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Song BK, Carr DA, Bruce ED, Nugent WH. Oxygenation through oral Ox66 in a two-hit rodent model of respiratory distress. ARTIFICIAL CELLS, NANOMEDICINE, AND BIOTECHNOLOGY 2024; 52:114-121. [PMID: 38423099 DOI: 10.1080/21691401.2024.2307462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 01/10/2024] [Indexed: 03/02/2024]
Abstract
Acute respiratory distress syndrome (ARDS) is a complication of pulmonary disease that produces life-threatening hypoxaemia. Despite ventilation and hyperoxic therapies, undetected hypoxia can manifest in capillary beds leading to multi-organ failure. Ox66™ is an ingestible, solid-state form of oxygen designed to supplement oxygen deficits. Twenty-four anaesthetized rats underwent a two-hit model of respiratory distress (ARDS), where a single dose (5 mg/kg) of lipopolysaccharide (LPS) was given intratracheally, and then the respiratory tidal volume was reduced by 40%. After 60 min, animals were randomized to receive Ox66™, or normal saline (NS; vehicle control) via gavage or supplemental inspired oxygen (40% FiO2). A second gavage was administered at 120 min. Cardiovascular function and blood oximetry/chemistry were measured alongside the peripheral spinotrapezius muscle's interstitial oxygenation (PISFO2). ARDS reduced mean arterial pressure (MAP) and PISFO2 compared to baseline (BL) for all treatment groups. Treatment with Ox66 or NS did not improve MAP, but 40% FiO2 caused a rapid return to BL. PISFO2 improved after treatment with Ox66™ and 40% FiO2 and remained elevated for both groups against NS until study conclusion. Both oxygen treatments also suppressed the inflammatory response to LPS, suggesting that Ox66™ can deliver therapeutically-impactful levels of oxygen in situations of pulmonary dysfunction.
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Affiliation(s)
| | | | - Erica D Bruce
- Department of Environmental Science, Baylor University, Waco, TX, USA
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D'Albo R, Pozzi T, Nicolardi RV, Galizia M, Catozzi G, Ghidoni V, Donati B, Romitti F, Herrmann P, Busana M, Gattarello S, Collino F, Sonzogni A, Camporota L, Marini JJ, Moerer O, Meissner K, Gattinoni L. Mechanical power ratio threshold for ventilator-induced lung injury. Intensive Care Med Exp 2024; 12:65. [PMID: 39080225 PMCID: PMC11289208 DOI: 10.1186/s40635-024-00649-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 07/10/2024] [Indexed: 08/02/2024] Open
Abstract
RATIONALE Mechanical power (MP) is a summary variable incorporating all causes of ventilator-induced-lung-injury (VILI). We expressed MP as the ratio between observed and normal expected values (MPratio). OBJECTIVE To define a threshold value of MPratio leading to the development of VILI. METHODS In a population of 82 healthy pigs, a threshold of MPratio for VILI, as assessed by histological variables and confirmed by using unsupervised cluster analysis was 4.5. The population was divided into two groups with MPratio above or below the threshold. MEASUREMENTS AND MAIN RESULTS We measured physiological variables every six hours. At the end of the experiment, we measured lung weight and wet-to-dry ratio to quantify edema. Histological samples were analyzed for alveolar ruptures, inflammation, alveolar edema, atelectasis. An MPratio threshold of 4.5 was associated with worse injury, lung weight, wet-to-dry ratio and fluid balance (all p < 0.001). After 48 h, in the two MPratio clusters (above or below 4.5), respiratory system elastance, mean pulmonary artery pressure and physiological dead space differed by 32%, 36% and 22%, respectively (all p < 0.001), being worse in the high MPratio group. Also, the changes in driving pressure, lung elastance, pulmonary artery occlusion pressure, central venous pressure differed by 17%, 64%, 8%, 25%, respectively (all p < 0.001). LIMITATIONS The main limitation of this study is its retrospective design. In addition, the computation for the expected MP in pigs is based on arbitrary criteria. Different values of expected MP may change the absolute value of MP ratio but will not change the concept of the existence of an injury threshold. CONCLUSIONS The concept of MPratio is a physiological and intuitive way to quantify the risk of ventilator-induced lung injury. Our results suggest that a mechanical power ratio > 4.5 MPratio in healthy lungs subjected to 48 h of mechanical ventilation appears to be a threshold for the development of ventilator-induced lung injury, as indicated by the convergence of histological, physiological, and anatomical alterations. In humans and in lungs that are already injured, this threshold is likely to be different.
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Affiliation(s)
- Rosanna D'Albo
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Tommaso Pozzi
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Rosmery V Nicolardi
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mauro Galizia
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Giulia Catozzi
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Valentina Ghidoni
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
- Department of Health Sciences, Section of Anesthesiology, Intensive Care and Pain Medicine, University of Florence, Florence, Italy
| | - Beatrice Donati
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
| | - Peter Herrmann
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
| | - Simone Gattarello
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Collino
- Department of Anesthesia, Intensive Care and Emergency, "City of Health and Science" Hospital, Turin, Italy
| | | | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St. Thomas' NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, St. Paul, MN, USA
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
| | - Konrad Meissner
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straβe 40, 37075, Göttingen, Germany.
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Leali M, Marongiu I, Spinelli E, Chiavieri V, Perez J, Panigada M, Grasselli G, Mauri T. Absolute values of regional ventilation-perfusion mismatch in patients with ARDS monitored by electrical impedance tomography and the role of dead space and shunt compensation. Crit Care 2024; 28:241. [PMID: 39010228 PMCID: PMC11251389 DOI: 10.1186/s13054-024-05033-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 07/11/2024] [Indexed: 07/17/2024] Open
Abstract
BACKGROUND Assessment of regional ventilation/perfusion (V'/Q) mismatch using electrical impedance tomography (EIT) represents a promising advancement for personalized management of the acute respiratory distress syndrome (ARDS). However, accuracy is still hindered by the need for invasive monitoring to calibrate ventilation and perfusion. Here, we propose a non-invasive correction that uses only EIT data and characterized patients with more pronounced compensation of V'/Q mismatch. METHODS We enrolled twenty-one ARDS patients on controlled mechanical ventilation. Cardiac output was measured invasively, and ventilation and perfusion were assessed by EIT. Relative V'/Q maps by EIT were calibrated to absolute values using the minute ventilation to invasive cardiac output (MV/CO) ratio (V'/Q-ABS), left unadjusted (V'/Q-REL), or corrected by MV/CO ratio derived from EIT data (V'/Q-CORR). The ratio between ventilation to dependent regions and perfusion reaching shunted units ( V D ' /QSHUNT) was calculated as an index of more effective hypoxic pulmonary vasoconstriction. The ratio between perfusion to non-dependent regions and ventilation to dead space units (QND/ V DS ' ) was calculated as an index of hypocapnic pneumoconstriction. RESULTS Our calibration factor correlated with invasive MV/CO (r = 0.65, p < 0.001), showed good accuracy and no apparent bias. Compared to V'/Q-ABS, V'/Q-REL maps overestimated ventilation (p = 0.013) and perfusion (p = 0.002) to low V'/Q units and underestimated ventilation (p = 0.011) and perfusion (p = 0.008) to high V'/Q units. The heterogeneity of ventilation and perfusion reaching different V'/Q compartments was underestimated. V'/Q-CORR maps eliminated all these differences with V'/Q-ABS (p > 0.05). HigherV D ' / Q SHUNT correlated with higher PaO2/FiO2 (r = 0.49, p = 0.025) and lower shunt fraction (ρ = - 0.59, p = 0.005). HigherQ ND / V DS ' correlated with lower PEEP (ρ = - 0.62, p = 0.003) and plateau pressure (ρ = - 0.59, p = 0.005). Lower values of both indexes were associated with less ventilator-free days (p = 0.05 and p = 0.03, respectively). CONCLUSIONS Regional V'/Q maps calibrated with a non-invasive EIT-only method closely approximate the ones obtained with invasive monitoring. Higher efficiency of shunt compensation improves oxygenation while compensation of dead space is less needed at lower airway pressure. Patients with more effective compensation mechanisms could have better outcomes.
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Affiliation(s)
- Marco Leali
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Ines Marongiu
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Chiavieri
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Joaquin Perez
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mauro Panigada
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tommaso Mauri
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
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Miserocchi G, Rezoagli E, Muñoz-Del-Carpio-Toia A, Paricahua-Yucra LP, Zubieta-DeUrioste N, Zubieta-Calleja G, Beretta E. Modelling lung diffusion-perfusion limitation in mechanically ventilated SARS-CoV-2 patients. Front Physiol 2024; 15:1408531. [PMID: 39072215 PMCID: PMC11272564 DOI: 10.3389/fphys.2024.1408531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/18/2024] [Indexed: 07/30/2024] Open
Abstract
This is the first study to describe the daytime evolution of respiratory parameters in mechanically ventilated COVID-19 patients. The data base refers to patients hospitalised in the intensive care unit (ICU) at Arequipa Hospital (Peru, 2335 m) in 2021. In both survivors (S) and non-survivors (NS) patients, a remarkable decrease in respiratory compliance was observed, revealing a proportional decrease in inflatable alveolar units. The S and NS patients were all hyperventilated and their SatO2 was maintained at >90%. However, while S remained normocapnic, NS developed progressive hypercapnia. We compared the efficiency of O2 uptake and CO2 removal in the air blood barrier relying on a model allowing to partition between diffusion and perfusion limitations to gas exchange. The decrease in O2 uptake was interpreted as diffusion limitation, while the impairment in CO2 removal was modelled by progressive perfusion limitation. The latter correlated with the increase in positive end-expiratory pressure (PEEP) and plateau pressure (Pplat), leading to capillary compression, increased blood velocity, and considerable shortening of the air-blood contact time.
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Affiliation(s)
- Giuseppe Miserocchi
- Dipartimento di Medicina e Chirurgia, Università Milano-Bicocca, Monza, Italy
| | - Emanuele Rezoagli
- Dipartimento di Medicina e Chirurgia, Università Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| | | | | | | | | | - Egidio Beretta
- Dipartimento di Medicina e Chirurgia, Università Milano-Bicocca, Monza, Italy
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Konsberg Y, Åneman A, Olsen F, Hessulf F, Nellgård B, Hård Af Segerstad M, Dalla K. Progressive changes in pulmonary gas exchange during invasive respiratory support for COVID-19 associated acute respiratory failure: A retrospective study of the association with 90-day mortality. Acta Anaesthesiol Scand 2024; 68:803-811. [PMID: 38563250 DOI: 10.1111/aas.14415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 03/09/2024] [Accepted: 03/13/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Ratio of arterial pressure of oxygen and fraction of inspired oxygen (P/F ratio) together with the fractional dead space (Vd/Vt) provides a global assessment of pulmonary gas exchange. The aim of this study was to assess the potential value of these variables to prognosticate 90-day survival in patients with COVID-19 associated ARDS admitted to the Intensive Care Unit (ICU) for invasive ventilatory support. METHODS In this single-center observational, retrospective study, P/F ratios and Vd/Vt were assessed up to 4 weeks after ICU-admission. Measurements from the first 2 weeks were used to evaluate the predictive value of P/F ratio and Vd/Vt for 90-day mortality and reported by the adjusted hazard ratio (HR) and 95% confidence intervals [95%CI] by Cox proportional hazard regression. RESULTS Almost 20,000 blood gases in 130 patients were analyzed. The overall 90-day mortality was 30% and using the data from the first ICU week, the HR was 0.85 [0.77-0.94] for every 10 mmHg increase in P/F ratio and 1.61 [1.20-2.16] for every 0.1 increase in Vd/Vt. In the second week, the HR for 90-day mortality was 0.82 [0.75-0.89] for every 10 mmHg increase in P/F ratio and 1.97 [1.42-2.73] for every 0.1 increase in Vd/Vt. CONCLUSION The progressive changes in P/F ratio and Vd/Vt in the first 2 weeks of invasive ventilatory support for COVID-19 ARDS were significant predictors for 90-day mortality.
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Affiliation(s)
- Ylva Konsberg
- Department of Anesthesiology and Intensive Care, Institute of Clinical Sciences, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Anders Åneman
- Department of Anesthesiology and Intensive Care, Institute of Clinical Sciences, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
- Intensive Care Unit, Liverpool Hospital, Southwestern Sydney Local Health District, Australia
- South Western Clinical School, University of New South Wales, Australia
- Ingham Institute for Applied Medical Science, Sydney, Australia
| | - Fredrik Olsen
- Department of Anesthesiology and Intensive Care, Institute of Clinical Sciences, the Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska, Sweden
| | - Fredrik Hessulf
- Department of Anesthesiology and Intensive Care, Institute of Clinical Sciences, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Bengt Nellgård
- Department of Anesthesiology and Intensive Care, Institute of Clinical Sciences, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
| | - Mathias Hård Af Segerstad
- Department of Anesthesiology and Intensive Care, Institute of Clinical Sciences, the Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska, Sweden
| | - Keti Dalla
- Department of Anesthesiology and Intensive Care, Institute of Clinical Sciences, the Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden
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Fischbach A, Wiegand SB, Simons JA, Ammon L, Kopp R, Soccoro Matos GI, Baigorri JJ, Crowley JC, Bagchi A. The Ventilatory Ratio as a Predictor of Successful Weaning from a Veno-Venous Extracorporeal Membrane Oxygenator. J Clin Med 2024; 13:3758. [PMID: 38999326 PMCID: PMC11242634 DOI: 10.3390/jcm13133758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/11/2024] [Accepted: 06/24/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a critical intervention for patients with severe lung failure, especially acute respiratory distress syndrome (ARDS). The weaning process from ECMO relies largely on expert opinion due to a lack of evidence-based guidelines. The ventilatory ratio (VR), which correlates with dead space and mortality in ARDS, is calculated as [minute ventilation (mL/min) x arterial pCO2 (mmHg)]/[predicted body weight × 100 × 37.5]. Objectives: The aim of this study was to determine whether the VR alone can serve as a reliable predictor of safe or unsafe liberation from VV-ECMO in critically ill patients. Methods: A multicenter retrospective analysis was conducted, involving ARDS patients undergoing VV-ECMO weaning at Massachusetts General Hospital (January 2016 - December 2020) and at the University Hospital Aachen (January 2012-December 2021). Safe liberation was defined as no need for ECMO recannulation within 48 h after decannulation. Clinical parameters were obtained for both centers at the same time point: 30 min after the start of the SGOT (sweep gas off trial). Results: Of the patients studied, 83.3% (70/84) were successfully weaned from VV-ECMO. The VR emerged as a significant predictor of unsafe liberation (OR per unit increase: 0.38; CI: 0.17-0.81; p = 0.01). Patients who could not be safely liberated had longer ICU and hospital stays, with a trend towards higher mortality (38% vs. 13%; p = 0.05). Conclusions: The VR may be a valuable predictor for safe liberation from VV-ECMO in ARDS patients, with higher VR values associated with an elevated risk of unsuccessful weaning and adverse clinical outcomes.
