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von Düring S, Parhar KKS, Adhikari NKJ, Urner M, Kim SJ, Munshi L, Liu K, Fan E. Understanding ventilator-induced lung injury: The role of mechanical power. J Crit Care 2024; 85:154902. [PMID: 39241350 DOI: 10.1016/j.jcrc.2024.154902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 07/31/2024] [Accepted: 08/24/2024] [Indexed: 09/09/2024]
Abstract
Mechanical ventilation stands as a life-saving intervention in the management of respiratory failure. However, it carries the risk of ventilator-induced lung injury. Despite the adoption of lung-protective ventilation strategies, including lower tidal volumes and pressure limitations, mortality rates remain high, leaving room for innovative approaches. The concept of mechanical power has emerged as a comprehensive metric encompassing key ventilator parameters associated with the genesis of ventilator-induced lung injury, including volume, pressure, flow, resistance, and respiratory rate. While numerous animal and human studies have linked mechanical power and ventilator-induced lung injury, its practical implementation at the bedside is hindered by calculation challenges, lack of equation consensus, and the absence of an optimal threshold. To overcome the constraints of measuring static respiratory parameters, dynamic mechanical power is proposed for all patients, regardless of their ventilation mode. However, establishing a causal relationship is crucial for its potential implementation, and requires further research. The objective of this review is to explore the role of mechanical power in ventilator-induced lung injury, its association with patient outcomes, and the challenges and potential benefits of implementing a ventilation strategy based on mechanical power.
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Affiliation(s)
- Stephan von Düring
- Division of Critical Care Medicine, Department of Acute Medicine, Geneva University Hospitals (HUG) and Faculty of Medicine, University of Geneva, Geneva, Switzerland; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada.
| | - Ken Kuljit S Parhar
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada; O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada; Libin Cardiovascular Institute, University of Calgary, Calgary, AB, Canada.
| | - Neill K J Adhikari
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada.
| | - Martin Urner
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology & Pain Medicine, University of Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada.
| | - S Joseph Kim
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Division of Nephrology, University Health Network, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada.
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada.
| | - Kuan Liu
- Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada.
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Toronto General Hospital Research Institute, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation (IHPME), University of Toronto, Toronto, ON, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto, ON, Canada.
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2
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Marini JJ, Gattinoni L. The ventilator of the future: key principles and unmet needs. Crit Care 2024; 28:284. [PMID: 39210377 PMCID: PMC11363519 DOI: 10.1186/s13054-024-05060-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 08/07/2024] [Indexed: 09/04/2024] Open
Abstract
Persistent shortcomings of invasive positive pressure ventilation make it less than an ideal intervention. Over the course of more than seven decades, clinical experience and scientific investigation have helped define its range of hazards and limitations. Apart from compromised airway clearance and lower airway contamination imposed by endotracheal intubation, the primary hazards inherent to positive pressure ventilation may be considered in three broad categories: hemodynamic impairment, potential for ventilation-induced lung injury, and impairment of the respiratory muscle pump. To optimize care delivery, it is crucial for monitoring and machine outputs to integrate information with the potential to impact the underlying requirements of the patient and/or responses of the cardiopulmonary system to ventilatory interventions. Trending analysis, timely interventions, and closer communication with the caregiver would limit adverse clinical trajectories. Judging from the rapid progress of recent years, we are encouraged to think that insights from physiologic research and emerging technological capability may eventually address important aspects of current deficiencies.
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Affiliation(s)
- John J Marini
- Pulmonary and Critical Care Medicine, Regions Hospital and University of Minnesota, 640 Jackson St., MS 11203B, St. Paul, MN, 55101-2595, USA.
| | - Luciano Gattinoni
- Department of Anaesthesiology, University Medical Center Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Germany
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3
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Szamos K, Balla B, Pálóczi B, Enyedi A, Sessler DI, Fülesdi B, Végh T. One-lung ventilation with fixed and variable tidal volumes on oxygenation and pulmonary outcomes: A randomized trial. J Clin Anesth 2024; 95:111465. [PMID: 38581926 DOI: 10.1016/j.jclinane.2024.111465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 03/22/2024] [Accepted: 04/01/2024] [Indexed: 04/08/2024]
Abstract
OBJECTIVE Test the hypothesis that one-lung ventilation with variable tidal volume improves intraoperative oxygenation and reduces postoperative pulmonary complications after lung resection. BACKGROUND Constant tidal volume and respiratory rate ventilation can lead to atelectasis. Animal and human ARDS studies indicate that oxygenation improves with variable tidal volumes. Since one-lung ventilation shares characteristics with ARDS, we tested the hypothesis that one-lung ventilation with variable tidal volume improves intraoperative oxygenation and reduces postoperative pulmonary complications after lung resection. DESIGN Randomized trial. SETTING Operating rooms and a post-anesthesia care unit. PATIENTS Adults having elective open or video-assisted thoracoscopic lung resection surgery with general anesthesia were randomly assigned to intraoperative ventilation with fixed (n = 70) or with variable (n = 70) tidal volumes. INTERVENTIONS Patients assigned to fixed ventilation had a tidal volume of 6 ml/kgPBW, whereas those assigned to variable ventilation had tidal volumes ranging from 6 ml/kg PBW ± 33% which varied randomly at 5-min intervals. MEASUREMENTS The primary outcome was intraoperative oxygenation; secondary outcomes were postoperative pulmonary complications, mortality within 90 days of surgery, heart rate, and SpO2/FiO2 ratio. RESULTS Data from 128 patients were analyzed with 65 assigned to fixed-tidal volume ventilation and 63 to variable-tidal volume ventilation. The time-weighted average PaO2 during one-lung ventilation was 176 (86) mmHg in patients ventilated with fixed-tidal volume and 147 (72) mmHg in the patients ventilated with variable-tidal volume, a difference that was statistically significant (p < 0.01) but less than our pre-defined clinically meaningful threshold of 50 mmHg. At least one composite complication occurred in 11 (17%) of patients ventilated with variable-tidal volume and in 17 (26%) of patients assigned to fixed-tidal volume ventilation, with a relative risk of 0.67 (95% CI 0.34-1.31, p = 0.24). Atelectasis in the ventilated lung was less common with variable-tidal volumes (4.7%) than fixed-tidal volumes (20%) in the initial three postoperative days, with a relative risk of 0.24 (95% CI 0.01-0.8, p = 0.02), but there were no significant late postoperative differences. No other secondary outcomes were both statistically significant and clinically meaningful. CONCLUSION One-lung ventilation with variable tidal volume does not meaningfully improve intraoperative oxygenation, and does not reduce postoperative pulmonary complications.
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Affiliation(s)
- Katalin Szamos
- University of Debrecen, Department of Anesthesiology and Intensive Care, Debrecen, Hungary
| | - Boglárka Balla
- University of Debrecen, Department of Anesthesiology and Intensive Care, Debrecen, Hungary
| | - Balázs Pálóczi
- University of Debrecen, Department of Anesthesiology and Intensive Care, Debrecen, Hungary
| | - Attila Enyedi
- University of Debrecen, Institute of Surgery, Department of Thoracic Surgery, Debrecen, Hungary
| | - Daniel I Sessler
- Outcomes Research Consortium, Cleveland, OH, USA; Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - Béla Fülesdi
- University of Debrecen, Department of Anesthesiology and Intensive Care, Debrecen, Hungary; Outcomes Research Consortium, Cleveland, OH, USA
| | - Tamás Végh
- University of Debrecen, Department of Anesthesiology and Intensive Care, Debrecen, Hungary; Outcomes Research Consortium, Cleveland, OH, USA.
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Buiteman-Kruizinga LA, Serpa Neto A, Botta M, List SS, de Boer BH, van Velzen P, Bühler PK, Wendel Garcia PD, Schultz MJ, van der Heiden PLJ, Paulus F. Effect of automated versus conventional ventilation on mechanical power of ventilation-A randomized crossover clinical trial. PLoS One 2024; 19:e0307155. [PMID: 39078857 PMCID: PMC11288413 DOI: 10.1371/journal.pone.0307155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 06/29/2024] [Indexed: 08/02/2024] Open
Abstract
INTRODUCTION Mechanical power of ventilation, a summary parameter reflecting the energy transferred from the ventilator to the respiratory system, has associations with outcomes. INTELLiVENT-Adaptive Support Ventilation is an automated ventilation mode that changes ventilator settings according to algorithms that target a low work-and force of breathing. The study aims to compare mechanical power between automated ventilation by means of INTELLiVENT-Adaptive Support Ventilation and conventional ventilation in critically ill patients. MATERIALS AND METHODS International, multicenter, randomized crossover clinical trial in patients that were expected to need invasive ventilation > 24 hours. Patients were randomly assigned to start with a 3-hour period of automated ventilation or conventional ventilation after which the alternate ventilation mode was selected. The primary outcome was mechanical power in passive and active patients; secondary outcomes included key ventilator settings and ventilatory parameters that affect mechanical power. RESULTS A total of 96 patients were randomized. Median mechanical power was not different between automated and conventional ventilation (15.8 [11.5-21.0] versus 16.1 [10.9-22.6] J/min; mean difference -0.44 (95%-CI -1.17 to 0.29) J/min; P = 0.24). Subgroup analyses showed that mechanical power was lower with automated ventilation in passive patients, 16.9 [12.5-22.1] versus 19.0 [14.1-25.0] J/min; mean difference -1.76 (95%-CI -2.47 to -10.34J/min; P < 0.01), and not in active patients (14.6 [11.0-20.3] vs 14.1 [10.1-21.3] J/min; mean difference 0.81 (95%-CI -2.13 to 0.49) J/min; P = 0.23). CONCLUSIONS In this cohort of unselected critically ill invasively ventilated patients, automated ventilation by means of INTELLiVENT-Adaptive Support Ventilation did not reduce mechanical power. A reduction in mechanical power was only seen in passive patients. STUDY REGISTRATION Clinicaltrials.gov (study identifier NCT04827927), April 1, 2021. URL OF TRIAL REGISTRY RECORD https://clinicaltrials.gov/study/NCT04827927?term=intellipower&rank=1.
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Affiliation(s)
- Laura A. Buiteman-Kruizinga
- Department of Intensive Care, Reinier de Graaf Hospital, Delft, the Netherlands
- Department of Intensive Care, Amsterdam University Medical Centers ‘Location AMC’, Amsterdam, the Netherlands
| | - Ary Serpa Neto
- Department of Intensive Care, Amsterdam University Medical Centers ‘Location AMC’, Amsterdam, the Netherlands
- Australian and New Zealand Intensive Care–Research Centre (ANZIC–RC), Monash University, Melbourne, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Michela Botta
- Department of Intensive Care, Amsterdam University Medical Centers ‘Location AMC’, Amsterdam, the Netherlands
| | - Stephanie S. List
- Department of Intensive Care, Dijklander Hospital ‘Location Hoorn’, Hoorn, the Netherlands
| | - Ben H. de Boer
- Department of Intensive Care, Dijklander Hospital ‘Location Hoorn’, Hoorn, the Netherlands
| | - Patricia van Velzen
- Department of Intensive Care, Dijklander Hospital ‘Location Hoorn’, Hoorn, the Netherlands
| | - Philipp Karl Bühler
- Institute of Intensive Care Medicine, University Hospital Zürich, Zürich, Switzerland
| | | | - Marcus J. Schultz
- Department of Intensive Care, Amsterdam University Medical Centers ‘Location AMC’, Amsterdam, the Netherlands
- Mahidol–Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Anesthesia, General Intensive Care and Pain Management, Medical University Wien, Vienna, Austria
| | | | - Frederique Paulus
- Department of Intensive Care, Amsterdam University Medical Centers ‘Location AMC’, Amsterdam, the Netherlands
- ACHIEVE, Centre of Applied Research, Faculty of Health, Amsterdam University of Applied Sciences, Amsterdam, The Netherlands
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D'Albo R, Pozzi T, Nicolardi RV, Galizia M, Catozzi G, Ghidoni V, Donati B, Romitti F, Herrmann P, Busana M, Gattarello S, Collino F, Sonzogni A, Camporota L, Marini JJ, Moerer O, Meissner K, Gattinoni L. Mechanical power ratio threshold for ventilator-induced lung injury. Intensive Care Med Exp 2024; 12:65. [PMID: 39080225 PMCID: PMC11289208 DOI: 10.1186/s40635-024-00649-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Accepted: 07/10/2024] [Indexed: 08/02/2024] Open
Abstract
RATIONALE Mechanical power (MP) is a summary variable incorporating all causes of ventilator-induced-lung-injury (VILI). We expressed MP as the ratio between observed and normal expected values (MPratio). OBJECTIVE To define a threshold value of MPratio leading to the development of VILI. METHODS In a population of 82 healthy pigs, a threshold of MPratio for VILI, as assessed by histological variables and confirmed by using unsupervised cluster analysis was 4.5. The population was divided into two groups with MPratio above or below the threshold. MEASUREMENTS AND MAIN RESULTS We measured physiological variables every six hours. At the end of the experiment, we measured lung weight and wet-to-dry ratio to quantify edema. Histological samples were analyzed for alveolar ruptures, inflammation, alveolar edema, atelectasis. An MPratio threshold of 4.5 was associated with worse injury, lung weight, wet-to-dry ratio and fluid balance (all p < 0.001). After 48 h, in the two MPratio clusters (above or below 4.5), respiratory system elastance, mean pulmonary artery pressure and physiological dead space differed by 32%, 36% and 22%, respectively (all p < 0.001), being worse in the high MPratio group. Also, the changes in driving pressure, lung elastance, pulmonary artery occlusion pressure, central venous pressure differed by 17%, 64%, 8%, 25%, respectively (all p < 0.001). LIMITATIONS The main limitation of this study is its retrospective design. In addition, the computation for the expected MP in pigs is based on arbitrary criteria. Different values of expected MP may change the absolute value of MP ratio but will not change the concept of the existence of an injury threshold. CONCLUSIONS The concept of MPratio is a physiological and intuitive way to quantify the risk of ventilator-induced lung injury. Our results suggest that a mechanical power ratio > 4.5 MPratio in healthy lungs subjected to 48 h of mechanical ventilation appears to be a threshold for the development of ventilator-induced lung injury, as indicated by the convergence of histological, physiological, and anatomical alterations. In humans and in lungs that are already injured, this threshold is likely to be different.
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Affiliation(s)
- Rosanna D'Albo
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Tommaso Pozzi
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Rosmery V Nicolardi
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Mauro Galizia
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Giulia Catozzi
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Valentina Ghidoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Health Sciences, Section of Anesthesiology, Intensive Care and Pain Medicine, University of Florence, Florence, Italy
| | - Beatrice Donati
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Federica Romitti
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Peter Herrmann
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Mattia Busana
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Simone Gattarello
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesca Collino
- Department of Anesthesia, Intensive Care and Emergency, "City of Health and Science" Hospital, Turin, Italy
| | | | - Luigi Camporota
- Department of Adult Critical Care, Guy's and St. Thomas' NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, UK
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota and Regions Hospital, St. Paul, Minnesota, USA
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Konrad Meissner
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Luciano Gattinoni
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany.
