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Yang R, Zhou L, Chen Z, He S, Lian S, Shen Y, Zhang X. Effect and mechanical mechanism of spontaneous breathing on oxygenation and lung injury in mild or moderate animal ARDS. BMC Pulm Med 2023; 23:428. [PMID: 37925442 PMCID: PMC10625710 DOI: 10.1186/s12890-023-02730-y] [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: 05/10/2023] [Accepted: 10/23/2023] [Indexed: 11/06/2023] Open
Abstract
OBJECTIVE The present study aimed to determine the effect and mechanical mechanism of spontaneous breathing during mechanical ventilation on oxygenation and lung injury using Beagles dogs mild or moderate acute respiratory distress syndrome (ARDS) model. METHODS After inducing mild or moderate ARDS by infusion of oleic acid, Eighteen Beagles dogs were randomly split into Spontaneous breathing group (BIPAPSB, n = 6), and Complete muscle paralysis group (BIPAPPC, n = 6),Six Beagles without ventilator support comprised the control group. Both groups were ventilated for 8 h under BIPAP mode. High-pressure was titrated TV to 6 ml/kg. A multi-pair esophageal balloon electrode catheter was used to measure respiratory mechanics and electromyogram. End-expiratory lung volume (EELV), gas exchange and respiratory variables were recorded in the process of mechanical ventilation. The contents of Interleukin (IL)-6 and IL-8 in lung tissue were measure using qRT-PCR. Besides, lung injury score was calculated in the end of mechanical ventilation. RESULTS Based on the comparable setting of ventilator, BIPAPSB group exhibited higher safety peak transpulmonary pressure, abdominal pressure, EELV and P/F(PaO2/FiO2) than BIPAPPC group, whereas mean transpulmonary pressure, the mRNA levels of the IL-6 and IL-8 in the lung tissues and lung injury score in BIPAPSB group were lower than those in BIPAPPC group. CONCLUSION In mild to moderate ARDS animal models, during mechanical ventilation, SB may improve respiratory function and reduce ventilator-induced lung injury. The mechanism may be that spontaneous inspiration up-regulates peak transpulmonary pressure and EELV; Spontaneous expiration decreases mean transpulmonary pressure by up-regulating intra-abdominal pressure, thereby reducing stress and strain.
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Affiliation(s)
- Rui Yang
- First People's Hospital of Guiyang City, Guiyang, Guizhou, China
| | - Leilei Zhou
- Department of Respiratory Medicine, The Affiliated Hospital of Guizhou Medical, 28 Guiyi Street, Guiyang, Guizhou, 550000, China
| | - Zongyu Chen
- Department of Respiratory Medicine, The Affiliated Hospital of Guizhou Medical, 28 Guiyi Street, Guiyang, Guizhou, 550000, China
| | - Shuang He
- Department of Respiratory Medicine, The Affiliated Hospital of Guizhou Medical, 28 Guiyi Street, Guiyang, Guizhou, 550000, China
| | - Siyu Lian
- Department of Respiratory Medicine, The Affiliated Hospital of Guizhou Medical, 28 Guiyi Street, Guiyang, Guizhou, 550000, China
| | - Yi Shen
- Department of Respiratory Medicine, The Affiliated Hospital of Guizhou Medical, 28 Guiyi Street, Guiyang, Guizhou, 550000, China
| | - Xianming Zhang
- Department of Respiratory Medicine, The Affiliated Hospital of Guizhou Medical, 28 Guiyi Street, Guiyang, Guizhou, 550000, China.
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2
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[Focus ventilation, oxygen therapy and weaning 2021/2022 : Summary of selected intensive medical care studies]. DIE ANAESTHESIOLOGIE 2023; 72:199-208. [PMID: 36695839 PMCID: PMC9876412 DOI: 10.1007/s00101-023-01250-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/02/2023] [Indexed: 01/26/2023]
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3
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Batchinsky A, Roberts T, Cancio L. Extracorporeal Carbon Dioxide Removal vs Standard Care Ventilation Effect on 90-Day Mortality in Patients With Acute Hypoxemic Respiratory Failure. JAMA 2022; 327:82-83. [PMID: 34982125 DOI: 10.1001/jama.2021.20999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Andriy Batchinsky
- Autonomous Reanimation and Evacuation (AREVA) Research Program, The Geneva Foundation, San Antonio, Texas
| | - Teryn Roberts
- Autonomous Reanimation and Evacuation (AREVA) Research Program, The Geneva Foundation, San Antonio, Texas
| | - Leopoldo Cancio
- US Army Burn Unit, Institute of Surgical Research, Ft Sam Houston, Texas
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4
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Time-Course of Physiologic Variables During Extracorporeal Membrane Oxygenation and Outcome of Severe Acute Respiratory Distress Syndrome. ASAIO J 2021; 66:663-670. [PMID: 31335371 DOI: 10.1097/mat.0000000000001048] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
In patients undergoing extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS), it is unknown which clinical physiologic variables should be monitored to follow the evolution of lung injury and extrapulmonary organ dysfunction and to differentiate patients according to their course. We analyzed the time-course of prospectively collected clinical physiologic variables in 83 consecutive ARDS patients undergoing ECMO at a single referral center. Selected variables-including ventilator settings, respiratory system compliance, intrapulmonary shunt, arterial blood gases, central hemodynamics, and sequential organ failure assessment (SOFA) score-were compared according to outcome at time-points corresponding to 0%, 25%, 50%, 75%, and 100% of the entire ECMO duration and daily during the first 7 days. A logistic regression analysis was performed to identify changes between ECMO start and end that independently predicted hospital mortality. Tidal volume, intrapulmonary shunt, arterial lactate, and SOFA score differentiated survivors and nonsurvivors early during the first 7 days and over the entire ECMO duration. Respiratory system compliance, PaO2/FiO2 ratio, arterial pH, and mean pulmonary arterial pressure showed distinct temporal course according to outcome over the entire ECMO duration. Lack of improvement of SOFA score independently predicted hospital mortality. In ARDS patients on ECMO, temporal trends of specific physiologic parameters differentiate survivors from non-survivors and could be used to monitor the evolution of lung injury. Progressive worsening of extrapulmonary organ dysfunction is associated with worse outcome.
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5
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Yin C, Gao X, Cao C, Xu L, Lu X. Individualized positive end-expiratory pressure setting in patients with severe acute respiratory distress syndrome supported with veno-venous extracorporeal membrane oxygenation. Perfusion 2020; 36:374-381. [PMID: 32777988 DOI: 10.1177/0267659120946728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Patients with acute respiratory distress syndrome supported with veno-venous extracorporeal membrane oxygenation benefit from higher positive end-expiratory pressure combined with conventional ventilation during the early extracorporeal membrane oxygenation period. The role of incremental positive end-expiratory pressure titration in patients with severe acute respiratory distress syndrome supported with veno-venous extracorporeal membrane oxygenation remains unclear. This study aimed to determine the preferred method for setting positive end-expiratory pressure in patients with severe acute respiratory distress syndrome on veno-venous extracorporeal membrane oxygenation support. METHODS We retrospectively reviewed all subjects supported with veno-venous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome from 2009 to 2019 in the intensive care units in Tianjin Third Central Hospital. Subjects were divided into two groups according to the positive end-expiratory pressure titration method used: P-V curve (quasi-static pressure-volume curve-guided positive end-expiratory pressure setting) group or Crs (respiratory system compliance-guided positive end-expiratory pressure setting) group. RESULTS Forty-three subjects were included in the clinical outcome analysis: 20 in the P-V curve group and 23 in the Crs group. Initial positive end-expiratory pressure levels during veno-venous extracorporeal membrane oxygenation were similar in both groups. Incidence rates of barotrauma and hemodynamic events were significantly lower in the Crs group (all p < 0.05). Mechanical ventilation duration, intensive care unit length of stay, and hospital length of stay were significantly shorter in the Crs group than the P-V curve group (all p < 0.05). Subjects in the Crs group showed non-significant improvements in the duration of extracorporeal membrane oxygenation support and 28-day mortality (p > 0.05). CONCLUSION Respiratory system compliance-guided positive end-expiratory pressure setting may lead to more optimal clinical outcomes for patients with severe acute respiratory distress syndrome supported by veno-venous extracorporeal membrane oxygenation. Moreover, the operation is simple, safe, and convenient in clinical practice.
