effects of airway pressure release ventilation on respiratory mechanics in extrapulmonary lung injury. Intensive Care Med Exp 2015; 3:35. [PMID: 26694915 PMCID: PMC4688284 DOI: 10.1186/s40635-015-0071-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 12/13/2015] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Lung injury is often studied without consideration for pathologic changes in the chest wall. In order to reduce the incidence of lung injury using preemptive mechanical ventilation, it is important to recognize the influence of altered chest wall mechanics on disease pathogenesis. In this study, we hypothesize that airway pressure release ventilation (APRV) may be able to reduce the chest wall elastance associated with an extrapulmonary lung injury model as compared with low tidal volume (LVt) ventilation. METHODS Female Yorkshire pigs were anesthetized and instrumented. Fecal peritonitis was established, and the superior mesenteric artery was clamped for 30 min to induce an ischemia/reperfusion injury. Immediately following injury, pigs were randomized into (1) LVt (n = 3), positive end-expiratory pressure (PEEP) 5 cmH2O, V t 6 cc kg(-1), FiO2 21 %, and guided by the ARDSnet protocol or (2) APRV (n = 3), P High 16-22 cmH2O, P Low 0 cmH2O, T High 4.5 s, T Low set to terminate the peak expiratory flow at 75 %, and FiO2 21 %. Pigs were monitored continuously for 48 h. Lung samples and bronchoalveolar lavage fluid were collected at necropsy. RESULTS LVt resulted in mild acute respiratory distress syndrome (ARDS) (PaO2/FiO2 = 226.2 ± 17.1 mmHg) whereas APRV prevented ARDS (PaO2/FiO2 = 465.7 ± 66.5 mmHg; p < 0.05). LVt had a reduced surfactant protein A concentration and increased histologic injury as compared with APRV. The plateau pressure in APRV (34.3 ± 0.9 cmH2O) was significantly greater than LVt (22.2 ± 2.0 cmH2O; p < 0.05) yet transpulmonary pressure between groups was similar (p > 0.05). This was because the pleural pressure was significantly lower in LVt (7.6 ± 0.5 cmH2O) as compared with APRV (17.4 ± 3.5 cmH2O; p < 0.05). Finally, the elastance of the lung, chest wall, and respiratory system were all significantly greater in LVt as compared with APRV (all p < 0.05). CONCLUSIONS APRV preserved surfactant and lung architecture and maintenance of oxygenation. Despite the greater plateau pressure and tidal volumes in the APRV group, the transpulmonary pressure was similar to that of LVt. Thus, the majority of the plateau pressure in the APRV group was distributed as pleural pressure in this extrapulmonary lung injury model. APRV maintained a normal lung elastance and an open, homogeneously ventilated lung without increasing lung stress.
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Affiliation(s)
- Michaela Kollisch-Singule
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA.
| | - Bryanna Emr
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA.
| | - Sumeet V Jain
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA.
| | - Penny Andrews
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Joshua Satalin
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA.
| | - Jiao Liu
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA.
| | - Elizabeth Porcellio
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA.
| | - Van Kenyon
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA.
| | - Guirong Wang
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA.
| | - William Marx
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA.
| | - Louis A Gatto
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA.
- Department of Biological Sciences, SUNY Cortland, Cortland, NY, USA.
| | - Gary F Nieman
- Department of Surgery, SUNY Upstate Medical University, 750 E. Adams Street, Syracuse, NY, 13210, USA.