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Affiliation(s)
- Anna Fischbach
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Steffen B. Wiegand
- Department of Anesthesiology and Intensive Care Medicine, Hannover Medical School, 30625 Hannover, Germany
| | - Julia Alexandra Simons
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Liselotte Ammon
- Department of Anesthesiology, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Rüdger Kopp
- Department of Operative Intensive Care Medicine, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | | | | | - Jerome C. Crowley
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Aranya Bagchi
- Department of Anesthesiology, Massachusetts General Hospital, Boston, MA 02114, USA
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Rixecker TM, Ast V, Rodriguez E, Mazuru V, Wagenpfeil G, Mang S, Muellenbach RM, Nobile L, Ajouri J, Bals R, Seiler F, Taccone FS, Lepper PM. Carbon Dioxide Targets in Extracorporeal Membrane Oxygenation for Acute Respiratory Distress Syndrome. ASAIO J 2024:00002480-990000000-00509. [PMID: 38905594 DOI: 10.1097/mat.0000000000002255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2024] Open
Abstract
Target values for arterial carbon dioxide tension (PaCO2) in extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS) are unknown. We hypothesized that lower PaCO2 values on ECMO would be associated with lighter sedation. We used data from two independent patient cohorts with ARDS spending 1,177 days (discovery cohort, 69 patients) and 516 days (validation cohort, 70 patients) on ECMO and evaluated the associations between daily PaCO2, pH, and bicarbonate (HCO3) with sedation. Median PaCO2 was 41 (interquartile range [IQR] = 37-46) mm Hg and 41 (IQR = 37-45) mm Hg in the discovery and the validation cohort, respectively. Lower PaCO2 and higher pH but not bicarbonate (HCO3) served as significant predictors for reaching a Richmond Agitation Sedation Scale (RASS) target range of -2 to +1 (lightly sedated to restless). After multivariable adjustment for mortality, tracheostomy, prone positioning, vasoactive inotropic score, Simplified Acute Physiology Score (SAPS) II or Sequential Organ Failure Assessment (SOFA) Score and day on ECMO, only PaCO2 remained significantly associated with the RASS target range (adjusted odds ratio 1.1 [95% confidence interval (CI) = 1.01-1.21], p = 0.032 and 1.29 [95% CI = 1.1-1.51], p = 0.001 per mm Hg decrease in PaCO2 for the discovery and the validation cohort, respectively). A PaCO2 ≤40 mm Hg, as determined by the concordance probability method, was associated with a significantly increased probability of a sedation level within the RASS target range in both patient cohorts (adjusted odds ratio = 2.92 [95% CI = 1.17-7.24], p = 0.021 and 6.82 [95% CI = 1.50-31.0], p = 0.013 for the discovery and the validation cohort, respectively).
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Affiliation(s)
- Torben M Rixecker
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Vanessa Ast
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Elianna Rodriguez
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Vitalie Mazuru
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Gudrun Wagenpfeil
- Department of Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg, Germany
| | - Sebastian Mang
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Ralf M Muellenbach
- Department of Anesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - Leda Nobile
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Jonas Ajouri
- Department of Anesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - Robert Bals
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Frederik Seiler
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Philipp M Lepper
- From the Department of Internal Medicine V (Pneumology, Allergology and Intensive Care Medicine), University Medical Center and Saarland University, Germany
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8
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Carvajal C, Giraldo Ramirez ND, De La Hoz Castro AD, Vidal Vargas CG, Pacheco HA, Fernández Sánchez D, González Salazar LV, Romero Otta SS, Vergara Jaimes S, Bolivar Ospina JF, Correa Céspedes J, Narvaez Orozco A, Donado JH, Cadavid CA, De La Rosa G. Association of dead space fraction to mortality in patients with COVID-19-related ARDS: A historical cohort observational study. Med Intensiva 2024:S2173-5727(24)00161-9. [PMID: 38906791 DOI: 10.1016/j.medine.2024.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 04/24/2024] [Accepted: 05/17/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE To assess the correlation of dead space fraction (VD/VT) measured through time capnography, corrected minute volume (CMV) and ventilation ratio (VR) with clinical outcomes in COVID-19 patients requiring invasive mechanical ventilation. DESIGN Observational study of a historical cohort. SETTING University hospital in Medellin, Colombia. PARTICIPANTS Patients aged 15 and above with a confirmed COVID-19 diagnosis admitted to the ICU and requiring mechanical ventilation. INTERVENTIONS Measurement of VD/VT, CMV, and VR in COVID-19 patients. MAIN VARIABLES OF INTEREST VD/VT, CMV, VR, demographic data, oxygenation indices and ventilatory parameters. RESULTS During the study period, 1047 COVID-19 patients on mechanical ventilation were analyzed, of whom 446 (42%) died. Deceased patients exhibited a higher prevalence of advanced age and obesity, elevated Charlson index, higher APACHE II and SOFA scores, as well as an increase in VD/VT ratio (0.27 in survivors and 0.31 in deceased) and minute ventilation volume on the first day of mechanical ventilation. The multivariate analysis revealed independent associations to in-hospital mortality, higher VD/VT (HR 1.24; 95%CI 1.003-1.525; p = 0.046), age (HR 1.024; 95%CI 1.014-1.034; p < 0.001), and SOFA score at onset (HR: 1.036; 95%CI: 1.001-1.07; p = 0.017). CONCLUSIONS VD/VT demonstrated an association with mortality in COVID-19 patients with ARDS on mechanical ventilation. These findings suggest that VD/VT measurement may serve as a severity marker for the disease.
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Affiliation(s)
- Carlos Carvajal
- Hospital Pablo Tobón Uribe, Medellín, Antioquia, Colombia; Departamento de Cuidado Crítico de adulto.
| | | | | | - Carlos Guillermo Vidal Vargas
- Departamento de Investigación; Estudiante de Medicina, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Hemel Antonio Pacheco
- Departamento de Investigación; Estudiante de Medicina, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | | | - Laura Vannesa González Salazar
- Departamento de Investigación; Estudiante de Medicina, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | | | - Silvia Vergara Jaimes
- Departamento de Investigación; Estudiante de Medicina, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Juan Fernando Bolivar Ospina
- Departamento de Investigación; Estudiante de Medicina, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Juliana Correa Céspedes
- Departamento de Investigación; Estudiante de Medicina, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | | | - Jorge Hernando Donado
- Hospital Pablo Tobón Uribe, Medellín, Antioquia, Colombia; Departamento de Investigación
| | - Carlos Alberto Cadavid
- Hospital Pablo Tobón Uribe, Medellín, Antioquia, Colombia; Departamento de Cuidado Crítico de adulto
| | - Gisela De La Rosa
- Hospital Pablo Tobón Uribe, Medellín, Antioquia, Colombia; Departamento de Cuidado Crítico de adulto
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Sipmann FS, Giralt JAS, Tusman G. Monitoring CO2 kinetics as a marker of cardiopulmonary efficiency. Curr Opin Crit Care 2024; 30:251-259. [PMID: 38690954 DOI: 10.1097/mcc.0000000000001156] [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: 05/03/2024]
Abstract
PURPOSE OF REVIEW To describe current and near future developments and applications of CO2 kinetics in clinical respiratory and cardiovascular monitoring. RECENT FINDINGS In the last years, we have witnessed a renewed interest in CO2 kinetics in relation with a better understanding of volumetric capnography and its derived parameters. This together with technological advances and improved measurement systems have expanded the monitoring potential of CO2 kinetics including breath by breath continuous end-expiratory lung volume and continuous noninvasive cardiac output. Dead space has slowly been gaining relevance in clinical monitoring and prognostic evaluation. Easy to measure dead space surrogates such as the ventilatory ratio have demonstrated a strong prognostic value in patients with acute respiratory failure. SUMMARY The kinetics of carbon dioxide describe many relevant physiological processes. The clinical introduction of new ways of assessing respiratory and circulatory efficiency based on advanced analysis of CO2 kinetics are paving the road to a long-desired goal in clinical monitoring of critically ill patients: the integration of respiratory and circulatory monitoring during mechanical ventilation.
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Affiliation(s)
- Fernando Suarez Sipmann
- Department of Intensive Care Medicine, Hospital Universitario de La Princesa, Universidad Autónoma de Madrid
- Ciber de enfermedades respiratorias, Instituto Carlos III, Madrid, Spain
| | - Juan Antonio Sanchez Giralt
- Department of Intensive Care Medicine, Hospital Universitario de La Princesa, Universidad Autónoma de Madrid
| | - Gerardo Tusman
- Department of Anesthesiology, Hospital Privado de Comunidad, Mar del Plata, Argentina
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10
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Gaulton TG, Xin Y, Victor M, Nova A, Cereda M. Imaging the pulmonary vasculature in acute respiratory distress syndrome. Nitric Oxide 2024; 147:6-12. [PMID: 38588918 PMCID: PMC11253040 DOI: 10.1016/j.niox.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/21/2024] [Accepted: 04/03/2024] [Indexed: 04/10/2024]
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by a redistribution of regional lung perfusion that impairs gas exchange. While speculative, experimental evidence suggests that perfusion redistribution may contribute to regional inflammation and modify disease progression. Unfortunately, tools to visualize and quantify lung perfusion in patients with ARDS are lacking. This review explores recent advances in perfusion imaging techniques that aim to understand the pulmonary circulation in ARDS. Dynamic contrast-enhanced computed tomography captures first-pass kinetics of intravenously injected dye during continuous scan acquisitions. Different contrast characteristics and kinetic modeling have improved its topographic measurement of pulmonary perfusion with high spatial and temporal resolution. Dual-energy computed tomography can map the pulmonary blood volume of the whole lung with limited radiation exposure, enabling its application in clinical research. Electrical impedance tomography can obtain serial topographic assessments of perfusion at the bedside in response to treatments such as inhaled nitric oxide and prone position. Ongoing technological improvements and emerging techniques will enhance lung perfusion imaging and aid its incorporation into the care of patients with ARDS.
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Affiliation(s)
- Timothy G Gaulton
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA.
| | - Yi Xin
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Marcus Victor
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA; Electronics Engineering Division, Aeronautics Institute of Technology, Sao Paulo, Brazil
| | - Alice Nova
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA
| | - Maurizio Cereda
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA; Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA, USA
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11
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Chiumello D, Fioccola A. Recent advances in cardiorespiratory monitoring in acute respiratory distress syndrome patients. J Intensive Care 2024; 12:17. [PMID: 38706001 PMCID: PMC11070081 DOI: 10.1186/s40560-024-00727-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 04/04/2024] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Recent advances on cardiorespiratory monitoring applied in ARDS patients undergoing invasive mechanical ventilation and noninvasive ventilatory support are available in the literature and may have potential prognostic implication in ARDS treatment. MAIN BODY The measurement of oxygen saturation by pulse oximetry is a valid, low-cost, noninvasive alternative for assessing arterial oxygenation. Caution must be taken in patients with darker skin pigmentation, who may experience a greater incidence of occult hypoxemia. Dead space surrogates, which are easy to calculate, have important prognostic implications. The mechanical power, which can be automatically computed by intensive care ventilators, is an important parameter correlated with ventilator-induced lung injury and outcome. In patients undergoing noninvasive ventilatory support, the use of esophageal pressure can measure inspiratory effort, avoiding possible delays in endotracheal intubation. Fluid responsiveness can also be evaluated using dynamic indices in patients ventilated at low tidal volumes (< 8 mL/kg). In patients ventilated at high levels of positive end expiratory pressure (PEEP), the PEEP test represents a valid alternative to passive leg raising. There is growing evidence on alternative parameters for evaluating fluid responsiveness, such as central venous oxygen saturation variations, inferior vena cava diameter variations and capillary refill time. CONCLUSION Careful cardiorespiratory monitoring in patients affected by ARDS is crucial to improve prognosis and to tailor treatment via mechanical ventilatory support.
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Affiliation(s)
- Davide Chiumello
- Department of Health Sciences, University of Milan, Milan, Italy.
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital Milan, Via Di Rudinì 9, Milan, Italy.
- Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy.
| | - Antonio Fioccola
- Department of Health Sciences, University of Milan, Milan, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
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12
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Chen L, Rackley CR. Diagnosis and Epidemiology of Acute Respiratory Failure. Crit Care Clin 2024; 40:221-233. [PMID: 38432693 DOI: 10.1016/j.ccc.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Acute respiratory failure is a common clinical finding caused by insufficient oxygenation (hypoxemia) or ventilation (hypocapnia). Understanding the pathophysiology of acute respiratory failure can help to facilitate recognition, diagnosis, and treatment. The cause of acute respiratory failure can be identified through utilization of physical examination findings, laboratory analysis, and chest imaging.
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Affiliation(s)
- Lingye Chen
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
| | - Craig R Rackley
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University Medical Center, Durham, NC, USA
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13
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Cervantes O, Berg MR, Kapnadak SG, Miller E, Fountain C, Curtis B, Thelen S, Ruff S, Huang H, Altemeier W, Adams Waldorf KM. Testing pulmonary physiology in ventilated non-human primates. J Med Primatol 2024; 53:e12694. [PMID: 38454198 PMCID: PMC10994148 DOI: 10.1111/jmp.12694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/15/2024] [Accepted: 02/19/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Animal models of respiratory viral infections are essential for investigating disease pathogenesis and the efficacy of antivirals and vaccine candidates. A major limitation in the research of respiratory diseases in animal models is correlating clinically relevant changes in pulmonary physiology with cellular and molecular mechanistic studies. Few animal models have captured and correlated physiologic changes in lung function and immune response within same experiment, which is critical given the heterogeneous nature of lung disease due to viral infections. In ventilated human patients, pulmonary physiology testing can be used to not only capture oxygenation, ventilation, but also pulmonary mechanics to yield quantitative measures of lung function and scalar tracings of flow-volume and pressure-volume loops. Application of this protocol during mechanical ventilation in non-human (NHP) models would represent a major advance in respiratory viral disease research. METHODS We have applied and optimized a human pulmonary physiology testing protocol to ventilated pigtail macaques (Macaca nemestrina) at baseline and 5 days after influenza A (IAV) viral inoculation. RESULTS The NHPs manifested clinical disease with hypothermia and loss of body weight. Declines in lung function were striking with a 66%-81% decline in P/F ratio, a measure of oxygenation reflecting the ratio of partial pressure of oxygen in arterial blood (PaO2 ) to the fraction of inspiratory oxygen concentration (FiO2 ). There was also a 16%-45% decline in lung compliance. CONCLUSION We describe a new approach to performing pulmonary physiology testing protocol in non-human primates to better capture quantitative correlates of respiratory disease and demonstrate protection by therapeutics and vaccines.