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Pearson-Lemme J, Halibullah I, Becher T, Tingay HD, Douglas E, Fatmous M, Kenna KR, Pereira-Fantini PM, Tingay DG, Sett A. Mechanical power made simple: validating a simplified calculation of mechanical power in preterm lungs. Pediatr Res 2024:10.1038/s41390-024-03339-5. [PMID: 38886507 DOI: 10.1038/s41390-024-03339-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 04/15/2024] [Accepted: 06/04/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND The incidence of chronic lung disease is increasing, suggesting a need to explore novel ways to understand ventilator induced lung injury (VILI) in preterm infants. Mechanical power (MP) is a unifying measure of energy transferred to the respiratory system and a proposed determinant of VILI. The gold-standard method for calculating MP (geometric method) is not feasible in the clinical setting. This has prompted the derivation of simplified equations for calculating MP. OBJECTIVE To validate the agreement between a simplified calculation of MP (MPSimple) and the true MP calculated using the geometric method (MPRef). METHODS MPSimple and MPRef was calculated in mechanically ventilated preterm lambs (n = 71) and the agreement between both measures was determined using intraclass correlation coefficients (ICC), linear regression, and Bland-Altman analysis. RESULTS A strong linear relationship (adjusted R2 = 0.98), and excellent agreement (ICC = 0.99, 95% CI = 0.98-0.99) between MPSimple and MPRef was demonstrated. Bland-Altman analysis demonstrated a negligible positive bias (mean difference = 0.131 J/min·kg). The 95% limits of agreement were -0.06 to 0.32 J/min·kg. CONCLUSIONS In a controlled setting, there was excellent agreement between MPSimple and gold-standard calculations. MPSimple should be validated and explored in preterm neonates to assess the cause-effect relationship with VILI and neonatal outcomes. IMPACT STATEMENT Mechanical power (MP) unifies the individual components of ventilator induced lung injury (VILI) and provides an estimate of total energy transferred to the respiratory system during mechanical ventilation. As gold-standard calculations of mechanical power at the bedside are not feasible, alternative simplified equations have been proposed. In this study, MP calculated using a simplified equation had excellent agreement with true MP in mechanically ventilated preterm lambs. These results lay foundations to explore the role of MP in neonatal VILI and determine its relationship with short and long term respiratory outcomes.
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Affiliation(s)
- Jack Pearson-Lemme
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Newborn Services, Joan Kirner Women's and Children's, Sunshine Hospital, Western Health, Melbourne, VIC, Australia
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Ikhwan Halibullah
- Newborn Services, Joan Kirner Women's and Children's, Sunshine Hospital, Western Health, Melbourne, VIC, Australia
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Tobias Becher
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein, Schleswig-Holstein, Germany
| | - Hamish D Tingay
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Ellen Douglas
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Monique Fatmous
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Kelly R Kenna
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Prue M Pereira-Fantini
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - David G Tingay
- Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Arun Sett
- Newborn Services, Joan Kirner Women's and Children's, Sunshine Hospital, Western Health, Melbourne, VIC, Australia.
- Neonatal Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne, Melbourne, Victoria, Australia.
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7
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Sousa MLA, Katira BH, Bouch S, Hsing V, Engelberts D, Amato MBP, Post M, Brochard LJ. Limiting Overdistention or Collapse When Mechanically Ventilating Injured Lungs: A Randomized Study in a Porcine Model. Am J Respir Crit Care Med 2024; 209:1441-1452. [PMID: 38354065 DOI: 10.1164/rccm.202310-1895oc] [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: 10/29/2023] [Accepted: 02/14/2024] [Indexed: 02/16/2024] Open
Abstract
Rationale: It is unknown whether preventing overdistention or collapse is more important when titrating positive end-expiratory pressure (PEEP) in acute respiratory distress syndrome (ARDS). Objectives: To compare PEEP targeting minimal overdistention or minimal collapse or using a compromise between collapse and overdistention in a randomized trial and to assess the impact on respiratory mechanics, gas exchange, inflammation, and hemodynamics. Methods: In a porcine model of ARDS, lung collapse and overdistention were estimated using electrical impedance tomography during a decremental PEEP titration. Pigs were randomized to three groups and ventilated for 12 hours: PEEP set at ⩽3% of overdistention (low overdistention), ⩽3% of collapse (low collapse), and the crossing point of collapse and overdistention. Measurements and Main Results: Thirty-six pigs (12 per group) were included. Median (interquartile range) values of PEEP were 7 (6-8), 11 (10-11), and 15 (12-16) cm H2O in the three groups (P < 0.001). With low overdistension, 6 (50%) pigs died, whereas survival was 100% in both other groups. Cause of death was hemodynamic in nature, with high transpulmonary vascular gradient and high epinephrine requirements. Compared with the other groups, pigs surviving with low overdistension had worse respiratory mechanics and gas exchange during the entire protocol. Minimal differences existed between crossing-point and low-collapse animals in physiological parameters, but postmortem alveolar density was more homogeneous in the crossing-point group. Inflammatory markers were not significantly different. Conclusions: PEEP to minimize overdistention resulted in high mortality in an animal model of ARDS. Minimizing collapse or choosing a compromise between collapse and overdistention may result in less lung injury, with potential benefits of the compromise approach.
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Affiliation(s)
- Mayson L A Sousa
- Keenan Centre for Biomedical Research, Critical Care Department, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine and
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bhushan H Katira
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Pediatric Critical Care Medicine, Washington University in St. Louis, St. Louis, Missouri
| | - Sheena Bouch
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Vanessa Hsing
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Doreen Engelberts
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Marcelo B P Amato
- Divisão de Pneumologia, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, Brazil
- Instituto do Coração - InCor, Hospital das Clinicas, Faculade de Medicina da Universidade de São Paulo, São Paulo, Brazil; and
| | - Martin Post
- Department of Physiology, University of Toronto, Toronto, Ontario, Canada
- Translational Medicine Program, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Laurent J Brochard
- Keenan Centre for Biomedical Research, Critical Care Department, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine and
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8
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Gutiérrez L, Araya K, Becerra M, Pérez C, Valenzuela J, Lera L, Lizana PA, Del Sol M, Muñoz-Cofré R. Predictive value of invasive mechanical ventilation parameters for mortality in COVID-19 related ARDS: a retrospective cohort study. Sci Rep 2024; 14:13725. [PMID: 38877186 PMCID: PMC11178920 DOI: 10.1038/s41598-024-64725-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 06/12/2024] [Indexed: 06/16/2024] Open
Abstract
The 2019 coronavirus (COVID-19) can generate acute respiratory distress syndrome (ARDS), requiring advanced management within the Intensive Care Unit (ICU) using invasive mechanical ventilation (IMV However, managing this phenomenon has seen learning and improvements through direct experience. Therefore, this study aims were to describe the assessment of the different IMV variables in patients with post-COVID-19 hospitalized in the ICU and their relation with mortality. Observational and retrospective study. The sample was divided into two, the surviving group (SG) and the non-surviving group (NSG). Clinical data were extracted from the electronic clinical file and the respiratory therapist record sheet. The following information was obtained: Patient medical history: gender, age, co-morbidities, arterial gases, days on IMV, and IMV parameters. Out of a total of 101 patients, the total mortality was 32%. There was a significant decrease in respiratory rate (RR) (29.12 ± 4.24-26.78 ± 3.59, p = 0.006), Driving pressure (DP) (11.33 ± 2.39-9.67 ± 1.84, p = 0.002), Ventilatory rate (VR) (2.26 ± 0.66-1.89 ± 0.45, p = 0.001) and a significant rise in Static compliance (Cest) (35.49 ± 8.64-41.45 ± 9.62, p = 0.003) and relation between Arterial oxygen pressure/Inspirated oxygen fraction (PaO2/FiO2) (201.5 ± 53.98- 227.8 ± 52.11, p = 0.008) after 72 h of IMV, within the NSG compared to the SG. Apart from these points, multi-morbidity (HR = 3.208, p = 0.010) and DP (HR = 1.228, p = 0.030) and VR variables (HR = 2.267, p = 0.027) had more death probabilities. The results of this study indicate that there was a significant increase in RR, DP, VR, and CO2 and a significant drop in Cest and PaO2/FiO2 among the NSG compared with the SG. Apart from this, the DP and VR variables, multi-morbidity and being male. have more possibility of death.
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Affiliation(s)
- Luis Gutiérrez
- Servicio de Medicina Física y Rehabilitación, Hospital El Carmen de Maipú, Camino A Rinconada 1201, Santiago, Chile.
| | - Karina Araya
- Servicio de Medicina Física y Rehabilitación, Hospital El Carmen de Maipú, Camino A Rinconada 1201, Santiago, Chile
| | - Mara Becerra
- Servicio de Medicina Física y Rehabilitación, Hospital El Carmen de Maipú, Camino A Rinconada 1201, Santiago, Chile
| | - Camilo Pérez
- Servicio de Medicina Física y Rehabilitación, Hospital El Carmen de Maipú, Camino A Rinconada 1201, Santiago, Chile
| | - Jorge Valenzuela
- Servicio de Medicina Física y Rehabilitación, Hospital El Carmen de Maipú, Camino A Rinconada 1201, Santiago, Chile
| | - Lydia Lera
- Latin Division, Keiser University eCampus, Fort Lauderdale, FL, USA
| | - Pablo A Lizana
- Laboratory of Epidemiology and Morphological Sciences, Instituto de Biología, Pontificia Universidad Católica de Valparaíso, Valparaíso, Chile
| | - Mariano Del Sol
- Programa de Doctorado en Ciencias Morfológicas, Universidad de La Frontera, Temuco, Chile
| | - Rodrigo Muñoz-Cofré
- Programa de Doctorado en Ciencias Morfológicas, Universidad de La Frontera, Temuco, Chile
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9
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Adrish M, Doppalapudi S, Lvovsky D. Driving pressure decoded: Precision strategies in adult respiratory distress syndrome management. World J Crit Care Med 2024; 13:92441. [PMID: 38855266 PMCID: PMC11155505 DOI: 10.5492/wjccm.v13.i2.92441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/17/2024] [Accepted: 04/24/2024] [Indexed: 06/03/2024] Open
Abstract
Mechanical ventilation (MV) is an important strategy for improving the survival of patients with respiratory failure. However, MV is associated with aggravation of lung injury, with ventilator-induced lung injury (VILI) becoming a major concern. Thus, ventilation protection strategies have been developed to minimize complications from MV, with the goal of relieving excessive breathing workload, improving gas exchange, and minimizing VILI. By opting for lower tidal volumes, clinicians seek to strike a balance between providing adequate ventilation to support gas exchange and preventing overdistension of the alveoli, which can contribute to lung injury. Additionally, other factors play a role in optimizing lung protection during MV, including adequate positive end-expiratory pressure levels, to maintain alveolar recruitment and prevent atelectasis as well as careful consideration of plateau pressures to avoid excessive stress on the lung parenchyma.
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Affiliation(s)
- Muhammad Adrish
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, United States
| | - Sai Doppalapudi
- Department of Medicine, BronxCare Health System/Icahn School of Medicine at Mount Sinai, Bronx, NY 10467, United States
| | - Dmitry Lvovsky
- Department of Medicine, BronxCare Health System/Icahn School of Medicine at Mount Sinai, Bronx, NY 10467, United States
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10
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Aşar S, Rahim F, Rahimi P, Acicbe Ö, Tontu F, Çukurova Z. Novel Oxygenation and Saturation Indices for Mortality Prediction in COVID-19 ARDS Patients: The Impact of Driving Pressure and Mechanical Power. J Intensive Care Med 2024; 39:595-608. [PMID: 38179691 PMCID: PMC11092301 DOI: 10.1177/08850666231223498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024]
Abstract
Background: The oxygenation index (OI) and oxygen saturation index (OSI) are proven mortality predictors in pediatric and adult patients, traditionally using mean airway pressure (Pmean). We introduce novel indices, replacing Pmean with DP (ΔPinsp), MPdyn, and MPtot, assessing their potential for predicting COVID-19 acute respiratory distress syndrome (ARDS) mortality, comparing them to traditional indices. Methods: We studied 361 adult COVID-19 ARDS patients for 7 days, collecting ΔPinsp, MPdyn, and MPtot, OI-ΔPinsp, OI-MPdyn, OI-MPtot, OSI-ΔPinsp, OSI-MPdyn, and OSI-MPtot. We compared these in surviving and non-surviving patients over the first 7 intensive care unit (ICU) days using Mann-Whitney U test. Logistic regression receiver operating characteristic (ROC) analysis assessed AUC and CI values for ICU mortality on day three. We determined cut-off values using Youden's method and conducted multivariate Cox regression on parameter limits. Results: All indices showed significant differences between surviving and non-surviving patients on the third day of ICU care. The AUC values of OI-ΔPinsp were significantly higher than those of P/F and OI-Pmean (P values .0002 and <.0001, respectively). Similarly, AUC and CI values of OSI-ΔPinsp and OSI-MPdyn were significantly higher than those of SpO2/FiO2 and OSI-Pmean values (OSI-ΔPinsp: P < .0001, OSI-MPdyn: P values .047 and .028, respectively). OI-ΔPinsp, OSI-ΔPinsp, OI-MPdyn, OSI-MPdyn, OI-MPtot, and OSI-MPtot had AUC values of 0.72, 0.71, 0.69, 0.68, 0.66, and 0.64, respectively, with cut-off values associated with hazard ratios and P values of 7.06 (HR = 1.84, P = .002), 8.04 (HR = 2.00, P ≤ .0001), 7.12 (HR = 1.68, P = .001), 5.76 (HR = 1.70, P ≤ .0001), 10.43 (HR = 1.52, P = .006), and 10.68 (HR = 1.66, P = .001), respectively. Conclusions: Critical values of all indices were associated to higher ICU mortality rates and extended mechanical ventilation durations. The OI-ΔPinsp, OSI-ΔPinsp, and OSI-MPdyn indices displayed the strongest predictive capabilities for ICU mortality. These novel indices offer valuable insights for intensivists in the clinical management and decision-making process for ARDS patients.