| | - Nader M Habashi
- Department of Trauma Critical Care Medicine, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
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Thabet FC, Bougmiza IM, Chehab MS, Bafaqih HA, AlMohaimeed SA, Malbrain MLNG. Incidence, Risk Factors, and Prognosis of Intra-Abdominal Hypertension in Critically Ill Children: A Prospective Epidemiological Study. J Intensive Care Med 2015; 31:403-8. [PMID: 25922384 DOI: 10.1177/0885066615583645] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 02/11/2015] [Indexed: 12/29/2022]
Abstract
PURPOSE To assess the incidence, risk factors, and outcomes of intra-abdominal hypertension (IAH) in a pediatric intensive care unit (PICU). METHODS Prospective cohort study from January 2011 to January 2013. All children consecutively admitted to the PICU, staying more than 24 hours and requiring bladder catheterization, were included in the study. On admission, demographic data and risk factors for IAH were studied. The intra-abdominal pressure was measured every 6 hours through a bladder catheter until discharge, death, or removal of the catheter. RESULTS Of the 175 patients, 22 (12.6%) had IAH and 7 (4%) had abdominal compartment syndrome during the intensive care unit (ICU) stay. The independent risk factors associated with IAH were the presence of abdominal distension (odds ratio [OR] 7.1; 95% confidence interval [CI], 2.6-19.9; P < .0001) and a plateau pressure of more than 30 cm H2O (OR 6.42; 95% CI, 2.13-19.36; P = .01). The presence of IAH was associated with higher mortality (40.9% vs 15.6%; P = .01) and prolonged ICU stay (19.5 [3-97] vs 8 [1-104] days, OR 1.02; 95% CI, 1.00-1.04; P = .02). Thirty-three (18.8%) patients died in the ICU, and IAH was an independent risk factor for mortality (OR 6.98; 95% CI, 1.75-27.86; P = .006). CONCLUSION Intra-abdominal hypertension does occur in about 13% of the critically ill children, albeit less frequently than adult patients, probably related to a better compliance of the abdominal wall. The presence of abdominal distension and a plateau pressure of more than 30 cm H2O was found to be independent predictors of IAH. Children with IAH had higher mortality rate and more prolonged ICU stay.
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Affiliation(s)
- Farah Chedly Thabet
- Division of Pediatric Intensive Care, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Iheb Mohamed Bougmiza
- Department of Family and Community Medicine, Faculty of Medicine of Sousse, Sousse, Tunisia
| | - May Said Chehab
- Division of Pediatric Intensive Care, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Hind Ali Bafaqih
- Division of Pediatric Intensive Care, Department of Pediatrics, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | | | - Manu L N G Malbrain
- Intensive Care Unit and High Care Burn Unit, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Antwerpen, Belgium
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LUNDIN S, GRIVANS C, STENQVIST O. Transpulmonary pressure and lung elastance can be estimated by a PEEP-step manoeuvre. Acta Anaesthesiol Scand 2015; 59:185-96. [PMID: 25443094 DOI: 10.1111/aas.12442] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 10/15/2014] [Indexed: 01/17/2023]
Abstract
BACKGROUND Transpulmonary pressure is a key factor for protective ventilation. This requires measurements of oesophageal pressure that is rarely used clinically. A simple method may be found, if it could be shown that tidal and positive end-expiratory pressure (PEEP) inflation of the lungs with the same volume increases transpulmonary pressure equally. The aim of the present study was to compare tidal and PEEP inflation of the respiratory system. METHODS A total of 12 patients with acute respiratory failure were subjected to PEEP trials of 0-4-8-12-16 cmH2O. Changes in end-expiratory lung volume (ΔEELV) following a PEEP step were determined from cumulative differences in inspiratory-expiratory tidal volumes. Oesophageal pressure was measured with a balloon catheter. RESULTS Following a PEEP increase from 0 to 16 cmH2O end-expiratory oesophageal pressure did not increase (0.5 ± 4.0 cmH2O). Average increase in EELV following a PEEP step of 4 cmH2O was 230 ± 132 ml. The increase in EELV was related to the change in PEEP divided by lung elastance (El) derived from oesophageal pressure as ΔPEEP/El. There was a good correlation between transpulmonary pressure by oesophageal pressure and transpulmonary pressure based on El determined as ΔPEEP/ΔEELV, r(2) = 0.80, y = 0.96x, mean bias -0.4 ± 3.0 cmH2 O with limits of agreement from 5.4 to -6.2 cmH2O (2 standard deviations). CONCLUSION PEEP inflation of the respiratory system is extremely slow, and allows the chest wall complex, especially the abdomen, to yield and adapt to intrusion of the diaphragm. As a consequence a change in transpulmonary pressure is equal to the change in PEEP and transpulmonary pressure can be determined without oesophageal pressure measurements.