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Affiliation(s)
- Chengfen Yin
- Department of Critical Care Medicine, The Third Central Clinical College of Tianjin Medical University, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Third Central Hospital, Hedong District, Tianjin, China
| | - Xinjing Gao
- Tianjin Third Central Hospital, Hedong District, Tianjin, China
| | - Chao Cao
- Department of Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Lei Xu
- Department of Critical Care Medicine, The Third Central Clinical College of Tianjin Medical University, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Third Central Hospital, Hedong District, Tianjin, China
| | - Xing Lu
- Department of Critical Care Medicine, The Third Central Clinical College of Tianjin Medical University, Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin, China.,Tianjin Third Central Hospital, Hedong District, Tianjin, China
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6
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Na SJ, Jeon K. Extracorporeal membrane oxygenation support in adult patients with acute respiratory distress syndrome. Expert Rev Respir Med 2020; 14:511-519. [PMID: 32089016 DOI: 10.1080/17476348.2020.1734457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Introduction: The global number of patients receiving extracorporeal membrane oxygenation (ECMO) support has been growing after several studies highlighted the favorable results attained in cases of severe respiratory failure. However, evidence-based guidelines for optimal use of ECMO are lacking.Areas covered: This review covers optimal candidates, timing of initiation, strategies for patient management including mechanical ventilation, and decision-making regarding discontinuation of ECMO based on its potential role in treatment of patients with acute respiratory distress syndrome.Expert opinion: Early initiation of ECMO should be considered if hypoxemia and uncompensated hypercapnia do not respond to optimal conventional treatment. Use of a comprehensive management approach for preventing additional lung injury and extrapulmonary organ failure is critical during ECMO support to ensure the best outcome. The possibility of weaning from ECMO should be fully assessed by a multidisciplinary team during ECMO support. Futility should not be determined solely by duration of ECMO, and use of prolonged ECMO for lung recovery may be worthwhile.
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Affiliation(s)
- Soo Jin Na
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Kim HS, Kim JH, Chung CR, Hong SB, Cho WH, Cho YJ, Sim YS, Kim WY, Kang BJ, Park SH, Oh JY, Park S, Park S. Lung Compliance and Outcomes in Patients With Acute Respiratory Distress Syndrome Receiving ECMO. Ann Thorac Surg 2019; 108:176-182. [PMID: 30836100 DOI: 10.1016/j.athoracsur.2019.01.055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 12/17/2018] [Accepted: 01/21/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Limited data are available regarding mechanical ventilation strategies in patients with acute respiratory distress syndrome receiving extracorporeal membrane oxygenation (ECMO). METHODS A retrospective analysis of acute respiratory distress syndrome patients on ECMO was conducted in 9 hospitals in Korea. Data on ventilator settings (pre-ECMO and 0, 4, 24, and 48 hours after ECMO) were collected. Based on the effect of the duration and intensity of mechanical ventilator on outcomes, time-weighted average values were calculated for ventilator parameters. RESULTS The 56 patients included in the study had a mean age of 55.5 years. The hospital and 6-month mortality rates were 48.1% and 54.0%, respectively, with a median ECMO duration of 9.4 days. After initiation of ECMO, peak inspiratory pressure, above positive end-expiratory pressure, tidal volume, and respiration rate were reduced, while lung compliance did not change significantly. Before and during ECMO support, tidal volume and lung compliance were higher in 6-month survivors than in nonsurvivors. In Cox proportional models, both lung compliance (odds ratio, 0.961; 95% confidence interval, 0.928 to 0.995) and time-weighted average-lung compliance (odds ratio, 0.943; 95% confidence interval, 0.903 to 0.986) were significantly associated with 6-month mortality. Kaplan-Meier curves revealed that patients with higher lung compliance before ECMO had a longer survival time at the 6-month follow-up than did those with lower lung compliance. CONCLUSIONS Lung compliance, whether before or during ECMO, may be an important predictor of outcome in acute respiratory distress syndrome patients receiving ECMO. However, this result requires confirmation in larger clinical studies.
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Affiliation(s)
- Hyoung Soo Kim
- Department of Cardiothoracic Surgery, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Jung-Hyun Kim
- Department of Pulmonary, Allergy and Critical Care Medicine, CHA Bundang Medical Center, Seongnam, South Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Seoul, South Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, Seoul, South Korea
| | - Woo Hyun Cho
- Department of Pulmonary, Allergy and Critical Care Medicine, Pusan National University Yangsan Hospital, Yangsan, South Korea
| | - Young-Jae Cho
- Department of Pulmonary and Critical Care Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yun Su Sim
- Department of Pulmonary and Critical Care Medicine, Kangnam Sacred Heart Hospital, Seoul, South Korea
| | - Won-Young Kim
- Department of Pulmonary, Allergy and Critical Care Medicine, Pusan National University Hospital, Busan, South Korea
| | - Byung Ju Kang
- Department of Internal Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - So Hee Park
- Department of Pulmonary and Critical Care Medicine, Kangdong Kyung Hee University Hospital, Seoul, South Korea
| | - Jin Young Oh
- Department of Pulmonology and Critical Care Medicine, Dongguk University Ilsan Hospital, Goyang, South Korea
| | - SeungYong Park
- Department of Pulmonary and Critical Care Medicine, Chonbuk National University Hospital, Jeonju, South Korea
| | - Sunghoon Park
- Department of Pulmonary and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea.
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8
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Fong KM, Au SY, Lily Chan KL, George Ng WY. Update on management of acute respiratory distress syndrome. AIMS MEDICAL SCIENCE 2018. [DOI: 10.3934/medsci.2018.2.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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9
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Chiumello D, Brochard L, Marini JJ, Slutsky AS, Mancebo J, Ranieri VM, Thompson BT, Papazian L, Schultz MJ, Amato M, Gattinoni L, Mercat A, Pesenti A, Talmor D, Vincent JL. Respiratory support in patients with acute respiratory distress syndrome: an expert opinion. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:240. [PMID: 28899408 PMCID: PMC5596474 DOI: 10.1186/s13054-017-1820-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a common condition in intensive care unit patients and remains a major concern, with mortality rates of around 30–45% and considerable long-term morbidity. Respiratory support in these patients must be optimized to ensure adequate gas exchange while minimizing the risks of ventilator-induced lung injury. The aim of this expert opinion document is to review the available clinical evidence related to ventilator support and adjuvant therapies in order to provide evidence-based and experience-based clinical recommendations for the management of patients with ARDS.