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Affiliation(s)
- Sinan Aşar
- Department of Anesthesiology and Reanimation, Bakırköy Dr SadiKonuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Fatih Rahim
- Department of Industrial Engineering, Koç University, Istanbul, Turkey
| | - Payam Rahimi
- Department of Anesthesiology and Reanimation, Bakırköy Dr SadiKonuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Özlem Acicbe
- Department of Anesthesiology and Reanimation, Şişli HamidiyeEtfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Furkan Tontu
- Department of Anesthesiology and Reanimation, Ağrı Training and Research Hospital, Ağrı, Turkey
| | - Zafer Çukurova
- Department of Anesthesiology and Reanimation, Bakırköy Dr SadiKonuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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11
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Yoon S, Nam JS, Blank RS, Ahn HJ, Park M, Kim H, Kim HJ, Choi H, Kang HU, Lee DK, Ahn J. Association of Mechanical Energy and Power with Postoperative Pulmonary Complications in Lung Resection Surgery: A Post Hoc Analysis of Randomized Clinical Trial Data. Anesthesiology 2024; 140:920-934. [PMID: 38109657 DOI: 10.1097/aln.0000000000004879] [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: 12/20/2023]
Abstract
BACKGROUND Mechanical power (MP), the rate of mechanical energy (ME) delivery, is a recently introduced unifying ventilator parameter consisting of tidal volume, airway pressures, and respiratory rates, which predicts pulmonary complications in several clinical contexts. However, ME has not been previously studied in the perioperative context, and neither parameter has been studied in the context of thoracic surgery utilizing one-lung ventilation. METHODS The relationships between ME variables and postoperative pulmonary complications were evaluated in this post hoc analysis of data from a multicenter randomized clinical trial of lung resection surgery conducted between 2020 and 2021 (n = 1,170). Time-weighted average MP and ME (the area under the MP time curve) were obtained for individual patients. The primary analysis was the association of time-weighted average MP and ME with pulmonary complications within 7 postoperative days. Multivariable logistic regression was performed to examine the relationships between energy variables and the primary outcome. RESULTS In 1,055 patients analyzed, pulmonary complications occurred in 41% (431 of 1,055). The median (interquartile ranges) ME and time-weighted average MP in patients who developed postoperative pulmonary complications versus those who did not were 1,146 (811 to 1,530) J versus 924 (730 to 1,240) J (P < 0.001), and 6.9 (5.5 to 8.7) J/min versus 6.7 (5.2 to 8.5) J/min (P = 0.091), respectively. ME was independently associated with postoperative pulmonary complications (ORadjusted, 1.44 [95% CI, 1.16 to 1.80]; P = 0.001). However, the association between time-weighted average MP and postoperative pulmonary complications was time-dependent, and time-weighted average MP was significantly associated with postoperative pulmonary complications in cases utilizing longer periods of mechanical ventilation (210 min or greater; ORadjusted, 1.46 [95% CI, 1.11 to 1.93]; P = 0.007). Normalization of ME and time-weighted average MP either to predicted body weight or to respiratory system compliance did not alter these associations. CONCLUSIONS ME and, in cases requiring longer periods of mechanical ventilation, MP were independently associated with postoperative pulmonary complications in thoracic surgery. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Susie Yoon
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, University of Seoul National College of Medicine, Seoul, South Korea
| | - Jae-Sik Nam
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Randal S Blank
- Department of Anesthesiology, University of Virginia Health System, Charlottesville, Virginia
| | - Hyun Joo Ahn
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - MiHye Park
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Heezoo Kim
- Department of Anesthesiology and Pain Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Hye Jin Kim
- Department of Anesthesiology and Pain Medicine, and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, South Korea
| | - Hoon Choi
- Department of Anesthesiology and Pain Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Hyun-Uk Kang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Do-Kyeong Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joonghyun Ahn
- Biomedical Statistics Center, Data Science Research Institute, Research Institute for Future Medicine, Samsung Medical Center, Seoul, South Korea
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12
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Gama de Abreu M, Costa ELV. Mechanical Energy and Power: Time to Incorporate Them into Routine Monitoring of Mechanical Ventilation? Anesthesiology 2024; 140:877-880. [PMID: 38592353 DOI: 10.1097/aln.0000000000004927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Affiliation(s)
- Marcelo Gama de Abreu
- Division of Intensive Care and Resuscitation, Outcomes Research Consortium, and Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Integrated Hospital-Care Institute, Cleveland Clinic, Cleveland, Ohio
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13
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Sottile PD, Smith B, Stroh JN, Albers DJ, Moss M. Flow-Limited and Reverse-Triggered Ventilator Dyssynchrony Are Associated With Increased Tidal and Dynamic Transpulmonary Pressure. Crit Care Med 2024; 52:743-751. [PMID: 38214566 PMCID: PMC11018465 DOI: 10.1097/ccm.0000000000006180] [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] [Indexed: 01/13/2024]
Abstract
OBJECTIVES Ventilator dyssynchrony may be associated with increased delivered tidal volumes (V t s) and dynamic transpulmonary pressure (ΔP L,dyn ), surrogate markers of lung stress and strain, despite low V t ventilation. However, it is unknown which types of ventilator dyssynchrony are most likely to increase these metrics or if specific ventilation or sedation strategies can mitigate this potential. DESIGN A prospective cohort analysis to delineate the association between ten types of breaths and delivered V t , ΔP L,dyn , and transpulmonary mechanical energy. SETTING Patients admitted to the medical ICU. PATIENTS Over 580,000 breaths from 35 patients with acute respiratory distress syndrome (ARDS) or ARDS risk factors. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients received continuous esophageal manometry. Ventilator dyssynchrony was identified using a machine learning algorithm. Mixed-effect models predicted V t , ΔP L,dyn , and transpulmonary mechanical energy for each type of ventilator dyssynchrony while controlling for repeated measures. Finally, we described how V t , positive end-expiratory pressure (PEEP), and sedation (Richmond Agitation-Sedation Scale) strategies modify ventilator dyssynchrony's association with these surrogate markers of lung stress and strain. Double-triggered breaths were associated with the most significant increase in V t , ΔP L,dyn , and transpulmonary mechanical energy. However, flow-limited, early reverse-triggered, and early ventilator-terminated breaths were also associated with significant increases in V t , ΔP L,dyn , and energy. The potential of a ventilator dyssynchrony type to increase V t , ΔP L,dyn , or energy clustered similarly. Increasing set V t may be associated with a disproportionate increase in high-volume and high-energy ventilation from double-triggered breaths, but PEEP and sedation do not clinically modify the interaction between ventilator dyssynchrony and surrogate markers of lung stress and strain. CONCLUSIONS Double-triggered, flow-limited, early reverse-triggered, and early ventilator-terminated breaths are associated with increases in V t , ΔP L,dyn , and energy. As flow-limited breaths are more than twice as common as double-triggered breaths, further work is needed to determine the interaction of ventilator dyssynchrony frequency to cause clinically meaningful changes in patient outcomes.
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Affiliation(s)
- Peter D Sottile
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado | Anschutz Medical Campus, Aurora, CO, 80045
| | - Bradford Smith
- Department of Bioengineering, University of Colorado | Anschutz Medical Campus, Aurora, CO, 80045
- Division of Pediatric Pulmonary and Sleep Medicine, University of Colorado | Anschutz Medical Campus, Aurora, CO, 80045
| | - Jake N Stroh
- Department of Bioengineering, University of Colorado | Anschutz Medical Campus, Aurora, CO, 80045
| | - David J Albers
- Department of Bioengineering, University of Colorado | Anschutz Medical Campus, Aurora, CO, 80045
- Department of Biomedical Informatics, University of Colorado | Anschutz Medical Campus, Aurora, CO, 80045
| | - Marc Moss
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado | Anschutz Medical Campus, Aurora, CO, 80045
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14
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Marini JJ, Rocco PRM, Thornton LT, Crooke PS. Stress & strain in mechanically nonuniform alveoli using clinical input variables: a simple conceptual model. Crit Care 2024; 28:141. [PMID: 38679712 PMCID: PMC11057067 DOI: 10.1186/s13054-024-04918-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 04/17/2024] [Indexed: 05/01/2024] Open
Abstract
Clinicians currently monitor pressure and volume at the airway opening, assuming that these observations relate closely to stresses and strains at the micro level. Indeed, this assumption forms the basis of current approaches to lung protective ventilation. Nonetheless, although the airway pressure applied under static conditions may be the same everywhere in healthy lungs, the stresses within a mechanically non-uniform ARDS lung are not. Estimating actual tissue stresses and strains that occur in a mechanically non-uniform environment must account for factors beyond the measurements from the ventilator circuit of airway pressures, tidal volume, and total mechanical power. A first conceptual step for the clinician to better define the VILI hazard requires consideration of lung unit tension, stress focusing, and intracycle power concentration. With reasonable approximations, better understanding of the value and limitations of presently used general guidelines for lung protection may eventually be developed from clinical inputs measured by the caregiver. The primary purpose of the present thought exercise is to extend our published model of a uniform, spherical lung unit to characterize the amplifications of stress (tension) and strain (area change) that occur under static conditions at interface boundaries between a sphere's surface segments having differing compliances. Together with measurable ventilating power, these are incorporated into our perspective of VILI risk. This conceptual exercise brings to light how variables that are seldom considered by the clinician but are both recognizable and measurable might help gauge the hazard for VILI of applied pressure and power.
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Affiliation(s)
- John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, St Paul, MN, USA.
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lauren T Thornton
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, St Paul, MN, USA
| | - Philip S Crooke
- Department of Mathematics, Vanderbilt University, Nashville, TN, USA
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15
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Simonte R, Cammarota G, Vetrugno L, De Robertis E, Longhini F, Spadaro S. Advanced Respiratory Monitoring during Extracorporeal Membrane Oxygenation. J Clin Med 2024; 13:2541. [PMID: 38731069 PMCID: PMC11084162 DOI: 10.3390/jcm13092541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 04/16/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Advanced respiratory monitoring encompasses a diverse range of mini- or noninvasive tools used to evaluate various aspects of respiratory function in patients experiencing acute respiratory failure, including those requiring extracorporeal membrane oxygenation (ECMO) support. Among these techniques, key modalities include esophageal pressure measurement (including derived pressures), lung and respiratory muscle ultrasounds, electrical impedance tomography, the monitoring of diaphragm electrical activity, and assessment of flow index. These tools play a critical role in assessing essential parameters such as lung recruitment and overdistention, lung aeration and morphology, ventilation/perfusion distribution, inspiratory effort, respiratory drive, respiratory muscle contraction, and patient-ventilator synchrony. In contrast to conventional methods, advanced respiratory monitoring offers a deeper understanding of pathological changes in lung aeration caused by underlying diseases. Moreover, it allows for meticulous tracking of responses to therapeutic interventions, aiding in the development of personalized respiratory support strategies aimed at preserving lung function and respiratory muscle integrity. The integration of advanced respiratory monitoring represents a significant advancement in the clinical management of acute respiratory failure. It serves as a cornerstone in scenarios where treatment strategies rely on tailored approaches, empowering clinicians to make informed decisions about intervention selection and adjustment. By enabling real-time assessment and modification of respiratory support, advanced monitoring not only optimizes care for patients with acute respiratory distress syndrome but also contributes to improved outcomes and enhanced patient safety.
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Affiliation(s)
- Rachele Simonte
- Department of Medicine and Surgery, Università degli Studi di Perugia, 06100 Perugia, Italy; (R.S.); (E.D.R.)
| | - Gianmaria Cammarota
- Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy;
| | - Luigi Vetrugno
- Department of Medical, Oral and Biotechnological Sciences, University of Chieti-Pescara, 66100 Chieti, Italy;
| | - Edoardo De Robertis
- Department of Medicine and Surgery, Università degli Studi di Perugia, 06100 Perugia, Italy; (R.S.); (E.D.R.)
| | - Federico Longhini
- Department of Medical and Surgical Sciences, Università della Magna Graecia, 88100 Catanzaro, Italy
- Anesthesia and Intensive Care Unit, “R. Dulbecco” University Hospital, 88100 Catanzaro, Italy
| | - Savino Spadaro
- Department of Morphology, Surgery and Experimental Medicine, University of Ferrara, 44100 Ferrara, Italy;
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16
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Robateau Z, Lin V, Wahlster S. Acute Respiratory Failure in Severe Acute Brain Injury. Crit Care Clin 2024; 40:367-390. [PMID: 38432701 DOI: 10.1016/j.ccc.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Acute respiratory failure is commonly encountered in severe acute brain injury due to a multitude of factors related to the sequelae of the primary injury. The interaction between pulmonary and neurologic systems in this population is complex, often with competing priorities. Many treatment modalities for acute respiratory failure can result in deleterious effects on cerebral physiology, and secondary brain injury due to elevations in intracranial pressure or impaired cerebral perfusion. High-quality literature is lacking to guide clinical decision-making in this population, and deliberate considerations of individual patient factors must be considered to optimize each patient's care.
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Affiliation(s)
- Zachary Robateau
- Department of Neurology, University of Washington, Seattle, USA.
| | - Victor Lin
- Department of Neurology, University of Washington, Seattle, USA
| | - Sarah Wahlster
- Department of Neurology, University of Washington, Seattle, USA; Department of Neurological Surgery, University of Washington, Seattle, USA; Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA
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17
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Bates JHT, Kaczka DW, Kollisch-Singule M, Nieman GF, Gaver DP. Mechanical Power and Ventilator-induced Lung Injury: What Does Physics Have to Say? Am J Respir Crit Care Med 2024; 209:787-788. [PMID: 37729623 PMCID: PMC10995572 DOI: 10.1164/rccm.202307-1292vp] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 09/20/2023] [Indexed: 09/22/2023] Open
Affiliation(s)
| | - David W. Kaczka
- Department of Anesthesia, Department of Radiology, and Department of Biomedical Engineering, University of Iowa, Iowa City, Iowa
| | | | - Gary F. Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, New York; and
| | - Donald P. Gaver
- Department of Biomedical Engineering, Tulane University, New Orleans, Louisiana
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18
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Van Oosten JP, Francovich JE, Somhorst P, van der Zee P, Endeman H, Gommers DAMPJ, Jonkman AH. Flow-controlled ventilation decreases mechanical power in postoperative ICU patients. Intensive Care Med Exp 2024; 12:30. [PMID: 38502268 PMCID: PMC10951187 DOI: 10.1186/s40635-024-00616-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 03/08/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Mechanical power (MP) is the energy delivered by the ventilator to the respiratory system and combines factors related to the development of ventilator-induced lung injury (VILI). Flow-controlled ventilation (FCV) is a new ventilation mode using a constant low flow during both inspiration and expiration, which is hypothesized to lower the MP and to improve ventilation homogeneity. Data demonstrating these effects are scarce, since previous studies comparing FCV with conventional controlled ventilation modes in ICU patients suffer from important methodological concerns. OBJECTIVES This study aims to assess the difference in MP between FCV and pressure-controlled ventilation (PCV). Secondary aims were to explore the effect of FCV in terms of minute volume, ventilation distribution and homogeneity, and gas exchange. METHODS This is a physiological study in post-cardiothoracic surgery patients requiring mechanical ventilation in the ICU. During PCV at baseline and 90 min of FCV, intratracheal pressure, airway flow and electrical impedance tomography (EIT) were measured continuously, and hemodynamics and venous and arterial blood gases were obtained repeatedly. Pressure-volume loops were constructed for the calculation of the MP. RESULTS In 10 patients, optimized FCV versus PCV resulted in a lower MP (7.7 vs. 11.0 J/min; p = 0.004). Although FCV did not increase overall ventilation homogeneity, it did lead to an improved ventilation of the dependent lung regions. A stable gas exchange at lower minute volumes was obtained. CONCLUSIONS FCV resulted in a lower MP and improved ventilation of the dependent lung regions in post-cardiothoracic surgery patients on the ICU. Trial registration Clinicaltrials.gov identifier: NCT05644418. Registered 1 December 2022, retrospectively registered.
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Affiliation(s)
- Julien P Van Oosten
- Intensive Care Volwassenen, Erasmus Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands.
| | - Juliette E Francovich
- Intensive Care Volwassenen, Erasmus Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
- Technical Medicine Program, Delft University of Technology, Delft, The Netherlands
| | - Peter Somhorst
- Intensive Care Volwassenen, Erasmus Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Philip van der Zee
- Intensive Care Volwassenen, Erasmus Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Henrik Endeman
- Intensive Care Volwassenen, Erasmus Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Diederik A M P J Gommers
- Intensive Care Volwassenen, Erasmus Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
| | - Annemijn H Jonkman
- Intensive Care Volwassenen, Erasmus Medical Center, Dr. Molewaterplein 40, 3015, GD, Rotterdam, The Netherlands
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19
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Abram J, Spraider P, Wagner J, Putzer G, Ranalter M, Rinner S, Lindner AK, Glodny B, Hell T, Barnes T, Enk D, Martini J. Individualised flow-controlled ventilation reduces applied mechanical power and improves ventilation efficiency in a porcine intra-abdominal hypertension model. Intensive Care Med Exp 2024; 12:27. [PMID: 38451347 PMCID: PMC10920549 DOI: 10.1186/s40635-024-00608-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/23/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Aim of this study was to evaluate feasibility and effects of individualised flow-controlled ventilation (FCV), based on compliance guided pressure settings, compared to standard of pressure-controlled ventilation (PCV) in a porcine intra-abdominal hypertension (IAH) model. The primary aim of this study was to investigate oxygenation. Secondary aims were to assess respiratory and metabolic variables and lung tissue aeration. METHODS Pigs were randomly assigned to FCV (n = 9) and PCV (n = 9). IAH was induced by insufflation of air into the abdomen to induce IAH grades ranging from 0 to 3. At each IAH grade FCV was undertaken using compliance guided pressure settings, or PCV (n = 9) was undertaken with the positive end-expiratory pressure titrated for maximum compliance and the peak pressure set to achieve a tidal volume of 7 ml/kg. Gas exchange, ventilator settings and derived formulas were recorded at two timepoints for each grade of IAH. Lung aeration was assessed by a computed tomography scan at IAH grade 3. RESULTS All 18 pigs (median weight 54 kg [IQR 51-67]) completed the observation period of 4 h. Oxygenation was comparable at each IAH grade, but a significantly lower minute volume was required to secure normocapnia in FCV at all IAH grades (7.6 vs. 14.4, MD - 6.8 (95% CI - 8.5 to - 5.2) l/min; p < 0.001). There was also a significant reduction of applied mechanical power being most evident at IAH grade 3 (25.9 vs. 57.6, MD - 31.7 (95% CI - 39.7 to - 23.7) J/min; p < 0.001). Analysis of Hounsfield unit distribution of the computed tomography scans revealed a significant reduction in non- (5 vs. 8, MD - 3 (95% CI - 6 to 0) %; p = 0.032) and poorly-aerated lung tissue (7 vs. 15, MD - 6 (95% CI - 13 to - 3) %, p = 0.002) for FCV. Concomitantly, normally-aerated lung tissue was significantly increased (84 vs. 76, MD 8 (95% CI 2 to 15) %; p = 0.011). CONCLUSIONS Individualised FCV showed similar oxygenation but required a significantly lower minute volume for CO2-removal, which led to a remarkable reduction of applied mechanical power. Additionally, there was a shift from non- and poorly-aerated lung tissue to normally-aerated lung tissue in FCV compared to PCV.
