1
|
Wennen M, Claassen W, Heunks L. Setting positive end-expiratory pressure: role in diaphragm-protective ventilation. Curr Opin Crit Care 2024; 30:61-68. [PMID: 38085880 DOI: 10.1097/mcc.0000000000001126] [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: 01/03/2024]
Abstract
PURPOSE OF REVIEW With mechanical ventilation, positive end-expiratory pressure (PEEP) is applied to improve oxygenation and lung homogeneity. However, PEEP setting has been hypothesized to contribute to critical illness associated diaphragm dysfunction via several mechanisms. Here, we discuss the impact of PEEP on diaphragm function, activity and geometry. RECENT FINDINGS PEEP affects diaphragm geometry: it induces a caudal movement of the diaphragm dome and shortening of the zone of apposition. This results in reduced diaphragm neuromechanical efficiency. After prolonged PEEP application, the zone of apposition adapts by reducing muscle fiber length, so-called longitudinal muscle atrophy. When PEEP is withdrawn, for instance during a spontaneous breathing trial, the shortened diaphragm muscle fibers may over-stretch which may lead to (additional) diaphragm myotrauma. Furthermore, PEEP may either increase or decrease respiratory drive and resulting respiratory effort, probably depending on lung recruitability. Finally, the level of PEEP can also influence diaphragm activity in the expiratory phase, which may be an additional mechanism for diaphragm myotrauma. SUMMARY Setting PEEP could play an important role in both lung and diaphragm protective ventilation. Both high and low PEEP levels could potentially introduce or exacerbate diaphragm myotrauma. Today, the impact of PEEP setting on diaphragm structure and function is in its infancy, and clinical implications are largely unknown.
Collapse
Affiliation(s)
- Myrte Wennen
- Department of Intensive Care, Erasmus Medical Center, Rotterdam
| | - Wout Claassen
- Department of Physiology, Amsterdam UMC, location VUmc, Amsterdam
| | - Leo Heunks
- Department of Intensive Care, Erasmus Medical Center, Rotterdam
- Department of intensive care medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
2
|
SCARAMUZZO G, OTTAVIANI I, VOLTA CA, SPADARO S. Mechanical ventilation and COPD: from pathophysiology to ventilatory management. Minerva Med 2022; 113:460-470. [DOI: 10.23736/s0026-4806.22.07974-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
3
|
Diagnostic Insights from Plethysmographic Alveolar Pressure Assessed during Spontaneous Breathing in COPD Patients. Diagnostics (Basel) 2021; 11:diagnostics11060918. [PMID: 34063762 PMCID: PMC8223795 DOI: 10.3390/diagnostics11060918] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/14/2021] [Accepted: 05/17/2021] [Indexed: 11/25/2022] Open
Abstract
Since its introduction in the clinical practice, body plethysmography has assisted pneumologists in the diagnosis of respiratory diseases and patients’ follow-up, by providing easy assessment of absolute lung volumes and airway resistance. In the last decade, emerging evidence suggested that estimation of alveolar pressure by electronically-compensated plethysmographs may contain information concerning the mechanics of the respiratory system which goes beyond those provided by the simple value of airway resistance or conductance. Indeed, the systematic study of expiratory alveolar pressure-flow loops produced during spontaneous breathing at rest has shown that the marked expansion of expiratory loops in chronic obstructive pulmonary disease patients mainly reflects the presence of tidal expiratory flow-limitation. The presence of this phenomenon can be accurately predicted on the basis of loop-derived parameters. Finally, we present results suggesting that plethysmographic alveolar pressure may be used to estimate non-invasively intrinsic positive end-expiratory pressure (PEEPi) in spontaneously breathing patients, a task which previously could be only accomplished by introducing a balloon-tipped catheter in the esophagus.
Collapse
|
4
|
Neural control of pressure support ventilation improved patient-ventilator synchrony in patients with different respiratory system mechanical properties: a prospective, crossover trial. Chin Med J (Engl) 2021; 134:281-291. [PMID: 33470654 PMCID: PMC7846453 DOI: 10.1097/cm9.0000000000001357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Conventional pressure support ventilation (PSP) is triggered and cycled off by pneumatic signals such as flow. Patient-ventilator asynchrony is common during pressure support ventilation, thereby contributing to an increased inspiratory effort. Using diaphragm electrical activity, neurally controlled pressure support (PSN) could hypothetically eliminate the asynchrony and reduce inspiratory effort. The purpose of this study was to compare the differences between PSN and PSP in terms of patient-ventilator synchrony, inspiratory effort, and breathing pattern. Methods Eight post-operative patients without respiratory system comorbidity, eight patients with acute respiratory distress syndrome (ARDS) and obvious restrictive acute respiratory failure (ARF), and eight patients with chronic obstructive pulmonary disease (COPD) and mixed restrictive and obstructive ARF were enrolled. Patient-ventilator interactions were analyzed with macro asynchronies (ineffective, double, and auto triggering), micro asynchronies (inspiratory trigger delay, premature, and late cycling), and the total asynchrony index (AI). Inspiratory efforts for triggering and total inspiration were analyzed. Results Total AI of PSN was consistently lower than that of PSP in COPD (3% vs. 93%, P = 0.012 for 100% support level; 8% vs. 104%, P = 0.012 for 150% support level), ARDS (8% vs. 29%, P = 0.012 for 100% support level; 16% vs. 41%, P = 0.017 for 150% support level), and post-operative patients (21% vs. 35%, P = 0.012 for 100% support level; 15% vs. 50%, P = 0.017 for 150% support level). Improved support levels from 100% to 150% statistically increased total AI during PSP but not during PSN in patients with COPD or ARDS. Patients’ inspiratory efforts for triggering and total inspiration were significantly lower during PSN than during PSP in patients with COPD or ARDS under both support levels (P < 0.05). There was no difference in breathing patterns between PSN and PSP. Conclusions PSN improves patient-ventilator synchrony and generates a respiratory pattern similar to PSP independently of any level of support in patients with different respiratory system mechanical properties. PSN, which reduces the trigger and total patient's inspiratory effort in patients with COPD or ARDS, might be an alternative mode for PSP. Trial Registration ClinicalTrials.gov, NCT01979627; https://clinicaltrials.gov/ct2/show/record/NCT01979627.