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Affiliation(s)
- S. LUNDIN
- Department of Anesthesiology and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| | - C. GRIVANS
- Department of Anesthesiology and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| | - O. STENQVIST
- Department of Anesthesiology and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
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Loring SH, Behazin N, Novero A, Novack V, Jones SB, O'Donnell CR, Talmor DS. Respiratory mechanical effects of surgical pneumoperitoneum in humans. J Appl Physiol (1985) 2014; 117:1074-9. [PMID: 25213641 DOI: 10.1152/japplphysiol.00552.2014] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pneumoperitoneum for laparoscopic surgery is known to stiffen the chest wall and respiratory system, but its effects on resting pleural pressure in humans are unknown. We hypothesized that pneumoperitoneum would raise abdominal pressure, push the diaphragm into the thorax, raise pleural pressure, and squeeze the lung, which would become stiffer at low volumes as in severe obesity. Nineteen predominantly obese laparoscopic patients without pulmonary disease were studied supine (level), under neuromuscular blockade, before and after insufflation of CO2 to a gas pressure of 20 cmH2O. Esophageal pressure (Pes) and airway pressure (Pao) were measured to estimate pleural pressure and transpulmonary pressure (Pl = Pao - Pes). Changes in relaxation volume (Vrel, at Pao = 0) were estimated from changes in expiratory reserve volume, the volume extracted between Vrel, and the volume at Pao = -25 cmH2O. Inflation pressure-volume (Pao-Vl) curves from Vrel were assessed for evidence of lung compression due to high Pl. Respiratory mechanics were measured during ventilation with a positive end-expiratory pressure of 0 and 7 cmH2O. Pneumoperitoneum stiffened the chest wall and the respiratory system (increased elastance), but did not stiffen the lung, and positive end-expiratory pressure reduced Ecw during pneumoperitoneum. Contrary to our expectations, pneumoperitoneum at Vrel did not significantly change Pes [8.7 (3.4) to 7.6 (3.2) cmH2O; means (SD)] or expiratory reserve volume [183 (142) to 155 (114) ml]. The inflation Pao-Vl curve above Vrel did not show evidence of increased lung compression with pneumoperitoneum. These results in predominantly obese subjects can be explained by the inspiratory effects of abdominal pressure on the rib cage.
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Affiliation(s)
- Stephen H Loring
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts;
| | - Negin Behazin
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Aileen Novero
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Victor Novack
- Soroka University Medical Center, Beer Sheva, Israel; and
| | - Stephanie B Jones
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Carl R O'Donnell
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Daniel S Talmor
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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12
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The assessment of transpulmonary pressure in mechanically ventilated ARDS patients. Intensive Care Med 2014; 40:1670-8. [PMID: 25112501 DOI: 10.1007/s00134-014-3415-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 07/19/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The optimal method for estimating transpulmonary pressure (i.e. the fraction of the airway pressure transmitted to the lung) has not yet been established. METHODS In this study on 44 patients with acute respiratory distress syndrome (ARDS), we computed the end-inspiratory transpulmonary pressure as the change in airway and esophageal pressure from end-inspiration to atmospheric pressure (i.e. release derived) and as the product of the end-inspiratory airway pressure and the ratio of lung to respiratory system elastance (i.e. elastance derived). The end-expiratory transpulmonary pressure was estimated as the product of positive end-expiratory pressure (PEEP) minus the direct measurement of esophageal pressure and by the release method. RESULTS The mean elastance- and release-derived transpulmonary pressure were 14.4 ± 3.7 and 14.4 ± 3.8 cmH₂O at 5 cmH₂O of PEEP and 21.8 ± 5.1 and 21.8 ± 4.9 cmH₂O at 15 cmH₂O of PEEP, respectively (P = 0.32, P = 0.98, respectively), indicating that these parameters were significantly related (r(2) = 0.98, P < 0.001 at 5 cmH₂O of PEEP; r(2) = 0.93, P < 0.001 at 15 cmH₂O of PEEP). The percentage error was 5.6 and 12.0 %, respectively. The mean directly measured and release-derived transpulmonary pressure were -8.0 ± 3.8 and 3.9 ± 0.9 cmH₂O at 5 cmH₂O of PEEP and -1.2 ± 3.2 and 10.6 ± 2.2 cmH₂O at 15 cmH₂O of PEEP, respectively, indicating that these parameters were not related (r(2) = 0.07, P = 0.08 at 5 cmH₂O of PEEP; r (2) = 0.10, P = 0.53 at 15 cmH₂O of PEEP). CONCLUSIONS Based on our observations, elastance-derived transpulmonary pressure can be considered to be an adequate surrogate of the release-derived transpulmonary pressure, while the release-derived and directly measured end-expiratory transpulmonary pressure are not related.
