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Chung FT, Lee CS, Lin SM, Kuo CH, Wang TY, Fang YF, Hsieh MH, Chen HC, Lin HC. Alveolar recruitment maneuver attenuates extravascular lung water in acute respiratory distress syndrome. Medicine (Baltimore) 2017; 96:e7627. [PMID: 28746224 PMCID: PMC5627850 DOI: 10.1097/md.0000000000007627] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND The alveolar recruitment maneuver (RM) has been reported to improve oxygenation in acute respiratory distress syndrome (ARDS) and may be related to reduced extravascular lung water (EVLW) in animals. This study was designed to investigate the effects of RM on EVLW in patients with ARDS. METHODS An open label, prospective, randomized controlled trial including patients with ARDS was conducted in hospitals in North Taiwan between 2010 and 2016. The patients were divided into 2 groups (with and without RM). The primary endpoint was the comparison of the EVLW index between the 2 groups. RESULTS Twenty-four patients with ARDS on mechanical ventilator support were randomized to receive ventilator treatment with RM (RM group, n = 12) or without RM (non-RM group, n = 12). Baseline demographic characteristics were similar between the 2 groups. After recruitment, the day 3 extravascular lung water index (EVLWI) (25.3 ± 9.3 vs 15.5 ± 7.3 mL/kg, P = .008) and the arterial oxygen tension/fractional inspired oxygen ratio (PaO2/FiO2) (132.3 ± 43.5 vs 185.6 ± 38.8 mL/kg, P = .003) both improved over that of day 1. However, both EVLWI and PaO2/FiO2 did not significantly change from day 1 to 3 in the non-RM group. CONCLUSION RM is a feasible method for improving oxygenation and the EVLW index in patients with ARDS, as well as for decreasing ventilator days and intensive care unit stay duration.
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Affiliation(s)
- Fu-Tsai Chung
- Department of Thoracic Medicine, Saint Paul's Hospital, Taoyuan
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taipei
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan
| | - Chung-Shu Lee
- Department of Thoracic Medicine, Saint Paul's Hospital, Taoyuan
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taipei
| | - Shu-Min Lin
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taipei
| | - Chih-Hsi Kuo
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taipei
| | - Tsai-Yu Wang
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taipei
| | - Yueh-Fu Fang
- Department of Thoracic Medicine, Saint Paul's Hospital, Taoyuan
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taipei
| | - Meng-Heng Hsieh
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taipei
| | - Hao-Cheng Chen
- Department of Thoracic Medicine, Saint Paul's Hospital, Taoyuan
- Division of Pulmonary Medicine, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Horng-Chyuan Lin
- Department of Thoracic Medicine, Chang Gung Memorial Hospital at Linkou, Chang Gung University, College of Medicine, Taipei
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Hata JS, Togashi K, Kumar AB, Hodges LD, Kaiser EF, Tessmann PB, Faust CA, Sessler DI. The effect of the pressure-volume curve for positive end-expiratory pressure titration on clinical outcomes in acute respiratory distress syndrome: a systematic review. J Intensive Care Med 2013; 29:348-56. [PMID: 23855040 DOI: 10.1177/0885066613488747] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE Methods to optimize positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS) remain controversial despite decades of research. The pressure-volume curve (PVC), a graphical ventilator relationship, has been proposed for prescription of PEEP in ARDS. Whether the use of PVC's improves survival remains unclear. METHODS In this systematic review, we assessed randomized controlled trials (RCTs) comparing PVC-guided treatment with conventional PEEP management on survival in ARDS based on the search of the National Library of Medicine from January 1, 1960, to January 1, 2010, and the Cochrane Central Register of Controlled Trials. Three RCTs were identified with a total of 185 patients, 97 with PVC-guided treatment and 88 with conventional PEEP management. RESULTS The PVC-guided PEEP was associated with an increased probability of 28-day or hospital survival (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.5, 4.9) using a random-effects model without significant heterogeneity (I (2) test: P = .75). The PVC-guided ventilator support was associated with reduced cumulative risk of mortality (-0.24 (95% CI -0.38, -0.11). The PVC-managed patients received greater PEEP (standardized mean difference [SMD] 5.7 cm H2O, 95% CI 2.4, 9.0) and lower plateau pressures (SMD -1.2 cm H2O, 95% CI -2.2, -0.2), albeit with greater hypercapnia with increased arterial pCO2 (SMD 8 mm Hg, 95% CI 2, 14). Weight-adjusted tidal volumes were significantly lower in PVC-guided than conventional ventilator management (SMD 2.6 mL/kg, 95% CI -3.3, -2.0). CONCLUSION This analysis supports an association that ventilator management guided by the PVC for PEEP management may augment survival in ARDS. Nonetheless, only 3 randomized trials have addressed the question, and the total number of patients remains low. Further outcomes studies appear required for the validation of this methodology.