Collapse
|
5
|
Abstract
PURPOSE OF REVIEW Accurate monitoring of the mechanical properties of the respiratory system is crucial to understand the pathophysiological mechanisms of respiratory failure in mechanically ventilated patients, to optimize mechanical ventilation settings and to reduce ventilator-induced lung injury. However, although the assessment of respiratory mechanics is simple in patients undergoing fully controlled ventilation, it becomes quite challenging in the presence of spontaneous breathing activity. Aim of the present review is to describe how the different components of respiratory mechanics [resistance, static compliance, and intrinsic positive end-expiratory pressure (PEEP)] can be measured at the bedside during assisted modes of ventilation. RECENT FINDINGS Available techniques for bedside measurement of resistance during assisted ventilation are complex and not commonly implemented. On the contrary, an increasing number of reports indicate that measurement of static compliance and intrinsic PEEP can be easily obtained, both with advanced monitoring systems (esophageal and gastric manometry, diaphragm electromyography, electrical impedance tomography) and, with some limitations, with simple airways occlusion maneuvers. SUMMARY Assessment of respiratory mechanics in spontaneously breathing patients, with some limitations, is feasible and should be included in everyday clinical practice; however, more data are needed to understand the clinical relevance of the measures obtained during assisted ventilation.
Collapse
|
6
|
Diniz-Silva F, Moriya HT, Alencar AM, Amato MBP, Carvalho CRR, Ferreira JC. Neurally adjusted ventilatory assist vs. pressure support to deliver protective mechanical ventilation in patients with acute respiratory distress syndrome: a randomized crossover trial. Ann Intensive Care 2020; 10:18. [PMID: 32040785 PMCID: PMC7010869 DOI: 10.1186/s13613-020-0638-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 02/02/2020] [Indexed: 01/06/2023] Open
Abstract
Background Protective mechanical ventilation is recommended for patients with acute respiratory distress syndrome (ARDS), but it usually requires controlled ventilation and sedation. Using neurally adjusted ventilatory assist (NAVA) or pressure support ventilation (PSV) could have additional benefits, including the use of lower sedative doses, improved patient–ventilator interaction and shortened duration of mechanical ventilation. We designed a pilot study to assess the feasibility of keeping tidal volume (VT) at protective levels with NAVA and PSV in patients with ARDS. Methods We conducted a prospective randomized crossover trial in five ICUs from a university hospital in Brazil and included patients with ARDS transitioning from controlled ventilation to partial ventilatory support. NAVA and PSV were applied in random order, for 15 min each, followed by 3 h in NAVA. Flow, peak airway pressure (Paw) and electrical activity of the diaphragm (EAdi) were captured from the ventilator, and a software (Matlab, Mathworks, USA), automatically detected inspiratory efforts and calculated respiratory rate (RR) and VT. Asynchrony events detection was based on waveform analysis. Results We randomized 20 patients, but the protocol was interrupted for five (25%) patients for whom we were unable to maintain VT below 6.5 mL/kg in PSV due to strong inspiratory efforts and for one patient for whom we could not detect EAdi signal. For the 14 patients who completed the protocol, VT was 5.8 ± 1.1 mL/kg for NAVA and 5.6 ± 1.0 mL/kg for PSV (p = 0.455) and there were no differences in RR (24 ± 7 for NAVA and 23 ± 7 for PSV, p = 0.661). Paw was greater in NAVA (21 ± 3 cmH2O) than in PSV (19 ± 3 cmH2O, p = 0.001). Most patients were under continuous sedation during the study. NAVA reduced triggering delay compared to PSV (p = 0.020) and the median asynchrony Index was 0.7% (0–2.7) in PSV and 0% (0–2.2) in NAVA (p = 0.6835). Conclusions It was feasible to keep VT in protective levels with NAVA and PSV for 75% of the patients. NAVA resulted in similar VT, RR and Paw compared to PSV. Our findings suggest that partial ventilatory assistance with NAVA and PSV is feasible as a protective ventilation strategy in selected ARDS patients under continuous sedation. Trial registration ClinicalTrials.gov (NCT01519258). Registered 26 January 2012, https://clinicaltrials.gov/ct2/show/NCT01519258
Collapse
Affiliation(s)
- Fabia Diniz-Silva
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil
| | - Henrique T Moriya
- Biomedical Engineering Laboratory, Escola Politécnica da USP, Av. Prof. Luciano Gualberto, trav. 3, 158, Cidade Universitária, São Paulo, SP, CEP 05586-0600, Brazil
| | - Adriano M Alencar
- Instituto de Física, Universidade de São Paulo, Caixa Postal 66318, São Paulo, SP, CEP 05314-970, Brazil
| | - Marcelo B P Amato
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil
| | - Carlos R R Carvalho
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil
| | - Juliana C Ferreira
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil.