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Affiliation(s)
- Julia Abram
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Patrick Spraider
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria.
| | - Julian Wagner
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Gabriel Putzer
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Manuela Ranalter
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Sarah Rinner
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
| | | | - Bernhard Glodny
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Tobias Hell
- Department of Mathematics, Faculty of Mathematics, Computer Science and Physics, University of Innsbruck, Innsbruck, Austria
| | - Tom Barnes
- Professor Emeritus, University of Greenwich, London, UK
| | - Dietmar Enk
- Faculty of Medicine, University of Münster, Münster, Germany
| | - Judith Martini
- Department of Anesthesiology and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria
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20
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González-Castro A, Medina Villanueva A, Escudero-Acha P, Fajardo Campoverdi A, Gordo Vidal F, Martin-Loeches I, Rocha AR, Romero MC, Hernández López M, Ferrando C, Protti A, Modesto I Alapont V. Comprehensive study of mechanical power in controlled mechanical ventilation: Prevalence of elevated mechanical power and component analysis. Med Intensiva 2024; 48:155-164. [PMID: 37996266 DOI: 10.1016/j.medine.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/17/2023] [Accepted: 10/12/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE To determine the prevalence of elevated mechanical power (MP) values (>17J/min) used in routine clinical practice. DESIGN Observational, descriptive, cross-sectional, analytical, multicenter, international study conducted on November 21, 2019, from 8:00 AM to 3:00 PM. NCT03936231. SETTING One hundred thirty-three Critical Care Units. PATIENTS Patients receiving invasive mechanical ventilation for any cause. INTERVENTIONS None. MAIN VARIABLES OF INTEREST Mechanical power. RESULTS A population of 372 patients was analyzed. PM was significantly higher in patients under pressure-controlled ventilation (PC) compared to volume-controlled ventilation (VC) (19.20±8.44J/min vs. 16.01±6.88J/min; p<0.001), but the percentage of patients with PM>17J/min was not different (41% vs. 35%, respectively; p=0.382). The best models according to AICcw expressing PM for patients in VC are described as follows: Surrogate Strain (Driving Pressure) + PEEP+Surrogate Strain Rate (PEEP/Flow Ratio) + Respiratory Rate. For patients in PC, it is defined as: Surrogate Strain (Expiratory Tidal Volume/PEEP) + PEEP+Surrogate Strain Rate (Surrogate Strain/Ti) + Respiratory Rate+Expiratory Tidal Volume+Ti. CONCLUSIONS A substantial proportion of mechanically ventilated patients may be at risk of experiencing elevated levels of mechanical power. Despite observed differences in mechanical power values between VC and PC ventilation, they did not result in a significant disparity in the prevalence of high mechanical power values.
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Affiliation(s)
| | | | - Patricia Escudero-Acha
- Department of Intensive Medicine, Hospital Universitario Marqués de Valdecilla, Santander, Spain
| | | | - Federico Gordo Vidal
- Department of Intensive Medicine, Hospital Universitario del Henares, Coslada-Madrid, Research Group for Critical Pathology, Universidad Francisco de Vitoria, Madrid, Spain
| | - Ignacio Martin-Loeches
- JFICMI, Consultant in Intensive Care Medicine, St James's University Hospital, Dublin, Ireland
| | - Angelo Roncalli Rocha
- Rehabilitation Division, Hélvio Auto Hospital, Alagoas, Brazil; University Center Cesmac, Alagoas, Brazil
| | - Marta Costa Romero
- Neonatology Department, Hospital Universitario de Cabueñes, Gijón, Spain
| | | | - Carlos Ferrando
- Anesthesiology and Resuscitation Service, Clinic University Hospital of Barcelona, Spain; CIBER Respiratory Diseases, ISCIII, Madrid, Spain
| | - Alessandro Protti
- IRCCS Humanitas Research Hospital, Rozzano, Milano, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milano, Italy
| | - Vicent Modesto I Alapont
- Department of Anesthesiology and Pediatric Critical Care, Hospital Universitari i Politecnic La Fe de Valencia, Spain
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21
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Solà MB, Fernández RF. Mechanical Power or the not harming power. Med Intensiva 2024; 48:131-132. [PMID: 38395691 DOI: 10.1016/j.medine.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Affiliation(s)
- Montse Batlle Solà
- Critical Care Department, Althaia Xarxa Assistencial Universitària Manresa, Manresa, Barcelona, Spain; Grupo 33, Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
| | - Rafael Fernández Fernández
- Grupo 33, Centro de Investigaciones Biomédicas en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain; Institut d'Investigació i Innovació I3PT, Sabadell, Spain.
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22
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El-Khatib M, Zeeni C, Shebbo FM, Karam C, Safi B, Toukhtarian A, Nafeh NA, Mkhayel S, Shadid CA, Chalhoub S, Beresian J. Intraoperative mechanical power and postoperative pulmonary complications in low-risk surgical patients: a prospective observational cohort study. BMC Anesthesiol 2024; 24:82. [PMID: 38413871 PMCID: PMC10898029 DOI: 10.1186/s12871-024-02449-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 02/08/2024] [Indexed: 02/29/2024] Open
Abstract
BACKGROUND Inadequate intraoperative mechanical ventilation (MV) can lead to ventilator-induced lung injury and increased risk for postoperative pulmonary complications (PPCs). Mechanical power (MP) was shown to be a valuable indicator for MV outcomes in critical care patients. The aim of this study is to assess the association between intraoperative MP in low-risk surgical patients undergoing general anesthesia and PPCs. METHODS Two-hundred eighteen low-risk surgical patients undergoing general anesthesia for elective surgery were included in the study. Intraoperative mechanical ventilatory support parameters were collected for all patients. Postoperatively, patients were followed throughout their hospital stay and up to seven days post discharge for the occurrence of any PPCs. RESULTS Out of 218 patients, 35% exhibited PPCs. The average body mass index, tidal volume per ideal body weight, peak inspiratory pressure, and MP were significantly higher in the patients with PPCs than in the patients without PPCs (30.3 ± 8.1 kg/m2 vs. 26.8 ± 4.9 kg.m2, p < 0.001; 9.1 ± 1.9 ml/kg vs. 8.6 ± 1.4 ml/kg, p = 0.02; 20 ± 4.9 cmH2O vs. 18 ± 3.7 cmH2O, p = 0.001; 12.9 ± 4.5 J/min vs. 11.1 ± 3.7 J/min, p = 0.002). A multivariable regression analysis revealed MP as the sole significant predictor for the risk of postoperative pulmonary complications [OR 1.1 (95% CI 1.0-1.2, p = 0.036]. CONCLUSIONS High intraoperative mechanical power is a risk factor for developing postoperative pulmonary complications. Furthermore, intraoperative mechanical power is superior to other traditional mechanical ventilation variables in identifying surgical patients who are at risk for developing postoperative pulmonary complications. CLINICAL TRIAL REGISTRATION NCT03551899; 24/02/2017.
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Affiliation(s)
- Mohamad El-Khatib
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Carine Zeeni
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Fadia M Shebbo
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Cynthia Karam
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Bilal Safi
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Aline Toukhtarian
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Nancy Abou Nafeh
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Samar Mkhayel
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Carol Abi Shadid
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon
| | - Sana Chalhoub
- Department of Emergency Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jean Beresian
- Department of Anesthesiology and Pain Medicine, American University of Beirut Medical Center, PO-Box: 11-0236, Beirut, 1107 2020, Lebanon.
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23
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Mounier R, Diop S, Kallel H, Constantin JM, Roujansky A. Tidal volume in mechanically ventilated patients: Searching for Cinderella's shoe rather than 6 mL/kg for all. Anaesth Crit Care Pain Med 2024; 43:101356. [PMID: 38365168 DOI: 10.1016/j.accpm.2024.101356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/25/2024] [Accepted: 01/30/2024] [Indexed: 02/18/2024]
Affiliation(s)
- R Mounier
- Department of Anaesthesiology and Critical Care, Georges Pompidou European Hospital, Paris, France; Université Paris, Paris, France; INSERM U955, Équipe 15, Institut Mondor de la Recherche Biomédicale, Université Paris-Est-Créteil, France.
| | - S Diop
- Department of Anesthesiology, Marie Lannelongue Hospital, Paris Saint Joseph Hospital, 133 Avenue de la Résistance, 92350 Le Plessis Robinson, France; Cardiothoracic Intensive Care Unit. Marie Lannelongue Hospital, Paris Saint Joseph Hospital, 133 Avenue de la Résistance, 92350 Le Plessis Robinson, France
| | - H Kallel
- Réanimation Polyvalente, Centre Hospitalier de Cayenne, Cayenne, French Guiana; Tropical Biome et Immunopathologie CNRS UMR-9017, Inserm U 1019, Université de Guyane, French Guiana
| | - J M Constantin
- Department of Anaesthesiology and Critical Care, Pitié-Salpêtrière Hospital, Paris, France; Sorbonne University, GRC 29, AP-HP, DMU DREAM, Paris, France
| | - A Roujansky
- Réanimation Polyvalente, Centre Hospitalier de Cayenne, Cayenne, French Guiana; Tropical Biome et Immunopathologie CNRS UMR-9017, Inserm U 1019, Université de Guyane, French Guiana
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24
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Scharffenberg M, Mandelli M, Bluth T, Simonassi F, Wittenstein J, Teichmann R, Birr K, Kiss T, Ball L, Pelosi P, Schultz MJ, Gama de Abreu M, Huhle R. Respiratory mechanics and mechanical power during low vs. high positive end-expiratory pressure in obese surgical patients - A sub-study of the PROBESE randomized controlled trial. J Clin Anesth 2024; 92:111242. [PMID: 37833194 DOI: 10.1016/j.jclinane.2023.111242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/21/2023] [Accepted: 08/26/2023] [Indexed: 10/15/2023]
Abstract
STUDY OBJECTIVE We aimed to characterize intra-operative mechanical ventilation with low or high positive end-expiratory pressure (PEEP) and recruitment manoeuvres (RM) regarding intra-tidal recruitment/derecruitment and overdistension using non-linear respiratory mechanics, and mechanical power in obese surgical patients enrolled in the PROBESE trial. DESIGN Prospective, two-centre substudy of the international, multicentre, two-arm, randomized-controlled PROBESE trial. SETTING Operating rooms of two European University Hospitals. PATIENTS Forty-eight adult obese patients undergoing abdominal surgery. INTERVENTIONS Intra-operative protective ventilation with either PEEP of 12 cmH2O and repeated RM (HighPEEP+RM) or 4 cmH2O without RM (LowPEEP). MEASUREMENTS The index of intra-tidal recruitment/de-recruitment and overdistension (%E2) as well as airway pressure, tidal volume (VT), respiratory rate (RR), resistance, elastance, and mechanical power (MP) were calculated from respiratory signals recorded after anesthesia induction, 1 h thereafter, and end of surgery (EOS). MAIN RESULTS Twenty-four patients were analyzed in each group. PEEP was higher (mean ± SD, 11.7 ± 0.4 vs. 3.7 ± 0.6 cmH2O, P < 0.001) and driving pressure lower (12.8 ± 3.5 vs. 21.7 ± 6.8 cmH2O, P < 0.001) during HighPEEP+RM than LowPEEP, while VT and RR did not differ significantly (7.3 ± 0.6 vs. 7.4 ± 0.8 ml∙kg-1, P = 0.835; and 14.6 ± 2.5 vs. 15.7 ± 2.0 min-1, P = 0.150, respectively). %E2 was higher in HighPEEP+RM than in LowPEEP following induction (-3.1 ± 7.2 vs. -12.4 ± 10.2%; P < 0.001) and subsequent timepoints. Total resistance and elastance (13.3 ± 3.8 vs. 17.7 ± 6.8 cmH2O∙l∙s-2, P = 0.009; and 15.7 ± 5.5 vs. 28.5 ± 8.4 cmH2O∙l, P < 0.001, respectively) were lower during HighPEEP+RM than LowPEEP. Additionally, MP was lower in HighPEEP+RM than LowPEEP group (5.0 ± 2.2 vs. 10.4 ± 4.7 J∙min-1, P < 0.001). CONCLUSIONS In this sub-cohort of PROBESE, intra-operative ventilation with high PEEP and RM reduced intra-tidal recruitment/de-recruitment as well as driving pressure, elastance, resistance, and mechanical power, as compared with low PEEP. TRIAL REGISTRATION The PROBESE study was registered at www. CLINICALTRIALS gov, identifier: NCT02148692 (submission for registration on May 23, 2014).
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Affiliation(s)
- Martin Scharffenberg
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Maura Mandelli
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16131 Genoa, Italy
| | - Thomas Bluth
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Francesca Simonassi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16131 Genoa, Italy
| | - Jakob Wittenstein
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Robert Teichmann
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Katharina Birr
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Thomas Kiss
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany; Department of Anaesthesiology, Intensive-, Pain- and Palliative Care Medicine, Radebeul Hospital, Academic Hospital of the Technische Universität Dresden, Heinrich-Zille-Strasse 13, 01445 Radebeul, Germany
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16131 Genoa, Italy; Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Largo Rosanna Benzi, 10, 16132 Genoa, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Largo Rosanna Benzi 8, 16131 Genoa, Italy; Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Largo Rosanna Benzi, 10, 16132 Genoa, Italy
| | - Marcus J Schultz
- Department of Intensive Care, Laboratory of Experimental Intensive Care & Anesthesiology (L E I C A), Amsterdam University Medical Centers, location AMC, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands
| | - Marcelo Gama de Abreu
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany; Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, 44195, OH, USA; Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, 44195, OH, USA.
| | - Robert Huhle
- Department of Anaesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307 Dresden, Germany
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25
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Rubulotta F, Blanch Torra L, Naidoo KD, Aboumarie HS, Mathivha LR, Asiri AY, Sarlabous Uranga L, Soussi S. Mechanical Ventilation, Past, Present, and Future. Anesth Analg 2024; 138:308-325. [PMID: 38215710 DOI: 10.1213/ane.0000000000006701] [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: 01/14/2024]
Abstract
Mechanical ventilation (MV) has played a crucial role in the medical field, particularly in anesthesia and in critical care medicine (CCM) settings. MV has evolved significantly since its inception over 70 years ago and the future promises even more advanced technology. In the past, ventilation was provided manually, intermittently, and it was primarily used for resuscitation or as a last resort for patients with severe respiratory or cardiovascular failure. The earliest MV machines for prolonged ventilatory support and oxygenation were large and cumbersome. They required a significant amount of skills and expertise to operate. These early devices had limited capabilities, battery, power, safety features, alarms, and therefore these often caused harm to patients. Moreover, the physiology of MV was modified when mechanical ventilators moved from negative pressure to positive pressure mechanisms. Monitoring systems were also very limited and therefore the risks related to MV support were difficult to quantify, predict and timely detect for individual patients who were necessarily young with few comorbidities. Technology and devices designed to use tracheostomies versus endotracheal intubation evolved in the last century too and these are currently much more reliable. In the present, positive pressure MV is more sophisticated and widely used for extensive period of time. Modern ventilators use mostly positive pressure systems and are much smaller, more portable than their predecessors, and they are much easier to operate. They can also be programmed to provide different levels of support based on evolving physiological concepts allowing lung-protective ventilation. Monitoring systems are more sophisticated and knowledge related to the physiology of MV is improved. Patients are also more complex and elderly compared to the past. MV experts are informed about risks related to prolonged or aggressive ventilation modalities and settings. One of the most significant advances in MV has been protective lung ventilation, diaphragm protective ventilation including noninvasive ventilation (NIV). Health care professionals are familiar with the use of MV and in many countries, respiratory therapists have been trained for the exclusive purpose of providing safe and professional respiratory support to critically ill patients. Analgo-sedation drugs and techniques are improved, and more sedative drugs are available and this has an impact on recovery, weaning, and overall patients' outcome. Looking toward the future, MV is likely to continue to evolve and improve alongside monitoring techniques and sedatives. There is increasing precision in monitoring global "patient-ventilator" interactions: structure and analysis (asynchrony, desynchrony, etc). One area of development is the use of artificial intelligence (AI) in ventilator technology. AI can be used to monitor patients in real-time, and it can predict when a patient is likely to experience respiratory distress. This allows medical professionals to intervene before a crisis occurs, improving patient outcomes and reducing the need for emergency intervention. This specific area of development is intended as "personalized ventilation." It involves tailoring the ventilator settings to the individual patient, based on their physiology and the specific condition they are being treated for. This approach has the potential to improve patient outcomes by optimizing ventilation and reducing the risk of harm. In conclusion, MV has come a long way since its inception, and it continues to play a critical role in anesthesia and in CCM settings. Advances in technology have made MV safer, more effective, affordable, and more widely available. As technology continues to improve, more advanced and personalized MV will become available, leading to better patients' outcomes and quality of life for those in need.