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Affiliation(s)
- J Steven Hata
- Departments of Outcomes Research, Cardiac Anesthesiology, and General Anesthesiology, Center for Critical Care, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA Department of Cardiac Anesthesiology, Center for Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA Department of General Anesthesiology, Center for Critical Care Medicine, Cleveland Clinic, Cleveland, OH, USA Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kei Togashi
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Avinash B Kumar
- Division of Critical Care in the Department of Anesthesia, University of Vanderbilt, Nashville, TN, USA
| | | | - Eric F Kaiser
- Department of Cardiac Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Paul B Tessmann
- Division of Cardiothoracic Surgery, University of Florida; Gainesville, FL, USA
| | | | - Daniel I Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, USA
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Pulmonary acute respiratory distress syndrome: positive end-expiratory pressure titration needs stress index. J Surg Res 2013; 185:347-52. [PMID: 23731684 DOI: 10.1016/j.jss.2013.05.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 04/29/2013] [Accepted: 05/03/2013] [Indexed: 11/20/2022]
Abstract
BACKGROUND The heterogeneity of lung injury in pulmonary acute respiratory distress syndrome (ARDS) may have contributed to the greater response of hyperinflated area with positive end-expiratory pressure (PEEP). PEEP titrated by stress index can reduce the risk of alveolar hyperinflation in patients with pulmonary ARDS. The authors sought to investigate the effects of PEEP titrated by stress index on lung recruitment and protection after recruitment maneuver (RM) in pulmonary ARDS patients. MATERIALS AND METHODS Thirty patients with pulmonary ARDS were enrolled. After RM, PEEP was randomly set according to stress index, oxygenation, static pulmonary compliance (Cst), or lower inflection point (LIP) + 2 cmH2O strategies. Recruitment volume, gas exchange, respiratory mechanics, and hemodynamic parameters were collected. RESULTS PEEP titrated by stress index (15.1 ± 1.8 cmH2O) was similar to the levels titrated by oxygenation (14.5 ± 2.9 cmH2O), higher than that titrated by Cst (11.3 ± 2.5 cmH2O) and LIP (12.9 ± 1.6 cmH2O) (P < 0.05). Compared with baseline, PaO2/FiO2 and recruitment volume were significantly improved after PEEP titration with the four strategies (P < 0.05). PaO2/FiO2 and recruitment volume were similar when using PEEP titrated by stress index and oxygenation but higher than that titrated by Cst and LIP. Compared with baseline, lung compliance increased significantly when PEEP determined by Cst, but there was no difference of Cst in these four strategies. There was no influence of PEEP titration with the four strategies on hemodynamic parameters. CONCLUSIONS PEEP titration by stress index might be more beneficial for pulmonary ARDS patients after RM.
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Positive end-expiratory pressure lung recruitment: comparison between lower inflection point and ultrasound assessment. Wien Klin Wochenschr 2012; 124:842-7. [PMID: 23229578 DOI: 10.1007/s00508-012-0303-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2012] [Accepted: 11/08/2012] [Indexed: 01/20/2023]
Abstract
BACKGROUND Maintenance of the open lung alveoli in the expiration on mechanical ventilation in acute lung injury/acute respiratory distress syndrome (ALI/ARDS) remains challenging despite advances in lung imaging. The inspiratory lower inflection point (LIP) on the ventilator pressure-volume (P-V) curve estimates the required end-expiratory pressure for recruitment of alveolar consolidation. Alternatively, the end-expiratory pressure for recruitment of crater-like subpleural alveolar consolidation could be simply followed with ultrasound. These two methods for setting the ventilators positive end-expiratory pressure (PEEP) were compared. METHODS The observational study in surgical/neurosurgical intensive care between October 2009 and November 2011 included 17 deeply sedated or relaxed patients. LIP was measured with continuous low-flow method, as a pressure in cmH(2)O. Expiratory levelling between lower border of subpleural consolidation and adjacent pleural line, which means lung recruitment, was followed with linear ultrasound probe. PEEP in cmH(2)O at which the levelling occurs was compared with LIP pressure. RESULTS LIP pressure never exceeds the PEEP for recruitment of subpleural consolidations followed with ultrasound. A significant correlation (r = 0.839; p < 0.05) was found between two methods. CONCLUSIONS In this study, positive end-expiratory pressures for recruitment of subpleural consolidations followed by ultrasound always exceed the pressures measured with LIP. Respecting this, ultrasound method could be the guide for PEEP lung recruitment.