| |
Collapse
|
7
|
A brief airway occlusion is sufficient to measure the patient's inspiratory effort/electrical activity of the diaphragm index (PEI). J Clin Monit Comput 2020; 35:183-188. [PMID: 31919632 PMCID: PMC7223874 DOI: 10.1007/s10877-020-00459-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 01/04/2020] [Indexed: 12/27/2022]
Abstract
Pressure generated by patient’s inspiratory muscles (Pmus) during assisted mechanical ventilation is of significant relevance. However, Pmus is not commonly measured since an esophageal balloon catheter is required. We have previously shown that Pmus can be estimated by measuring the electrical activity of the diaphragm (EAdi) through the Pmus/EAdi index (PEI). We investigated whether PEI could be reliably measured by a brief end-expiratory occlusion maneuver to propose an automated PEI measurement performed by the ventilator. Pmus, EAdi, airway pressure (Paw), and flow waveforms of 12 critically ill patients undergoing assisted mechanical ventilation were recorded. Repeated end-expiratory occlusion maneuvers were performed. PEI was measured at 100 ms (PEI0.1) and 200 ms (PEI0.2) from the start of the occlusion and compared to the PEI measured at the maximum Paw deflection (PEIoccl, reference). PEI0.1 and PEI0.2 tightly correlated with PEIoccl, (p < 0.001, R2 = 0.843 and 0.847). At a patient-level analysis, the highest percentage error was -64% and 50% for PEI0.1 and PEI0.2, respectively, suggesting that PEI0.2 might be a more reliable measurement. After correcting the error bias, the PEI0.2 percentage error was lower than ± 30% in all but one subjects (range − 39 to + 29%). It is possible to calculate PEI over a brief airway occlusion of 200 ms at inspiratory onset without the need for a full patient's inspiratory effort. Automated and repeated brief airway occlusions performed by the ventilator can provide a real time measurement of PEI; combining the automatically measured PEI with the EAdi trace could be used to continuously display the Pmus waveform at the bedside without the need of an esophageal balloon catheter.
Collapse
|
8
|
Widing CH, Pellegrini M, Larsson A, Perchiazzi G. The Effects of Positive End-Expiratory Pressure on Transpulmonary Pressure and Recruitment-Derecruitment During Neurally Adjusted Ventilator Assist: A Continuous Computed Tomography Study in an Animal Model of Acute Respiratory Distress Syndrome. Front Physiol 2019; 10:1392. [PMID: 31824326 PMCID: PMC6882775 DOI: 10.3389/fphys.2019.01392] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 10/28/2019] [Indexed: 01/22/2023] Open
Abstract
Background Whether spontaneous breathing (SB) should be used in early acute respiratory distress syndrome (ARDS) is questioned because it may cause ventilator-induced lung injury (VILI) by tidal high strain/stress and recruitment/derecruitment (R/D). However, SB has shown beneficial effects when used appropriately. We hypothesized that high levels of positive end-expiratory pressure (PEEP), during assisted SB, would prevent tidal R/D, reducing ventilatory variation and respiratory rate while potentially increasing transpulmonary pressure (PTP). The aim was to test this hypothesis in experimental mild ARDS during continuous SB using neurally adjusted ventilator assist (NAVA) and uninterrupted computed tomography (CT) exposure. Methods Mild experimental ARDS (PaO2/FiO2-ratio of 250) was induced in anesthetized pigs (n = 5), ventilated using uninterrupted NAVA. PEEP was changed in steps of 3 cmH2O, from 0 to 15 and back to 0 cmH2O. Dynamic CT scans, ventilatory parameters, and esophageal pressure were acquired simultaneously. PTP and R/D were calculated and compared among PEEP levels. Results When increasing PEEP from 0 to 15 cmH2O, tidal R/D decreased from 4.3 ± 5.9 to 1.1 ± 0.7% (p < 0.01), breath-to-breath variability decreased, and PTP increased from 11.4 ± 3.7 to 29.7 ± 14.1 cmH2O (R2 = 0.96). Conclusion This study shows that injurious phenomena like R/D and high PTP are present in NAVA at the two extremes of the PEEP spectrum. Willing to titrate PEEP to limit these phenomena, the physician must choose the best compromise between restraining the R/D or PTP.