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Abstract
Mechanical ventilation (MV) is, by definition, the application of external forces to the lungs. Depending on their magnitude, these forces can cause a continuum of pathophysiological alterations ranging from the stimulation of inflammation to the disruption of cell-cell contacts and cell membranes. These side effects of MV are particularly relevant for patients with inhomogeneously injured lungs such as in acute lung injury (ALI). These patients require supraphysiological ventilation pressures to guarantee even the most modest gas exchange. In this situation, ventilation causes additional strain by overdistension of the yet non-injured region, and additional stress that forms because of the interdependence between intact and atelectatic areas. Cells are equipped with elaborate mechanotransduction machineries that respond to strain and stress by the activation of inflammation and repair mechanisms. Inflammation is the fundamental response of the host to external assaults, be they of mechanical or of microbial origin and can, if excessive, injure the parenchymal tissue leading to ALI. Here, we will discuss the forces generated by MV and how they may injure the lungs mechanically and through inflammation. We will give an overview of the mechanotransduction and how it leads to inflammation and review studies demonstrating that ventilator-induced lung injury can be prevented by blocking pathways of mechanotransduction or inflammation.
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Affiliation(s)
- Ulrike Uhlig
- Department of Pharmacology & Toxicology, Medical Faculty, RWTH Aachen University, Aachen, Germany
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14
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Value and limitations of transpulmonary pressure calculations during intra-abdominal hypertension. Crit Care Med 2013; 41:1870-7. [PMID: 23863222 DOI: 10.1097/ccm.0b013e31828a3bea] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To clarify the effect of progressively increasing intra-abdominal pressure on esophageal pressure, transpulmonary pressure, and functional residual capacity. DESIGN Controlled application of increased intra-abdominal pressure at two positive end-expiratory pressure levels (1 and 10 cm H2O) in an anesthetized porcine model of controlled ventilation. SETTING Large animal laboratory of a university-affiliated hospital. SUBJECTS Eleven deeply anesthetized swine (weight 46.2 ± 6.2 kg). INTERVENTIONS Air-regulated intra-abdominal hypertension (0-25 mm Hg). MEASUREMENTS Esophageal pressure, tidal compliance, bladder pressure, and end-expiratory lung aeration by gas dilution. MAIN RESULTS Functional residual capacity was significantly reduced by increasing intra-abdominal pressure at both positive end-expiratory pressure levels (p ≤ 0.0001) without corresponding changes of end-expiratory esophageal pressure. Above intra-abdominal pressure 5 mm Hg, plateau airway pressure increased linearly by ~ 50% of the applied intra-abdominal pressure value, associated with commensurate changes of esophageal pressure. With tidal volume held constant, negligible changes occurred in transpulmonary pressure due to intra-abdominal pressure. Driving pressures calculated from airway pressures alone (plateau airway pressure--positive end-expiratory pressure) did not equate to those computed from transpulmonary pressure (tidal changes in transpulmonary pressure). Increasing positive end-expiratory pressure shifted the predominantly negative end-expiratory transpulmonary pressure at positive end-expiratory pressure 1 cm H2O (mean -3.5 ± 0.4 cm H2O) into the positive range at positive end-expiratory pressure 10 cm H2O (mean 0.58 ± 1.2 cm H2O). CONCLUSIONS Despite its insensitivity to changes in functional residual capacity, measuring transpulmonary pressure may be helpful in explaining how different levels of positive end-expiratory pressure influence recruitment and collapse during tidal ventilation in the presence of increased intra-abdominal pressure and in calculating true transpulmonary driving pressure (tidal changes of transpulmonary pressure). Traditional interpretations of respiratory mechanics based on unmodified airway pressure were misleading regarding lung behavior in this setting.