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Increased extravascular lung water reduces the efficacy of alveolar recruitment maneuver in acute respiratory distress syndrome. Crit Care Res Pract 2012; 2012:606528. [PMID: 22649717 PMCID: PMC3356898 DOI: 10.1155/2012/606528] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 02/20/2012] [Indexed: 11/30/2022] Open
Abstract
Introduction. In acute respiratory distress syndrome (ARDS) the recruitment maneuver (RM) is used to reexpand atelectatic areas of the lungs aiming to improve arterial oxygenation. The goal of our paper was to evaluate the response to RM, as assessed by measurements of extravascular lung water index (EVLWI) in ARDS patients. Materials and Methods. Seventeen adult ARDS patients were enrolled into a prospective study. Patients received protective ventilation. The RM was performed by applying a continuous positive airway pressure of 40 cm H2O for 40 sec. The efficacy of the RM was assessed 5 min later. Patients were identified as responders if PaO2/FiO2 increased by >20% above the baseline. EVLWI was assessed by transpulmonary thermodilution before the RM, and patients were divided into groups of low EVLWI (<10 mL/kg) and high EVLWI (≥10 mL/kg). Results. EVLWI was increased in 12 patients. Following RM, PaO2/FiO2 increased by 33 (4–65) % in the patients with low EVLWI, whereas those in
the high EVLWI group experienced a change by only −1((−13)–(+5)) % (P = 0.035). Conclusion. In ARDS, the response to a recruitment maneuver might be related to the severity of pulmonary edema. In patients with incresed EVLWI, the recruitment maneuver is less effective.
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Abstract
OBJECTIVE To determine which flow setting most accurately detects the lower inflection point (Pflex) using an automated constant flow method and varying endotracheal tube (ETT) sizes with and without an airleak in a pediatric lung model. DESIGN Interventional laboratory study. SETTING Children's hospital research center. INTERVENTIONS A pediatric lung model was created with Pflexs of the inspiratory pressure-volume (P-V) curve set at 5 and 10 cm H2O using the ASL 5000 Test Lung (IngMar Medical, Pittsburgh, PA). Three ETT sizes (3.0, 4.0, 5.0 mm) were tested with and without a 25% airleak. P-V curves were obtained using an automated constant flow method at ten different flow rates. MEASUREMENTS AND MAIN RESULTS Without an ETT airleak, the lowest flow of 0.5 L/min led to the most accurate determination of Pflex regardless of ETT size or set Pflex (p < 0.001). When a 25% leak was introduced, accuracy of measured Pflex depended on both ETT size (p < 0.001) and flow rate (p < 0.001). Optimum flow rates for Pflex determination were 0.5, 1.0, and 1.5 L/min at Pflex of 5 cm H2O, and 2.0, 3.5, and 4.5 L/min at 10 cm H2O for 3.0, 4.0, and 5.0 mm ETTs, respectively (p < 0.001). CONCLUSIONS Estimation of Pflex can be achieved using automated P-V curves with ETTs appropriate for pediatric use, with and without an airleak. ETT size and flow rate affect the accuracy of these measurements when an airleak is present, and use of increased flow rates to create the automated P-V curves can reduce error. These data support the idea that a low-flow technique provides the most accurate determination of Pflex in pediatric patients without a leak around their ETT, whereas increased flows are needed to compensate when an ETT airleak is present.