Collapse
Affiliation(s)
- Carl Hannes Widing
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,NU-Hospital Organization, Trollhättan, Sweden
| | - Mariangela Pellegrini
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,Department of Anaesthesia and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
| | - Anders Larsson
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,Department of Anaesthesia and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
| | - Gaetano Perchiazzi
- Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,Department of Anaesthesia and Intensive Care Medicine, Uppsala University Hospital, Uppsala, Sweden
| |
Collapse
|
9
|
Heili-Frades S, Suarez-Sipmann F, Santos A, Carballosa MP, Naya-Prieto A, Castilla-Reparaz C, Rodriguez-Nieto MJ, González-Mangado N, Peces-Barba G. Continuous monitoring of intrinsic PEEP based on expired CO 2 kinetics: an experimental validation study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:192. [PMID: 31142337 PMCID: PMC6540388 DOI: 10.1186/s13054-019-2430-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 04/10/2019] [Indexed: 12/03/2022]
Abstract
Background Quantification of intrinsic PEEP (PEEPi) has important implications for patients subjected to invasive mechanical ventilation. A new non-invasive breath-by-breath method (etCO2D) for determination of PEEPi is evaluated. Methods In 12 mechanically ventilated pigs, dynamic hyperinflation was induced by interposing a resistance in the endotracheal tube. Airway pressure, flow, and exhaled CO2 were measured at the airway opening. Combining different I:E ratios, respiratory rates, and tidal volumes, 52 different levels of PEEPi (range 1.8–11.7 cmH2O; mean 8.45 ± 0.32 cmH2O) were studied. The etCO2D is based on the detection of the end-tidal dilution of the capnogram. This is measured at the airway opening by means of a CO2 sensor in which a 2-mm leak is added to the sensing chamber. This allows to detect a capnogram dilution with fresh air when the pressure coming from the ventilator exceeds the PEEPi. This method was compared with the occlusion method. Results The etCO2D method detected PEEPi step changes of 0.2 cmH2O. Reference and etCO2D PEEPi presented a good correlation (R2 0.80, P < 0.0001) and good agreement, bias − 0.26, and limits of agreement ± 1.96 SD (2.23, − 2.74) (P < 0.0001). Conclusions The etCO2D method is a promising accurate simple way of continuously measure and monitor PEEPi. Its clinical validity needs, however, to be confirmed in clinical studies and in conditions with heterogeneous lung diseases. Electronic supplementary material The online version of this article (10.1186/s13054-019-2430-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Sarah Heili-Frades
- Intermediate Respiratory Care Unit, Pulmonology Department, IIS-Fundación Jiménez Díaz, UAM, CIBERES, Madrid, Spain.,CIBER de Enfermedades Respiratorias, Instituto Carlos III, Madrid, Spain
| | - Fernando Suarez-Sipmann
- Servicio de Medicina Intensiva, Hospital Universitario de la Princesa, Madrid, Spain. .,CIBER de Enfermedades Respiratorias, Instituto Carlos III, Madrid, Spain. .,Department of surgical Sciences, Section of Anesthesia and Critical Care, Hedenstierna Laboratory, Uppsala University Hospital, Uppsala, Sweden.
| | - Arnoldo Santos
- ITC Ingeniería y Técnicas Clínicas, CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Maria Pilar Carballosa
- Intermediate Respiratory Care Unit, Pulmonology Department, IIS-Fundación Jiménez Díaz, UAM, CIBERES, Madrid, Spain
| | - Alba Naya-Prieto
- Intermediate Respiratory Care Unit, Pulmonology Department, IIS-Fundación Jiménez Díaz, UAM, CIBERES, Madrid, Spain
| | | | - Maria Jesús Rodriguez-Nieto
- Intermediate Respiratory Care Unit, Pulmonology Department, IIS-Fundación Jiménez Díaz, UAM, CIBERES, Madrid, Spain.,CIBER de Enfermedades Respiratorias, Instituto Carlos III, Madrid, Spain
| | - Nicolás González-Mangado
- Intermediate Respiratory Care Unit, Pulmonology Department, IIS-Fundación Jiménez Díaz, UAM, CIBERES, Madrid, Spain.,CIBER de Enfermedades Respiratorias, Instituto Carlos III, Madrid, Spain
| | - German Peces-Barba
- Intermediate Respiratory Care Unit, Pulmonology Department, IIS-Fundación Jiménez Díaz, UAM, CIBERES, Madrid, Spain.,CIBER de Enfermedades Respiratorias, Instituto Carlos III, Madrid, Spain
| |
Collapse
|
10
|
Physiological Effect of Prone Position in Children with Severe Bronchiolitis: A Randomized Cross-Over Study (BRONCHIO-DV). J Pediatr 2019; 205:112-119.e4. [PMID: 30448014 DOI: 10.1016/j.jpeds.2018.09.066] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 09/21/2018] [Accepted: 09/26/2018] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To assess the effect of the prone position on physiological measures, including inspiratory effort, metabolic cost of breathing, and neural drive to the diaphragm as compared with the supine position in infants with severe bronchiolitis requiring noninvasive ventilation. STUDY DESIGN Fourteen infants, median age 33 days (IQR [first and third quartiles], 25-58) were randomized to receive 7 cmH2O continuous positive airway pressure for 1 hour in the prone position or in the supine position, which was followed by cross-over to the supine position and the prone position for 1 hour, respectively. Flow, esophageal, airway, gastric, and transdiaphragmatic pressures, as well as electrical activity of the diaphragm were simultaneously recorded. The modified Wood clinical asthma score was also assessed. RESULTS Median esophageal pressure-time product per minute was significantly lower in the prone position than in the supine position (227 cmH2O*s/minute [IQR, 156-282] cmH2O*s/minute vs 353 cmH2O*s/minute [IQR, 249-386 cmH2O*s/minute]; P = .048), as were the modified Wood clinical asthma score (P = .033) and electrical activity of the diaphragm (P = .006). The neuromechanical efficiency of the diaphragm, as assessed by transdiaphramagtic pressure to electrical activity of the diaphragm swing ratio, was significantly higher in the prone position than in the supine position (1.1 cmH2O/µV [IQR, 0.9-1.3 cmH2O/µV] vs 0.7 cmH2O/µV [IQR, 0.6-1.2 cmH2O/µV], respectively; P = .022). CONCLUSIONS This study suggests a benefit of the prone position for infants with severe bronchiolitis requiring noninvasive ventilation by significantly decreasing the inspiratory effort and the metabolic cost of breathing. Further studies are needed to evaluate the potential impact of these physiological findings in a larger population. TRIAL REGISTRATION Clinicaltrials.gov: NCT02602678.