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Affiliation(s)
- Orlando Cervantes
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Melissa R. Berg
- Washington National Primate Research Center, University of Washington, Seattle, Washington, USA
| | - Siddhartha G. Kapnadak
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
| | - Elizabeth Miller
- Washington National Primate Research Center, University of Washington, Seattle, Washington, USA
| | - Connie Fountain
- Washington National Primate Research Center, University of Washington, Seattle, Washington, USA
| | - Britni Curtis
- Washington National Primate Research Center, University of Washington, Seattle, Washington, USA
| | - Sandi Thelen
- Washington National Primate Research Center, University of Washington, Seattle, Washington, USA
| | - Shannon Ruff
- Washington National Primate Research Center, University of Washington, Seattle, Washington, USA
| | - Hazel Huang
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
| | - William Altemeier
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Washington, USA
- Center for Lung Biology, University of Washington, Seattle, Washington, USA
| | - Kristina M. Adams Waldorf
- Department of Global Health, University of Washington, Seattle, Washington, USA
- Department of Obstetrics and Gynecology, University of Washington, Seattle, Washington, USA
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14
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Tomarchio E, Momigliano F, Giosa L, Collins PD, Barrett NA, Camporota L. The intricate physiology of veno-venous extracorporeal membrane oxygenation: an overview for clinicians. Perfusion 2024; 39:49S-65S. [PMID: 38654449 DOI: 10.1177/02676591241238156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
During veno-venous extracorporeal membrane oxygenation (V-V ECMO), blood is drained from the central venous circulation to be oxygenated and decarbonated by an artificial lung. It is then reinfused into the right heart and pulmonary circulation where further gas-exchange occurs. Each of these steps is characterized by a peculiar physiology that this manuscript analyses, with the aim of providing bedside tools for clinical care: we begin by describing the factors that affect the efficiency of blood drainage, such as patient and cannulae position, fluid status, cardiac output and ventilatory strategies. We then dig into the complexity of extracorporeal gas-exchange, with particular reference to the effects of extracorporeal blood-flow (ECBF), fraction of delivered oxygen (FdO2) and sweep gas-flow (SGF) on oxygenation and decarbonation. Subsequently, we focus on the reinfusion of arterialized blood into the right heart, highlighting the effects on recirculation and, more importantly, on right ventricular function. The importance and challenges of haemodynamic monitoring during V-V ECMO are also analysed. Finally, we detail the interdependence between extracorporeal circulation, native lung function and mechanical ventilation in providing adequate arterial blood gases while allowing lung rest. In the absence of evidence-based strategies to care for this particular group of patients, clinical practice is underpinned by a sound knowledge of the intricate physiology of V-V ECMO.
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Affiliation(s)
- Emilia Tomarchio
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Francesca Momigliano
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Lorenzo Giosa
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Patrick Duncan Collins
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Nicholas A Barrett
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Luigi Camporota
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
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15
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Jiang L, Chen H, Xie J, Liu L, Yang Y. Prognostic value of time-varying dead space estimates in mechanically ventilated patients with acute respiratory distress syndrome. JOURNAL OF INTENSIVE MEDICINE 2024; 4:187-193. [PMID: 38681797 PMCID: PMC11043632 DOI: 10.1016/j.jointm.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 05/01/2024]
Abstract
Background The dead space fraction (VD/VT) has proven to be a powerful predictor of higher mortality in acute respiratory distress syndrome (ARDS). However, its measurement relies on expired carbon dioxide, limiting its widespread application in clinical practice. Several estimates employing routine variables have been found to be reliable substitutes for direct measurement of VD/VT. In this study, we evaluated the prognostic value of these dead space estimates obtained in the first 7 days following the initiation of ventilation. Methods This retrospective observational study was conducted using data from the Chinese database in intensive care (CDIC). Eligible participants were adult ARDS patients receiving invasive mechanical ventilation while in the intensive care unit between 1st January 2014 and 31st March 2021. We collected data during the first 7 days of ventilation to calculate various dead space estimates, including ventilatory ratio (VR), corrected minute ventilation (V ˙ Ecorr ), VD/VT (Harris-Benedict), VD/VT (Siddiki estimate), and VD/VT (Penn State estimate) longitudinally. A time-dependent Cox model was used to handle these time-varying estimates. Results A total of 392 patients (median age 66 [interquartile range: 55-77] years, median SOFA score 9 [interquartile range: 7-12]) were finally included in our analysis, among whom 132 (33.7%) patients died within 28 days of admission. VR (hazard ratio [HR]=1.04 per 0.1 increase, 95% confidence interval [CI]: 1.01 to 1.06; P=0.013), V ˙ Ecorr (HR=1.08 per 1 increase, 95% CI: 1.04 to 1.12; P < 0.001), VD/VT (Harris-Benedict) (HR=1.25 per 0.1 increase, 95% CI: 1.06 to 1.47; P=0.006), and VD/VT (Penn State estimate) (HR=1.22 per 0.1 increase, 95% CI: 1.04 to 1.44; P=0.017) remained significant after adjustment, while VD/VT (Siddiki estimate) (HR=1.10 per 0.1 increase, 95% CI: 1.00 to 1.20; P=0.058) did not. Given a large number of negative values, VD/VT (Siddiki estimate) and VD/VT (Penn State estimate) were not recommended as reliable substitutes. Long-term exposure to VR >1.3, V ˙ Ecorr >7.53, and VD/VT (Harris-Benedict) >0.59 was independently associated with an increased risk of mortality in ARDS patients. These findings were validated in the fluid and catheter treatment trial (FACTT) database. Conclusions In cases where VD/VT cannot be measured directly, early time-varying estimates of VD/VT such as VR, V ˙ Ecorr , and VD/VT (Harris-Benedict) can be considered for predicting mortality in ARDS patients, offering a rapid bedside application.
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Affiliation(s)
- Lianlian Jiang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
- Department of Critical Care Medicine, The First Affiliated Hospital of Soochow University, Soochow University, Suzhou, Jiangsu, China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
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16
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Roggeveen LF, Hassouni AE, de Grooth HJ, Girbes ARJ, Hoogendoorn M, Elbers PWG. Reinforcement learning for intensive care medicine: actionable clinical insights from novel approaches to reward shaping and off-policy model evaluation. Intensive Care Med Exp 2024; 12:32. [PMID: 38526681 PMCID: PMC10963714 DOI: 10.1186/s40635-024-00614-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 03/07/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Reinforcement learning (RL) holds great promise for intensive care medicine given the abundant availability of data and frequent sequential decision-making. But despite the emergence of promising algorithms, RL driven bedside clinical decision support is still far from reality. Major challenges include trust and safety. To help address these issues, we introduce cross off-policy evaluation and policy restriction and show how detailed policy analysis may increase clinical interpretability. As an example, we apply these in the setting of RL to optimise ventilator settings in intubated covid-19 patients. METHODS With data from the Dutch ICU Data Warehouse and using an exhaustive hyperparameter grid search, we identified an optimal set of Dueling Double-Deep Q Network RL models. The state space comprised ventilator, medication, and clinical data. The action space focused on positive end-expiratory pressure (peep) and fraction of inspired oxygen (FiO2) concentration. We used gas exchange indices as interim rewards, and mortality and state duration as final rewards. We designed a novel evaluation method called cross off-policy evaluation (OPE) to assess the efficacy of models under varying weightings between the interim and terminal reward components. In addition, we implemented policy restriction to prevent potentially hazardous model actions. We introduce delta-Q to compare physician versus policy action quality and in-depth policy inspection using visualisations. RESULTS We created trajectories for 1118 intensive care unit (ICU) admissions and trained 69,120 models using 8 model architectures with 128 hyperparameter combinations. For each model, policy restrictions were applied. In the first evaluation step, 17,182/138,240 policies had good performance, but cross-OPE revealed suboptimal performance for 44% of those by varying the reward function used for evaluation. Clinical policy inspection facilitated assessment of action decisions for individual patients, including identification of action space regions that may benefit most from optimisation. CONCLUSION Cross-OPE can serve as a robust evaluation framework for safe RL model implementation by identifying policies with good generalisability. Policy restriction helps prevent potentially unsafe model recommendations. Finally, the novel delta-Q metric can be used to operationalise RL models in clinical practice. Our findings offer a promising pathway towards application of RL in intensive care medicine and beyond.
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Affiliation(s)
- Luca F Roggeveen
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence (C4I), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AI&II), Amsterdam Public Health (APH), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands
| | - Ali El Hassouni
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence (C4I), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AI&II), Amsterdam Public Health (APH), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Armand R J Girbes
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence (C4I), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AI&II), Amsterdam Public Health (APH), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands
| | - Mark Hoogendoorn
- Quantitative Data Analytics Group, Department of Computer Science, Faculty of Science, Vrije Universiteit, Amsterdam, The Netherlands
| | - Paul W G Elbers
- Department of Intensive Care Medicine, Center for Critical Care Computational Intelligence (C4I), Amsterdam Medical Data Science (AMDS), Amsterdam Cardiovascular Science (ACS), Amsterdam Institute for Infection and Immunity (AI&II), Amsterdam Public Health (APH), Amsterdam UMC, Vrije Universiteit, Amsterdam, The Netherlands.
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17
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Ratano D, Zhang B, Dianti J, Georgopoulos D, Brochard LJ, Chan TCY, Goligher EC. Lung- and diaphragm-protective strategies in acute respiratory failure: an in silico trial. Intensive Care Med Exp 2024; 12:20. [PMID: 38416269 PMCID: PMC10902250 DOI: 10.1186/s40635-024-00606-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/21/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Lung- and diaphragm-protective (LDP) ventilation may prevent diaphragm atrophy and patient self-inflicted lung injury in acute respiratory failure, but feasibility is uncertain. The objectives of this study were to estimate the proportion of patients achieving LDP targets in different modes of ventilation, and to identify predictors of need for extracorporeal carbon dioxide removal (ECCO2R) to achieve LDP targets. METHODS An in silico clinical trial was conducted using a previously published mathematical model of patient-ventilator interaction in a simulated patient population (n = 5000) with clinically relevant physiological characteristics. Ventilation and sedation were titrated according to a pre-defined algorithm in pressure support ventilation (PSV) and proportional assist ventilation (PAV+) modes, with or without adjunctive ECCO2R, and using ECCO2R alone (without ventilation or sedation). Random forest modelling was employed to identify patient-level factors associated with achieving targets. RESULTS After titration, the proportion of patients achieving targets was lower in PAV+ vs. PSV (37% vs. 43%, odds ratio 0.78, 95% CI 0.73-0.85). Adjunctive ECCO2R substantially increased the probability of achieving targets in both PSV and PAV+ (85% vs. 84%). ECCO2R alone without ventilation or sedation achieved LDP targets in 9%. The main determinants of success without ECCO2R were lung compliance, ventilatory ratio, and strong ion difference. In silico trial results corresponded closely with the results obtained in a clinical trial of the LDP titration algorithm (n = 30). CONCLUSIONS In this in silico trial, many patients required ECCO2R in combination with mechanical ventilation and sedation to achieve LDP targets. ECCO2R increased the probability of achieving LDP targets in patients with intermediate degrees of derangement in elastance and ventilatory ratio.
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Affiliation(s)
- Damian Ratano
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto General Hospital, 585 University Ave, 9-MaRS-9024, Toronto, ON, M5G 2N2, Canada
- Intensive Care and Burn Unit, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Binghao Zhang
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Canada
| | - Jose Dianti
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto General Hospital, 585 University Ave, 9-MaRS-9024, Toronto, ON, M5G 2N2, Canada
| | - Dimitrios Georgopoulos
- Department of Intensive Care Medicine, University Hospital of Heraklion, University of Crete, Heraklion, Greece
| | - Laurent J Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto General Hospital, 585 University Ave, 9-MaRS-9024, Toronto, ON, M5G 2N2, Canada
| | - Timothy C Y Chan
- Department of Mechanical and Industrial Engineering, University of Toronto, Toronto, Canada
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto General Hospital, 585 University Ave, 9-MaRS-9024, Toronto, ON, M5G 2N2, Canada.
- Division of Respirology, Department of Medicine, University Health Network, Toronto, Canada.
- Toronto General Hospital Research Institute, University Health Network, Toronto, Canada.
- Department of Physiology, University of Toronto, Toronto, Canada.
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18
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Brazee PL, Cartier A, Kuo A, Haring AM, Nguyen T, Hariri LP, Griffith JW, Hla T, Medoff BD, Knipe RS. Augmentation of Endothelial S1PR1 Attenuates Postviral Pulmonary Fibrosis. Am J Respir Cell Mol Biol 2024; 70:119-128. [PMID: 37934676 PMCID: PMC10848698 DOI: 10.1165/rcmb.2023-0286oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/07/2023] [Indexed: 11/09/2023] Open
Abstract
Respiratory viral infections are frequent causes of acute respiratory distress syndrome (ARDS), a disabling condition with a mortality of up to 46%. The pulmonary endothelium plays an important role in the development of ARDS as well as the pathogenesis of pulmonary fibrosis; however, the therapeutic potential to modulate endothelium-dependent signaling to prevent deleterious consequences has not been well explored. Here, we used a clinically relevant influenza A virus infection model, endothelial cell-specific transgenic gain-of-function and loss-of-function mice as well as pharmacologic approaches and in vitro modeling, to define the mechanism by which S1PR1 expression is dampened during influenza virus infection and determine whether therapeutic augmentation of S1PR1 has the potential to reduce long-term postviral fibrotic complications. We found that the influenza virus-induced inflammatory milieu promoted internalization of S1PR1, which was pharmacologically inhibited with paroxetine, an inhibitor of GRK2. Moreover, genetic overexpression or administration of paroxetine days after influenza virus infection was sufficient to reduce postviral pulmonary fibrosis. Taken together, our data suggest that endothelial S1PR1 signaling provides critical protection against long-term fibrotic complications after pulmonary viral infection. These findings support the development of antifibrotic strategies that augment S1PR1 expression in virus-induced ARDS to improve long-term patient outcomes.