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Affiliation(s)
- Davide Chiumello
- Dipartimento di Scienze della Salute, Università degli Studi di Milano, Milan, Italy
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - John J Marini
- University of Minnesota, Minneapolis, Saint Paul, MN, USA
| | - Arthur S Slutsky
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Jordi Mancebo
- University of Montreal and Department of Intensive Care, Centre Hospitalier Université de Montréal, Montréal, QC, Canada
| | - V Marco Ranieri
- Department of Anesthesia and Critical Care Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Viale del Policlinico 155, 00161, Rome, Italy
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Laurent Papazian
- Réanimation des Détresses Respiratoires et Infections Sévères, Hôpital Nord-Assistance Publique-Hôpitaux de Marseille Aix-Marseille Université, Marseille, France
| | - Marcus J Schultz
- Mahidol Oxford Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Marcelo Amato
- Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (InCor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Luciano Gattinoni
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Alain Mercat
- CHU d'Angers, Réanimation Médicale et Médecine Hyperbare, Angers, France
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Daniel Talmor
- Department of Anesthesia and Critical Care Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
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Franchineau G, Bréchot N, Lebreton G, Hekimian G, Nieszkowska A, Trouillet JL, Leprince P, Chastre J, Luyt CE, Combes A, Schmidt M. Bedside Contribution of Electrical Impedance Tomography to Setting Positive End-Expiratory Pressure for Extracorporeal Membrane Oxygenation–treated Patients with Severe Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2017; 196:447-457. [DOI: 10.1164/rccm.201605-1055oc] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Guillaume Franchineau
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
| | - Nicolas Bréchot
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
| | - Guillaume Lebreton
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Cardiac Surgery Department, Assistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière Hospital, Paris, France
| | - Guillaume Hekimian
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
| | - Ania Nieszkowska
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
| | - Jean-Louis Trouillet
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
| | - Pascal Leprince
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Cardiac Surgery Department, Assistance Publique–Hôpitaux de Paris, Pitié–Salpêtrière Hospital, Paris, France
| | - Jean Chastre
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
| | - Charles-Edouard Luyt
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
| | - Alain Combes
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
| | - Matthieu Schmidt
- INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Université Pierre et Marie Curie Univ Paris 06, Paris, France; and
- Medical Intensive Care Unit and
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11
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Combes A, Pesenti A, Ranieri VM. Fifty Years of Research in ARDS. Is Extracorporeal Circulation the Future of Acute Respiratory Distress Syndrome Management? Am J Respir Crit Care Med 2017; 195:1161-1170. [PMID: 28459322 DOI: 10.1164/rccm.201701-0217cp] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Mechanical ventilation (MV) remains the cornerstone of acute respiratory distress syndrome (ARDS) management. It guarantees sufficient alveolar ventilation, high FiO2 concentration, and high positive end-expiratory pressure levels. However, experimental and clinical studies have accumulated, demonstrating that MV also contributes to the high mortality observed in patients with ARDS by creating ventilator-induced lung injury. Under these circumstances, extracorporeal lung support (ECLS) may be beneficial in two distinct clinical settings: to rescue patients from the high risk for death associated with severe hypoxemia, hypercapnia, or both not responding to maximized conventional MV, and to replace MV and minimize/abolish the harmful effects of ventilator-induced lung injury. High extracorporeal blood flow venovenous extracorporeal membrane oxygenation (ECMO) may therefore rescue the sickest patients with ARDS from the high risk for death associated with severe hypoxemia, hypercapnia, or both not responding to maximized conventional MV. Successful venovenous ECMO treatment in patients with extremely severe H1N1-associated ARDS and positive results of the CESAR trial have led to an exponential use of the technology in recent years. Alternatively, lower-flow extracorporeal CO2 removal devices may be used to reduce the intensity of MV (by reducing Vt from 6 to 3-4 ml/kg) and to minimize or even abolish the harmful effects of ventilator-induced lung injury if used as an alternative to conventional MV in nonintubated, nonsedated, and spontaneously breathing patients. Although conceptually very attractive, the use of ECLS in patients with ARDS remains controversial, and high-quality research is needed to further advance our knowledge in the field.
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Affiliation(s)
- Alain Combes
- 1 Medical-Surgical Intensive Care Unit, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,2 Sorbonne University Paris, INSERM, UMRS 1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
| | - Antonio Pesenti
- 3 Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy.,4 Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy; and
| | - V Marco Ranieri
- 5 Anesthesia and Intensive Care Medicine, Sapienza University of Rome, Policlinico Umberto I Hospital, Rome, Italy
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12
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Zhang X, Du J, Wu W, Zhu Y, Jiang Y, Chen R. An experimental study on the impacts of inspiratory and expiratory muscles activities during mechanical ventilation in ARDS animal model. Sci Rep 2017; 7:42785. [PMID: 28230150 PMCID: PMC5322359 DOI: 10.1038/srep42785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 01/17/2017] [Indexed: 11/09/2022] Open
Abstract
In spite of intensive investigations, the role of spontaneous breathing (SB) activity in ARDS has not been well defined yet and little has been known about the different contribution of inspiratory or expiratory muscles activities during mechanical ventilation in patients with ARDS. In present study, oleic acid-induced beagle dogs' ARDS models were employed and ventilated with the same level of mean airway pressure. Respiratory mechanics, lung volume, gas exchange and inflammatory cytokines were measured during mechanical ventilation, and lung injury was determined histologically. As a result, for the comparable ventilator setting, preserved inspiratory muscles activity groups resulted in higher end-expiratory lung volume (EELV) and oxygenation index. In addition, less lung damage scores and lower levels of system inflammatory cytokines were revealed after 8 h of ventilation. In comparison, preserved expiratory muscles activity groups resulted in lower EELV and oxygenation index. Moreover, higher lung injury scores and inflammatory cytokines levels were observed after 8 h of ventilation. Our findings suggest that the activity of inspiratory muscles has beneficial effects, whereas that of expiratory muscles exerts adverse effects during mechanical ventilation in ARDS animal model. Therefore, for mechanically ventilated patients with ARDS, the demands for deep sedation or paralysis might be replaced by the strategy of expiratory muscles paralysis through epidural anesthesia.
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Affiliation(s)
- Xianming Zhang
- Department of Respiratory Medicine, First Affiliated Hospital of Guizhou Medical University, Guizhou, China
| | - Juan Du
- Department of Respiratory Medicine, First Affiliated Hospital of Guizhou Medical University, Guizhou, China
| | - Weiliang Wu
- Respiratory Mechanics Lab, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yongcheng Zhu
- Respiratory Mechanics Lab, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Ying Jiang
- Respiratory Mechanics Lab, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Rongchang Chen
- Respiratory Mechanics Lab, State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
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14
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Abdominal Muscle Activity during Mechanical Ventilation Increases Lung Injury in Severe Acute Respiratory Distress Syndrome. PLoS One 2016; 11:e0145694. [PMID: 26745868 PMCID: PMC4712828 DOI: 10.1371/journal.pone.0145694] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 12/06/2015] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE It has proved that muscle paralysis was more protective for injured lung in severe acute respiratory distress syndrome (ARDS), but the precise mechanism is not clear. The purpose of this study was to test the hypothesis that abdominal muscle activity during mechanically ventilation increases lung injury in severe ARDS. METHODS Eighteen male Beagles were studied under mechanical ventilation with anesthesia. Severe ARDS was induced by repetitive oleic acid infusion. After lung injury, Beagles were randomly assigned into spontaneous breathing group (BIPAPSB) and abdominal muscle paralysis group (BIPAPAP). All groups were ventilated with BIPAP model for 8h, and the high pressure titrated to reached a tidal volume of 6ml/kg, the low pressure was set at 10 cmH2O, with I:E ratio 1:1, and respiratory rate adjusted to a PaCO2 of 35-60 mmHg. Six Beagles without ventilator support comprised the control group. Respiratory variables, end-expiratory volume (EELV) and gas exchange were assessed during mechanical ventilation. The levels of Interleukin (IL)-6, IL-8 in lung tissue and plasma were measured by qRT-PCR and ELISA respectively. Lung injury scores were determined at end of the experiment. RESULTS For the comparable ventilator setting, as compared with BIPAPSB group, the BIPAPAP group presented higher EELV (427±47 vs. 366±38 ml) and oxygenation index (293±36 vs. 226±31 mmHg), lower levels of IL-6(216.6±48.0 vs. 297.5±71.2 pg/ml) and IL-8(246.8±78.2 vs. 357.5±69.3 pg/ml) in plasma, and lower express levels of IL-6 mRNA (15.0±3.8 vs. 21.2±3.7) and IL-8 mRNA (18.9±6.8 vs. 29.5±7.9) in lung tissues. In addition, less lung histopathology injury were revealed in the BIPAPAP group (22.5±2.0 vs. 25.2±2.1). CONCLUSION Abdominal muscle activity during mechanically ventilation is one of the injurious factors in severe ARDS, so abdominal muscle paralysis might be an effective strategy to minimize ventilator-induce lung injury.