Collapse
|
11
|
|
12
|
Ferreira JC, Diniz-Silva F, Moriya HT, Alencar AM, Amato MBP, Carvalho CRR. Neurally Adjusted Ventilatory Assist (NAVA) or Pressure Support Ventilation (PSV) during spontaneous breathing trials in critically ill patients: a crossover trial. BMC Pulm Med 2017; 17:139. [PMID: 29115949 PMCID: PMC5678780 DOI: 10.1186/s12890-017-0484-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 10/31/2017] [Indexed: 12/12/2022] Open
Abstract
Background Neurally Adjusted Ventilatory Assist (NAVA) is a proportional ventilatory mode that uses the electrical activity of the diaphragm (EAdi) to offer ventilatory assistance in proportion to patient effort. NAVA has been increasingly used for critically ill patients, but it has not been evaluated during spontaneous breathing trials (SBT). We designed a pilot trial to assess the feasibility of using NAVA during SBTs, and to compare the breathing pattern and patient-ventilator asynchrony of NAVA with Pressure Support (PSV) during SBTs. Methods We conducted a crossover trial in the ICU of a university hospital in Brazil and included mechanically ventilated patients considered ready to undergo an SBT on the day of the study. Patients underwent two SBTs in randomized order: 30 min in PSV of 5 cmH2O or NAVA titrated to generate equivalent peak airway pressure (Paw), with a positive end-expiratory pressure of 5 cmH2O. The ICU team, blinded to ventilatory mode, evaluated whether patients passed each SBT. We captured flow, Paw and electrical activity of the diaphragm (EAdi) from the ventilator and used it to calculate respiratory rate (RR), tidal volume (VT), and EAdi. Detection of asynchrony events used waveform analysis and we calculated the asynchrony index as the number of asynchrony events divided by the number of neural cycles. Results We included 20 patients in the study. All patients passed the SBT in PSV, and three failed the SBT in NAVA. Five patients were reintubated and the extubation failure rate was 25% (95% CI 9–49%). Respiratory parameters were similar in the two modes: VT = 6.1 (5.5–6.5) mL/Kg in NAVA vs. 5.5 (4.8–6.1) mL/Kg in PSV (p = 0.076) and RR = 27 (17–30) rpm in NAVA vs. 26 (20–30) rpm in PSV, p = 0.55. NAVA reduced AI, with a median of 11.5% (4.2–19.7) compared to 24.3% (6.3–34.3) in PSV (p = 0.033). Conclusions NAVA reduces patient-ventilator asynchrony index and generates a respiratory pattern similar to PSV during SBTs. Patients considered ready for mechanical ventilation liberation may be submitted to an SBT in NAVA using the same objective criteria used for SBTs in PSV. Trial registration ClinicalTrials.gov (NCT01337271), registered April 12, 2011. Electronic supplementary material The online version of this article (10.1186/s12890-017-0484-5) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Juliana C Ferreira
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Fabia Diniz-Silva
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Henrique T Moriya
- Biomedical Engineering Laboratory, Escola Politécnica da Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Adriano M Alencar
- Instituto de Física, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marcelo B P Amato
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Carlos R R Carvalho
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| |
Collapse
|
13
|
Muñoz IC, Hernández AM. Cambios en la mecánica ventilatoria debidos a variaciones de la PEEP y la presión soporte: estudio en sujetos sanos bajo ventilación mecánica no invasiva. REVISTA DE LA FACULTAD DE MEDICINA 2017. [DOI: 10.15446/revfacmed.v65n2.60938] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Introducción. Por lo general, la mecánica ventilatoria se ha estimado en modo controlado con el uso de aproximaciones no adecuadas para ventilación espontánea.Objetivo. Medir los cambios de la mecánica ventilatoria ante variaciones de la presión positiva al final de la expiración (PEEP, por su sigla en inglés) y la presión soporte (PS) en ventilación mecánica no invasiva.Materiales y métodos. A través de una estrategia no invasiva, se estimó la mecánica ventilatoria bajo diferentes niveles de PEEP y PS. Para tal fin, se utilizó un simulador mecánico y se registró una base de datos de 14 sujetos sanos conectados de manera no invasiva a un ventilador mecánico.Resultados. Se obtuvieron valores medianos de resistencia y compliancia de 91.2[77.8-135.9]mL/cmH2O y 8.3[6.1-10.4]cmH2O/L/s para los 14 sujetos sanos con PEEP y PS de 0 cmH2O, respectivamente. En los incrementos de PEEP, los sujetos presentaron aumento estadísticamente significativo en la compliancia. Por el contrario, en el incremento de presión soporte, no se observaron cambios de ningún parámetro.Conclusiones. Se encontraron valores de compliancia y resistencia, acordes con los configurados en el simulador mecánico y coherentes con los reportados en la literatura en el caso de sujetos sanos. Esto resulta de gran utilidad al tomar decisiones en unidades de cuidados intensivos.