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Affiliation(s)
- Patricia L. Brazee
- Center for Immunology and Inflammatory Diseases, Division of Pulmonary and Critical Care
| | - Andreane Cartier
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew Kuo
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alexis M. Haring
- Center for Immunology and Inflammatory Diseases, Division of Pulmonary and Critical Care
| | - Trong Nguyen
- Center for Immunology and Inflammatory Diseases, Division of Pulmonary and Critical Care
| | - Lida P. Hariri
- Department of Pathology, Massachusetts General Hospital, and
| | - Jason W. Griffith
- Center for Immunology and Inflammatory Diseases, Division of Pulmonary and Critical Care
| | - Timothy Hla
- Vascular Biology Program, Department of Surgery, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Benjamin D. Medoff
- Center for Immunology and Inflammatory Diseases, Division of Pulmonary and Critical Care
| | - Rachel S. Knipe
- Center for Immunology and Inflammatory Diseases, Division of Pulmonary and Critical Care
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19
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Gattinoni L, Collino F, Camporota L. Ventilator induced lung injury: a case for a larger umbrella? Intensive Care Med 2024; 50:275-278. [PMID: 38172299 PMCID: PMC10907410 DOI: 10.1007/s00134-023-07296-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 11/25/2023] [Indexed: 01/05/2024]
Affiliation(s)
- Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Robert Koch Straße 40, 37075, Göttingen, Germany.
| | - Francesca Collino
- Department of Anesthesia, Intensive Care and Emergency, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Piemonte, Turin, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Centre for Human and Applied Physiological Sciences, Guy's and St. Thomas' NHS Foundation Trust, King's College London, London, UK
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Pozzi T, Fratti I, Tomarchio E, Bruno G, Catozzi G, Monte A, Chiumello D, Coppola S. Early time-course of respiratory mechanics, mechanical power and gas exchange in ARDS patients. J Crit Care 2024; 79:154444. [PMID: 37862955 DOI: 10.1016/j.jcrc.2023.154444] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 09/04/2023] [Accepted: 09/30/2023] [Indexed: 10/22/2023]
Abstract
PURPOSE To describe the clinical course of ARDS during the first three days of mechanical ventilation, to compare ventilatory setting, respiratory mechanics and gas exchange variables collected during the first three days of mechanical ventilation between patients who survived and died during intensive care unit (ICU) stay and to investigate the variables associated with mortality at ICU admission and throughout the first three days of mechanical ventilation. MATERIALS AND METHODS Prospective observational study. Mechanically ventilated ARDS patients were studied at ICU admission and for the following three days. Univariate logistic regression models were performed for PaO2/FiO2 ratio, driving pressure and alveolar dead space fraction and for mechanical power and mechanical power ratio. RESULTS Mechanical power ratio was higher in non survivors at ICU admission and over time; PaO2/FiO2 ratio was higher in survivors with a similar behavior over time in the two groups while alveolar dead space fraction was similar at ICU admission and over time between groups. Mechanical power ratio was the only physiological variable which remained consistently associated with ICU mortality throughout the study. CONCLUSIONS The alteration in oxygenation, dead space, and mechanical power ratio should be assessed not at intensive care admission, but during the first days of mechanical ventilation to better predict outcome.
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Affiliation(s)
- Tommaso Pozzi
- Department of Health Sciences, University of Milan, Italy
| | | | | | - Giovanni Bruno
- Department of Health Sciences, University of Milan, Italy
| | - Giulia Catozzi
- Department of Health Sciences, University of Milan, Italy
| | | | - Davide Chiumello
- Department of Health Sciences, University of Milan, Italy; Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital Milan, Italy; Coordinated Research Center on Respiratory Failure, University of Milan, Italy.
| | - Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital Milan, Italy
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21
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Mekontso Dessap A, Bagate F, Repesse X, Blayau C, Fartoukh M, Canoui-Poitrine F, de Prost N, Vieillard-Baron A. Low-flow ECCO 2R conjoined with renal replacement therapy platform to manage pulmonary vascular dysfunction with refractory hypercapnia in ARDS. Heliyon 2024; 10:e23878. [PMID: 38226285 PMCID: PMC10788508 DOI: 10.1016/j.heliyon.2023.e23878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 12/12/2023] [Accepted: 12/14/2023] [Indexed: 01/17/2024] Open
Abstract
Background Hypercapnia worsens lung vascular dysfunction during acute respiratory distress syndrome (ARDS). We tested whether an extracorporeal carbon dioxide removal (ECCO2R) device based on a renal replacement therapy platform (Prismalung®) may reduce PaCO2 and alleviate lung vascular dysfunction in ARDS patients with refractory hypercapnia. Methods We planned to prospectively include 20 patients with moderate-to-severe ARDS, pulmonary vascular dysfunction on echocardiography, and PaCO2 ≥ 48 mmHg despite instrumental dead space reduction and the increase in respiratory rate. Hemodynamics, echocardiography, respiratory mechanics, and arterial blood gases were recorded at 2 (H2), 6 (H6) and 24 (H24) hours as ECCO2R treatment was continued for at least 24 h. Results Only eight patients were included, and the study was stopped due to worldwide shortage of ECCO2R membranes and the pandemic. Only one patient fulfilled the primary endpoint criterion (decrease in PaCO2 of more than 20 %) at H2, but this objective was achieved in half of patients (n = 4) at H6. The percentage of patients with a PaCO2 value < 48 mmHg increased with time, from 0/8 (0 %) at H0, to 3/8 (37.5 %) at H2 and 4/8 (50 %) at H6 (p = 0.04). There was no major change in hemodynamic and echocardiographic variables with ECCO2R, except for a significant decrease in heart rate. ECCO2R was prematurely discontinued before H24 in five (62.5 %) patients, due to membrane clotting in all cases. Conclusions This pilot study testing showed a narrow efficacy and high rate of membrane thrombosis with the first version of the system. Improved versions should be tested in future trials. Trial registration Registered at clinicaltrials.gov, identifier: NCT03303807, Registered: October 6, 2017, https://clinicaltrials.gov/ct2/show/NCT03303807.
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Affiliation(s)
- Armand Mekontso Dessap
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, F-94010, Créteil, France
- Univ Paris Est Créteil, CARMAS, Créteil, F-94010, France
- Univ Paris Est Créteil, INSERM, IMRB, Créteil, F-94010, France
| | - François Bagate
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, F-94010, Créteil, France
- Univ Paris Est Créteil, CARMAS, Créteil, F-94010, France
- Univ Paris Est Créteil, INSERM, IMRB, Créteil, F-94010, France
| | - Xavier Repesse
- AP-HP, Hôpital Ambroise Paré, Service de Médecine Intensive Réanimation, Boulogne Billancourt, Créteil, France
| | - Clarisse Blayau
- AP-HP, Hôpital Tenon, Service de Médecine Intensive Réanimation, Paris, France
| | - Muriel Fartoukh
- AP-HP, Hôpital Tenon, Service de Médecine Intensive Réanimation, Paris, France
| | - Florence Canoui-Poitrine
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Santé Publique, F-94010, Créteil, France
| | - Nicolas de Prost
- AP-HP, Hôpitaux Universitaires Henri-Mondor, Service de Médecine Intensive Réanimation, F-94010, Créteil, France
- Univ Paris Est Créteil, CARMAS, Créteil, F-94010, France
- Univ Paris Est Créteil, INSERM, IMRB, Créteil, F-94010, France
| | - Antoine Vieillard-Baron
- AP-HP, Hôpital Ambroise Paré, Service de Médecine Intensive Réanimation, Boulogne Billancourt, Créteil, France
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22
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Spadaro S, Jimenez-Santana JD, La Rosa R, Spinazzola G, Argente Navarro P, Volta CA, Scaramuzzo G. Prone Positioning and Molecular Biomarkers in COVID and Non-COVID ARDS: A Narrative Review. J Clin Med 2024; 13:317. [PMID: 38256451 PMCID: PMC10816213 DOI: 10.3390/jcm13020317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/25/2023] [Accepted: 12/29/2023] [Indexed: 01/24/2024] Open
Abstract
Prone positioning (PP) represents a therapeutic intervention with the proven capacity of ameliorating gas exchanges and ventilatory mechanics indicated in acute respiratory distress syndrome (ARDS). When PP is selectively applied to moderate-severe cases of ARDS, it sensitively affects clinical outcomes, including mortality. After the COVID-19 outbreak, clinical application of PP peaked worldwide and was applied in 60% of treated cases, according to large reports. Research on this topic has revealed many physiological underpinnings of PP, focusing on regional ventilation redistribution and the reduction of parenchymal stress and strain. However, there is a lack of evidence on biomarkers behavior in different phases and phenotypes of ARDS. Patients response to PP are, to date, decided on PaO2/FiO2 ratio improvement, whereas scarce data exist on biomarker tracking during PP. The purpose of this review is to explore current evidence on the clinical relevance of biomarkers in the setting of moderate-severe ARDS of different etiologies (i.e., COVID and non-COVID-related ARDS). Moreover, this review focuses on how PP may modulate biomarkers and which biomarkers may have a role in outcome prediction in ARDS patients.
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Affiliation(s)
- Savino Spadaro
- Department of Translational Medicine, University of Ferrara, 44124 Ferrara, Italy; (R.L.R.); (C.A.V.); (G.S.)
- Anesthesia and Intensive Care Unit, Emergency Department, Azienda Ospedaliera Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Jose Daniel Jimenez-Santana
- Department of Anaesthesiology, Hospital Universitari i Politécnic la Fe, 46026 Valencia, Spain; (J.D.J.-S.); (P.A.N.)
| | - Riccardo La Rosa
- Department of Translational Medicine, University of Ferrara, 44124 Ferrara, Italy; (R.L.R.); (C.A.V.); (G.S.)
- Anesthesia and Intensive Care Unit, Emergency Department, Azienda Ospedaliera Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Giorgia Spinazzola
- Department of Emergency, Anesthesiologic and Reanimation Sciences, Fondazione Policlinico Universitario Gemelli, IRCSS, 00168 Rome, Italy;
| | - Pilar Argente Navarro
- Department of Anaesthesiology, Hospital Universitari i Politécnic la Fe, 46026 Valencia, Spain; (J.D.J.-S.); (P.A.N.)
| | - Carlo Alberto Volta
- Department of Translational Medicine, University of Ferrara, 44124 Ferrara, Italy; (R.L.R.); (C.A.V.); (G.S.)
- Anesthesia and Intensive Care Unit, Emergency Department, Azienda Ospedaliera Universitaria di Ferrara, 44124 Ferrara, Italy
| | - Gaetano Scaramuzzo
- Department of Translational Medicine, University of Ferrara, 44124 Ferrara, Italy; (R.L.R.); (C.A.V.); (G.S.)
- Anesthesia and Intensive Care Unit, Emergency Department, Azienda Ospedaliera Universitaria di Ferrara, 44124 Ferrara, Italy
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23
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Levine AR, Calfee CS. Subphenotypes of Acute Respiratory Distress Syndrome: Advancing Towards Precision Medicine. Tuberc Respir Dis (Seoul) 2024; 87:1-11. [PMID: 37675452 PMCID: PMC10758309 DOI: 10.4046/trd.2023.0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 08/25/2023] [Accepted: 09/06/2023] [Indexed: 09/08/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a common cause of severe hypoxemia defined by the acute onset of bilateral non-cardiogenic pulmonary edema. The diagnosis is made by defined consensus criteria. Supportive care, including prevention of further injury to the lungs, is the only treatment that conclusively improves outcomes. The inability to find more advanced therapies is due, in part, to the highly sensitive but relatively non-specific current syndromic consensus criteria, combining a heterogenous population of patients under the umbrella of ARDS. With few effective therapies, the morality rate remains 30% to 40%. Many subphenotypes of ARDS have been proposed to cluster patients with shared combinations of observable or measurable traits. Subphenotyping patients is a strategy to overcome heterogeneity to advance clinical research and eventually identify treatable traits. Subphenotypes of ARDS have been proposed based on radiographic patterns, protein biomarkers, transcriptomics, and/or machine-based clustering of clinical and biological variables. Some of these strategies have been reproducible across patient cohorts, but at present all have practical limitations to their implementation. Furthermore, there is no agreement on which strategy is the most appropriate. This review will discuss the current strategies for subphenotyping patients with ARDS, including the strengths and limitations, and the future directions of ARDS subphenotyping.
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Affiliation(s)
- Andrea R. Levine
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Carolyn S. Calfee
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
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24
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Artigas A, Barbas CSV, Matthay MA. Unraveling the enigma of genetics and phenotypes in ARDS. Intensive Care Med 2024; 50:125-127. [PMID: 38085336 DOI: 10.1007/s00134-023-07277-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/13/2023] [Indexed: 01/27/2024]
Affiliation(s)
- Antonio Artigas
- Intensive Care Department, Corporacion Sanitaria Universitaria Parc Tauli, Institut d'Investigació I Innovació Parc Tauli I3PT, CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Sabadell, Spain.
| | - Carmen Silvia Valente Barbas
- Pulmonary Division, INCOR, HC-FMUSP, Adult-ICU Albert Einstein Hospital, University of Sao Paulo Medical School, São Paulo, Brazil
| | - Michael A Matthay
- Department of Medicine, Cardiovascular Research Institute, University of California, San Francisco, USA
- Department of Anesthesia, Cardiovascular Research Institute, University of California, San Francisco, USA
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25
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Harbut P, Campoccia Jalde F, Dahlberg M, Forsgren A, Andersson E, Lundholm A, Janc J, Lesnik P, Suchanski M, Zatorski P, Trzebicki J, Skalec T, Günther M. Improved oxygenation in prone positioning of mechanically ventilated patients with COVID-19 acute respiratory distress syndrome is associated with decreased pulmonary shunt fraction: a prospective multicenter study. Eur J Med Res 2023; 28:597. [PMID: 38102699 PMCID: PMC10725003 DOI: 10.1186/s40001-023-01559-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 11/29/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Prone position is used in acute respiratory distress syndrome and in coronavirus disease 2019 (Covid-19) acute respiratory distress syndrome (ARDS). However, physiological mechanisms remain unclear. The aim of this study was to determine whether improved oxygenation was related to pulmonary shunt fraction (Q's/Q't), alveolar dead space (Vd/Vtalv) and ventilation/perfusion mismatch (V'A/Q'). METHODS This was an international, prospective, observational, multicenter, cohort study, including six intensive care units in Sweden and Poland and 71 mechanically ventilated adult patients. RESULTS Prone position increased PaO2:FiO2 after 30 min, by 78% (83-148 mm Hg). The effect persisted 120 min after return to supine (p < 0.001). The oxygenation index decreased 30 min after prone positioning by 43% (21-12 units). Q's/Q't decreased already after 30 min in the prone position by 17% (0.41-0.34). The effect persisted 120 min after return to supine (p < 0.005). Q's/Q't and PaO2:FiO2 were correlated both in prone (Beta -137) (p < 0.001) and in the supine position (Beta -270) (p < 0.001). V'A/Q' was unaffected and did not correlate to PaO2:FiO2 (p = 0.8). Vd/Vtalv increased at 120 min by 11% (0.55-0.61) (p < 0.05) and did not correlate to PaO2:FiO2 (p = 0.3). The ventilatory ratio increased after 30 min in the prone position by 58% (1.9-3.0) (p < 0.001). PaO2:FiO2 at baseline predicted PaO2:FiO2 at 30 min after proning (Beta 1.3) (p < 0.001). CONCLUSIONS Improved oxygenation by prone positioning in COVID-19 ARDS patients was primarily associated with a decrease in pulmonary shunt fraction. Dead space remained high and the global V'A/Q' measure could not explain the differences in gas exchange.