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Partial extracorporeal carbon dioxide removal using a standard continuous renal replacement therapy device: a preliminary study. ASAIO J 2015; 60:564-9. [PMID: 25000386 DOI: 10.1097/mat.0000000000000114] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
To test the feasibility, safety, and efficacy of partial extracorporeal CO2 removal (PECCO2R) using a standard continuous renal replacement (CRRT) device with a pediatric oxygenation membrane introduced into the circuit in a serial manner. In this retrospective single-center study, we have studied mechanically ventilated patients with persistent significant respiratory acidosis and acute renal failure requiring ongoing CRRT. Sixteen patients were treated with our PECCO2R device. PaCO2 and arterial pH were measured before as well as at 6 and 12 hours after PECCO2R implementation. Hemodynamic parameters were continuously monitored. Our PECCO2R system was efficient to significantly reduce PaCO2 and increase arterial pH. The median PaCO2 before treatment was 77 mm Hg (59-112) with a median reduction of 24 mm Hg after 6 hours and 30 mm Hg after 12 hours (31% and 39%, respectively). The median pH increase was 0.16 at 6 hours and 0.23 at 12 hours. Partial extracorporeal CO2 removal treatment had no effect on oxygenation. No complication was observed. Our PECCO2R approach based on the simple introduction of a pediatric extracorporeal membrane oxygenation membrane into the circuit of a standard CRRT device is easy to implement, safe, and efficient to improve respiratory acidosis.
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Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: a retrospective international multicenter study. Crit Care Med 2015; 43:654-64. [PMID: 25565460 DOI: 10.1097/ccm.0000000000000753] [Citation(s) in RCA: 141] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To describe mechanical ventilation settings in adult patients treated for an acute respiratory distress syndrome with extracorporeal membrane oxygenation and assess the potential impact of mechanical ventilation settings on ICU mortality. DESIGN Retrospective observational study. SETTING Three international high-volume extracorporeal membrane oxygenation centers. PATIENTS A total of 168 patients treated with extracorporeal membrane oxygenation for severe acute respiratory distress syndrome from January 2007 to January 2013. INTERVENTIONS We analyzed the association between mechanical ventilation settings (i.e. plateau pressure, tidal volume, and positive end-expiratory pressure) on ICU mortality using multivariable logistic regression model and Cox-proportional hazards model. MEASUREMENT AND MAIN RESULTS We obtained detailed demographic, clinical, daily mechanical ventilation settings and ICU outcome data. One hundred sixty-eight patients (41 ± 14 years old; PaO2/FIO2 67 ± 19 mm Hg) fulfilled our inclusion criteria. Median duration of extracorporeal membrane oxygenation and ICU stay were 10 days (6-18 d) and 28 days (16-42 d), respectively. Lower positive end-expiratory pressure levels and significantly lower plateau pressures during extracorporeal membrane oxygenation were used in the French center than in both Australian centers (23.9 ± 1.4 vs 27.6 ± 3.7 and 27.8 ± 3.6; p < 0.0001). Overall ICU mortality was 29%. Lower positive end-expiratory pressure levels (until day 7) and lower delivered tidal volume after 3 days on extracorporeal membrane oxygenation were associated with significantly higher mortality (p < 0.05). In multivariate analysis, higher positive end-expiratory pressure levels during the first 3 days of extracorporeal membrane oxygenation support were associated with lower mortality (odds ratio, 0.75; 95% CI, 0.64-0.88; p = 0.0006). Other independent predictors of ICU mortality included time between ICU admission and extracorporeal membrane oxygenation initiation, plateau pressure greater than 30 cm H2O before extracorporeal membrane oxygenation initiation, and lactate level on day 3 of extracorporeal membrane oxygenation support. CONCLUSIONS Protective mechanical ventilation strategies were routinely used in high-volume extracorporeal membrane oxygenation centers. However, higher positive end-expiratory pressure levels during the first 3 days on extracorporeal membrane oxygenation support were independently associated with improved survival. Further prospective trials on the optimal mechanical ventilation strategy during extracorporeal membrane oxygenation support are warranted.
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Effects of ultraprotective ventilation, extracorporeal carbon dioxide removal, and spontaneous breathing on lung morphofunction and inflammation in experimental severe acute respiratory distress syndrome. Anesthesiology 2015; 122:631-46. [PMID: 25371037 DOI: 10.1097/aln.0000000000000504] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND To investigate the role of ultraprotective mechanical ventilation (UP-MV) and extracorporeal carbon dioxide removal with and without spontaneous breathing (SB) to improve respiratory function and lung protection in experimental severe acute respiratory distress syndrome. METHODS Severe acute respiratory distress syndrome was induced by saline lung lavage and mechanical ventilation (MV) with higher tidal volume (VT) in 28 anesthetized pigs (32.8 to 52.5 kg). Animals (n = 7 per group) were randomly assigned to 6 h of MV (airway pressure release ventilation) with: (1) conventional P-MV with VT ≈6 ml/kg (P-MVcontr); (2) UP-MV with VT ≈3 ml/kg (UP-MVcontr); (3) UP-MV with VT ≈3 ml/kg and SB (UP-MVspont); and (4) UP-MV with VT ≈3 ml/kg and pressure supported SB (UP-MVPS). In UP-MV groups, extracorporeal carbon dioxide removal was used. RESULTS The authors found that: (1) UP-MVcontr reduced diffuse alveolar damage score in dorsal lung zones (median[interquartile]) (12.0 [7.0 to 16.8] vs. 22.5 [13.8 to 40.8]), but worsened oxygenation and intrapulmonary shunt, compared to P-MVcontr; (2) UP-MVspont and UP-MVPS improved oxygenation and intrapulmonary shunt, and redistributed ventilation towards dorsal areas, as compared to UP-MVcontr; (3) compared to P-MVcontr, UP-MVcontr and UP-MVspont, UP-MVPS yielded higher levels of tumor necrosis factor-α (6.9 [6.5 to 10.1] vs. 2.8 [2.2 to 3.0], 3.6 [3.0 to 4.7] and 4.0 [2.8 to 4.4] pg/mg, respectively) and interleukin-8 (216.8 [113.5 to 343.5] vs. 59.8 [45.3 to 66.7], 37.6 [18.8 to 52.0], and 59.5 [36.1 to 79.7] pg/mg, respectively) in dorsal lung zones. CONCLUSIONS In this model of severe acute respiratory distress syndrome, MV with VT ≈3 ml/kg and extracorporeal carbon dioxide removal without SB slightly reduced lung histologic damage, but not inflammation, as compared to MV with VT = 4 to 6 ml/kg. During UP-MV, pressure supported SB increased lung inflammation.