Collapse
|
14
|
Control of Respiratory Drive and Effort in Extracorporeal Membrane Oxygenation Patients Recovering from Severe Acute Respiratory Distress Syndrome. Anesthesiology 2016; 125:159-67. [DOI: 10.1097/aln.0000000000001103] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Abstract
Background
The amount of extracorporeal carbon dioxide removal may influence respiratory drive in acute respiratory distress syndrome (ARDS) patients undergoing extracorporeal membrane oxygenation (ECMO). The authors evaluated the effects of different levels of extracorporeal carbon dioxide removal in patients recovering from severe ARDS undergoing pressure support ventilation (PSV) and neurally adjusted ventilatory assist (NAVA).
Methods
The authors conducted a prospective, randomized, crossover study on eight spontaneously breathing ARDS patients undergoing venovenous ECMO since 28 ± 20 days. To modulate carbon dioxide extraction, ECMO gas flow (GF) was decreased from baseline resting protective conditions (i.e., GF100%, set to obtain pressure generated in the first 100 ms of inspiration against an occluded airway less than 2 cm H2O, respiratory rate less than or equal to 25 bpm, tidal volume less than 6 ml/kg, and peak airway pressure less than 25 cm H2O) to GF50%-GF25%-GF0% during both PSV and NAVA (random order for ventilation mode). Continuous recordings of airway pressure and flow and esophageal pressure were obtained and analyzed during all study phases.
Results
At higher levels of extracorporeal carbon dioxide extraction, pressure generated in the first 100 ms of inspiration against an occluded airway decreased from 2.8 ± 2.7 cm H2O (PSV, GF0%) and 3.0 ± 2.1 cm H2O (NAVA, GF0%) to 0.9 ± 0.5 cm H2O (PSV, GF100%) and 1.0 ± 0.8 cm H2O (NAVA, GF100%; P < 0.001) and patients’ inspiratory muscle pressure passed from 8.5 ± 6.3 and 6.5 ± 5.5 cm H2O to 4.5 ± 3.1 and 4.2 ± 3.7 cm H2O (P < 0.001). In time, decreased inspiratory drive and effort determined by higher carbon dioxide extraction led to reduction of tidal volume from 6.6 ± 0.9 and 7.5 ± 1.2 ml/kg to 4.9 ± 0.8 and 5.3 ± 1.3 ml/kg (P < 0.001) and of peak airway pressure from 21 ± 3 and 25 ± 4 cm H2O to 21 ± 3 and 21 ± 5 cm H2O (P < 0.001). Finally, transpulmonary pressure linearly decreased when the amount of carbon dioxide extracted by ECMO increased (R2 = 0.823, P < 0.001).
Conclusions
In patients recovering from ARDS undergoing ECMO, the amount of carbon dioxide removed by the artificial lung may influence spontaneous breathing. The effects of carbon dioxide removal on spontaneous breathing during the earlier acute phases of ARDS remain to be elucidated.
Collapse
|
15
|
Esophageal and transpulmonary pressure in the clinical setting: meaning, usefulness and perspectives. Intensive Care Med 2016; 42:1360-73. [PMID: 27334266 DOI: 10.1007/s00134-016-4400-x] [Citation(s) in RCA: 288] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Accepted: 05/17/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE Esophageal pressure (Pes) is a minimally invasive advanced respiratory monitoring method with the potential to guide management of ventilation support and enhance specific diagnoses in acute respiratory failure patients. To date, the use of Pes in the clinical setting is limited, and it is often seen as a research tool only. METHODS This is a review of the relevant technical, physiological and clinical details that support the clinical utility of Pes. RESULTS After appropriately positioning of the esophageal balloon, Pes monitoring allows titration of controlled and assisted mechanical ventilation to achieve personalized protective settings and the desired level of patient effort from the acute phase through to weaning. Moreover, Pes monitoring permits accurate measurement of transmural vascular pressure and intrinsic positive end-expiratory pressure and facilitates detection of patient-ventilator asynchrony, thereby supporting specific diagnoses and interventions. Finally, some Pes-derived measures may also be obtained by monitoring electrical activity of the diaphragm. CONCLUSIONS Pes monitoring provides unique bedside measures for a better understanding of the pathophysiology of acute respiratory failure patients. Including Pes monitoring in the intensivist's clinical armamentarium may enhance treatment to improve clinical outcomes.
Collapse
|
16
|
Rabec C, Emeriaud G, Amadeo A, Fauroux B, Georges M. New modes in non-invasive ventilation. Paediatr Respir Rev 2016; 18:73-84. [PMID: 26688194 DOI: 10.1016/j.prrv.2015.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 10/19/2015] [Indexed: 02/07/2023]
Abstract
Non-invasive ventilation is useful to treat some forms of respiratory failure. Hence, the number of patients receiving this treatment is steadily increasing. Considerable conceptual and technical progress has been made in the last years by manufacturers concerning this technique. This includes new features committed to improve its effectiveness as well as patient-ventilator interactions. The goal of this review is to deal with latest advances in ventilatory modes and features available for non-invasive ventilation. We present a comprehensive analysis of new modes of ventilator assistance committed to treat respiratory failure (hybrid modes) and central and complex sleep apnea (adaptive servo ventilation), and of new modes of triggering and cycling (neurally adjusted ventilatory assist). Technical aspects, modes of operation and settings of these new features as well as an exhaustive review of published data, their benefits and limits, and the potential place of these devices in clinical practice, are discussed.
Collapse
Affiliation(s)
- Claudio Rabec
- Pulmonary Departement and Respiratory Critical Care Unit, University Hospital Dijon, France; Inserm U 866, University of Burgundy, School of Medicine, Dijon, France.