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Affiliation(s)
- Piotr Harbut
- Department of Clinical Sciences Danderyd, Karolinska Institutet, Stockholm, Sweden
| | - Francesca Campoccia Jalde
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative Medicine and Intensive Care, Thoracic Anesthesia and Intensive Care Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Martin Dahlberg
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Anders Forsgren
- Department of Clinical Science and Education Södersjukhuset, Section for Anesthesiology and Intensive Care, Karolinska Institutet, Sjukhusbacken 10, SE-118 83, Stockholm, Sweden
| | - Elisabeth Andersson
- Department of Clinical Science and Education Södersjukhuset, Section for Anesthesiology and Intensive Care, Karolinska Institutet, Sjukhusbacken 10, SE-118 83, Stockholm, Sweden
| | - Andreas Lundholm
- Department of Clinical Sciences Danderyd, Karolinska Institutet, Stockholm, Sweden
| | | | | | | | | | | | | | - Mattias Günther
- Department of Clinical Science and Education Södersjukhuset, Section for Anesthesiology and Intensive Care, Karolinska Institutet, Sjukhusbacken 10, SE-118 83, Stockholm, Sweden.
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26
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Shi X, Shi Y, Fan L, Yang J, Chen H, Ni K, Yang J. Prognostic value of oxygen saturation index trajectory phenotypes on ICU mortality in mechanically ventilated patients: a multi-database retrospective cohort study. J Intensive Care 2023; 11:59. [PMID: 38031107 PMCID: PMC10685672 DOI: 10.1186/s40560-023-00707-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/15/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Heterogeneity among critically ill patients undergoing invasive mechanical ventilation (IMV) treatment could result in high mortality rates. Currently, there are no well-established indicators to help identify patients with a poor prognosis in advance, which limits physicians' ability to provide personalized treatment. This study aimed to investigate the association of oxygen saturation index (OSI) trajectory phenotypes with intensive care unit (ICU) mortality and ventilation-free days (VFDs) from a dynamic and longitudinal perspective. METHODS A group-based trajectory model was used to identify the OSI-trajectory phenotypes. Associations between the OSI-trajectory phenotypes and ICU mortality were analyzed using doubly robust analyses. Then, a predictive model was constructed to distinguish patients with poor prognosis phenotypes. RESULTS Four OSI-trajectory phenotypes were identified in 3378 patients: low-level stable, ascending, descending, and high-level stable. Patients with the high-level stable phenotype had the highest mortality and fewest VFDs. The doubly robust estimation, after adjusting for unbalanced covariates in a model using the XGBoost method for generating propensity scores, revealed that both high-level stable and ascending phenotypes were associated with higher mortality rates (odds ratio [OR]: 1.422, 95% confidence interval [CI] 1.246-1.623; OR: 1.097, 95% CI 1.027-1.172, respectively), while the descending phenotype showed similar ICU mortality rates to the low-level stable phenotype (odds ratio [OR] 0.986, 95% confidence interval [CI] 0.940-1.035). The predictive model could help identify patients with ascending or high-level stable phenotypes at an early stage (area under the curve [AUC] in the training dataset: 0.851 [0.827-0.875]; AUC in the validation dataset: 0.743 [0.709-0.777]). CONCLUSIONS Dynamic OSI-trajectory phenotypes were closely related to the mortality of ICU patients requiring IMV treatment and might be a useful prognostic indicator in critically ill patients.
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Affiliation(s)
- Xiawei Shi
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Yangyang Shi
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong, China
| | - Liming Fan
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Jia Yang
- The First Affiliated Hospital of Zhejiang Chinese Medical University, No. 54 Youdian Road, Shangcheng District, Hangzhou, 310006, Zhejiang, China
| | - Hao Chen
- Longhua Hospital, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Kaiwen Ni
- Zhejiang Chinese Medical University, Hangzhou, China
| | - Junchao Yang
- The First Affiliated Hospital of Zhejiang Chinese Medical University, No. 54 Youdian Road, Shangcheng District, Hangzhou, 310006, Zhejiang, China.
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27
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Xu H, Sheng S, Luo W, Xu X, Zhang Z. Acute respiratory distress syndrome heterogeneity and the septic ARDS subgroup. Front Immunol 2023; 14:1277161. [PMID: 38035100 PMCID: PMC10682474 DOI: 10.3389/fimmu.2023.1277161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/30/2023] [Indexed: 12/02/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is an acute diffuse inflammatory lung injury characterized by the damage of alveolar epithelial cells and pulmonary capillary endothelial cells. It is mainly manifested by non-cardiogenic pulmonary edema, resulting from intrapulmonary and extrapulmonary risk factors. ARDS is often accompanied by immune system disturbance, both locally in the lungs and systemically. As a common heterogeneous disease in critical care medicine, researchers are often faced with the failure of clinical trials. Latent class analysis had been used to compensate for poor outcomes and found that targeted treatment after subgrouping contribute to ARDS therapy. The subphenotype of ARDS caused by sepsis has garnered attention due to its refractory nature and detrimental consequences. Sepsis stands as the most predominant extrapulmonary cause of ARDS, accounting for approximately 32% of ARDS cases. Studies indicate that sepsis-induced ARDS tends to be more severe than ARDS caused by other factors, leading to poorer prognosis and higher mortality rate. This comprehensive review delves into the immunological mechanisms of sepsis-ARDS, the heterogeneity of ARDS and existing research on targeted treatments, aiming to providing mechanism understanding and exploring ideas for accurate treatment of ARDS or sepsis-ARDS.
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Affiliation(s)
- Huikang Xu
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shiying Sheng
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Weiwei Luo
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaofang Xu
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhaocai Zhang
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- Key Laboratory of the Diagnosis and Treatment for Severe Trauma and Burn of Zhejiang Province, Hangzhou, China
- Zhejiang Province Clinical Research Center for Emergency and Critical Care Medicine, Hangzhou, China
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28
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Parada-Gereda HM, Avendaño JM, Melo JE, Ruiz CI, Castañeda MI, Medina-Parra J, Merchán-Chaverra R, Corzzo D, Molano-Franco D, Masclans JR. Association between ventilatory ratio and mortality in patients with acute respiratory distress syndrome and COVID 19: A multicenter, retrospective cohort study. BMC Pulm Med 2023; 23:425. [PMID: 37924051 PMCID: PMC10623871 DOI: 10.1186/s12890-023-02733-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/25/2023] [Indexed: 11/06/2023] Open
Abstract
BACKGROUND Mortality rates in patients with COVID-19 undergoing mechanical ventilation in the intensive care unit are high. The causes of this mortality have been rigorously investigated. The aim of the present study is to establish mortality risk factors related to lung mechanics measured at days 1 and 5 in patients with covid-19 ARDS managed with invasive mechanical ventilation in the intensive care unit. METHODS A retrospective observational multicenter study including consecutive patients with a confirmed diagnosis of COVID-19-induced ARDS, admitted to three institutions and seven intensive care units in the city of Bogota between May 20, 2020 and May 30, 2022 who required mechanical ventilation for at least five days. Data were collected from the medical records of patients who met the inclusion criteria on day 1 and day 5 of mechanical ventilation. The primary outcome assessed was mortality at day 30. RESULTS A total of 533 consecutive patients admitted with ARDS with COVID-19 were included. Ventilatory ratio, plateau pressure and driving pressure measured on day 5 were significantly higher in non-survivors (p < 0.05). Overall, 30-day follow-up mortality was 48.8%. The increases between day 1 and day 5 in the ventilatory ratio (OR 1.42, 95%CI 1.03-2.01, p = 0.04), driving pressure (OR 1.56, 95%CI 1.10-2.22, p = 0.01); and finally plateau pressure (OR 1.9, 95%CI 1.34-2.69, p = 0.001) were associated with an increased risk of death. There was no association between deterioration of PaO2/FIO2 index and mortality (OR 1.34, 95%CI 0.96-1.56, p = 0.053). CONCLUSIONS Ventilatory ratio, plateau pressure, driving pressure, and age were identified as independent risk factors for 30-day mortality in patients with ARDS due to COVID-19 on day 5 of invasive mechanical ventilation.
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Affiliation(s)
- Henry M Parada-Gereda
- Intensive Care Unit Clínica Reina Sofia, Clínica Colsanitas. Clinical Nutrition and Rehabilitation Research Group, Fundación Universitaria Sanitas. Grupo Keralty, Bogotá, Colombia.
| | - Janneth M Avendaño
- Intensive Care Unit Clínica Reina Sofia, Mujer y Pediátrica, Clínica Colsanitas, Clinical Nutrition and Rehabilitation Research Group, Fundación Universitaria Sanitas. Grupo Keralty, Bogotá, Colombia
| | - Johana E Melo
- Intensive Care Unit Clinica Universitaria Colombia, Fundacion Universitaria Sanitas. Grupo Keralty, Bogotá, Colombia
| | - Claudia I Ruiz
- Department Clínica Reina Sofía, Clínica Reina Sofia, Mujer y Pediátrica. Grupo Keralty, Bogotá, Colombia
| | | | - Jorge Medina-Parra
- Clinical Nutrition and Rehabilitation Research Group, Fundación Universitaria Sanitas. grupo Keralty, Bogotá, Colombia
| | - Ricardo Merchán-Chaverra
- Clinical Nutrition and Rehabilitation Research Group, Fundación Universitaria Sanitas. Clinica Santa Maria del Lago. Grupo Keralty, Bogota, Colombia
- Facultad de Medicina, Fundación Universitaria Sanitas, Bogotá, Colombia
- Latin American Nutrition Center (CELAN), Chía (Cundinamarca), Colombia
| | - Dinia Corzzo
- Intensive Care Unit Clínica Reina Sofía, Intensive Care Unit Center of Cancer Research and Treatment (CTIC), Bogotá, Colombia
| | - Daniel Molano-Franco
- Intensive Care Unit, Los Cobos Medical Center, Hospital San José, Center of Cancer Research and Treatment, Research Group Gribos, Bogotá, Colombia
| | - Joan Ramón Masclans
- Critical Care Department, Hospital del Mar Barcelona, Barcelona, Spain
- Critical Care Illness Research Group (GREPAC), IMIM. Department of Medicine and Life Sciences (MELIS), Universitat Pompeu Fabra (UPF), Barcelona, Spain
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29
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Upchurch CP, Wessman BT, Roberts BW, Fuller BM. Arterial to end-tidal carbon dioxide gap and its characterization in mechanically ventilated adults in the emergency department. Am J Emerg Med 2023; 73:154-159. [PMID: 37683313 DOI: 10.1016/j.ajem.2023.08.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/23/2023] [Accepted: 08/25/2023] [Indexed: 09/10/2023] Open
Abstract
PURPOSE To evaluate early measurement of the arterial to end-tidal carbon dioxide (PaCO2-PetCO2) gap, a surrogate for physiologic dead space, and its association with clinical outcomes in intubated adults in the emergency department (ED). MATERIALS AND METHODS Observational cohort study of invasively mechanically ventilated adults in an academic medical center (years 2009 to 2016). The association of the PaCO2-PetCO2 gap was evaluated with respect to clinical outcomes; the primary outcome was in-hospital mortality. RESULTS 519 patients were included. 325 (63%) patients had an elevated (>5 mmHg) PaCO2-PetCO2. Patients with an elevated PaCO2-PetCO2 were significantly older, had higher APACHE II scores, more frequently had chronic obstructive pulmonary disease (COPD), had lower arterial oxygen to fraction of inspired oxygen (P:F) ratios, and were more likely to be intubated for exacerbation of COPD or sepsis. There was no difference in mortality for patients with an elevated PaCO2-PetCO2 (25% vs 26%) in unadjusted analysis (p = 0.829) or adjusted analysis (aOR = 0.81 [95% CI: 0.53-1.26]), as compared to a non-elevated PaCO2-PetCO2. CONCLUSIONS An elevated PaCO2-PetCO2 gap is common in the post-intubation period in the ED, but not significantly associated with clinical outcomes.
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Affiliation(s)
- Cameron P Upchurch
- Department of Medicine, Division of Pulmonary and Critical Care. MSC 8052-43-14. Washington University School of Medicine. 660 S. Euclid Ave. St. Louis, MO 63110, USA.
| | - Brian T Wessman
- Department of Emergency Medicine 660 S. Euclid Ave Campus Box 8072 St. Louis, MO 63110, USA; Department of Anesthesiology, Division of Critical Care 660 S. Euclid Ave. St. Louis, MO 63110, USA
| | - Brian W Roberts
- Cooper University Hospital Department of Emergency Medicine One Cooper Plaza Camden, NJ 08103, USA
| | - Brian M Fuller
- Department of Emergency Medicine 660 S. Euclid Ave Campus Box 8072 St. Louis, MO 63110, USA; Department of Anesthesiology, Division of Critical Care 660 S. Euclid Ave. St. Louis, MO 63110, USA
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Teijeiro-Paradis R, Cherkos Dawit T, Munshi L, Ferguson ND, Fan E. Liberation From Venovenous Extracorporeal Membrane Oxygenation for Respiratory Failure: A Scoping Review. Chest 2023; 164:1184-1203. [PMID: 37353070 DOI: 10.1016/j.chest.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 06/03/2023] [Accepted: 06/14/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Safe and timely liberation from venovenous extracorporeal membrane oxygenation (ECMO) would be expected to reduce the duration of ECMO, the risk of complications, and costs. However, how to liberate patients from venovenous ECMO effectively remains understudied. RESEARCH QUESTION What is the current state of the evidence on liberation from venovenous ECMO? STUDY DESIGN AND METHODS We systematically searched for relevant publications on liberation from venovenous ECMO in Medline and EMBASE. Citations were included if the manuscripts provided any of the following: criteria for readiness for liberation, a liberation protocol, or a definition of successful decannulation or decannulation failure. We included randomized trials, observational trials, narrative reviews, guidelines, editorials, and commentaries. We excluded single case reports and citations where the full text was unavailable. RESULTS We screened 1,467 citations to identify 39 key publications on liberation from venovenous ECMO. We then summarized the data into five main topics: current strategies used for liberation, criteria used to define readiness for liberation, conducting liberation trials, criteria used to proceed with decannulation, and parameters used to predict decannulation outcomes. INTERPRETATION Practices on liberation from venovenous ECMO are heterogeneous and are influenced strongly by clinician preference. Additional research on liberation thresholds is needed to define optimal liberation strategies and to close existing knowledge gaps in essential topics on liberation from venovenous ECMO.