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Pleural pressure and optimal positive end-expiratory pressure based on esophageal pressure versus chest wall elastance: incompatible results*. Crit Care Med 2013; 41:1951-7. [PMID: 23863227 DOI: 10.1097/ccm.0b013e31828a3de5] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES 1) To compare two published methods for estimating pleural pressure, one based on directly measured esophageal pressure and the other based on chest wall elastance. 2) To evaluate the agreement between two published positive end-expiratory pressure optimization strategies based on these methods, one targeting an end-expiratory esophageal pressure-based transpulmonary pressure of 0 cm H2O and the other targeting an end-inspiratory elastance-based transpulmonary pressure of 26 cm H2O. DESIGN Retrospective study using clinical data. SETTING Medical and surgical ICUs. PATIENTS Sixty-four patients mechanically ventilated for acute respiratory failure with esophageal balloons placed for clinical management. METHODS Esophageal pressure and chest wall elastance-based methods for estimating pleural pressure and setting positive end-expiratory pressure were retrospectively applied to each of the 64 patients. In patients who were ventilated at two positive end-expiratory pressure levels, chest wall and respiratory system elastances were calculated at each positive end-expiratory pressure level. MEASUREMENTS AND MAIN RESULTS The pleural pressure estimates using both methods were discordant and differed by as much as 10 cm H2O for a given patient. The two positive end-expiratory pressure optimization strategies recommended positive end-expiratory pressure changes in opposite directions in 33% of patients. The ideal positive end-expiratory pressure levels recommended by the two methods for each patient were discordant and uncorrelated (R = 0.05). Chest wall and respiratory system elastances grew with increases in positive end-expiratory pressure in patients with positive end-expiratory esophageal pressure-based transpulmonary pressures (p < 0.05). CONCLUSIONS Esophageal pressure and chest wall elastance-based methods for estimating pleural pressure do not yield similar results. The strategies of targeting an end-expiratory esophageal pressure-based transpulmonary pressure of 0 cm H2O and targeting an end-inspiratory elastance-based transpulmonary pressure of 26 cm H2O cannot be considered interchangeable. Finally, chest wall and respiratory system elastances may vary unpredictably with changes in positive end-expiratory pressure.
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16
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Experimental intra-abdominal hypertension influences airway pressure limits for lung protective mechanical ventilation. J Trauma Acute Care Surg 2013; 74:1468-73. [PMID: 23694861 DOI: 10.1097/ta.0b013e31829243a7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) may complicate monitoring of pulmonary mechanics owing to their impact on the respiratory system. However, recommendations for mechanical ventilation of patients with IAH/ACS and the interpretation of thoracoabdominal interactions remain unclear. Our study aimed to characterize the influence of elevated intra-abdominal pressure (IAP) and positive end-expiratory pressure (PEEP) on airway plateau pressure (PPLAT) and bladder pressure (PBLAD). METHODS Nine deeply anesthetized swine were mechanically ventilated via tracheostomy: volume-controlled mode at tidal volume (VT) of 10 mL/kg, frequency of 15, inspiratory-expiratory ratio of 1:2, and PEEP of 1 and 10 cm H2O (PEEP1 and PEEP10, respectively). A tracheostomy tube was placed in the peritoneal cavity, and IAP levels of 5, 10, 15, 20, and 25 mm Hg were applied, using a continuous positive airway pressure system. At each IAP level, PBLAD and airway pressure measurements were performed during both PEEP1 and PEEP10. RESULTS PBLAD increased as experimental IAP rose (y = 0.83x + 0.5; R = 0.98; p < 0.001 at PEEP1). Minimal underestimation of IAP by PBLAD was observed (-2.5 ± 0.8 mm Hg at an IAP of 10-25 mm Hg). Applying PEEP10 did not significantly affect the correlation between experimental IAP and PBLAD. Approximately 50% of the PBLAD (in cm H2O) was reflected by changes in PPLAT, regardless of the PEEP level applied. Increasing IAP did not influence hemodynamics at any level of IAP generated. CONCLUSION With minimal underestimation, PBLAD measurements closely correlated with experimentally regulated IAP, independent of the PEEP level applied. For each PEEP level applied, a constant proportion (approximately 50%) of measured PBLAD (in cm H2O) was reflected in PPLAT. A higher safety threshold for PPLAT should be considered in the setting of IAH/ACS as the clinician considers changes in VT. A strategy of reducing VT to cap PPLAT at widely recommended values may not be warranted in the setting of increased IAP.