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Marhong JD, Munshi L, Detsky M, Telesnicki T, Fan E. Mechanical ventilation during extracorporeal life support (ECLS): a systematic review. Intensive Care Med 2015; 41:994-1003. [PMID: 25752302 DOI: 10.1007/s00134-015-3716-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 02/24/2015] [Indexed: 01/18/2023]
Abstract
PURPOSE In patients with acute respiratory distress syndrome (ARDS), extracorporeal life support (ECLS) has been utilized to support gas exchange and mitigate ventilator-induced lung injury (VILI). The optimal ventilation settings while on ECLS are unknown. The purpose of this systematic review is to describe the ventilation practices in patients with ARDS who require ECLS. METHODS We electronically searched MEDLINE, EMBASE, CENTRAL, AMED, and HAPI (inception to January 2015). Studies included were randomized controlled trials, observational studies, or case series (≥4 patients) of ARDS patients undergoing ECLS. Our review focused on studies describing ventilation practices employed during ECLS for ARDS. RESULTS Forty-nine studies (2,042 patients) met our inclusion criteria. Prior to initiation of ECLS, at least one parameter consistent with injurious ventilation [tidal volume >8 mL/kg predicted body weight (PBW), peak pressure >35 cmH2O (or plateau pressure >30 cmH2O), or FiO2 ≥0.8] was noted in 90% of studies. After initiation of ECLS, studies reported median [interquartile range (IQR)] reductions in: tidal volume [2.4 mL/kg PBW (2.2-2.9)], plateau pressure [4.3 cmH2O (3.5-5.8)], positive end-expiratory pressure (PEEP) [0.20 cmH2O (0-3.0)], and FiO2 [0.40 (0.30-0.60)]. Median (IQR) overall mortality was 41 % (31-51%). CONCLUSIONS Reduction in the intensity of mechanical ventilation in patients with ARDS supported by ECLS is common, suggesting that clinicians may be focused on reducing VILI after ECLS initiation. Future investigations should focus on establishing the optimal ventilatory strategy for patients with ARDS who require ECLS.
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Affiliation(s)
- Jonathan D Marhong
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada,
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Elevation of procalcitonin after implantation of an interventional lung assist device in critically ill patients. ASAIO J 2014; 60:249-53. [PMID: 24399068 DOI: 10.1097/mat.0000000000000041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A pumpless interventional arteriovenous lung assist device (iLA) facilitates the removal of carbon dioxide from the blood and is used as part of the lung-protective ventilation strategy in patients with acute respiratory distress syndrome (ARDS). In case of bacterial infection, delayed antimicrobial therapy increases the mortality in this group of high-risk critically ill patients, whereas overtreatment promotes bacterial resistance and leads to increased drug toxicity and costs. Besides clinical signs and symptoms, antimicrobial treatment is based on the kinetics of biomarkers such as procalcitonin (PCT). We hereby report an up to 10-fold increase in PCT serum concentrations in four mechanically ventilated patients with ARDS detected within 12-20 hours after iLA implantation in the absence of any infection. Procalcitonin concentrations returned to nearly baseline values in all patients on the fourth day after iLA implantation. We discuss the possible mechanisms of PCT induction in this specific patient population and recommend the onset of antibiotics administration after iLA implantation to be carefully considered in the context of other clinical findings and not solely based on the PCT kinetics. Repeated PCT measurements in short time intervals should be performed in these patients.
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Low Respiratory Rate Plus Minimally Invasive Extracorporeal Co2 Removal Decreases Systemic and Pulmonary Inflammatory Mediators in Experimental Acute Respiratory Distress Syndrome*. Crit Care Med 2014; 42:e451-60. [DOI: 10.1097/ccm.0000000000000312] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Schmidt M, Pellegrino V, Combes A, Scheinkestel C, Cooper DJ, Hodgson C. Mechanical ventilation during extracorporeal membrane oxygenation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:203. [PMID: 24447458 PMCID: PMC4057516 DOI: 10.1186/cc13702] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The timing of extracorporeal membrane oxygenation (ECMO) initiation and its outcome in the management of respiratory and cardiac failure have received considerable attention, but very little attention has been given to mechanical ventilation during ECMO. Mechanical ventilation settings in non-ECMO studies have been shown to have an effect on survival and may also have contributed to a treatment effect in ECMO trials. Protective lung ventilation strategies established for non-ECMO-supported respiratory failure patients may not be optimal for more severe forms of respiratory failure requiring ECMO support. The influence of positive end-expiratory pressure on the reduction of the left ventricular compliance may be a matter of concern for patients receiving ECMO support for cardiac failure. The objectives of this review were to describe potential mechanisms for lung injury during ECMO for respiratory or cardiac failure, to assess the possible benefits from the use of ultra-protective lung ventilation strategies and to review published guidelines and expert opinions available on mechanical ventilation-specific management of patients requiring ECMO, including mode and ventilator settings. Articles were identified through a detailed search of PubMed, Ovid, Cochrane databases and Google Scholar. Additional references were retrieved from the selected studies. Growing evidence suggests that mechanical ventilation settings are important in ECMO patients to minimize further lung damage and improve outcomes. An ultra-protective ventilation strategy may be optimal for mechanical ventilation during ECMO for respiratory failure. The effects of airway pressure on right and left ventricular afterload should be considered during venoarterial ECMO support of cardiac failure. Future studies are needed to better understand the potential impact of invasive mechanical ventilation modes and settings on outcomes.
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Effect of PEEP and tidal volume on ventilation distribution and end-expiratory lung volume: a prospective experimental animal and pilot clinical study. PLoS One 2013; 8:e72675. [PMID: 23991138 PMCID: PMC3750001 DOI: 10.1371/journal.pone.0072675] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2012] [Accepted: 07/18/2013] [Indexed: 11/19/2022] Open
Abstract
Introduction Lung-protective ventilation aims at using low tidal volumes (VT) at optimum positive end-expiratory pressures (PEEP). Optimum PEEP should recruit atelectatic lung regions and avoid tidal recruitment and end-inspiratory overinflation. We examined the effect of VT and PEEP on ventilation distribution, regional respiratory system compliance (CRS), and end-expiratory lung volume (EELV) in an animal model of acute lung injury (ALI) and patients with ARDS by using electrical impedance tomography (EIT) with the aim to assess tidal recruitment and overinflation. Methods EIT examinations were performed in 10 anaesthetized pigs with normal lungs ventilated at 5 and 10 ml/kg body weight VT and 5 cmH2O PEEP. After ALI induction, 10 ml/kg VT and 10 cmH2O PEEP were applied. Afterwards, PEEP was set according to the pressure-volume curve. Animals were randomized to either low or high VT ventilation changed after 30 minutes in a crossover design. Ventilation distribution, regional CRS and changes in EELV were analyzed. The same measures were determined in five ARDS patients examined during low and high VT ventilation (6 and 10 (8) ml/kg) at three PEEP levels. Results In healthy animals, high compared to low VT increased CRS and ventilation in dependent lung regions implying tidal recruitment. ALI reduced CRS and EELV in all regions without changing ventilation distribution. Pressure-volume curve-derived PEEP of 21±4 cmH2O (mean±SD) resulted in comparable increase in CRS in dependent and decrease in non-dependent regions at both VT. This implied that tidal recruitment was avoided but end-inspiratory overinflation was present irrespective of VT. In patients, regional CRS differences between low and high VT revealed high degree of tidal recruitment and low overinflation at 3±1 cmH2O PEEP. Tidal recruitment decreased at 10±1 cmH2O and was further reduced at 15±2 cmH2O PEEP. Conclusions Tidal recruitment and end-inspiratory overinflation can be assessed by EIT-based analysis of regional CRS.