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Affiliation(s)
- Ricardo Teijeiro-Paradis
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Tsega Cherkos Dawit
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Mekelle University College of Health Sciences, Mekelle, Ethiopia
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Division of Respirology & Critical Care, Department of Medicine, Sinai Health System and University Health Network, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada.
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31
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Jayasimhan D, Chieng J, Kolbe J, Sidebotham DA. Dead-Space Ventilation Indices and Mortality in Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis. Crit Care Med 2023; 51:1363-1372. [PMID: 37204257 DOI: 10.1097/ccm.0000000000005921] [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: 05/20/2023]
Abstract
OBJECTIVES Acute respiratory distress syndrome (ARDS) is associated with high ventilation-perfusion heterogeneity and dead-space ventilation. However, whether the degree of dead-space ventilation is associated with outcomes is uncertain. In this systematic review and meta-analysis, we evaluated the ability of dead-space ventilation measures to predict mortality in patients with ARDS. DATA SOURCES MEDLINE, CENTRAL, and Google Scholar from inception to November 2022. STUDY SELECTION Studies including adults with ARDS reporting a dead-space ventilation index and mortality. DATA EXTRACTION Two reviewers independently identified eligible studies and extracted data. We calculated pooled effect estimates using a random effects model for both adjusted and unadjusted results. The quality and strength of evidence were assessed using the Quality in Prognostic Studies and Grading of Recommendations, Assessment, Development, and Evaluation, respectively. DATA SYNTHESIS We included 28 studies in our review, 21 of which were included in our meta-analysis. All studies had a low risk of bias. A high pulmonary dead-space fraction was associated with increased mortality (odds ratio [OR], 3.52; 95% CI, 2.22-5.58; p < 0.001; I2 = 84%). After adjusting for other confounding variables, every 0.05 increase in pulmonary-dead space fraction was associated with an increased odds of death (OR, 1.23; 95% CI, 1.13-1.34; p < 0.001; I2 = 57%). A high ventilatory ratio was also associated with increased mortality (OR, 1.55; 95% CI, 1.33-1.80; p < 0.001; I2 = 48%). This association was independent of common confounding variables (OR, 1.33; 95% CI, 1.12-1.58; p = 0.001; I2 = 66%). CONCLUSIONS Dead-space ventilation indices were independently associated with mortality in adults with ARDS. These indices could be incorporated into clinical trials and used to identify patients who could benefit from early institution of adjunctive therapies. The cut-offs identified in this study should be prospectively validated.
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Affiliation(s)
- Dilip Jayasimhan
- Cardiothoracic and Vascular Intensive Care Unit, Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
- Respiratory Services, Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
| | - Jennifer Chieng
- Respiratory Services, Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
| | - John Kolbe
- Respiratory Services, Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - David A Sidebotham
- Cardiothoracic and Vascular Intensive Care Unit, Te Whatu Ora Te Toka Tumai Auckland, Auckland, New Zealand
- Department of Medicine, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Petersson J, Glenny RW. Gas Exchange in the Lung. Semin Respir Crit Care Med 2023; 44:555-568. [PMID: 37816345 DOI: 10.1055/s-0043-1770060] [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: 10/12/2023]
Abstract
Gas exchange in the lung depends on tidal breathing, which brings new oxygen to and removes carbon dioxide from alveolar gas. This maintains alveolar partial pressures that promote passive diffusion to add oxygen and remove carbon dioxide from blood in alveolar capillaries. In a lung model without ventilation and perfusion (V̇AQ̇) mismatch, alveolar partial pressures of oxygen and carbon dioxide are primarily determined by inspiratory pressures and alveolar ventilation. Regions with shunt or low ratios worsen arterial oxygenation while alveolar dead space and high lung units lessen CO2 elimination efficiency. Although less common, diffusion limitation might cause hypoxemia in some situations. This review covers the principles of lung gas exchange and therefore mechanisms of hypoxemia or hypercapnia. In addition, we discuss different metrics that quantify the deviation from ideal gas exchange.
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Affiliation(s)
- Johan Petersson
- Section of Anesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Anaesthesiology, Surgical Services and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Robb W Glenny
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
- Department of Physiology and Biophysics, University of Washington, Seattle, Washington
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Caridi-Scheible M, Leiendecker ER. Dead-Space Ventilation Indices and Mortality: Finally Addressing the Other Reason We Breathe. Crit Care Med 2023; 51:1442-1444. [PMID: 37707384 DOI: 10.1097/ccm.0000000000005965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Affiliation(s)
- Mark Caridi-Scheible
- Both authors: Department of Anesthesiology, Emory Healthcare, Anesthesiology, Atlanta, GA
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34
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Motta-Ribeiro GC, Winkler T, Costa ELV, de Prost N, Tucci MR, Vidal Melo MF. Worsening of lung perfusion to tissue density distributions during early acute lung injury. J Appl Physiol (1985) 2023; 135:239-250. [PMID: 37289955 PMCID: PMC10393328 DOI: 10.1152/japplphysiol.00028.2023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 05/12/2023] [Accepted: 06/05/2023] [Indexed: 06/10/2023] Open
Abstract
Lung perfusion magnitude and distribution are essential for oxygenation and, potentially, lung inflammation and protection during acute respiratory distress syndrome (ARDS). Yet, perfusion patterns and their relationship to inflammation are unknown pre-ARDS. We aimed to assess perfusion/density ratios and spatial perfusion-density distributions and associate these to lung inflammation, during early lung injury in large animals at different physiological conditions caused by different systemic inflammation and positive end-expiratory pressure (PEEP) levels. Sheep were protectively ventilated (16-24 h) and imaged for lung density, pulmonary capillary perfusion (13Nitrogen-saline), and inflammation (18F-fluorodeoxyglucose) using positron emission and computed tomography. We studied four conditions: permissive atelectasis (PEEP = 0 cmH2O); and ARDSNet low-stretch PEEP-setting strategy with supine moderate or mild endotoxemia, and prone mild endotoxemia. Perfusion/density heterogeneity increased pre-ARDS in all groups. Perfusion redistribution to density depended on ventilation strategy and endotoxemia level, producing more atelectasis in mild than moderate endotoxemia (P = 0.010) with the oxygenation-based PEEP-setting strategy. The spatial distribution of 18F-fluorodeoxyglucose uptake was related to local Q/D (P < 0.001 for Q/D group interaction). Moderate endotoxemia yielded markedly low/zero perfusion in normal-low density lung, with 13Nitrogen-saline perfusion indicating nondependent capillary obliteration. Prone animals' perfusion was remarkably homogeneously distributed with density. Lung perfusion redistributes heterogeneously to density during pre-ARDS protective ventilation in animals. This is associated with increased inflammation, nondependent capillary obliteration, and lung derecruitment susceptibility depending on endotoxemia level and ventilation strategy.NEW & NOTEWORTHY Perfusion redistribution does not follow lung density redistribution in the first 16-24 h of systemic endotoxemia and protective tidal volume mechanical ventilation. The same oxygenation-based positive end-expiratory pressure (PEEP)-setting strategy can lead at different endotoxemia levels to different perfusion redistributions, PEEP values, and lung aerations, worsening lung biomechanical conditions. During early acute lung injury, regional perfusion-to-tissue density ratio is associated with increased neutrophilic inflammation, and susceptibility to nondependent capillary occlusion and lung derecruitment, potentially marking and/or driving lung injury.
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Affiliation(s)
- Gabriel C Motta-Ribeiro
- Biomedical Engineering Program, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Tilo Winkler
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Eduardo L V Costa
- Divisão de Pneumologia, Faculdade de Medicina, Instituto do Coração (Incor), Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
- Instituto de Ensino e Pesquisa do Hospital Sírio Libanês, São Paulo, Brazil
| | - Nicolas de Prost
- Hôpitaux Universitaires Henri Mondor and Université Paris Est Créteil and INSERM - Unité U955, Créteil, France
| | - Mauro R Tucci
- Divisão de Pneumologia, Faculdade de Medicina, Instituto do Coração (Incor), Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Marcos F Vidal Melo
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, New York, United States
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Yucepur S, Kepekci AB, Erbin A, Ozenc E. Effects of lithotomy and prone positions on hemodynamic parameters, respiratory mechanics, and arterial oxygenation in percutaneous nephrolithotomy performed under general anesthesia. Folia Med (Plovdiv) 2023; 65:427-433. [PMID: 38351819 DOI: 10.3897/folmed.65.e81068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 06/10/2022] [Indexed: 02/16/2024] Open
Abstract
AIM The position of the body during surgery may affect the patient's body functions, especially the hemodynamic parameters. We aimed to comparatively analyze the effects of lithotomy and prone position on respiratory mechanics, arterial oxygenation, and hemodynamic parameters in patients who underwent percutaneous nephrolithotomy (PNL).
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Affiliation(s)
- Serkan Yucepur
- Bilecik Training and Research Hospital, Bilecik, Turkiye
| | | | - Akif Erbin
- Haseki Training and Research Hospital, Istanbul, Turkiye
| | - Ecder Ozenc
- Haseki Training and Research Hospital, Istanbul, Turkiye
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36
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Öhman T, Jalde FC, Fredby M, Björne H, Karlsson J. Effect of external dead space removal on CO 2 homeostasis in mechanically ventilated adult Covid-19 patients. Acta Anaesthesiol Scand 2023. [PMID: 37354078 DOI: 10.1111/aas.14252] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 12/29/2022] [Accepted: 03/29/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Patients with Covid-19 respiratory failure present with hypoxemia, often in combination with hypercapnia. In this prospective, observational study we examined the effect of removing external dead space (DS) on CO2 -homeostasis in mechanically ventilated Covid-19 patients. In addition, volumetric capnography was validated for its ability to estimate external DS volume using in vitro measured DS volumes as reference. METHODS In total, 10 patients with acute respiratory distress syndrome from Covid-19 were included. Volumetric capnography, mechanical ventilation, and arterial blood gas data were analyzed before and after removal of external DS and analyzed for potentially significant changes in response to DS removal. Measurements of external DS were obtained in circuit using volumetric capnography and compared to actual measured DS volumes off the circuit. RESULTS After the removal of external DS, the alveolar minute ventilation and CO2 elimination improved, notwithstanding unchanged respiratory rate and tidal volumes. The increase in CO2 elimination was associated with a decrease in arterial CO2 partial pressure (PaCO2 ). The volumetric capnography method for assessment of external DS showed a low bias of -9 mL (lower limit of agreement -40, 95% CI -60 to -20 mL, upper limit of agreement 21 mL, 95% CI: 1-40 mL) and a percentage error of 48% compared to absolute values measured in vitro. CONCLUSION Removal of external DS increased alveolar minute ventilation and CO2 elimination in Covid-19 patients with respiratory failure in the current study. This was associated with a decrease in PaCO2 . This may indicate a decreased CO2 production due to decreased work of breathing and more effective gas-exchange in response to DS removal. In addition, volumetric capnography appears to be a clinically feasible method for continuous measurement of external DS in the current study and may be of value in optimizing ventilator treatment.
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Affiliation(s)
- Tomas Öhman
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Francesca Campoccia Jalde
- Department of Thoracic Anesthesiology, Surgical Services and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Magnus Fredby
- Department of Thoracic Anesthesiology, Surgical Services and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Håkan Björne
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Jacob Karlsson
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
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37
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Yang H, Ni Y, Huang D, Liang Z. Ventilatory ratio as a predictor for extubation failure in critical ill patients based on MIMIC-IV database (from 2008 to 2019). Front Physiol 2023; 14:1137115. [PMID: 37324397 PMCID: PMC10267390 DOI: 10.3389/fphys.2023.1137115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/22/2023] [Indexed: 06/17/2023] Open
Abstract
Background: The predictive ability of the ventilatory ratio (VR) for extubation failure risk in critically ill patients on mechanical ventilation is unclear. This study aims to examine the predictive ability of VR for extubation failure risk. Methods: This retrospective study was based on the MIMIC-IV database. The MIMIC-IV database consists of the clinical information of patients who were admitted to the intensive care unit at the Beth Israel Deaconess Medical Center between 2008 and 2019. With extubation failure as the primary outcome and in-hospital mortality as the secondary outcome, we assessed the predictive value of VR 4 hours before extubation using a multivariate logistic regression model. Results: Of 3,569 ventilated patients who were included, the rate of extubation-failure was 12.7% and the median Sequential Organ Failure Assessment (SOFA) score was 6 before extubation. Increased VR, elevated heart rate, greater positive end-expiratory pressure, higher blood urea nitrogen level, higher platelet count, greater SOFA score, decreased pH, decreased tidal volume, presence of chronic pulmonary disease, paraplegia, and metastatic solid tumor were independent predictors for extubation failure. A threshold of 1.595 of VR was associated with prolonged intensive care unit length of stay, higher risk of mortality and extubation failure. The area under the receiver operating characteristic curve (ROC) for VR was 0.669 [0.635-0.703], which was significantly larger than the rapid shallow breathing index [0.510 (0.476-0.545)] and the partial pressure of oxygen to the fraction of inspired oxygen [0.586 (0.551-0.621)]. Conclusion: VR 4 hours before extubation was associated with extubation failure, mortality, and prolonged length of stay in the intensive care unit. VR provides good predictive performance for extubation failure (measured by ROC) than the rapid shallow breathing index. Further prospective studies are warranted to confirm these findings.
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Tuffet S, Maraffi T, Lacheny M, Perier F, Haudebourg AF, Boujelben MA, Alcala G, Mekontso-Dessap A, Carteaux G. Impact of cardiac output and alveolar ventilation in estimating ventilation/perfusion mismatch in ARDS using electrical impedance tomography. Crit Care 2023; 27:176. [PMID: 37158963 PMCID: PMC10165791 DOI: 10.1186/s13054-023-04467-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/28/2023] [Indexed: 05/10/2023] Open
Abstract
INTRODUCTION Electrical impedance tomography (EIT) can be used to assess ventilation/perfusion (V/Q) mismatch within the lungs. Several methods have been proposed, some of them neglecting the absolute value of alveolar ventilation (VA) and cardiac output (QC). Whether this omission results in acceptable bias is unknown. METHODS Pixel-level V/Q maps of 25 ARDS patients were computed once considering (absolute V/Q map) and once neglecting (relative V/Q map) the value of QC and VA. Previously published indices of V/Q mismatch were computed using absolute V/Q maps and relative V/Q maps. Indices computed with relative V/Q maps were compared to their counterparts computed using absolute V/Q maps. RESULTS Among 21 patients with ratio of alveolar ventilation to cardiac output (VA/QC) > 1, relative shunt fraction was significantly higher than absolute shunt fraction [37% (24-66) vs 19% (11-46), respectively, p < 0.001], while relative dead space fraction was significantly lower than absolute dead space fraction [40% (22-49) vs 58% (46-84), respectively, p < 0.001]. Relative wasted ventilation was significantly lower than the absolute wasted ventilation [16% (11-27) vs 29% (19-35), respectively, p < 0.001], while relative wasted perfusion was significantly higher than absolute wasted perfusion [18% (11-23) vs 11% (7-19), respectively, p < 0.001]. The opposite findings were retrieved in the four patients with VA/QC < 1. CONCLUSION Neglecting cardiac output and alveolar ventilation when assessing V/Q mismatch indices using EIT in ARDS patients results in significant bias, whose direction depends on the VA/QC ratio value.