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Agarwal R, Srinivas R, Nath A, Jindal SK. Is the mortality higher in the pulmonary vs the extrapulmonary ARDS? A meta analysis. Chest 2007; 133:1463-1473. [PMID: 17989150 DOI: 10.1378/chest.07-2182] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND AND AIM ARDS can occur from the following two pathogenetic pathways: a direct pulmonary injury (ARDSp); and an indirect injury (ARDSexp). The predisposing clinical factor can influence the pathogenesis and clinical outcome of ARDS. This metaanalysis was aimed at evaluating whether there is any difference in mortality between the two groups. METHODS We searched the MEDLINE, EMBASE, and CINAHL databases for relevant studies published from 1987 to 2007, and included studies that have reported mortality in the two groups of ARDS. We calculated the odds ratio (OR) and 95% confidence interval (CI) to assess mortality in patients with ARDSp vs patients with ARDSexp and pooled the results using three different statistical models. RESULTS Our search yielded 34 studies. In all, the studies involved 4,311 patients with 2,330 patients in the ARDSp group and 1,981 patients in the ARDSexp group. The OR of mortality in ARDSp group compared to the ARDSexp group was 1.11 (95% CI, 0.88 to 1.39), as determined by the random-effects model; 1.04 (95% CI, 0.92 to 1.18), as determined by the fixed-effects model; and 1.04 (95% CI, 0.92 to 1.18), as determined by the exact method, indicating that mortality is similar in the two groups. The mortality was no different whether the studies were classified as prospective (OR, 1.15; 95% CI, 0.87 to 1.51) or retrospective (OR, 1.01; 95% CI, 0.61 to 1.69); small (OR, 1.11; 95% CI, 0.77 to 1.60) or large (OR, 1.1; 95% CI, 0.82 to 1.49); or observational (OR, 1.10; 95% CI, 0.82 to 1.49) or interventional (OR, 0.97; 95% CI, 0.79 to 1.19). There was methodological and statistical heterogeneity (I(2), 50.9%; 95% CI, 21.3 to 66.2%; chi(2) statistic, 67.22; p = 0.0004). CONCLUSIONS The results of this study suggest that there is no difference in mortality between these two groups. Further studies should focus on specific etiologies within the subgroups rather than focusing on the broader division of ARDSp and ARDSexp.
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Affiliation(s)
- Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajagopala Srinivas
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Alok Nath
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Surinder K Jindal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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Pestaña D, Hernández-Gancedo C, Royo C, Pérez-Chrzanowska H, Criado A. Pressure-volume curve variations after a recruitment manoeuvre in acute lung injury/ARDS patients: implications for the understanding of the inflection points of the curve. Eur J Anaesthesiol 2005; 22:175-80. [PMID: 15852989 DOI: 10.1017/s0265021505000311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Although the pressure-volume (P-V) curve has been proposed in the management of mechanically ventilated patients, its interpretation remains unclear. Our aim has been to study the variations of the P-V curve after a recruitment manoeuvre (RM). Our hypothesis was that the lower inflection point (LIP) represents the presence of compressive atelectases, so it should not change after lung recruitment, while the upper inflection point (UIP) reflects reabsorptive atelectases, and an effective recruitment should result in changes at this level. METHODS Two P-V curves (quasi-static method) separated by an RM (40 cmH2O, two consecutive manoeuvres) were plotted in 35 postoperative patients with criteria of acute lung injury/acute respiratory distress syndrome (ARDS). LIP, UIP and expiratory inflection point (EIP) were defined as the first point where the curve consistently starts to separate from the line. RESULTS One to six measurements were obtained per patient (73 procedures). Neither the lower nor the EIPs varied significantly after the RM (P = 0.11 and 0.35, respectively). An UIP was observed in 18 curves (25%) before the RM and disappeared on nine occasions after the recruitment. Similar results were obtained when first measurements only were analysed, and when the cause (pulmonary vs. extrapulmonary), severity of lung injury or duration of mechanical ventilation at first measurement were studied. CONCLUSIONS An RM does not modify the LIP significantly, but induces the disappearance of the UIP in 50% of the cases in which this point is found.
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Affiliation(s)
- D Pestaña
- Hospital Universitario La Paz, Servicio de Anestesia-Reanimación, Residencia General, Madrid, Spain.
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Pestaña D. Pressure-volume curve patterns in ARDS patients. Intensive Care Med 2004; 30:1002; author reply 1003. [PMID: 14997290 DOI: 10.1007/s00134-004-2219-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2004] [Indexed: 10/26/2022]
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