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Affiliation(s)
- Francesca Rubulotta
- From the Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada
| | - Lluis Blanch Torra
- Department of Critical Care, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Kuban D Naidoo
- Division of Critical Care, University of Witwatersrand, Johannesburg, South Africa
| | - Hatem Soliman Aboumarie
- Department of Anaesthetics, Critical Care and Mechanical Circulatory Support, Harefield Hospital, Royal Brompton and Harefield Hospitals, London, United Kingdom
- School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, United Kingdom
| | - Lufuno R Mathivha
- Department of Anaesthetics, Critical Care and Mechanical Circulatory Support, The Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand
| | - Abdulrahman Y Asiri
- Department of Internal Medicine and Critical Care, King Khalid University Medical City, Abha, Saudi Arabia
- Department of Critical Care Medicine, McGill University
| | - Leonardo Sarlabous Uranga
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Sabri Soussi
- Department of Anesthesia and Pain Management, University Health Network - Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto
- UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Institut national de la santé et de la recherche médicale (INSERM), Université de Paris Cité, France
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26
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Sim JK, Lee SM, Kang HK, Kim KC, Kim YS, Kim YS, Lee WY, Park S, Park SY, Park JH, Sim YS, Lee K, Lee YJ, Lee JH, Lee HB, Lim CM, Choi WI, Hong JY, Song WJ, Suh GY. Association between mechanical power and intensive care unit mortality in Korean patients under pressure-controlled ventilation. Acute Crit Care 2024; 39:91-99. [PMID: 38303581 PMCID: PMC11002610 DOI: 10.4266/acc.2023.00871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2024] [Revised: 12/11/2023] [Accepted: 12/13/2023] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND Mechanical power (MP) has been reported to be associated with clinical outcomes. Because the original MP equation is derived from paralyzed patients under volume-controlled ventilation, its application in practice could be limited in patients receiving pressure-controlled ventilation (PCV). Recently, a simplified equation for patients under PCV was developed. We investigated the association between MP and intensive care unit (ICU) mortality. METHODS We conducted a retrospective analysis of Korean data from the Fourth International Study of Mechanical Ventilation. We extracted data of patients under PCV on day 1 and calculated MP using the following simplified equation: MPPCV = 0.098 ∙ respiratory rate ∙ tidal volume ∙ (ΔPinsp + positive end-expiratory pressure), where ΔPinsp is the change in airway pressure during inspiration. Patients were divided into survivors and non-survivors and then compared. Multivariable logistic regression was performed to determine association between MPPCV and ICU mortality. The interaction of MPPCV and use of neuromuscular blocking agent (NMBA) was also analyzed. RESULTS A total of 125 patients was eligible for final analysis, of whom 38 died in the ICU. MPPCV was higher in non-survivors (17.6 vs. 26.3 J/min, P<0.001). In logistic regression analysis, only MPPCV was significantly associated with ICU mortality (odds ratio, 1.090; 95% confidence interval, 1.029-1.155; P=0.003). There was no significant effect of the interaction between MPPCV and use of NMBA on ICU mortality (P=0.579). CONCLUSIONS MPPCV is associated with ICU mortality in patients mechanically ventilated with PCV mode, regardless of NMBA use.
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Affiliation(s)
- Jae Kyeom Sim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyung Koo Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Kyung Chan Kim
- Department of Internal Medicine, Daegu Catholic University Medical Center, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Young Sam Kim
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Disease, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yun Seong Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea
| | - Won-Yeon Lee
- Divison of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Yonsei University Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Sunghoon Park
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - So Young Park
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Ju-Hee Park
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Yun Su Sim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Hallym University Kangnam Sacred Heart Hospital, Seoul, Korea
| | - Kwangha Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Yeon Joo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jin Hwa Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Heung Bum Lee
- Division of Respiratory Disease and Critical Care Medicine, Department of Internal Medicine, Jeonbuk National University Medical School and Hospital, Jeonju, Korea
| | - Chae-Man Lim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won-Il Choi
- Department of Internal Medicine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Korea
| | - Ji Young Hong
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Chuncheon Sacred Heart Hospital, Hallym University Medical Center, Chuncheon, Korea
| | - Won Jun Song
- Department of Critical Care Medicine, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Korea
| | - Gee Young Suh
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Menga LS, Subirà C, Wong A, Sousa M, Brochard LJ. Setting positive end-expiratory pressure: does the 'best compliance' concept really work? Curr Opin Crit Care 2024; 30:20-27. [PMID: 38085857 DOI: 10.1097/mcc.0000000000001121] [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 Determining the optimal positive end-expiratory pressure (PEEP) setting remains a central yet debated issue in the management of acute respiratory distress syndrome (ARDS).The 'best compliance' strategy set the PEEP to coincide with the peak respiratory system compliance (or 2 cmH 2 O higher) during a decremental PEEP trial, but evidence is conflicting. RECENT FINDINGS The physiological rationale that best compliance is always representative of functional residual capacity and recruitment has raised serious concerns about its efficacy and safety, due to its association with increased 28-day all-cause mortality in a randomized clinical trial in ARDS patients.Moreover, compliance measurement was shown to underestimate the effects of overdistension, and neglect intra-tidal recruitment, airway closure, and the interaction between lung and chest wall mechanics, especially in obese patients. In response to these concerns, alternative approaches such as recruitment-to-inflation ratio, the nitrogen wash-in/wash-out technique, and electrical impedance tomography (EIT) are gaining attention to assess recruitment and overdistention more reliably and precisely. SUMMARY The traditional 'best compliance' strategy for determining optimal PEEP settings in ARDS carries risks and overlooks some key physiological aspects. The advent of new technologies and methods presents more reliable strategies to assess recruitment and overdistention, facilitating personalized approaches to PEEP optimization.
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Affiliation(s)
- Luca S Menga
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
- Università Cattolica del Sacro Cuore, Facoltà di Medicina e Chirurgia, Anesthesiology and Intensive Care Medicine
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Anesthesia, Emergency and Intensive Care Medicine, Roma, Italy
| | - Carles Subirà
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid
- Critical Care Department, Althaia Xarxa Assistencial Universitària de Manresa, IRIS Research Institute, Manresa, Spain
- Grup de Recerca de Malalt Crític (GMC). Institut de Recerca Biomèdica Catalunya Central IRIS-CC
| | - Alfred Wong
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Mayson Sousa
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
| | - Laurent J Brochard
- St Michael's Hospital, Li Ka Shing Knowledge Institute, Keenan Research Centre
- University of Toronto, Interdepartmental Division of Critical Care Medicine, Toronto, Ontario, Canada
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Shaikh FAR, Ramaswamy KN, Chirla DK, Venkataraman ST, Kneyber MCJ. Mechanical power and normalized mechanical power in pediatric acute respiratory distress syndrome. Front Pediatr 2024; 12:1293639. [PMID: 38298612 PMCID: PMC10829106 DOI: 10.3389/fped.2024.1293639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/03/2024] [Indexed: 02/02/2024] Open
Abstract
Background Mechanical power (MP) refers to the energy transmitted over time to the respiratory system and serves as a unifying determinant of ventilator-induced lung injury. MP normalization is required to account for developmental changes in children. We sought to examine the relationship between mechanical energy (MEBW), MP normalized to body weight (MPBW), and MP normalized to respiratory compliance (MPCRS) concerning the severity and outcomes of pediatric acute respiratory distress syndrome (pARDS). Method In this retrospective study, children aged 1 month to 18 years diagnosed with pARDS who underwent pressure-control ventilation for at least 24 h between January 2017 and September 2020 were enrolled. We calculated MP using Becher's equation. Multivariable logistic regression analysis adjusted for age, pediatric organ dysfunction score, and oxygenation index (OI) was performed to determine the independent association of MP and its derivatives 24 h after diagnosing pARDS with 28-day mortality. The association was also studied for 28 ventilator-free days (VFD-28) and the severity of pARDS in terms of OI. Results Out of 246 admitted with pARDS, 185 were eligible, with an overall mortality of 43.7%. Non-survivors exhibited higher severity of illness, as evidenced by higher values of MP, MPBW, and MEBW. Multivariable logistic regression analysis showed that only MEBW but not MP, MPBW, or MPCRS at 24 h was independently associated with mortality [adjusted OR: 1.072 (1.002-1.147), p = 0.044]. However, after adjusting for the type of pARDS, MEBW was not independently associated with mortality [adjusted OR: 1.061 (0.992-1.136), p = 0.085]. After adjusting for malnutrition, only MP at 24 h was found to be independently associated. Only MPCRS at 1-4 and 24 h but not MP, MPBW, or MEBW at 24 h of diagnosing pARDS was significantly correlated with VFD-28. Conclusions Normalization of MP is better related to outcomes and severity of pARDS than non-normalized MP. Malnutrition can be a significant confounding factor in resource-limited settings.
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Affiliation(s)
- Farhan A. R. Shaikh
- Department of Pediatric Intensive Care, Rainbow Children’s Hospital, Hyderabad, India
| | - Karthik N. Ramaswamy
- Department of Pediatric Intensive Care, Rainbow Children’s Hospital, Chennai, India
| | - Dinesh K. Chirla
- Department of Pediatric Intensive Care, Rainbow Children’s Hospital, Hyderabad, India
| | - Shekhar T. Venkataraman
- Departments of Critical Care Medicine and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Martin C. J. Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children’s Hospital, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Critical Care, Anaesthesiology, Peri-Operative & Emergency Medicine (CAPE), University of Groningen, Groningen, Netherlands
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Xie Y, Shi J, Liu S, Chen X, Wang Y, Li X, Yan Y. Association of elastic power in mechanical ventilation with the severity of acute respiratory distress syndrome: a retrospective study. Eur J Med Res 2024; 29:5. [PMID: 38173033 PMCID: PMC10763103 DOI: 10.1186/s40001-023-01577-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 12/07/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Mechanical power (MP) is the total energy released into the entire respiratory system per minute which mainly comprises three components: elastic static power, Elastic dynamic power and resistive power. However, the energy to overcome resistance to the gas flow is not the key factor in causing lung injury, but the elastic power (EP) which generates the baseline stretch of the lung fibers and overcomes respiratory system elastance may be closely related to the ARDS severity. Thus, this study aimed to investigate whether EP is superior to other ventilator variables for predicting the severity of lung injury in ARDS patients. METHODS We retrieved patient data from the Medical Information Mart for Intensive Care III (MIMIC-III) database. The retrieved data involved adults (≥ 18 years) diagnosed with ARDS and subjected to invasive mechanical ventilation for ≥ 48 h. We employed univariate and multivariate logistic regression analyses to investigate the correlation between EP and development of moderate-severe ARDS. Furthermore, we utilized restricted cubic spline models to assess whether there is a linear association between EP and incidence of moderate-severe ARDS. In addition, we employed a stratified linear regression model and likelihood ratio test in subgroups to identify potential modifications and interactions. RESULTS Moderate-severe ARDS occurred in 73.4% (296/403) of the patients analyzed. EP and MP were significantly associated with moderate-severe ARDS (odds ratio [OR] 1.21, 95% confidence interval [CI] 1.15-1.28, p < 0.001; and OR 1.15, 95%CI 1.11-1.20, p < 0.001; respectively), but EP showed a higher area-under-curve (95%CI 0.72-0.82, p < 0.001) than plateau pressure, driving pressure, and static lung compliance in predicting ARDS severity. The optimal cutoff value for EP was 14.6 J/min with a sensitivity of 75% and specificity of 66%. Quartile analysis revealed that the relationship between EP and ARDS severity remained robust and reliable in subgroup analysis. CONCLUSION EP is a good ventilator variable associated with ARDS severity and can be used for grading ARDS severity. Close monitoring of EP is advised in patients undergoing mechanical ventilation. Additional experimental trials are needed to investigate whether adjusting ventilator variables according to EP can yield significant improvements in clinical outcomes.
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Affiliation(s)
- Yongpeng Xie
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang, 222000, Jiangsu, China
| | - Jiaxin Shi
- Department of Respiratory and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang, 222000, Jiangsu, China
| | - Suxia Liu
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang, 222000, Jiangsu, China
| | - Xiaobing Chen
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang, 222000, Jiangsu, China
| | - Yanli Wang
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang, 222000, Jiangsu, China
| | - Xiaomin Li
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang, 222000, Jiangsu, China.
| | - Yao Yan
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang, 222000, Jiangsu, China.
- Department of Critical Care Medicine, The Second people,s Hospital of Lianyungang City, Lianyungang, 222000, Jiangsu, China.
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30
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Collins PD, Giosa L, Camporota L, Barrett NA. State of the art: Monitoring of the respiratory system during veno-venous extracorporeal membrane oxygenation. Perfusion 2024; 39:7-30. [PMID: 38131204 DOI: 10.1177/02676591231210461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Monitoring the patient receiving veno-venous extracorporeal membrane oxygenation (VV ECMO) is challenging due to the complex physiological interplay between native and membrane lung. Understanding these interactions is essential to understand the utility and limitations of different approaches to respiratory monitoring during ECMO. We present a summary of the underlying physiology of native and membrane lung gas exchange and describe different tools for titrating and monitoring gas exchange during ECMO. However, the most important role of VV ECMO in severe respiratory failure is as a means of avoiding further ergotrauma. Although optimal respiratory management during ECMO has not been defined, over the last decade there have been advances in multimodal respiratory assessment which have the potential to guide care. We describe a combination of imaging, ventilator-derived or invasive lung mechanic assessments as a means to individualise management during ECMO.