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Bein T, Weber-Carstens S, Goldmann A, Müller T, Staudinger T, Brederlau J, Muellenbach R, Dembinski R, Graf BM, Wewalka M, Philipp A, Wernecke KD, Lubnow M, Slutsky AS. Lower tidal volume strategy (≈3 ml/kg) combined with extracorporeal CO2 removal versus 'conventional' protective ventilation (6 ml/kg) in severe ARDS: the prospective randomized Xtravent-study. Intensive Care Med 2013; 39:847-56. [PMID: 23306584 PMCID: PMC3625408 DOI: 10.1007/s00134-012-2787-6] [Citation(s) in RCA: 367] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 11/29/2012] [Indexed: 01/11/2023]
Abstract
Background Acute respiratory distress syndrome is characterized by damage to the lung caused by various insults, including ventilation itself, and tidal hyperinflation can lead to ventilator induced lung injury (VILI). We investigated the effects of a low tidal volume (VT) strategy (VT ≈ 3 ml/kg/predicted body weight [PBW]) using pumpless extracorporeal lung assist in established ARDS. Methods Seventy-nine patients were enrolled after a ‘stabilization period’ (24 h with optimized therapy and high PEEP). They were randomly assigned to receive a low VT ventilation (≈3 ml/kg) combined with extracorporeal CO2 elimination, or to a ARDSNet strategy (≈6 ml/kg) without the extracorporeal device. The primary outcome was the 28-days and 60-days ventilator-free days (VFD). Secondary outcome parameters were respiratory mechanics, gas exchange, analgesic/sedation use, complications and hospital mortality. Results Ventilation with very low VT’s was easy to implement with extracorporeal CO2-removal. VFD’s within 60 days were not different between the study group (33.2 ± 20) and the control group (29.2 ± 21, p = 0.469), but in more hypoxemic patients (PaO2/FIO2 ≤150) a post hoc analysis demonstrated significant improved VFD-60 in study patients (40.9 ± 12.8) compared to control (28.2 ± 16.4, p = 0.033). The mortality rate was low (16.5 %) and did not differ between groups. Conclusions The use of very low VT combined with extracorporeal CO2 removal has the potential to further reduce VILI compared with a ‘normal’ lung protective management. Whether this strategy will improve survival in ARDS patients remains to be determined (Clinical trials NCT 00538928). Electronic supplementary material The online version of this article (doi:10.1007/s00134-012-2787-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas Bein
- Department of Anesthesia and Operative Intensive Care, Regensburg University Hospital, Regensburg, Germany.
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Abstract
Despite advances in the therapy for acute lung injury and adult respiratory distress syndrome, mortality remains high. The iatrogenic risk of ventilator-induced lung injury might contribute to this high mortality because the lungs are hyperinflated. Low tidal volume and inspiratory pressure are surrogates for the stress and strain concept; but lung compliance, transpulmonary pressure, and chest wall elastance might differ in individual patients. In previous published studies, an increasing number of patients were treated successfully with extracorporeal support. Extracorporeal membrane oxygenation and interventional lung assist allow ultraprotective ventilation strategies. However, these assists have different technical aspects and different indications.
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Kopp R, Bensberg R, Wardeh M, Rossaint R, Kuhlen R, Henzler D. Pumpless arterio-venous extracorporeal lung assist compared with veno-venous extracorporeal membrane oxygenation during experimental lung injury. Br J Anaesth 2012; 108:745-53. [DOI: 10.1093/bja/aes021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Kredel M, Muellenbach RM, Johannes A, Brederlau J, Roewer N, Wunder C. Hepatic effects of lung-protective pressure-controlled ventilation and a combination of high-frequency oscillatory ventilation and extracorporeal lung assist in experimental lung injury. Med Sci Monit 2012; 17:BR275-81. [PMID: 21959601 PMCID: PMC3539465 DOI: 10.12659/msm.881974] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Ventilation with high positive end-expiratory pressure (PEEP) can lead to hepatic dysfunction. The aim of this study was to investigate the hepatic effects of strategies using high airway pressures either in pressure-controlled ventilation (PCV) or in high-frequency oscillatory ventilation (HFOV) combined with an arteriovenous extracorporeal lung assist (ECLA). Material/Methods Pietrain pigs underwent induction of lung injury by saline lavage. Ventilation was continued for 24 hours either as PCV with tidal volumes of 6 ml/kg and PEEP 3 cmH2O above the lower inflection point of the pressure-volume curve or as HFOV (≥12 Hz) with a mean tracheal airway pressure 3 cmH2O above the lower inflection point combined with arteriovenous ECLA (HFOV+ECLA). Fluids and norepinephrine stabilized the circulation. The indocyanine green plasma disappearance rate, serum bilirubin, aspartate aminotransferase, alanine aminotransferase, γ-glutamyltransferase, alkaline phosphatase, glutamate dehydrogenase, lactate dehydrogenase and creatine kinase were determined repeatedly. Finally, liver neutrophils were counted and liver cell apoptosis was assessed by terminal deoxynucleotidyl transferase nick end labeling (TUNEL). Results Aspartate aminotransferase increased in the PCV group about three-fold and in the HFOV+ECLA group five-fold (p<0.001). Correspondingly, creatine kinase increased about two-fold and four-fold, respectively (p<0.001). Lactate dehydrogenase was increased in the HFOV+ECLA group (p<0.028). The number of neutrophils infiltrating the liver tissue and the apoptotic index were low. Conclusions High airway pressure PCV and HFOV with ECLA in the treatment of lavage-induced lung injury in pigs did not cause liver dysfunction or damage. The detected elevation of enzymes might be of extrahepatic origin.
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Affiliation(s)
- Markus Kredel
- Department of Anaesthesia and Critical Care, University of Würzburg, Würzburg, Germany
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Abstract
A 41-year-old woman presents with severe community-acquired pneumococcal pneumonia. Chest radiography reveals diffuse bilateral infiltrates, and hypoxemic respiratory failure develops despite appropriate antibiotic therapy. She is intubated and mechanical ventilation is initiated with a volume- and pressure-limited approach for the acute respiratory distress syndrome (ARDS). Over the ensuing 24 hours, her partial pressure of arterial oxygen (Pao2) decreases to 40 mm Hg, despite ventilatory support with a fraction of inspired oxygen (Fio2) of 1.0 and a positive end-expiratory pressure (PEEP) of 20 cm of water. She is placed in the prone position and a neuromuscular blocking agent is administered, without improvement in her Pao2. An intensive care specialist recommends the initiation of extracorporeal membrane oxygenation (ECMO).
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Affiliation(s)
- Daniel Brodie
- Columbia University College of Physicians and Surgeons, and New York-Presbyterian Hospital, New York, NY 10032, USA.