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The importance of timing of decompression in severe acute pancreatitis combined with abdominal compartment syndrome. J Trauma Acute Care Surg 2013; 74:1060-6. [PMID: 23511145 DOI: 10.1097/ta.0b013e318283d927] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Surgical decompression is widely considered as an important treatment in patients with severe acute pancreatitis (SAP) and abdominal compartment syndrome (ACS). Until now, the indication and optimal time of decompression remain unknown, and no experimental data exist, although extremely high mortality has been repeatedly reported in these patients. The aim of this study was to evaluate the effects of three different time points for decompression in a 24-hour lasting porcine model. METHODS Following baseline registrations, 32 animals were divided into four groups (8 animals each group) as follows: one SAP-alone group and three SAP + ACS groups, which received decompression at 6, 9, and 12 hours. We used a N2 pneumoperitoneum to increase the intra-abdominal pressure to 25 mm Hg and retrograde intra-ductal infusion of sodium taurocholate to induce SAP. Global hemodynamic profiles, urine output, systemic oxygenation, and serum biochemical parameters of the animals were studied. At the end of the experiment, histologic examination of the intestine and lung was performed. RESULTS The survival time of the 12-hour group was significantly shortened (p = 0.037 vs. 9 hours and p = 0.008 vs. 6 hours). In SAP + ACS animals, decompression at 6 hours restored systemic hemodynamics, oxygen-derived parameters, organ function, and inflammatory intensity to a level comparable with that of the SAP-alone group. In contrast, animals in the 9 hours and 12 hours developed more severe hemodynamic and organ dysfunction. The histopathologic analyses also revealed higher grade injury of the intestine and lung in animals receiving delayed decompression. CONCLUSION Well-timed decompression in a porcine model of SAP incorporating 25-mm Hg intra-abdominal hypertension/ACS was associated with significantly reduced mortality, improved systemic hemodynamics and organ function, as well as alleviated histologic injury and inflammatory intensity. According to our results and previous reports, both too early and too late decompression should be avoided owing to significant morbidity for the former and unfavorable outcomes for the latter.
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18
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Liu Q, Li W, Zeng QS, Zhong NS, Chen RC. Lung stress and strain during mechanical ventilation in animals with and without pulmonary acute respiratory distress syndrome. J Surg Res 2013; 181:300-7. [DOI: 10.1016/j.jss.2012.07.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 06/19/2012] [Accepted: 07/03/2012] [Indexed: 11/27/2022]
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Hua S, Zhang X, Zhang S, Xu J, Feng Z. Effects of different ventilation strategies on lung injury in newborn rabbits. Pediatr Pulmonol 2012; 47:1103-12. [PMID: 22451169 DOI: 10.1002/ppul.22541] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Accepted: 01/11/2012] [Indexed: 11/12/2022]
Abstract
BACKGROUND The results from experimental and clinical studies have shown that mechanical ventilation (MV) and/or hyperoxia may aggravate a pre-existing lung injury, or even cause lung injury in healthy lungs, despite the fact that it might be the only life-saving intervention available to a patient. The present study was designed to investigate the roles of MV and hyperoxia in the pathogenesis of lung injury. METHODS Newborn New Zealand white rabbits were randomly assigned to an unventilated air control group or to one of the 2 × 3 × 3 ventilation strategies using a factorial design. The experimental groups were assigned different fractions of inspired oxygen (FiO(2)), peak inspiratory pressures (PIP), and respiratory times (RT). The lung wet-to-dry ratio (W/D), lung histopathology scores, and cells in the bronchoalveolar lavage fluid (BALF) were analyzed for each group. The apoptosis levels were studied by immunohistochemistry and a terminal deoxynucleotidyl transferase dUTP nick end-labeling (TUNEL) assay. RESULTS Different ventilation regimes induced alterations in microvascular permeability, differential histopathological grading, WBC and/or neutrophil and/or lymphocyte influx, and apoptosis levels; moreover, there were significant correlations and interaction effects between these indices. CONCLUSIONS Our data demonstrate that different ventilation regimes can induce lung injury and that the interaction effects of the FiO(2), the PIP and the RT may play crucial roles in the pathogenesis of lung injury.