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Affiliation(s)
- Patrick Duncan Collins
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Lorenzo Giosa
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
| | - Luigi Camporota
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
| | - Nicholas A Barrett
- Department of Critical Care Medicine, Guy's and St Thomas' National Health Service Foundation Trust, London, UK
- Centre for Human and Applied Physiological Sciences, School of Basic and Medical Biosciences, King's College London, London, UK
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31
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Ofoma UR. Mechanical Power and Safer Lung Ventilation: Not Ready for Prime Time. Crit Care Med 2024; 52:150-153. [PMID: 38095523 PMCID: PMC10751058 DOI: 10.1097/ccm.0000000000006064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Affiliation(s)
- Uchenna R Ofoma
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, MO
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32
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Acicbe Ö, Özgür CY, Rahimi P, Canan E, Aşar S, Çukurova Z. The effect of inspiratory rise time on mechanical power calculations in pressure control ventilation: dynamic approach. Intensive Care Med Exp 2023; 11:98. [PMID: 38117345 PMCID: PMC10733269 DOI: 10.1186/s40635-023-00584-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 12/14/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Mechanical power may serve as a valuable parameter for predicting ventilation-induced injury in mechanically ventilated patients. Over time, several equations have been developed to calculate power in both volume control ventilation (VCV) and pressure control ventilation (PCV). Among these equations, the linear model mechanical power equation (MPLM) closely approximates the reference method when applied in PCV. The dynamic mechanical power equation (MPdyn) computes power by utilizing the ventilatory work of breathing parameter (WOBv), which is automatically measured by the mechanical ventilator. In our study, conducted in patients with Covid-19 Acute Respiratory Distress Syndrome (C-ARDS), we calculated mechanical power using both the MPLM and MPdyn equations, employing different inspiratory rise times (Tslope) at intervals of 5%, ranging from 5 to 20% and compared the obtained results. RESULTS In our analysis, we used univariate linear regression at both I:E ratios of 1:2 and 1:1, considering all Tslope values. These analyses revealed that the MPdyn and MPLM equations exhibited strong correlations, with R2 values exceeding 0.96. Furthermore, our Bland-Altman analysis, which compared the power values derived from the MPdyn and MPLM equations for patient averages and all measurements, revealed a mean difference of -0.42 ± 0.41 J/min (equivalent to 2.6% ± 2.3%, p < 0.0001) and -0.39 ± 0.57 J/min (equivalent to 3.6% ± 3.5%, p < 0.0001), respectively. While there was a statistically significant difference between the equations in both absolute value and relative proportion, this difference was not considered clinically relevant. Additionally, we observed that each 5% increase in Tslope time corresponded to a decrease in mechanical power values by approximately 1 J/min. CONCLUSIONS The differences between mechanical power values calculated using the MPdyn and MPLM equations at various Tslope durations were determined to lack clinical significance. Consequently, for practical and continuous mechanical power estimation in Pressure-Controlled Ventilation (PCV) mode, the MPdyn equation presents itself as a viable option. It is important to note that as Tslope times increased, the calculated mechanical power exhibited a clinically relevant decrease.
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Affiliation(s)
- Özlem Acicbe
- Department of Anesthesiology and Reanimation, Şişli Hamidiye Etfal Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Canan Yazıcı Özgür
- Department of Anesthesiology and Reanimation, Bakırköy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Payam Rahimi
- Department of Anesthesiology and Reanimation, Bakırköy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Emral Canan
- Department of Anesthesiology and Reanimation, Bakırköy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Sinan Aşar
- Department of Anesthesiology and Reanimation, Bakırköy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey.
| | - Zafer Çukurova
- Department of Anesthesiology and Reanimation, Bakırköy Dr. Sadi Konuk Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
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33
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Rehman TA, John K, Maslow A. Protective Lung Ventilation: What Do We Know?-"In An Investigation, Details Matter"-Jack Reacher TV Series. J Cardiothorac Vasc Anesth 2023; 37:2572-2576. [PMID: 37423839 PMCID: PMC10264327 DOI: 10.1053/j.jvca.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/11/2023] [Indexed: 07/11/2023]
Affiliation(s)
- T A Rehman
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Boston, MA
| | - K John
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI
| | - A Maslow
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI.
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34
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Wang L, Lin Q, Wei B, Guo Y, Li Q, Wang Z, Wu L, Zhang Y, Yin J, Wan B. CircUBR1 knockdown relieves ventilator-induced lung injury through regulating miR-20a-5p/GGPPS1 pathway. Cell Signal 2023; 112:110920. [PMID: 37827345 DOI: 10.1016/j.cellsig.2023.110920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Revised: 09/21/2023] [Accepted: 10/09/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE To assess the influences and underlying mechanism of circular RNA UBR1 (circUBR1) in ventilator-induced lung injury (VILI). METHODS In mice and mouse alveolar epithelial cells, VILI model was established. CircUBR1 and miR-20a-5p expression was assessed via quantitative real time polymerase chain reaction. Western blot and immunohistochemistry were applied to assess geranylgeranyl diphosphate synthase 1 (GGPPS1) protein expression. In lung tissues, the histopathological changes were utilized using hematoxylin and eosin staining. Cell counting kit-8 assay and flow cytometer were applied to detect cell proliferation and apoptosis. The levels of inflammatory cytokines [interleukin (IL)-1β, IL-18, IL-6, and tumor necrosis factor (TNF)-α] were measured by western blot and enzyme-linked immunosorbent assay. RESULTS In lung tissues of VILI mice, circUBR1 and GGPPS1 expression were upregulated, while miR-20a-5p expression was downregulated. In vivo, circUBR1 knockdown alleviated lung injury, inhibited cell apoptosis, and decreased the levels of inflammatory cytokines. In cells treated with cyclic stretch (CS), circUBR1 knockdown promoted cell viability, inhibited cell apoptosis, and reduced inflammatory cytokines. CircUBR1 could sponge miR-20a-5p, and GGPPS1 was the target gene of miR-20a-5p. In addition, in cells treated with CS, downregulation of miR-20a-5p or the overexpression of GGPPS1 reversed the promotive effect of circUBR1 knockdown on cell viability and the inhibitive effect of circUBR1 knockdown on cell apoptosis and inflammation production. CONCLUSIONS In VILI, knockdown of circUBR1 attenuated lung injury and inflammation via regulating the miR-20a-5p/GGPPS1 pathway. Our study may provide a potential therapeutic target for treatment of VILI.
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Affiliation(s)
- Li Wang
- Department of Respiratory and Critical Care Medicine, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing 210002, China
| | - Qiuqi Lin
- Department of Respiratory and Critical Care Medicine, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing 210002, China
| | - Benzhong Wei
- Department of Anesthesiology, Yizheng Hospital, Nanjing Gulou Hospital Group, Yizheng 211900, China
| | - Yufang Guo
- Department of Respiratory and Critical Care Medicine, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing 210002, China
| | - Qian Li
- Department of Respiratory and Critical Care Medicine, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing 210002, China
| | - Zexu Wang
- Department of Respiratory and Critical Care Medicine, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing 210002, China
| | - Liangquan Wu
- Department of Respiratory and Critical Care Medicine, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing 210002, China
| | - Yunlei Zhang
- Department of Respiratory and Critical Care Medicine, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing 210002, China
| | - Jiangning Yin
- Emergency Department, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing 210002, China.
| | - Bing Wan
- Department of Respiratory and Critical Care Medicine, The Affiliated Jiangning Hospital of Nanjing Medical University, Nanjing 210002, China.
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35
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Zhang YY, Zhang YM, Wu SL, Wei M, Deng ZP, Lei XY, Bai YP, Wang XB. Association of mechanical power during one-lung ventilation and post-operative pulmonary complications among patients undergoing lobectomy: a protocol for a prospective cohort study. Updates Surg 2023; 75:2365-2375. [PMID: 37540406 DOI: 10.1007/s13304-023-01595-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 05/27/2023] [Indexed: 08/05/2023]
Abstract
The association of intra-operative mechanical power (MP) with post-operative pulmonary complications (PPCs) has been described before, but it is uncertain whether the potential inherent bias can limit the use of this parameter, particularly in the context of one-lung ventilation. This single-center study aims to investigate the effect of MP during one-lung ventilation (OLV), and the risks of PPCs in patients undergoing thoracoscopic lobectomy. This prospective observational study is being conducted in an academic tertiary hospital in mainland China. Participants diagnosed with lung cancer, and aged 50 to 80 years are eligible. Video-assisted thoracoscopic surgery (VATS) lobectomy is performed for all patients. The primary outcome is the occurrence of PPCs over 5 consecutive days after the surgery, or until discharge from the hospital. Secondary outcomes include the composite conditions of PPCs, in-hospital stay, systematic inflammation tested by blood samples, and changes in aeration compartments in the ventilated lung as assessed by CT scans. We aim to evaluate the association of mean MP and the temporal patterns in the trend of MP during OLV with the occurrence of PPCs. A total of 120 patients will be enrolled in this study. The study protocol has received approval from the Ethics Committee of the affiliated hospital of Southwest Medical University, China (Reference number: KY2022162). The findings will be made available to the funder and researchers via scientific conferences and peer-reviewed publications. This controlled trial was approved by the Ethics Committee of Southwest Medical University(ChiCTR2200062173), and registered in the Chinese Clinical Trial Register website ( http://www.chictr.org.cn/edit.aspx?pid=172533&htm=4 , ChiCTR2200062173). A written consent was obtained from each patient.
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Affiliation(s)
- Ying-Ying Zhang
- Department of Anaesthesiology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Jiangyang District, Luzhou, 646000, People's Republic of China
| | - Yu-Mei Zhang
- Department of Anaesthesiology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Jiangyang District, Luzhou, 646000, People's Republic of China
| | - Song-Lin Wu
- Department of Intensive Care Unit, The Affiliated Hospital of Southwest Medical University, Luzhou, People's Republic of China
| | - Min Wei
- Department of Intensive Care Unit, The Affiliated Hospital of Southwest Medical University, Luzhou, People's Republic of China
| | - Zhi-Peng Deng
- Faculty of Computer Science, Technical University of Dresden, Dresden, Germany
| | - Xian-Ying Lei
- Department of Intensive Care Unit, The Affiliated Hospital of Southwest Medical University, Luzhou, People's Republic of China
| | - Yi-Ping Bai
- Department of Anaesthesiology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Jiangyang District, Luzhou, 646000, People's Republic of China.
| | - Xiao-Bin Wang
- Department of Anaesthesiology, The Affiliated Hospital of Southwest Medical University, No.25 of Taiping Street, Jiangyang District, Luzhou, 646000, People's Republic of China.
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36
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Xie Y, Yan Y, Shi J, Luo J, Wang Y, Chen H, Li X. Elastic power, a novel predictor of the severity and prognosis of ARDS. J Crit Care 2023; 78:154380. [PMID: 37480658 DOI: 10.1016/j.jcrc.2023.154380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 04/13/2023] [Accepted: 07/11/2023] [Indexed: 07/24/2023]
Abstract
PURPOSE To explore the predictive value of the new comprehensive respiratory mechanics parameters elastic power (EP) and elastic power normalized to the compliance (Cst-EP) in the evaluation of the severity and 28-day prognosis of ARDS patients. METHODS The MIMIC-III database was used to identify ARDS patients under invasive mechanical ventilation for at least 48 h. Their baseline data and ventilatory variables were collected. EP, elastic energy, driving pressure and mechanical power were calculated according to the corresponding formulas. Their value in assessing the severity of ARDS was evaluated. The correlation between Cst-EP and 28-day prognosis of ARDS patients was analyzed. RESULTS EP was independently associated with the severity of the ARDS and the odds ratio (OR) was 1.301 [95% CI (1.190-1.423), p < 0.001]. It has higher accuracy for the severity of ARDS, with an optimal cut-off value of 14.6 J/min. The Cst-EP was significantly associated with increased risk of death and the hazard ratio (HR) per 100 J/min × cmH2O/ml × 10-3 was 1.169 [95% CI (1.093-1.250), p < 0.001]. In addition, the 28-day cumulative survival rate of the high Cst-EP group was significantly lower than that of the low Cst-EP group. CONCLUSION EP can be used to predict the severity of ARDS, and Cst-EP is associated with mortality during controlled mechanical ventilation in ARDS.
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Affiliation(s)
- Yongpeng Xie
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang 222000, Jiangsu, China
| | - Yao Yan
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang 222000, Jiangsu, China; Department of Critical Care Medicine, The Second People's Hospital of Lianyungang City, Lianyungang 222000, Jiangsu, China
| | - Jiaxin Shi
- Department of Respiratory and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang 222000, Jiangsu, China
| | - Jiye Luo
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang 222000, Jiangsu, China
| | - Yanli Wang
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang 222000, Jiangsu, China
| | - Hui Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, No. 87, Dingjiaqiao Road, Gulou District, Nanjing 210009, Jiangsu,China..
| | - Xiaomin Li
- Department of Emergency and Critical Care Medicine, Lianyungang Clinical College of Nanjing Medical University, Lianyungang 222000, Jiangsu, China.
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37
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Silva PL, Scharffenberg M, Rocco PRM. Understanding the mechanisms of ventilator-induced lung injury using animal models. Intensive Care Med Exp 2023; 11:82. [PMID: 38010595 PMCID: PMC10682329 DOI: 10.1186/s40635-023-00569-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023] Open
Abstract
Mechanical ventilation is a life-saving therapy in several clinical situations, promoting gas exchange and providing rest to the respiratory muscles. However, mechanical ventilation may cause hemodynamic instability and pulmonary structural damage, which is known as ventilator-induced lung injury (VILI). The four main injury mechanisms associated with VILI are as follows: barotrauma/volutrauma caused by overstretching the lung tissues; atelectrauma, caused by repeated opening and closing of the alveoli resulting in shear stress; and biotrauma, the resulting biological response to tissue damage, which leads to lung and multi-organ failure. This narrative review elucidates the mechanisms underlying the pathogenesis, progression, and resolution of VILI and discusses the strategies that can mitigate VILI. Different static variables (peak, plateau, and driving pressures, positive end-expiratory pressure, and tidal volume) and dynamic variables (respiratory rate, airflow amplitude, and inspiratory time fraction) can contribute to VILI. Moreover, the potential for lung injury depends on tissue vulnerability, mechanical power (energy applied per unit of time), and the duration of that exposure. According to the current evidence based on models of acute respiratory distress syndrome and VILI, the following strategies are proposed to provide lung protection: keep the lungs partially collapsed (SaO2 > 88%), avoid opening and closing of collapsed alveoli, and gently ventilate aerated regions while keeping collapsed and consolidated areas at rest. Additional mechanisms, such as subject-ventilator asynchrony, cumulative power, and intensity, as well as the damaging threshold (stress-strain level at which tidal damage is initiated), are under experimental investigation and may enhance the understanding of VILI.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Martin Scharffenberg
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.
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Marini JJ, Thornton LT, Rocco PRM, Crooke PS. From pressure to tension: a model of damaging inflation stress. Crit Care 2023; 27:441. [PMID: 37968744 PMCID: PMC10652628 DOI: 10.1186/s13054-023-04675-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 10/04/2023] [Indexed: 11/17/2023] Open
Abstract
Although the stretch that generates ventilator-induced lung injury (VILI) occurs within the peripheral tissue that encloses the alveolar space, airway pressures and volumes monitor the gas within the interior core of the lung unit, not its cellular enclosure. Measured pressures (plateau pressure, positive end-expiratory pressure, and driving pressure) and tidal volumes paint a highly relevant but incomplete picture of forces that act on the lung tissues themselves. Convenient and clinically useful measures of the airspace, such as pressure and volume, neglect the partitioning of tidal elastic energy into the increments of tension and surface area that constitute actual stress and strain at the alveolar margins. More sharply focused determinants of VILI require estimates of absolute alveolar dimension and morphology and the lung's unstressed volume at rest. We present a highly simplified but informative mathematical model that translates the radial energy of pressure and volume of the airspace into its surface energy components. In doing so it elaborates conceptual relationships that highlight the forces tending to cause end-tidal hyperinflation of aerated units within the 'baby lung' of acute respiratory distress syndrome (ARDS).