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Affiliation(s)
- Samuel Tuffet
- CHU Henri Mondor-Albert Chenevier, Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, 51, Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France.
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, 94010, Créteil Cedex, France.
- INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil Cedex, France.
| | - Tommaso Maraffi
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, 94010, Créteil Cedex, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil Cedex, France
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Intercommunal de Créteil, Créteil, France
| | - Matthieu Lacheny
- CHU Henri Mondor-Albert Chenevier, Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, 51, Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France
| | - François Perier
- Service de Réanimation, Centre Hospitalier de La Rochelle, La Rochelle, France
| | - Anne-Fleur Haudebourg
- CHU Henri Mondor-Albert Chenevier, Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, 51, Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, 94010, Créteil Cedex, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil Cedex, France
| | - Mohamed Ahmed Boujelben
- CHU Henri Mondor-Albert Chenevier, Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, 51, Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, 94010, Créteil Cedex, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil Cedex, France
| | | | - Armand Mekontso-Dessap
- CHU Henri Mondor-Albert Chenevier, Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, 51, Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, 94010, Créteil Cedex, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil Cedex, France
| | - Guillaume Carteaux
- CHU Henri Mondor-Albert Chenevier, Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, 51, Avenue du Maréchal de Lattre de Tassigny, 94010, Créteil Cedex, France
- Groupe de Recherche Clinique CARMAS, Faculté de Santé, Université Paris Est-Créteil, 94010, Créteil Cedex, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil Cedex, France
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Camporota L, Sanderson B, Worrall S, Ostermann M, Barrett NA, Retter A, Busana M, Collins P, Romitti F, Hunt BJ, Rose L, Gattinoni L, Chiumello D. Relationship between D-dimers and dead-space on disease severity and mortality in COVID-19 acute respiratory distress syndrome: A retrospective observational cohort study. J Crit Care 2023; 77:154313. [PMID: 37116437 PMCID: PMC10129848 DOI: 10.1016/j.jcrc.2023.154313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/13/2023] [Accepted: 04/11/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND Despite its diagnostic and prognostic importance, physiologic dead space fraction is not included in the current ARDS definition or severity classification. ARDS caused by COVID-19 (C-ARDS) is characterized by increased physiologic dead space fraction and hypoxemia. Our aim was to investigate the relationship between dead space indices, markers of inflammation, immunothrombosis, severity and intensive care unit (ICU) mortality. RESULTS Retrospective data including demographics, gas exchange, ventilatory parameters, and respiratory mechanics in the first 24 h of invasive ventilation. Plasma concentrations of D-dimers and ferritin were not significantly different across C-ARDS severity categories. Weak relationships were found between D-dimers and VR (r = 0.07, p = 0.13), PETCO2/PaCO2 (r = -0.1, p = 0.02), or estimated dead space fraction (r = 0.019, p = 0.68). Age, PaO2/FiO2, pH, PETCO2/PaCO2 and ferritin, were independently associated with ICU mortality. We found no association between D-dimers or ferritin and any dead-space indices adjusting for PaO2/FiO2, days of ventilation, tidal volume, and respiratory system compliance. CONCLUSIONS We report no association between dead space and inflammatory markers in mechanically ventilated patients with C-ARDS. Our results support theories suggesting that multiple mechanisms, in addition to immunothrombosis, play a role in the pathophysiology of respiratory failure and degree of dead space in C-ARDS.
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Affiliation(s)
- Luigi Camporota
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK; Centre of Human Applied Physiological Sciences, King's College London, London, UK
| | - Barnaby Sanderson
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Stephanie Worrall
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Marlies Ostermann
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Nicholas A Barrett
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Andrew Retter
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center of Göttingen, Germany
| | - Patrick Collins
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center of Göttingen, Germany
| | - Beverley J Hunt
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK
| | - Louise Rose
- Guy's and St Thomas' NHS Foundation Trust, St Thomas' Hospital, London SE1 7EH, UK; Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center of Göttingen, Germany
| | - Davide Chiumello
- Department of Anesthesiology and Intensive Care, ASST Santi e Paolo Hospital, University of Milan, Italy.
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Mollura M, Baroncelli F, Mandelli G, Tricella G, Weissman GE, Poole D, Caironi P, Celi LA, Barbieri R, Finazzi S. Physiologic dead space is independently associated with mortality and discharge of mechanically ventilated patients with COVID-19 ARDS: a retrospective study. Sci Rep 2023; 13:5719. [PMID: 37029215 PMCID: PMC10081332 DOI: 10.1038/s41598-023-31999-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 03/21/2023] [Indexed: 04/09/2023] Open
Abstract
Physiologic dead space is a well-established independent predictor of death in patients with acute respiratory distress syndrome (ARDS). Here, we explore the association between a surrogate measure of dead space (DS) and early outcomes of mechanically ventilated patients admitted to Intensive Care Unit (ICU) because of COVID-19-associated ARDS. Retrospective cohort study on data derived from Italian ICUs during the first year of the COVID-19 epidemic. A competing risk Cox proportional hazard model was applied to test for the association of DS with two competing outcomes (death or discharge from the ICU) while adjusting for confounders. The final population consisted of 401 patients from seven ICUs. A significant association of DS with both death (HR 1.204; CI 1.019-1.423; p = 0.029) and discharge (HR 0.434; CI 0.414-0.456; p [Formula: see text]) was noticed even when correcting for confounding factors (age, sex, chronic obstructive pulmonary disease, diabetes, PaO[Formula: see text]/FiO[Formula: see text], tidal volume, positive end-expiratory pressure, and systolic blood pressure). These results confirm the important association between DS and death or ICU discharge in mechanically ventilated patients with COVID-19-associated ARDS. Further work is needed to identify the optimal role of DS monitoring in this setting and to understand the physiological mechanisms underlying these associations.
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Affiliation(s)
- Maximiliano Mollura
- Department of Electronic, Information and Bioengineering, Politecnico di Milano, Milan, Lombardia, Italy.
- Department of Medical Epidemiology, Mario Negri Institute for Pharmacological Research IRCCS, 24020, Ranica, Lombardia, Italy.
| | - Francesca Baroncelli
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital-ASL Città di Torino, Turin, Piemonte, Italy
| | - Giulia Mandelli
- Department of Medical Epidemiology, Mario Negri Institute for Pharmacological Research IRCCS, 24020, Ranica, Lombardia, Italy
| | - Giovanni Tricella
- Department of Medical Epidemiology, Mario Negri Institute for Pharmacological Research IRCCS, 24020, Ranica, Lombardia, Italy
| | - Gary E Weissman
- Palliative and Advanced Illness Research (PAIR) Center and Pulmonary, Allergy and Critical Care Division, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Daniele Poole
- Operative Unit ofAnesthesia and Intensive Care Unit, S. Martino Hospital, Belluno, Veneto, Italy
| | - Pietro Caironi
- Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria S. Luigi Gonzaga, Orbassano, Piemonte, Italy
- Department of Oncology, University of Turin, Turin, Piemonte, Italy
| | - Leo Anthony Celi
- Laboratory for Computational Physiology, Massachusetts Institute of Technology, Cambridge, MA, USA
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Riccardo Barbieri
- Department of Electronic, Information and Bioengineering, Politecnico di Milano, Milan, Lombardia, Italy
| | - Stefano Finazzi
- Department of Medical Epidemiology, Mario Negri Institute for Pharmacological Research IRCCS, 24020, Ranica, Lombardia, Italy
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Maj R, Palermo P, Gattarello S, Brusatori S, D’Albo R, Zinnato C, Velati M, Romitti F, Busana M, Wieditz J, Herrmann P, Moerer O, Quintel M, Meissner K, Sanderson B, Chiumello D, Marini JJ, Camporota L, Gattinoni L. Ventilatory ratio, dead space, and venous admixture in patients with acute respiratory distress syndrome. Br J Anaesth 2023; 130:360-367. [PMID: 36470747 PMCID: PMC9718027 DOI: 10.1016/j.bja.2022.10.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Ventilatory ratio (VR) has been proposed as an alternative approach to estimate physiological dead space. However, the absolute value of VR, at constant dead space, might be affected by venous admixture and CO2 volume expired per minute (VCO2). METHODS This was a retrospective, observational study of mechanically ventilated patients with acute respiratory distress syndrome (ARDS) in the UK and Italy. Venous admixture was either directly measured or estimated using the surrogate measure PaO2/FiO2 ratio. VCO2 was estimated through the resting energy expenditure derived from the Harris-Benedict formula. RESULTS A total of 641 mechanically ventilated patients with mild (n=65), moderate (n=363), or severe (n=213) ARDS were studied. Venous admixture was measured (n=153 patients) or estimated using the PaO2/FiO2 ratio (n=448). The VR increased exponentially as a function of the dead space, and the absolute values of this relationship were a function of VCO2. At a physiological dead space of 0.6, VR was 1.1, 1.4, and 1.7 in patients with VCO2 equal to 200, 250, and 300, respectively. VR was independently associated with mortality (odds ratio [OR]=2.5; 95% confidence interval [CI], 1.8-3.5), but was not associated when adjusted for VD/VTphys, VCO2, PaO2/FiO2 (ORadj=1.2; 95% CI, 0.7-2.1). These three variables remained independent predictors of ICU mortality (VD/VTphys [ORadj=17.9; 95% CI, 1.8-185; P<0.05]; VCO2 [ORadj=0.99; 95% CI, 0.99-1.00; P<0.001]; and PaO2/FiO2 (ORadj=0.99; 95% CI, 0.99-1.00; P<0.001]). CONCLUSIONS VR is a useful aggregate variable associated with outcome, but variables not associated with ventilation (VCO2 and venous admixture) strongly contribute to the high values of VR seen in patients with severe illness.
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Affiliation(s)
- Roberta Maj
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany,Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paola Palermo
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany,Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Simone Gattarello
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany,Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Serena Brusatori
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Rosanna D’Albo
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Carmelo Zinnato
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Mara Velati
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany,Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Federica Romitti
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Mattia Busana
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Johannes Wieditz
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Peter Herrmann
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Onnen Moerer
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Micheal Quintel
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Konrad Meissner
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany
| | - Barnaby Sanderson
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Davide Chiumello
- Department of Anaesthesiology and Intensive Care, ASST Santi Paolo e Carlo Hospital, University of Milan, Milan, Italy
| | - John J. Marini
- Department of Pulmonary and Critical Care Medicine, Regions Hospital, St. Paul, MN, USA
| | - Luigi Camporota
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - Luciano Gattinoni
- Department of Anaesthesiology, Medical University of Göttingen, University Medical Centre Göttingen, Göttingen, Germany.
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Fu LX, Yu H, Lan L, Luo FM, Ni YN. Association between ventilatory ratio and ICU mortality in interstitial lung disease patients on mechanical ventilation: A retrospective study. Heart Lung 2023; 58:223-228. [PMID: 36638763 DOI: 10.1016/j.hrtlng.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 01/03/2023] [Accepted: 01/03/2023] [Indexed: 01/13/2023]
Abstract
BACKGROUND Ventilatory ratio (VR) is a simple bedside index of ventilatory efficiency. Interstitial lung disease (ILD) is a diverse group of diseases that causes fibrosis or inflammation of the pulmonary parenchyma, and the main clinical manifestation is hypoxemia. To date, no study has explored ventilation efficiency in patients with ILD. OBJECTIVES This study aimed to explore the features of VR in mechanically ventilated patients with ILD and their relationship with intensive care unit (ICU) mortality. METHODS In this retrospective analysis, we included mechanically ventilated patients with ILD in the ICU of West China Hospital, Sichuan University, from 2013 to 2021. Demographic data and mechanical ventilation (MV) parameters within 24 h of intubation were collected. The characteristics of VR and their relationships with ICU mortality were also analyzed. RESULTS 224 patients were included in the final analysis. There were 146 males (53.9%), and the median age was 65 years (interquartile range [IQR]54∼74). The mean value of VR was 2.22, and VR was significantly higher in nonsurvivors than in survivors (1.79 vs 2.32, P < 0.001). A high VR value was an independent risk factor for ICU mortality (odds ratio=1.602, P = 0.038) after adjustment. A high value of VR was associated with a shorter survival time after admission to ICU (hazard ratio=1.485, P = 0.006) CONCLUSIONS: VR in patients with ILD on MV was increased, and the VR of nonsurvivors within 24 h of intubation was higher than that of survivors. The high VR value within 24 h of intubation was an independent risk factor for ICU mortality after adjusting for other factors.
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Affiliation(s)
- Lin-Xi Fu
- Department of Pulmonary and Critical Care Medicine, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041 China
| | - He Yu
- Department of Pulmonary and Critical Care Medicine, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041 China
| | - Lan Lan
- Department of Pulmonary and Critical Care Medicine, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041 China
| | - Feng-Ming Luo
- Department of Pulmonary and Critical Care Medicine, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041 China.
| | - Yue-Nan Ni
- Department of Pulmonary and Critical Care Medicine, West China Hospital of Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041 China.
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43
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Bhalla AK, Chau A, Khemani RG, Newth CJL. The end-tidal alveolar dead space fraction for risk stratification during the first week of invasive mechanical ventilation: an observational cohort study. Crit Care 2023; 27:54. [PMID: 36759925 PMCID: PMC9912669 DOI: 10.1186/s13054-023-04339-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND The end-tidal alveolar dead space fraction (AVDSf = [PaCO2-PETCO2]/PaCO2) is a metric used to estimate alveolar dead space. Higher AVDSf on the first day of mechanical ventilation is associated with mortality and fewer ventilator-free days. It is not clear if AVDSf is associated with length of ventilation in survivors, how AVDSf performs for risk stratification beyond the first day of ventilation, or whether AVDSf adds predictive value to oxygenation (oxygenation index [OI]) or severity of illness (Pediatric Risk of Mortality [PRISM III]) markers. METHODS Retrospective single-center observational cohort study of children and young adults receiving invasive mechanical ventilation. In those with arterial or capillary blood gases, AVDSf was calculated at the time of every blood gas for the first week of mechanical ventilation. RESULTS There were 2335 children and young adults (median age 5.8 years [IQR 1.2, 13.2]) enrolled with 8004 analyzed AVDSf values. Higher AVDSf was associated with mortality and longer length of ventilation in survivors throughout the first week of ventilation after controlling for OI and PRISM III. Higher OI was not associated with increased mortality until ≥ 48 h of ventilation after controlling for AVDSf and PRISM III. When using standardized variables, AVDSf effect estimates were generally higher than OI for mortality, whereas OI effect estimates were generally higher than AVDSf for the length of ventilation in survivors. An AVDSf > 0.3 was associated with a higher mortality than an AVDSf < 0.2 within each pediatric acute respiratory distress syndrome severity category. The maximum AVDSf within 12 h of intensive care unit admission demonstrated good risk stratification for mortality (AUC 0.768 [95% CI 0.732, 0.803]). AVDSf did not improve mortality risk stratification when added to PRISM III but did improve mortality risk stratification when added to the gas exchange components of PRISM III (minimum 12-h PaO2 and maximum 12-h PCO2) (p < 0.00001). CONCLUSIONS AVDSf is associated with mortality and length of ventilation in survivors throughout the first week of invasive mechanical ventilation. Some analyses suggest AVDSf may better stratify mortality risk than OI, whereas OI may better stratify risk for prolonged ventilation in survivors than AVDSf.