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Cho WH, Lee K, Huh JW, Lim CM, Koh Y, Hong SB. Physiologic effect and safety of the pumpless extracorporeal interventional lung assist system in patients with acute respiratory failure--a pilot study. Artif Organs 2011; 36:434-8. [PMID: 22040296 DOI: 10.1111/j.1525-1594.2011.01359.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Interventional lung assist (iLA) effectively reduces CO(2) tension and permits protective lung ventilation in patients with acute respiratory distress syndrome. However, there is little experience in using iLA in acute respiratory failure from various causes and no experience for small body sizes such as Asian patients. We evaluated the physiologic effect and safety of the iLA device in patients with acute respiratory failure from various causes. We enrolled 11 consecutive patients with severe respiratory failure from various causes. Wire-enforced cannulae (13-15 Fr) were inserted under ultrasound guidance and connected to iLA. Arterial blood gas analysis, ventilator parameters, hemodynamic parameter, and adverse events were recorded serially. During the first 24h of iLA use, mean blood flow was 1.08±0.15L/min, PaCO(2) decreased from 83.9±23.4mmHg to 40.7±10.2mmHg, and PaO(2) /FiO(2) ratio increased from 110±37 to 141±74. Minute ventilation decreased from 9.4±2.5 to 6.3±1.5L/min, and peak inspiratory pressure decreased from 30.3±7.1cm H(2) O to 28.8±9.4cm H(2) O. No serious adverse events were observed during iLA use. iLA showed effective CO(2) removal, allowed for reducing the invasiveness of mechanical ventilation in patients with severe respiratory failure from various causes even using a small-sized catheter and was safe in small body-sized patients.
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Affiliation(s)
- Woo Hyun Cho
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Korea
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Fuchs H, Mendler MR, Scharnbeck D, Ebsen M, Hummler HD. Very low tidal volume ventilation with associated hypercapnia--effects on lung injury in a model for acute respiratory distress syndrome. PLoS One 2011; 6:e23816. [PMID: 21886825 PMCID: PMC3158784 DOI: 10.1371/journal.pone.0023816] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 07/27/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Ventilation using low tidal volumes with permission of hypercapnia is recommended to protect the lung in acute respiratory distress syndrome. However, the most lung protective tidal volume in association with hypercapnia is unknown. The aim of this study was to assess the effects of different tidal volumes with associated hypercapnia on lung injury and gas exchange in a model for acute respiratory distress syndrome. METHODOLOGY/PRINCIPAL FINDINGS In this randomized controlled experiment sixty-four surfactant-depleted rabbits were exposed to 6 hours of mechanical ventilation with the following targets: Group 1: tidal volume = 8-10 ml/kg/PaCO(2) = 40 mm Hg; Group 2: tidal volume = 4-5 ml/kg/PaCO(2) = 80 mm Hg; Group 3: tidal volume = 3-4 ml/kg/PaCO(2) = 120 mm Hg; Group 4: tidal volume = 2-3 ml/kg/PaCO(2) = 160 mm Hg. Decreased wet-dry weight ratios of the lungs, lower histological lung injury scores and higher PaO(2) were found in all low tidal volume/hypercapnia groups (group 2, 3, 4) as compared to the group with conventional tidal volume/normocapnia (group 1). The reduction of the tidal volume below 4-5 ml/kg did not enhance lung protection. However, oxygenation and lung protection were maintained at extremely low tidal volumes in association with very severe hypercapnia and no adverse hemodynamic effects were observed with this strategy. CONCLUSION Ventilation with low tidal volumes and associated hypercapnia was lung protective. A tidal volume below 4-5 ml/kg/PaCO(2) 80 mm Hg with concomitant more severe hypercapnic acidosis did not increase lung protection in this surfactant deficiency model. However, even at extremely low tidal volumes in association with severe hypercapnia lung protection and oxygenation were maintained.
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Affiliation(s)
- Hans Fuchs
- Division of Neonatology and Pediatric Critical Care, Department of Pediatrics and Adolescent Medicine, Ulm University, Ulm, Germany.
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In vivo microscopy in a porcine model of acute lung injury. Respir Physiol Neurobiol 2010; 172:192-200. [DOI: 10.1016/j.resp.2010.05.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Revised: 05/05/2010] [Accepted: 05/27/2010] [Indexed: 11/22/2022]
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Muellenbach RM, Kredel M, Wilhelm J, Küstermann J, Fink L, Siebenliest G, Klosterhalfen B, Foerster CY, Kranke P, Wunder C, Roewer N, Brederlau J. High-frequency oscillation combined with arteriovenous extracorporeal lung assist reduces lung injury. Exp Lung Res 2010; 36:148-58. [DOI: 10.3109/01902140903214683] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Henzler D, Hochhausen N, Bensberg R, Schachtrupp A, Biechele S, Rossaint R, Kuhlen R. Effects of preserved spontaneous breathing activity during mechanical ventilation in experimental intra-abdominal hypertension. Intensive Care Med 2010; 36:1427-35. [PMID: 20237763 DOI: 10.1007/s00134-010-1827-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Accepted: 12/22/2009] [Indexed: 01/30/2023]
Abstract
PURPOSE Ventilation problems are common in critically ill patients with intra-abdominal hypertension. The aim of this study was to investigate the effects of preserved spontaneous breathing during mechanical ventilation on hemodynamics, gas exchange, respiratory function and lung injury in experimental intra-abdominal hypertension. METHODS Twenty anesthetized pigs were intubated and ventilated for 24 h with biphasic positive airway pressure without (BIPAP(PC)) or with additional, unsynchronized spontaneous breathing (BIPAP(SB)). In 12 animals, intra-abdominal pressure was increased to 30 mmHg for two 9 h periods followed by a 3 h pressure relief each. Eight animals served as controls and were ventilated for 24 h. Hemodynamics, gas exchange and respiratory mechanics were measured and lung injury was determined histologically. RESULTS Intra-abdominal hypertension caused significant impairment of hemodynamics and respiratory mechanics in both modes. In the presence of intra-abdominal hypertension, BIPAP(SB) did not demonstrate superior respiratory mechanics and cardiovascular stability as compared to BIPAP(PC). Although the decrease of dynamic compliance and the increase of airway pressures were mitigated, BIPAP(SB) failed to lower pulmonary vascular resistance and caused increased dead space ventilation (p = 0.007). Blood pressures and cardiac output increased in BIPAP(SB), caused by an increase in heart rate (p < 0.001), but not in stroke volume (p = 0.06). BIPAP(SB) was associated with an increased breathing effort, decreased transpulmonary pressure during inspiration and lower lobe diffuse alveolar damage (p = 0.002). CONCLUSIONS In the presence of severe intra-abdominal hypertension, the addition of unsupported spontaneous breaths to BIPAP did not improve hemodynamic and respiratory function and caused greater histopathologic damage to the lungs.
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Affiliation(s)
- Dietrich Henzler
- Department of Anesthesiology, University Hospital, RWTH Aachen, Aachen, Germany.
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El-Ferzli GT, Philips JB, Bulger A, Ambalavanan N. Evaluation of a pumpless lung assist device in hypoxia-induced pulmonary hypertension in juvenile piglets. Pediatr Res 2009; 66:677-81. [PMID: 19687777 PMCID: PMC2796290 DOI: 10.1203/pdr.0b013e3181bbc7ec] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Persistent pulmonary hypertension is an important cause of mortality and morbidity in term infants. The lung assist device (LAD) is a novel, pumpless, low-resistance extracorporeal oxygenator to supplement mechanical ventilation. The LAD may be associated with fewer complications compared with conventional extracorporeal membrane oxygenation. The objective was to test the feasibility and efficacy of the LAD in juvenile piglets with hypoxia-induced pulmonary hypertension. Pulmonary hypertension was acutely induced by hypoxia in six 3- to 4-wk-old acutely instrumented and intubated piglets. The LAD was attached between a carotid artery and jugular vein. Gas exchange and hemodynamic variables, including pulmonary arterial pressure (PAP) and cardiac output (CO), were measured. Successful LAD cannulation was achieved without complications in all animals. Extracorporeal shunt flow through the device averaged 18% of CO. The LAD achieved oxygen delivery of 20% of total oxygen consumption. PAP was reduced by 35% from 28 +/- 5 to 18 +/- 4 mm Hg (p < 0.05) and systemic Pao2 increased by 33% from 27 +/- 2 to 36 +/- 4 mm Hg (p < 0.05). Other hemodynamic variables remained stable. The novel LAD shows feasibility and efficacy in improving gas exchange and reducing PAPs in a juvenile animal model of hypoxia-induced pulmonary hypertension.