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Affiliation(s)
- John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, St Paul, MN, USA.
| | - Lauren T Thornton
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, St Paul, MN, USA
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Philip S Crooke
- Department of Mathematics, Vanderbilt University, Nashville, TN, USA
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Richard JC, Terzi N, Yonis H, Chorfa F, Wallet F, Dupuis C, Argaud L, Delannoy B, Thiery G, Pommier C, Abraham P, Muller M, Sigaud F, Rigault G, Joffredo E, Mezidi M, Souweine B, Baboi L, Serrier H, Rabilloud M, Bitker L. Ultra-low tidal volume ventilation for COVID-19-related ARDS in France (VT4COVID): a multicentre, open-label, parallel-group, randomised trial. THE LANCET. RESPIRATORY MEDICINE 2023; 11:991-1002. [PMID: 37453445 DOI: 10.1016/s2213-2600(23)00221-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/28/2023] [Accepted: 05/16/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND COVID-19-related acute respiratory distress syndrome (ARDS) is associated with a high mortality rate and longer mechanical ventilation. We aimed to assess the effectiveness of ventilation with ultra-low tidal volume (ULTV) compared with low tidal volume (LTV) in patients with COVID-19-related ARDS. METHODS This study was a multicentre, open-label, parallel-group, randomised trial conducted in ten intensive care units in France. Eligible participants were aged 18 years or older, received invasive mechanical ventilation for COVID-19 (confirmed by RT-PCR), had ARDS according to the Berlin definition, a partial pressure of arterial oxygen to inspiratory oxygen fraction (PaO2/FiO2) ratio of 150 mm Hg or less, a tidal volume (VT) of 6·0 mL/kg predicted bodyweight or less, and received continuous intravenous sedation. Patients were randomly assigned (1:1) using randomisation blocks to receive ULTV (intervention group) aiming for VT of 4·0 mL/kg predicted bodyweight or LTV (control group) aiming for VT 6·0 mL/kg predicted bodyweight. Participants, investigators, and outcome assessors were not masked to group assignment. The primary outcome was a ranked composite score based on all-cause mortality at day 90 as the first criterion and ventilator-free days among patients alive at day 60 as the second criterion. Effect size was computed with the unmatched win ratio, on the basis of pairwise prioritised comparison of primary outcome components between every patient in the ULTV group and every patient in the LTV group. The unmatched win ratio was calculated as the ratio of the number of pairs with more favourable outcome in the ULTV group over the number of pairs with less favourable outcome in the ULTV group. Primary analysis was done in the modified intention-to-treat population, which included all participants who were randomly assigned and not lost to follow-up. This trial is registered with ClinicalTrials.gov, NCT04349618. FINDINGS Between April 15, 2020, and April 13, 2021, 220 patients were included and five (2%) were excluded. 215 patients were randomly assigned (106 [49%] to the ULTV group and 109 [51%] to the LTV group). 58 (27%) patients were female and 157 (73%) were male. The median age was 68 years (IQR 60-74). 214 patients completed follow-up (one lost to follow-up in the ULTV group) and were included in the modified intention-to-treat analysis. The primary outcome was not significantly different between groups (unmatched win ratio in the ULTV group 0·85 [95% CI 0·60 to 1·19]; p=0·38). 46 (44%) of 105 patients in the ULTV group and 43 (39%) of 109 in the LTV group died by day 90 (absolute difference 4% [-9 to 18]; p=0·52). The rate of severe respiratory acidosis in the first 28 days was higher in the ULTV group than in the LTV group (35 [33%] vs 14 [13%]; absolute difference 20% [95% CI 9 to 31]; p=0·0004). INTERPRETATION In patients with moderate-to-severe COVID-19-related ARDS, there was no significant difference with ULTV compared with LTV in the composite score based on mortality and ventilator-free days among patients alive at day 60. These findings do not support the systematic use of ULTV in patients with COVID-19-related ARDS. FUNDING French Ministry of Solidarity and Health and Hospices Civils de Lyon.
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Affiliation(s)
- Jean-Christophe Richard
- Hospices Civils de Lyon, Croix-Rousse Hospital, Medical Intensive Care Unit, Lyon, France; Université de Lyon, Université Lyon 1, Lyon, France; CREATIS INSERM 1044 CNRS 5220, Lyon, France.
| | - Nicolas Terzi
- CHU Grenoble Alpes, Service de Médecine Intensive Réanimation, Grenoble, France; Université de Grenoble-Alpes, Grenoble, France; INSERM U1042, Grenoble, France
| | - Hodane Yonis
- Hospices Civils de Lyon, Croix-Rousse Hospital, Medical Intensive Care Unit, Lyon, France
| | - Fatima Chorfa
- Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France
| | - Florent Wallet
- Hospices Civils de Lyon, Lyon-Sud Hospital, Medical-Surgical Intensive Care Unit, Lyon, France; International Center of Research in Infectiology, Lyon University, INSERM U1111, CNRS UMR 5308, ENS, UCBL, Lyon, France
| | - Claire Dupuis
- CHU Gabriel Montpied, Medical Intensive Care Unit, Clermont-Ferrand, France
| | - Laurent Argaud
- Hospices Civils de Lyon, Edouard Herriot Hospital, Medical Intensive Care Unit, Lyon, France
| | - Bertrand Delannoy
- Clinique de la Sauvegarde, Medical-Surgical Intensive Care Unit, Lyon, France
| | - Guillaume Thiery
- CHU Saint-Etienne, Hopital Nord, Medical Intensive Care Unit, Saint-Priest-En-Jarez, France; Research on Healthcare Performance RESHAPE, INSERM U1290, Université Lyon 1, Lyon, France
| | - Christian Pommier
- Centre Hospitalier Saint Joseph-Saint Luc, Medical-Surgical Intensive Care Unit, Lyon, France
| | - Paul Abraham
- Hospices Civils de Lyon, Edouard Herriot Hospital, Surgical Intensive Care Unit, Lyon, France
| | - Michel Muller
- Centre Hospitalier Annecy Genevois, Medical-Surgical Intensive Care Unit, Pringy, France
| | - Florian Sigaud
- CHU Grenoble Alpes, Service de Médecine Intensive Réanimation, Grenoble, France
| | - Guillaume Rigault
- CHU Grenoble Alpes, Service de Médecine Intensive Réanimation, Grenoble, France; Université de Grenoble-Alpes, Grenoble, France
| | - Emilie Joffredo
- Hospices Civils de Lyon, Lyon-Sud Hospital, Medical-Surgical Intensive Care Unit, Lyon, France
| | - Mehdi Mezidi
- Hospices Civils de Lyon, Croix-Rousse Hospital, Medical Intensive Care Unit, Lyon, France
| | - Bertrand Souweine
- CHU Gabriel Montpied, Medical Intensive Care Unit, Clermont-Ferrand, France
| | - Loredana Baboi
- Hospices Civils de Lyon, Croix-Rousse Hospital, Medical Intensive Care Unit, Lyon, France
| | - Hassan Serrier
- Hospices Civils de Lyon, Cellule Innovation, Délégation à la Recherche Clinique et à l'Innovation, Lyon, France
| | - Muriel Rabilloud
- Université de Lyon, Université Lyon 1, Lyon, France; Hospices Civils de Lyon, Pôle Santé Publique, Service de Biostatistique et Bioinformatique, Lyon, France; CNRS, UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Lyon, France
| | - Laurent Bitker
- Hospices Civils de Lyon, Croix-Rousse Hospital, Medical Intensive Care Unit, Lyon, France; Université de Lyon, Université Lyon 1, Lyon, France; CREATIS INSERM 1044 CNRS 5220, Lyon, France
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An MZ, Xu CY, Hou YR, Li ZP, Gao TS, Zhou QH. Effect of intravenous vs. inhaled penehyclidine on respiratory mechanics in patients during one-lung ventilation for thoracoscopic surgery: a prospective, double-blind, randomised controlled trial. BMC Pulm Med 2023; 23:353. [PMID: 37726724 PMCID: PMC10508004 DOI: 10.1186/s12890-023-02653-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Accepted: 09/12/2023] [Indexed: 09/21/2023] Open
Abstract
BACKGROUND Minimising postoperative pulmonary complications (PPCs) after thoracic surgery is of utmost importance. A major factor contributing to PPCs is the driving pressure, which is determined by the ratio of tidal volume to lung compliance. Inhalation and intravenous administration of penehyclidine can improve lung compliance during intraoperative mechanical ventilation. Therefore, our study aimed to compare the efficacy of inhaled vs. intravenous penehyclidine during one-lung ventilation (OLV) in mitigating driving pressure and mechanical power among patients undergoing thoracic surgery. METHODS A double-blind, prospective, randomised study involving 176 patients scheduled for elective thoracic surgery was conducted. These patients were randomly divided into two groups, namely the penehyclidine inhalation group and the intravenous group before their surgery. Driving pressure was assessed at T1 (5 min after OLV), T2 (15 min after OLV), T3 (30 min after OLV), and T4 (45 min after OLV) in both groups. The primary outcome of this study was the composite measure of driving pressure during OLV. The area under the curve (AUC) of driving pressure from T1 to T4 was computed. Additionally, the secondary outcomes included mechanical power, lung compliance and the incidence of PPCs. RESULTS All 167 participants, 83 from the intravenous group and 84 from the inhalation group, completed the trial. The AUC of driving pressure for the intravenous group was 39.50 ± 9.42, while the inhalation group showed a value of 41.50 ± 8.03 (P = 0.138). The incidence of PPCs within 7 days after surgery was 27.7% in the intravenous group and 23.8% in the inhalation group (P = 0.564). No significant differences were observed in any of the other secondary outcomes between the two groups (all P > 0.05). CONCLUSIONS Our study found that among patients undergoing thoracoscopic surgery, no significant differences were observed in the driving pressure and mechanical power during OLV between those who received an intravenous injection of penehyclidine and those who inhaled it. Moreover, no significant difference was observed in the incidence of PPCs between the two groups.
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Affiliation(s)
- Ming-Zi An
- Anesthesia Medicine, Jiaxing University Master Degree Cultivation Base, Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, China
- Department of anaesthesiology, Jiaxing Chinese Medical Hospital, No. 1501, Zhongshan East Road, Jiaxing, Zhejiang Province, China
| | - Cheng-Yun Xu
- Anesthesia Medicine, Jiaxing University Master Degree Cultivation Base, Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, China
- Department of anaesthesiology and pain medicine, affiliated hospital of Jiaxing University, No.1882, South Central Road, Jiaxing, Zhejiang Province, China
| | - Yue-Ru Hou
- Anesthesia Medicine, Jiaxing University Master Degree Cultivation Base, Zhejiang Chinese Medical University, Hangzhou, Zhejiang Province, China
- Department of anaesthesiology and pain medicine, affiliated hospital of Jiaxing University, No.1882, South Central Road, Jiaxing, Zhejiang Province, China
| | - Zhen-Ping Li
- Department of anaesthesiology and pain medicine, affiliated hospital of Jiaxing University, No.1882, South Central Road, Jiaxing, Zhejiang Province, China
| | - Te-Sheng Gao
- Department of anaesthesiology, Jiaxing Chinese Medical Hospital, No. 1501, Zhongshan East Road, Jiaxing, Zhejiang Province, China.
| | - Qing-He Zhou
- Department of anaesthesiology and pain medicine, affiliated hospital of Jiaxing University, No.1882, South Central Road, Jiaxing, Zhejiang Province, China.
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Bachmann KF, Berger D, Moller PW. Interactions between extracorporeal support and the cardiopulmonary system. Front Physiol 2023; 14:1231016. [PMID: 37772062 PMCID: PMC10523013 DOI: 10.3389/fphys.2023.1231016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 08/29/2023] [Indexed: 09/30/2023] Open
Abstract
This review describes the intricate physiological interactions involved in the application of extracorporeal therapy, with specific focus on cardiopulmonary relationships. Extracorporeal therapy significantly influences cardiovascular and pulmonary physiology, highlighting the necessity for clinicians to understand these interactions for improved patient care. Veno-arterial extracorporeal membrane oxygenation (veno-arterial ECMO) unloads the right ventricle and increases left ventricular (LV) afterload, potentially exacerbating LV failure and pulmonary edema. Veno-venous (VV) ECMO presents different challenges, where optimal device and ventilator settings remain unknown. Influences on right heart function and native gas exchange as well as end-expiratory lung volumes are important concepts that should be incorporated into daily practice. Future studies should not be limited to large clinical trials focused on mortality but rather address physiological questions to advance the understanding of extracorporeal therapies. This includes exploring optimal device and ventilator settings in VV ECMO, standardizing cardiopulmonary function monitoring strategies, and developing better strategies for device management throughout their use. In this regard, small human or animal studies and computational physiological modeling may contribute valuable insights into optimizing the management of extracorporeal therapies.
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Affiliation(s)
- Kaspar F. Bachmann
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
| | - David Berger
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Per Werner Moller
- Department of Anaesthesia, SV Hospital Group, Institute of Clinical Sciences at the Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Wittenstein J, Scharffenberg M, Yang X, Bluth T, Kiss T, Schultz MJ, Rocco PRM, Pelosi P, Gama de Abreu M, Huhle R. Distribution of transpulmonary pressure during one-lung ventilation in pigs at different body positions. Front Physiol 2023; 14:1204531. [PMID: 37601645 PMCID: PMC10436328 DOI: 10.3389/fphys.2023.1204531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/13/2023] [Indexed: 08/22/2023] Open
Abstract
Background. Global and regional transpulmonary pressure (PL) during one-lung ventilation (OLV) is poorly characterized. We hypothesized that global and regional PL and driving PL (ΔPL) increase during protective low tidal volume OLV compared to two-lung ventilation (TLV), and vary with body position. Methods. In sixteen anesthetized juvenile pigs, intra-pleural pressure sensors were placed in ventral, dorsal, and caudal zones of the left hemithorax by video-assisted thoracoscopy. A right thoracotomy was performed and lipopolysaccharide administered intravenously to mimic the inflammatory response due to thoracic surgery. Animals were ventilated in a volume-controlled mode with a tidal volume (VT) of 6 mL kg-1 during TLV and of 5 mL kg-1 during OLV and a positive end-expiratory pressure (PEEP) of 5 cmH2O. Global and local transpulmonary pressures were calculated. Lung instability was defined as end-expiratory PL<2.9 cmH2O according to previous investigations. Variables were acquired during TLV (TLVsupine), left lung ventilation in supine (OLVsupine), semilateral (OLVsemilateral), lateral (OLVlateral) and prone (OLVprone) positions randomized according to Latin-square sequence. Effects of position were tested using repeated measures ANOVA. Results. End-expiratory PL and ΔPL were higher during OLVsupine than TLVsupine. During OLV, regional end-inspiratory PL and ΔPL did not differ significantly among body positions. Yet, end-expiratory PL was lower in semilateral (ventral: 4.8 ± 2.9 cmH2O; caudal: 3.1 ± 2.6 cmH2O) and lateral (ventral: 1.9 ± 3.3 cmH2O; caudal: 2.7 ± 1.7 cmH2O) compared to supine (ventral: 4.8 ± 2.9 cmH2O; caudal: 3.1 ± 2.6 cmH2O) and prone position (ventral: 1.7 ± 2.5 cmH2O; caudal: 3.3 ± 1.6 cmH2O), mainly in ventral (p ≤ 0.001) and caudal (p = 0.007) regions. Lung instability was detected more often in semilateral (26 out of 48 measurements; p = 0.012) and lateral (29 out of 48 measurements, p < 0.001) as compared to supine position (15 out of 48 measurements), and more often in lateral as compared to prone position (19 out of 48 measurements, p = 0.027). Conclusion. Compared to TLV, OLV increased lung stress. Body position did not affect stress of the ventilated lung during OLV, but lung stability was lowest in semilateral and lateral decubitus position.