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Affiliation(s)
- Anoopindar K. Bhalla
- grid.42505.360000 0001 2156 6853Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, MS#12, Los Angeles, CA 90027 USA
| | - Ariya Chau
- grid.168010.e0000000419368956Division of Cardiology, Department of Pediatrics, Lucile Packard Children’s Hospital at Stanford, Stanford University School of Medicine, Palo Alto, CA USA
| | - Robinder G. Khemani
- grid.42505.360000 0001 2156 6853Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, MS#12, Los Angeles, CA 90027 USA
| | - Christopher J. L. Newth
- grid.42505.360000 0001 2156 6853Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, MS#12, Los Angeles, CA 90027 USA
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Zheng M. Dead space ventilation-related indices: bedside tools to evaluate the ventilation and perfusion relationship in patients with acute respiratory distress syndrome. Crit Care 2023; 27:46. [PMID: 36732812 PMCID: PMC9894747 DOI: 10.1186/s13054-023-04338-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
Cumulative evidence has demonstrated that the ventilatory ratio closely correlates with mortality in acute respiratory distress syndrome (ARDS), and a primary feature in coronavirus disease 2019 (COVID-19)-ARDS is increased dead space that has been reported recently. Thus, new attention has been given to this group of dead space ventilation-related indices, such as physiological dead space fraction, ventilatory ratio, and end-tidal-to-arterial PCO2 ratio, which, albeit distinctive, are all global indices with which to assess the relationship between ventilation and perfusion. These parameters have already been applied to positive end expiratory pressure titration, prediction of responses to the prone position and the field of extracorporeal life support for patients suffering from ARDS. Dead space ventilation-related indices remain hampered by several deflects; notwithstanding, for this catastrophic syndrome, they may facilitate better stratifications and identifications of subphenotypes, thereby providing therapy tailored to individual needs.
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Affiliation(s)
- Mingjia Zheng
- Department of Respiratory and Critical Care Medicine, Huzhou Central Hospital, Affiliated Central Hospital Huzhou University, No. 1558, Sanhuan North Road, Wuxing, Huzhou, Zhejiang, People's Republic of China.
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45
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Zhang Y, Gao Z, Jiang F, Yan H, Yang B, He Q, Luo P, Xu Z, Yang X. JAK-STAT signaling as an ARDS therapeutic target: Status and future trends. Biochem Pharmacol 2023; 208:115382. [PMID: 36528067 DOI: 10.1016/j.bcp.2022.115382] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by noncardiogenic pulmonary edema. It has a high mortality rate and lacks effective pharmacotherapy. With the outbreak of COVID-19 worldwide, the mortality of ARDS has increased correspondingly, which makes it urgent to find effective targets and strategies for the treatment of ARDS. Recent clinical trials of Janus kinase (JAK) inhibitors in treating COVID-19-induced ARDS have shown a positive outcome, which makes the Janus kinase/signal transducer and activator of transcription (JAK/STAT) pathway a potential therapeutic target for treating ARDS. Here, we review the complex cause of ARDS, the molecular JAK/STAT pathway involved in ARDS pathology, and the progress that has been made in strategies targeting JAK/STAT to treat ARDS. Specifically, JAK/STAT signaling directly participates in the progression of ARDS or colludes with other pathways to aggravate ARDS. We summarize JAK and STAT inhibitors with ARDS treatment benefits, including inhibitors in clinical trials and preclinical studies and natural products, and discuss the side effects of the current JAK inhibitors to reveal future trends in the design of JAK inhibitors, which will help to develop effective treatment strategies for ARDS in the future.
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Affiliation(s)
- Yuanteng Zhang
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, Zhejiang, China; Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, Zhejiang, China
| | - Zizheng Gao
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, Zhejiang, China
| | - Feng Jiang
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, Zhejiang, China
| | - Hao Yan
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, Zhejiang, China
| | - Bo Yang
- Institute of Pharmacology & Toxicology, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, Zhejiang, China
| | - Qiaojun He
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, Zhejiang, China; Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, Hangzhou 310018, Zhejiang, China; Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang, China
| | - Peihua Luo
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, Zhejiang, China; Hangzhou Institute of Innovative Medicine, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, China
| | - Zhifei Xu
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, Zhejiang, China.
| | - Xiaochun Yang
- Center for Drug Safety Evaluation and Research of Zhejiang University, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou 310058, Zhejiang, China.
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Ranieri VM, Rubenfeld G, Slutsky AS. Rethinking Acute Respiratory Distress Syndrome after COVID-19: If a "Better" Definition Is the Answer, What Is the Question? Am J Respir Crit Care Med 2023; 207:255-260. [PMID: 36150099 PMCID: PMC9896638 DOI: 10.1164/rccm.202206-1048cp] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
The definition of acute respiratory distress syndrome (ARDS) has a somewhat controversial history, with some even questioning the need for the term "ARDS." This controversy has been amplified by the coronavirus disease (COVID-19) pandemic given the marked increase in the incidence of ARDS, the relatively new treatment modalities that do not fit neatly with the Berlin definition, and the difficulty of making the diagnosis in resource-limited settings. We propose that attempts to revise the definition of ARDS should apply the framework originally developed by psychologists and social scientists and used by other medical disciplines to generate and assess definitions of clinical syndromes that do not have gold standards. This framework is structured around measures of reliability, feasibility, and validity. Future revisions of the definition of ARDS should contain the purpose, the methodology, and the framework for empirically testing any proposed definition. Attempts to revise critical illness syndromes' definitions usually hope to make them "better"; our recommendation is that future attempts use the same criteria used by other fields in defining what "better" means.
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Affiliation(s)
- V Marco Ranieri
- Alma Mater Studiorum - Università di Bologna, Dipartimento di Scienze Mediche e Chirurgiche, IRCCS Policlinico di Sant'Orsola, Anesthesia and Intensive Care Medicine, Bologna, Italy
| | - Gordon Rubenfeld
- Department of Critical Care, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Arthur S Slutsky
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada; and.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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47
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Bhalla A, Baudin F, Takeuchi M, Cruces P. Monitoring in Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S112-S123. [PMID: 36661440 PMCID: PMC9980912 DOI: 10.1097/pcc.0000000000003163] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Monitoring is essential to assess changes in the lung condition, to identify heart-lung interactions, and to personalize and improve respiratory support and adjuvant therapies in pediatric acute respiratory distress syndrome (PARDS). The objective of this article is to report the rationale of the revised recommendations/statements on monitoring from the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2). DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION We included studies focused on respiratory or cardiovascular monitoring of children less than 18 years old with a diagnosis of PARDS. We excluded studies focused on neonates. DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize evidence and develop recommendations. We identified 342 studies for full-text review. Seventeen good practice statements were generated related to respiratory and cardiovascular monitoring. Four research statements were generated related to respiratory mechanics and imaging monitoring, hemodynamics monitoring, and extubation readiness monitoring. CONCLUSIONS PALICC-2 monitoring good practice and research statements were developed to improve the care of patients with PARDS and were based on new knowledge generated in recent years in patients with PARDS, specifically in topics of general monitoring, respiratory system mechanics, gas exchange, weaning considerations, lung imaging, and hemodynamic monitoring.
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Affiliation(s)
- Anoopindar Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Florent Baudin
- Hospices civils de Lyon, Hôpital Femme Mère Enfant, Service de réanimation pédiatrique, Bron F-69500, France
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Pablo Cruces
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile; and Pediatric Intensive Care Unit, Hospital el Carmen de Maipú, Santiago, Chile
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48
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Extracorporeal CO 2 Removal During Renal Replacement Therapy to Allow Lung-Protective Ventilation in Patients With COVID-19-Associated Acute Respiratory Distress Syndrome. ASAIO J 2023; 69:36-42. [PMID: 35998214 PMCID: PMC9797119 DOI: 10.1097/mat.0000000000001803] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The aim of this retrospective multicenter observational study is to test the feasibility and safety of a combined extracorporeal CO 2 removal (ECCO 2 R) plus renal replacement therapy (RRT) system to use an ultraprotective ventilator setting while maintaining (1) an effective support of renal function and (2) values of pH within the physiologic limits in a cohort of coronavirus infectious disease 2019 (COVID-19) patients. Among COVID-19 patients admitted to the intensive care unit of 9 participating hospitals, 27 patients with acute respiratory distress syndrome (ARDS) and acute kidney injury (AKI) requiring invasive mechanical ventilation undergoing ECCO 2 R-plus-RRT treatment were included in the analysis. The treatment allowed to reduce V T from 6.0 ± 0.6 mL/kg at baseline to 4.8 ± 0.8, 4.6 ± 1.0, and 4.3 ± 0.3 mL/kg, driving pressure (ΔP) from 19.8 ± 2.5 cm H 2 O to 14.8 ± 3.6, 14.38 ± 4.1 and 10.2 ± 1.6 cm H 2 O after 24 hours, 48 hours, and at discontinuation of ECCO 2 R-plus-RRT (T3), respectively ( p < 0.001). PaCO 2 and pH remained stable. Plasma creatinine decreased over the study period from 3.30 ± 1.27 to 1.90 ± 1.30 and 1.27 ± 0.90 mg/dL after 24 and 48 hours of treatment, respectively ( p < 0.01). No patient-related events associated with the extracorporeal system were reported. These data show that in patients with COVID-19-induced ARDS and AKI, ECCO 2 R-plus-RRT is effective in allowing ultraprotective ventilator settings while maintaining an effective support of renal function and values of pH within physiologic limits.
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Slobod D, Damia A, Leali M, Spinelli E, Mauri T. Pathophysiology and Clinical Meaning of Ventilation-Perfusion Mismatch in the Acute Respiratory Distress Syndrome. BIOLOGY 2022; 12:biology12010067. [PMID: 36671759 PMCID: PMC9855693 DOI: 10.3390/biology12010067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 12/20/2022] [Accepted: 12/27/2022] [Indexed: 01/03/2023]
Abstract
Acute respiratory distress syndrome (ARDS) remains an important clinical challenge with a mortality rate of 35-45%. It is being increasingly demonstrated that the improvement of outcomes requires a tailored, individualized approach to therapy, guided by a detailed understanding of each patient's pathophysiology. In patients with ARDS, disturbances in the physiological matching of alveolar ventilation (V) and pulmonary perfusion (Q) (V/Q mismatch) are a hallmark derangement. The perfusion of collapsed or consolidated lung units gives rise to intrapulmonary shunting and arterial hypoxemia, whereas the ventilation of non-perfused lung zones increases physiological dead-space, which potentially necessitates increased ventilation to avoid hypercapnia. Beyond its impact on gas exchange, V/Q mismatch is a predictor of adverse outcomes in patients with ARDS; more recently, its role in ventilation-induced lung injury and worsening lung edema has been described. Innovations in bedside imaging technologies such as electrical impedance tomography readily allow clinicians to determine the regional distributions of V and Q, as well as the adequacy of their matching, providing new insights into the phenotyping, prognostication, and clinical management of patients with ARDS. The purpose of this review is to discuss the pathophysiology, identification, consequences, and treatment of V/Q mismatch in the setting of ARDS, employing experimental data from clinical and preclinical studies as support.
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Affiliation(s)
- Douglas Slobod
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Critical Care Medicine, McGill University, Montreal, QC H3A 3R1, Canada
| | - Anna Damia
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Marco Leali
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, 20122 Milan, Italy
- Correspondence:
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Pavlovsky B, Pesenti A, Spinelli E, Scaramuzzo G, Marongiu I, Tagliabue P, Spadaro S, Grasselli G, Mercat A, Mauri T. Effects of PEEP on regional ventilation-perfusion mismatch in the acute respiratory distress syndrome. Crit Care 2022; 26:211. [PMID: 35818077 PMCID: PMC9272883 DOI: 10.1186/s13054-022-04085-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 07/05/2022] [Indexed: 11/10/2022] Open
Abstract
Purpose In the acute respiratory distress syndrome (ARDS), decreasing Ventilation-Perfusion \documentclass[12pt]{minimal}
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\begin{document}$$\left( {{{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}} \right)$$\end{document}V˙/Q˙ mismatch might enhance lung protection. We investigated the regional effects of higher Positive End Expiratory Pressure (PEEP) on \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ mismatch and their correlation with recruitability. We aimed to verify whether PEEP improves regional \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ mismatch, and to study the underlying mechanisms. Methods In fifteen patients with moderate and severe ARDS, two PEEP levels (5 and 15 cmH2O) were applied in random order. \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ mismatch was assessed by Electrical Impedance Tomography at each PEEP. Percentage of ventilation and perfusion reaching different ranges of \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ ratios were analyzed in 3 gravitational lung regions, leading to precise assessment of their distribution throughout different \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ mismatch compartments. Recruitability between the two PEEP levels was measured by the recruitment-to-inflation ratio method. Results In the non-dependent region, at higher PEEP, ventilation reaching the normal \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ compartment (p = 0.018) increased, while it decreased in the high \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ one (p = 0.023). In the middle region, at PEEP 15 cmH2O, ventilation and perfusion to the low \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ compartment decreased (p = 0.006 and p = 0.011) and perfusion to normal \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ increased (p = 0.003). In the dependent lung, the percentage of blood flowing through the non-ventilated compartment decreased (p = 0.041). Regional \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ mismatch improvement was correlated to lung recruitability and changes in regional tidal volume. Conclusions In patients with ARDS, higher PEEP optimizes the distribution of both ventilation (in the non-dependent areas) and perfusion (in the middle and dependent lung). Bedside measure of recruitability is associated with improved \documentclass[12pt]{minimal}
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\begin{document}$${{\dot{V}} \mathord{\left/ {\vphantom {{\dot{V}} {\dot{Q}}}} \right. \kern-\nulldelimiterspace} {\dot{Q}}}$$\end{document}V˙/Q˙ mismatch. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04085-y.
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