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Affiliation(s)
- Shaodong Hua
- Department of Pediatrics, BaYi Children's Hospital of The General Military Hospital of Beijing PLA, Beijing, PR China
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20
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Abdominal compartment syndrome: a decade of progress. J Am Coll Surg 2012; 216:135-46. [PMID: 23062520 DOI: 10.1016/j.jamcollsurg.2012.09.004] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 08/26/2012] [Accepted: 09/10/2012] [Indexed: 12/22/2022]
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Physiological effects of an open lung ventilatory strategy titrated on elastance-derived end-inspiratory transpulmonary pressure. Crit Care Med 2012; 40:2124-31. [DOI: 10.1097/ccm.0b013e31824e1b65] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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The chest wall. Crit Care Med 2012; 40:2258-9. [DOI: 10.1097/ccm.0b013e318256b974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
PURPOSE OF REVIEW Despite the well recognized role of mechanical ventilation in lung injury, appropriate surrogate markers to guide titration of ventilator settings remain elusive. One would like to strike a balance between protecting aerated units from overdistension while recruiting unstable units, thereby reducing tissue damage associated with their cyclic recruitment and derecruitment. To do so requires some estimate of the topographical distribution of parenchymal stress and strain. RECENT FINDINGS Recent studies have highlighted the importance of chest wall recoil and its effect on pleural pressure (Ppl) in determining lung stress. Although esophageal pressure (Pes) has traditionally been used to measure the average Ppl in normal upright patients, in recumbent acute lung injury/acute respiratory distress syndrome patients Pes-based estimates of Ppl are subject to untestable assumptions. Nevertheless, Pes measurements in recumbent patients with injured lungs strongly suggest that Ppl over dependent parts of the lung can exceed airway pressure by substantial amounts. Moreover, results of a pilot study in which Pes was used to titrate positive end-expiratory pressure (PEEP) suggest clinical benefit. SUMMARY Notwithstanding its theoretical limitations, esophageal manometry has shown promise in PEEP titration and deserves further evaluation in a larger trial on patients with injured lungs.
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Affiliation(s)
- Maria Plataki
- Thoracic Diseases Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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Cardiopulmonary effects of matching positive end-expiratory pressure to abdominal pressure in concomitant abdominal hypertension and acute lung injury. ACTA ACUST UNITED AC 2010; 69:375-83. [PMID: 20699747 DOI: 10.1097/ta.0b013e3181e12b3a] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND To evaluate the cardiopulmonary effects of positive end-expiratory pressure (PEEP) equalization to intra-abdominal pressure (IAP) in an experimental model of intra-abdominal hypertension (IAH) and acute lung injury (ALI). METHODS Eight anesthetized pigs were submitted to IAH of 20 mm Hg with a carbon dioxide insufflator for 30 minutes and then submitted to lung lavage with saline and Tween (2.5%). Pressure x volume curves of the respiratory system were performed by a low flow method during IAH and ALI, and PEEP was subsequently adjusted to 27 cm . H2O for 30 minutes. RESULTS IAH decreases pulmonary and respiratory system static compliances and increases airway resistance, alveolar-arterial oxygen gradient, and respiratory dead space. The presence of concomitant ALI exacerbates these findings. PEEP identical to AP moderately improved oxygenation and respiratory mechanics; however, an important decline in stroke index and right ventricle ejection fraction was observed. CONCLUSIONS Simultaneous IAH and ALI produce important impairments in the respiratory physiology. PEEP equalization to AP may improve the respiratory performance, nevertheless with a secondary hemodynamic derangement.
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