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, Saint Justine Hospital, Université de Montréal, Montreal, Canada
| | - Alessandro Amadeo
- AP-HP, Hôpital Necker, Pediatric Noninvasive Ventilation and Sleep Unit, Paris, France; Paris Descartes University, France; Inserm U 955, Team 13, Créteil, France
| | - Brigitte Fauroux
- AP-HP, Hôpital Necker, Pediatric Noninvasive Ventilation and Sleep Unit, Paris, France; Paris Descartes University, France; Inserm U 955, Team 13, Créteil, France
| | - Marjolaine Georges
- Pulmonary Departement and Respiratory Critical Care Unit, University Hospital Dijon, France; Inserm U 866, University of Burgundy, School of Medicine, Dijon, France
| |
Collapse
|
17
|
Baudin F, Pouyau R, Cour-Andlauer F, Berthiller J, Robert D, Javouhey E. Neurally adjusted ventilator assist (NAVA) reduces asynchrony during non-invasive ventilation for severe bronchiolitis. Pediatr Pulmonol 2015; 50:1320-7. [PMID: 25488197 DOI: 10.1002/ppul.23139] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Revised: 09/08/2014] [Accepted: 10/30/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND To determine the prevalence of main inspiratory asynchrony events during non-invasive intermittent positive-pressure ventilation (NIV) for severe bronchiolitis. Ventilator response time and asynchrony were compared in neurally adjusted ventilator assist (NAVA) and in pressure assist/control (PAC) modes. METHODS This prospective physiological study was performed in a university hospital's paediatric intensive care unit and included 11 children (aged 35.2 ± 23 days) with respiratory syncytial virus bronchiolitis with failure of nCPAP. Patients received NIV for 2 hr in PAC mode followed by 2 hr in NAVA mode. Electrical activity of the diaphragm and pressure curves were recorded for 10 min. Trigger delay, main asynchronies (auto-triggering, double triggering, or non-triggered breaths) were analyzed, and the asynchrony index was calculated for each period. RESULTS The asynchrony index was lower during NAVA than during PAC (3 ± 3% vs. 38 ± 21%, P < 0.0001), and the trigger delay was shorter (43.9 ± 7.2 vs. 116.0 ± 38.9 ms, P < 0.0001). Ineffective efforts were significantly less frequent in NAVA mode (0.54 ± 1.5 vs. 21.8 ± 16.5 events/min, P = 0.01). Patient respiratory rates were similar, but the ventilator rate was higher in NAVA than in PAC mode (59.5 ± 17.9 vs. 49.8 ± 8.5/min, P = 0.03). The TcPCO2 baselines values (64 ± 12 mmHg vs. 62 ± 9 mmHg during NAVA, P = 0.30) were the same and their evolution over the 2 hr study period (-6 ± 10 mmHg vs. -12 ± 17 mmHg during NAVA, P = 0.36) did not differ. CONCLUSION Patient-ventilator inspiratory asynchronies and trigger delay were dramatically lower in NAVA mode than in PAC mode during NIV in infants with severe bronchiolitis.
Collapse
Affiliation(s)
- Florent Baudin
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Robin Pouyau
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Fleur Cour-Andlauer
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France.,Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Bron, France
| | - Julien Berthiller
- Pôle Information Médicale Evaluation Recherche, Hospices Civils de Lyon, Bron, France.,Epidémiologie, Pharmacologie, Investigation Clinique, Equipe d'Accueil 4129, Hospices Civils de Lyon & Université Claude Bernard Lyon 1, Lyon, France
| | | | - Etienne Javouhey
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France.,Université Claude Bernard Lyon 1, Lyon, France
| |
Collapse
|
18
|
Abstract
Purpose of review Compared with the conventional forms of partial support, neurally adjusted ventilatory assist was repeatedly shown to improve patient–ventilator synchrony and reduce the risk of overassistance, while guaranteeing adequate inspiratory effort and gas exchange. A few animal studies also suggested the potential of neurally adjusted ventilatory assist in averting the risk of ventilator-induced lung injury. Recent work adds new information on the physiological effects of neurally adjusted ventilatory assist. Recent findings Compared with pressure support, neurally adjusted ventilatory assist has been shown to improve patient–ventilator interaction and synchrony in patients with the most challenging respiratory system mechanics, such as very low compliance consequent to severe acute respiratory distress syndrome and high resistance and air trapping due to chronic airflow obstruction; enhance redistribution of the ventilation in the dependent lung regions; avert the risk of patient–ventilator asynchrony due to sedation; avoid central apneas; limit the risk of high (injurious) tidal volumes in patients with acute respiratory distress syndrome of varied severity; and improve patient–ventilator interaction and synchrony during noninvasive ventilation, irrespective of the interface utilized. Summary Several studies nowadays prove the physiological benefits of neurally adjusted ventilatory assist, as opposed to the conventional modes of partial support. Whether these advantages translate into improvement of clinical outcomes remains to be determined.
Collapse
|
19
|
Abstract
Abstract
Background:
In patients with acute respiratory distress syndrome (ARDS), the use of assisted mechanical ventilation is a subject of debate. Assisted ventilation has benefits over controlled ventilation, such as preserved diaphragm function and improved oxygenation. Therefore, higher level of “patient control” of ventilator assist may be preferable in ARDS. However, assisted modes may also increase the risk of high tidal volumes and lung-distending pressures. The current study aims to quantify how differences in freedom to control the ventilator affect lung-protective ventilation, breathing pattern variability, and patient–ventilator interaction.