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Affiliation(s)
- George T El-Ferzli
- Division of Neonatology, Department of Pediatrics, 525 New Hillman Building, 619 South 19th Street, University of Alabama, Birmingham, AL 35233, USA.
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Quintel M, Moerer O. Is smaller high enough? Another piece in the puzzle of stress, strain, size, and systems. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:126. [PMID: 19435467 PMCID: PMC2689463 DOI: 10.1186/cc7738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Extracorporeal lung-supporting procedures open the possibility of staying within widely accepted margins of 'protective' mechanical ventilation (tidal volume of less than 6 mL per kg of predicted ideal body weight and plateau pressure of less than 30 cm H2O) in most any case of respiratory failure or even of further reducing ventilator settings while still providing adequate gas exchange. There is evidence that, at least in some patients, a further reduction in tidal volumes might be beneficial. Extracorporeal procedures to support the lungs have undergone tremendous technical developments, thus reducing the procedure-related risks. However, what is true for ventilator settings should also be true for extracorporeal procedures: studies will have to demonstrate a convincing risk-benefit ratio. In addition, a simple reduction of the tidal volume will certainly not be the right answer. If extracorporeal support largely influences gas exchange, the 'optimal' tidal volume/positive end-expiratory pressure ratio keeping stress and strain low and avoiding alveolar derecruitment will still have to be individually defined.
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Affiliation(s)
- Michael Quintel
- Department of Anaesthesia and Intensive Care Medicine, University of Göttingen, Robert Koch Strasse 40, 37075 Göttingen, Germany.
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Bein T, Zimmermann M, Hergeth K, Ramming M, Rupprecht L, Schlitt HJ, Slutsky AS. Pumpless extracorporeal removal of carbon dioxide combined with ventilation using low tidal volume and high positive end-expiratory pressure in a patient with severe acute respiratory distress syndrome. Anaesthesia 2009; 64:195-8. [PMID: 19143699 DOI: 10.1111/j.1365-2044.2008.05735.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The effects of the combination of a 'lowest' lung ventilation with extracorporeal elimination of carbon dioxide by interventional lung assist are described in a patient presenting with severe acute respiratory distress syndrome due to fulminant pneumonia. Reducing tidal volume to 3 ml.kg(-1) together with interventional lung assist resulted in a decrease in severe hypercapnia without alveolar collapse or hypoxaemia but with a decrease in serum levels of interleukin-6. This approach was applied for 12 days with recovery of the patient, without complications. Extracorporeal removal of carbon dioxide by interventional lung assist may be a useful tool to enable 'ultraprotective' ventilation in severe acute respiratory distress syndrome.
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Affiliation(s)
- T Bein
- Department of Anaesthesia & Intensive Care, University Hospital of Regensburg, Regensburg, Germany.
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Hypercapnia in late-phase ALI/ARDS: providing spontaneous breathing using pumpless extracorporeal lung assist. Intensive Care Med 2009; 35:1100-5. [DOI: 10.1007/s00134-009-1426-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Accepted: 01/10/2009] [Indexed: 10/21/2022]
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Muellenbach RM, Kuestermann J, Kredel M, Johannes A, Wolfsteiner U, Schuster F, Wunder C, Kranke P, Roewer N, Brederlau J. Arteriovenous Extracorporeal Lung Assist Allows For Maximization Of Oscillatory Frequencies: A Large-animal Model Of Respiratory Distress. BMC Anesthesiol 2008; 8:7. [PMID: 19014575 PMCID: PMC2588559 DOI: 10.1186/1471-2253-8-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2008] [Accepted: 11/14/2008] [Indexed: 11/21/2022] Open
Abstract
Background Although the minimization of the applied tidal volume (VT) during high-frequency oscillatory ventilation (HFOV) reduces the risk of alveolar shear stress, it can also result in insufficient CO2-elimination with severe respiratory acidosis. We hypothesized that in a model of acute respiratory distress (ARDS) the application of high oscillatory frequencies requires the combination of HFOV with arteriovenous extracorporeal lung assist (av-ECLA) in order to maintain or reestablish normocapnia. Methods After induction of ARDS in eight female pigs (56.5 ± 4.4 kg), a recruitment manoeuvre was performed and intratracheal mean airway pressure (mPaw) was adjusted 3 cmH2O above the lower inflection point (Plow) of the pressure-volume curve. All animals were ventilated with oscillatory frequencies ranging from 3–15 Hz. The pressure amplitude was fixed at 60 cmH2O. At each frequency gas exchange and hemodynamic measurements were obtained with a clamped and de-clamped av-ECLA. Whenever the av-ECLA was de-clamped, the oxygen sweep gas flow through the membrane lung was adjusted aiming at normocapnia. Results Lung recruitment and adjustment of the mPaw above Plow resulted in a significant improvement of oxygenation (p < 0.05). Compared to lung injury, oxygenation remained significantly improved with rising frequencies (p < 0.05). Normocapnia during HFOV was only maintained with the addition of av-ECLA during frequencies of 9 Hz and above. Conclusion In this animal model of ARDS, maximization of oscillatory frequencies with subsequent minimization of VT leads to hypercapnia that can only be reversed by adding av-ECLA. When combined with a recruitment strategy, these high frequencies do not impair oxygenation
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Affiliation(s)
- Ralf M Muellenbach
- University of Wuerzburg, Department of Anaesthesiology; University hospital Wuerzburg; Oberduerrbacherstr, 6; 97080 Wuerzburg, Germany.
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Soni N, Williams P. Positive pressure ventilation: what is the real cost? Br J Anaesth 2008; 101:446-57. [PMID: 18782885 DOI: 10.1093/bja/aen240] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Positive pressure ventilation is a radical departure from the physiology of breathing spontaneously. The immediate physiological consequences of positive pressure ventilation such as haemodynamic changes are recognized, studied, and understood. There are other significant physiological interactions which are less obvious, more insidious, and may only produce complications if ventilation is prolonged. The interaction of positive pressure with airway resistance and alveolar compliance affects distribution of gas flow within the lung. The result is a wide range of ventilation efficacy throughout different areas of the lung, but the pressure differentials between alveolus and interstitium also influence capillary perfusion. The hydrostatic forces across the capillaries associated with the effects of raised venous pressures compound these changes resulting in interstitial fluid sequestration. This is increased by impaired lymphatic drainage which is secondary to raised intrathoracic pressure but also influenced by raised central venous pressure. Ventilation and PEEP promulgate further physiological derangement. In theory, avoiding these physiological disturbances in a rested lung may be better for the lung and other organs. An alternative to positive pressure ventilation might be to investigate oxygen supplementation of a physiologically neutral and rested lung. Abandoning heroic ventilation would be a massive departure from current practice but might be a more rationale approach to future practice.
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Affiliation(s)
- N Soni
- Imperial College Medical School, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK.
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Apneic Oxygenation Combined With Extracorporeal Arteriovenous Carbon Dioxide Removal Provides Sufficient Gas Exchange in Experimental Lung Injury. ASAIO J 2008; 54:401-5. [DOI: 10.1097/mat.0b013e31817e2b5f] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Rosenberg A, Tremper KK. Plumbing the limits of low tidal volumes for acute lung injury*. Crit Care Med 2007; 35:2451-3. [PMID: 17885388 DOI: 10.1097/01.ccm.0000284739.63782.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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