Methods:
Twelve patients with ARDS were ventilated in a randomized order with assist pressure control ventilation (PCV), pressure support ventilation (PSV), and neurally adjusted ventilatory assist (NAVA). Transpulmonary pressure, tidal volume, diaphragm electrical activity, and patient–ventilator interaction were measured. Respiratory variability was assessed using the coefficient of variation of tidal volume.
Results:
During inspiration, transpulmonary pressure was slightly lower with NAVA (10.3 ± 0.7, 11.2 ± 0.7, and 9.4 ± 0.7 cm H2O for PCV, PSV, and NAVA, respectively; P < 0.01). Tidal volume was similar between modes (6.6 [5.7 to 7.0], 6.4 [5.8 to 7.0], and 6.0 [5.6 to 7.3] ml/kg for PCV, PSV, and NAVA, respectively), but respiratory variability was higher with NAVA (8.0 [6.4 to 10.0], 7.1 [5.9 to 9.0], and 17.0 [12.0 to 36.1] % for PCV, PSV, and NAVA, respectively; P < 0.001). Patient–ventilator interaction improved with NAVA (6 [5 to 8] % error) compared with PCV (29 [14 to 52] % error) and PSV (12 [9 to 27] % error); P < 0.0001.
Conclusion:
In patients with mild-to-moderate ARDS, increasing freedom to control the ventilator maintains lung-protective ventilation in terms of tidal volume and lung-distending pressure, but it improves patient–ventilator interaction and preserves respiratory variability.
Collapse
|
20
|
Liu L, Xia F, Yang Y, Longhini F, Navalesi P, Beck J, Sinderby C, Qiu H. Neural versus pneumatic control of pressure support in patients with chronic obstructive pulmonary diseases at different levels of positive end expiratory pressure: a physiological study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:244. [PMID: 26059238 PMCID: PMC4487968 DOI: 10.1186/s13054-015-0971-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 06/01/2015] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Intrinsic positive end-expiratory pressure (PEEPi) is a "threshold" load that must be overcome to trigger conventional pneumatically-controlled pressure support (PSP) in chronic obstructive pulmonary disease (COPD). Application of extrinsic PEEP (PEEPe) reduces trigger delays and mechanical inspiratory efforts. Using the diaphragm electrical activity (EAdi), neurally controlled pressure support (PSN) could hypothetically eliminate asynchrony and reduce mechanical inspiratory effort, hence substituting the need for PEEPe. The primary objective of this study was to show that PSN can reduce the need for PEEPe to improve patient-ventilator interaction and to reduce both the "pre-trigger" and "total inspiratory" neural and mechanical efforts in COPD patients with PEEPi. A secondary objective was to evaluate the impact of applying PSN on breathing pattern. METHODS Twelve intubated and mechanically ventilated COPD patients with PEEPi ≥ 5 cm H2O underwent comparisons of PSP and PSN at different levels of PEEPe (at 0 %, 40 %, 80 %, and 120 % of static PEEPi, for 12 minutes at each level on average), at matching peak airway pressure. We measured flow, airway pressure, esophageal pressure, and EAdi, and analyzed neural and mechanical efforts for triggering and total inspiration. Patient-ventilator interaction was analyzed with the NeuroSync index. RESULTS Mean airway pressure and PEEPe were comparable for PSP and PSN at same target levels. During PSP, the NeuroSync index was 29 % at zero PEEPe and improved to 21 % at optimal PEEPe (P < 0.05). During PSN, the NeuroSync index was lower (<7 %, P < 0.05) regardless of PEEPe. Both pre-trigger (P < 0.05) and total inspiratory mechanical efforts (P < 0.05) were consistently higher during PSP compared to PSN at same PEEPe. The change in total mechanical efforts between PSP at PEEPe0% and PSN at PEEPe0% was not different from the change between PSP at PEEPe0% and PSP at PEEPe80%. CONCLUSION PSN abolishes the need for PEEPe in COPD patients, improves patient-ventilator interaction, and reduces the inspiratory mechanical effort to breathe. TRIAL REGISTRATION Clinicaltrials.gov NCT02114567 . Registered 04 November 2013.
Collapse
Affiliation(s)
- Ling Liu
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
| | - Feiping Xia
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
| | - Yi Yang
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
| | - Federico Longhini
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China. .,Department of Translational Medicine, Eastern Piedmont University "A. Avogadro", Novara, Italy.
| | - Paolo Navalesi
- Department of Translational Medicine, Eastern Piedmont University "A. Avogadro", Novara, Italy. .,Anaesthesia and Intensive Care, Sant'Andrea Hospital, ASL VC, Vercelli, Italy. .,CRRF Mons. L. Novarese, Moncrivello, VC, Italy.
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada. .,Department of Pediatrics, University of Toronto, Toronto, Ontario, M5G 1X8, Canada. .,Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, Canada.
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada. .,Department of Medicine, University of Toronto, Toronto, Ontario, Canada. .,Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, Canada.
| | - Haibo Qiu
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
| |
Collapse
|
21
|
Diaphragmatic electrical activity: a new tool to assess lung hyperinflation? Anesthesiology 2014; 121:447-9. [PMID: 25046571 DOI: 10.1097/aln.0000000000000372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|