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Affiliation(s)
- Jakob Wittenstein
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Martin Scharffenberg
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Xiuli Yang
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
- Department of Anesthesiology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Thomas Bluth
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
| | - Thomas Kiss
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
- Department of Anaesthesiology, Intensive-Pain- and Palliative Care Medicine, Radebeul Hospital, Academic Hospital of the Technische Universität Dresden, Radebeul, Germany
| | - Marcus J. Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anaesthesiology, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Marcelo Gama de Abreu
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
- Department of Intensive Care and Resuscitation, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, OH, United States
| | - Robert Huhle
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus Dresden at Technische Universität Dresden, Dresden, Germany
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Abbott M, Li Y, Brochard L, Zhang H. Precision Medicine Using Simultaneous Monitoring and Assessment with Imaging and Biomarkers to Manage Mechanical Ventilation in ARDS. INTENSIVE CARE RESEARCH 2023; 3:195-203. [PMID: 37664686 PMCID: PMC10471647 DOI: 10.1007/s44231-023-00045-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/24/2023] [Indexed: 09/05/2023]
Abstract
Acute respiratory distress syndrome (ARDS) has a ~ 40% mortality rate with an increasing prevalence exacerbated by the COVID-19 pandemic. Mechanical ventilation is the primary means for life-saving support to buy time for lung healing in ARDS patients, however, it can also lead to ventilator-induced lung injury (VILI). Effective strategies to reduce or prevent VILI are necessary but are not currently delivered. Therefore, we aim at evaluating the current imaging technologies to visualize where pressure and volume being delivered to the lung during mechanical ventilation; and combining plasma biomarkers to guide management of mechanical ventilation. We searched PubMed and Medline using keywords and analyzed the literature, including both animal models and human studies, to examine the independent use of computed tomography (CT) to evaluate lung mechanics, electrical impedance tomography (EIT) to guide ventilation, ultrasound to monitor lung injury, and plasma biomarkers to indicate status of lung pathophysiology. This investigation has led to our proposal of the combination of imaging and biomarkers to precisely deliver mechanical ventilation to improve patient outcomes in ARDS.
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Affiliation(s)
- Megan Abbott
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON Canada
- Department of Physiology, University of Toronto, Toronto, ON Canada
| | - Yuchong Li
- The State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON Canada
| | - Haibo Zhang
- Keenan Research Centre for Biomedical Science, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON Canada
- Department of Physiology, University of Toronto, Toronto, ON Canada
- The State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON Canada
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Battaglini D, Iavarone IG, Robba C, Ball L, Silva PL, Rocco PRM. Mechanical ventilation in patients with acute respiratory distress syndrome: current status and future perspectives. Expert Rev Med Devices 2023; 20:905-917. [PMID: 37668146 DOI: 10.1080/17434440.2023.2255521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/14/2023] [Accepted: 09/01/2023] [Indexed: 09/06/2023]
Abstract
INTRODUCTION Although there has been extensive research on mechanical ventilation for acute respiratory distress syndrome (ARDS), treatment remains mainly supportive. Recent studies and new ventilatory modes have been proposed to manage patients with ARDS; however, the clinical impact of these strategies remains uncertain and not clearly supported by guidelines. The aim of this narrative review is to provide an overview and update on ventilatory management for patients with ARDS. AREAS COVERED This article reviews the literature regarding mechanical ventilation in ARDS. A comprehensive overview of the principal settings for the ventilator parameters involved is provided as well as a report on the differences between controlled and assisted ventilation. Additionally, new modes of assisted ventilation are presented and discussed. The evidence concerning rescue strategies, including recruitment maneuvers and extracorporeal membrane oxygenation support, is analyzed. PubMed, EBSCO, and the Cochrane Library were searched up until June 2023, for relevant literature. EXPERT OPINION Available evidence for mechanical ventilation in cases of ARDS suggests the use of a personalized mechanical ventilation strategy. Although promising, new modes of assisted mechanical ventilation are still under investigation and guidelines do not recommend rescue strategies as the standard of care. Further research on this topic is required.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Ida Giorgia Iavarone
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Senturk E, Ugur S, Celik Y, Cukurova Z, Asar S, Cakar N. The power of mechanical ventilation may predict mortality in critically ill patients. Minerva Anestesiol 2023; 89:663-670. [PMID: 37079284 DOI: 10.23736/s0375-9393.23.17080-5] [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: 04/21/2023]
Abstract
BACKGROUND Mechanical power (MP) is the amount of energy transferred from the ventilator to the patient within a unit of time. It has been emphasized in ventilation-induced lung injury (VILI) and mortality. However, its measurement and use in clinical practice are challenging. "Electronic recording systems (ERS)" using mechanical ventilation parameters provided by the ventilator can be helpful to measure and record the MP. The MP (J/minutes) formula is 0.098 x tidal volume x respiratory rate x (Ppeak - ½ ∆P), in which ∆P is the driving pressure and Ppeak is the peak pressure. We aimed to define the association between MP values and ICU mortality, mechanical ventilation days, and intensive care unit length of stay (ICU-LOS). The secondary outcome was to determine the most potent or essential component of power in the equation that has a role in mortality. METHODS This retrospective study was performed in two centers (VKV American Hospital and Bakırköy Sadi Konuk Hospital ICUs) that used ERS (Metavision IMDsoft) between 2014 and 2018. We uploaded the power formula (MP (J/minutes)=0.098×VT×RR×(Ppeak - ½ ∆P) to ERS (METAvision, iMDsoft, and Consult Orion Health) and calculated the MP value by using MV parameters automatically sent from the ventilator. (∆P; driving pressure, VT; tidal volume, RR; respiratory rate and Ppeak; peak pressure). RESULTS A total of 3042 patients were included in the study. The median value of MP was 11.3 J/min. Mortality in MP<11.3 J/min was 35.4%, and 49.1% in MP>11.3J/min.; P<0.001. Mechanical ventilation days and ICU-LOS were also statistically longer in the MVP>11.3 J/min group. CONCLUSIONS The first 24 h MP maybe a predictive value for the ICU patients' prognosis. This implies that MP may be used as a decision-making system to define the clinical approach and as a scoring system to predict patient prognosis.
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Affiliation(s)
- Evren Senturk
- Department of Anesthesiology and Reanimation, Koç University Hospital, Istanbul, Türkiye
| | - Semra Ugur
- Department of Anesthesiology and Reanimation, Koç University Hospital, Istanbul, Türkiye -
| | - Yeliz Celik
- Department of Pulmonology, Koç University Hospital, Istanbul, Türkiye
| | - Zafer Cukurova
- Department of Anesthesiology and Reanimation, Bakirkoy Sadi Konuk Research Hospital, Istanbul, Türkiye
| | - Sinan Asar
- Department of Anesthesiology and Reanimation, Bakirkoy Sadi Konuk Research Hospital, Istanbul, Türkiye
| | - Nahit Cakar
- Department of Anesthesiology and Reanimation, Koç University Hospital, Istanbul, Türkiye
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Dankhara N, Holla I, Ramarao S, Kalikkot Thekkeveedu R. Bronchopulmonary Dysplasia: Pathogenesis and Pathophysiology. J Clin Med 2023; 12:4207. [PMID: 37445242 DOI: 10.3390/jcm12134207] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/15/2023] [Accepted: 06/19/2023] [Indexed: 07/15/2023] Open
Abstract
Bronchopulmonary dysplasia (BPD), also known as chronic lung disease, is the most common respiratory morbidity in preterm infants. "Old" or "classic" BPD, as per the original description, is less common now. "New BPD", which presents with distinct clinical and pathological features, is more frequently observed in the current era of advanced neonatal care, where extremely premature infants are surviving because of medical advancements. The pathogenesis of BPD is complex and multifactorial and involves both genetic and environmental factors. This review provides an overview of the pathology of BPD and discusses the influence of several prenatal and postnatal factors on its pathogenesis, such as maternal factors, genetic susceptibility, ventilator-associated lung injury, oxygen toxicity, sepsis, patent ductus arteriosus (PDA), and nutritional deficiencies. This in-depth review draws on existing literature to explore these factors and their potential contribution to the development of BPD.
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Affiliation(s)
- Nilesh Dankhara
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Ira Holla
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Sumana Ramarao
- Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS 39216, USA
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Barbeta E, Arrieta M, Motos A, Bobi J, Yang H, Yang M, Tanzella G, Di Ginnatale P, Nogas S, Vargas CR, Cabrera R, Battaglini D, Meli A, Kiarostami K, Vázquez N, Fernández-Barat L, Rigol M, Mellado-Artigas R, Frigola G, Camprubí-Rimblas M, Ferrer P, Martinez D, Artigas A, Ferrando C, Ferrer M, Torres A. A long-lasting porcine model of ARDS caused by pneumonia and ventilator-induced lung injury. Crit Care 2023; 27:239. [PMID: 37328874 PMCID: PMC10276390 DOI: 10.1186/s13054-023-04512-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/30/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Animal models of acute respiratory distress syndrome (ARDS) do not completely resemble human ARDS, struggling translational research. We aimed to characterize a porcine model of ARDS induced by pneumonia-the most common risk factor in humans-and analyze the additional effect of ventilator-induced lung injury (VILI). METHODS Bronchoscopy-guided instillation of a multidrug-resistant Pseudomonas aeruginosa strain was performed in ten healthy pigs. In six animals (pneumonia-with-VILI group), pulmonary damage was further increased by VILI applied 3 h before instillation and until ARDS was diagnosed by PaO2/FiO2 < 150 mmHg. Four animals (pneumonia-without-VILI group) were protectively ventilated 3 h before inoculum and thereafter. Gas exchange, respiratory mechanics, hemodynamics, microbiological studies and inflammatory markers were analyzed during the 96-h experiment. During necropsy, lobar samples were also analyzed. RESULTS All animals from pneumonia-with-VILI group reached Berlin criteria for ARDS diagnosis until the end of experiment. The mean duration under ARDS diagnosis was 46.8 ± 7.7 h; the lowest PaO2/FiO2 was 83 ± 5.45 mmHg. The group of pigs that were not subjected to VILI did not meet ARDS criteria, even when presenting with bilateral pneumonia. Animals developing ARDS presented hemodynamic instability as well as severe hypercapnia despite high-minute ventilation. Unlike the pneumonia-without-VILI group, the ARDS animals presented lower static compliance (p = 0.011) and increased pulmonary permeability (p = 0.013). The highest burden of P. aeruginosa was found at pneumonia diagnosis in all animals, as well as a high inflammatory response shown by a release of interleukin (IL)-6 and IL-8. At histological examination, only animals comprising the pneumonia-with-VILI group presented signs consistent with diffuse alveolar damage. CONCLUSIONS In conclusion, we established an accurate pulmonary sepsis-induced ARDS model.
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Affiliation(s)
- Enric Barbeta
- Surgical Intensive Care Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona (UB), Barcelona, Spain
| | - Marta Arrieta
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona (UB), Barcelona, Spain
| | - Ana Motos
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.
- University of Barcelona (UB), Barcelona, Spain.
| | - Joaquim Bobi
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona (UB), Barcelona, Spain
- Department of Cardiology, Erasmus MC, University Medical Center Rotterdam, 3015, Rotterdam, The Netherlands
- Cardiology Department, Institute Clinic Cardiovascular (ICCV), Hospital Clinic, Barcelona, Spain
| | - Hua Yang
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona (UB), Barcelona, Spain
- Department of Respiratory and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing Institute of Respiratory Medicine, Beijing, China
| | - Minlan Yang
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona (UB), Barcelona, Spain
- Department of Infectious Diseases, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Giacomo Tanzella
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Department of Anesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy
| | - Pierluigi Di Ginnatale
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy
| | - Stefano Nogas
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Department of Anesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy
| | - Carmen Rosa Vargas
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona (UB), Barcelona, Spain
| | - Roberto Cabrera
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Denise Battaglini
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona (UB), Barcelona, Spain
- Department of Anesthesia and Intensive Care, IRCCS for Oncology and Neurosciences, San Martino Policlinico Hospital, Genoa, Italy
| | - Andrea Meli
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Department of Anesthesia and Intensive Care, Fondazione IRCCS Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Kasra Kiarostami
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona (UB), Barcelona, Spain
| | - Nil Vázquez
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona (UB), Barcelona, Spain
| | - Laia Fernández-Barat
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona (UB), Barcelona, Spain
| | - Montserrat Rigol
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona (UB), Barcelona, Spain
- Cardiology Department, Institute Clinic Cardiovascular (ICCV), Hospital Clinic, Barcelona, Spain
| | - Ricard Mellado-Artigas
- Surgical Intensive Care Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Gerard Frigola
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Marta Camprubí-Rimblas
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Pau Ferrer
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Universitat Pompeu Fabra, Barcelona, Spain
| | - Daniel Martinez
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- Department of Pathology, Hospital Clinic, Barcelona, Spain
| | - Antonio Artigas
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Critical Care Center, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Carlos Ferrando
- Surgical Intensive Care Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona (UB), Barcelona, Spain
| | - Miquel Ferrer
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
- University of Barcelona (UB), Barcelona, Spain
- Pneumology Service, Respiratory Institute, Hospital Clinic of Barcelona, Villarroel st. 170, 08036, Barcelona, Spain
| | - Antoni Torres
- CIBER de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.
- Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain.
- University of Barcelona (UB), Barcelona, Spain.
- Pneumology Service, Respiratory Institute, Hospital Clinic of Barcelona, Villarroel st. 170, 08036, Barcelona, Spain.
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Tharp WG, Neilson MR, Breidenstein MW, Harned RG, Chatfield SE, Friend AF, Nunez D, Abnet KR, Farhang B, Klick JC, Horn N, Bender SP, Bates JHT, Dixon AE. Effects of obesity, pneumoperitoneum, and body position on mechanical power of intraoperative ventilation: an observational study. J Appl Physiol (1985) 2023; 134:1390-1402. [PMID: 37022962 PMCID: PMC10211461 DOI: 10.1152/japplphysiol.00551.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 04/03/2023] [Accepted: 04/03/2023] [Indexed: 04/07/2023] Open
Abstract
Mechanical power can describe the complex interaction between the respiratory system and the ventilator and may predict lung injury or pulmonary complications, but the power associated with injury of healthy human lungs is unknown. Body habitus and surgical conditions may alter mechanical power but the effects have not been measured. In a secondary analysis of an observational study of obesity and lung mechanics during robotic laparoscopic surgery, we comprehensively quantified the static elastic, dynamic elastic, and resistive energies comprising mechanical power of ventilation. We stratified by body mass index (BMI) and examined power at four surgical stages: level after intubation, with pneumoperitoneum, in Trendelenburg, and level after releasing the pneumoperitoneum. Esophageal manometry was used to estimate transpulmonary pressures. Mechanical power of ventilation and its bioenergetic components increased over BMI categories. Respiratory system and lung power were nearly doubled in subjects with class 3 obesity compared with lean at all stages. Power dissipated into the respiratory system was increased with class 2 or 3 obesity compared with lean. Increased power of ventilation was associated with decreasing transpulmonary pressures. Body habitus is a prime determinant of increased intraoperative mechanical power. Obesity and surgical conditions increase the energies dissipated into the respiratory system during ventilation. The observed elevations in power may be related to tidal recruitment or atelectasis, and point to specific energetic features of mechanical ventilation of patients with obesity that may be controlled with individualized ventilator settings.NEW & NOTEWORTHY Mechanical power describes the complex interaction between a patient's lungs and the ventilator and may be useful in predicting lung injury. However, its behavior in obesity and during dynamic surgical conditions is not understood. We comprehensively quantified ventilation bioenergetics and effects of body habitus and common surgical conditions. These data show body habitus is a prime determinant of intraoperative mechanical power and provide quantitative context for future translation toward a useful perioperative prognostic measurement.
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Affiliation(s)
- William G Tharp
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Maegan R Neilson
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
| | - Max W Breidenstein
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Ryan G Harned
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Sydney E Chatfield
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
| | - Alexander F Friend
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Denis Nunez
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Kevin R Abnet
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Borzoo Farhang
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - John C Klick
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Nathan Horn
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - S Patrick Bender
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Anesthesiology, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Jason H T Bates
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Medicine, University of Vermont Medical Center, Burlington, Vermont, United States
| | - Anne E Dixon
- Larner College of Medicine, University of Vermont, Burlington, Vermont, United States
- Department of Medicine, University of Vermont Medical Center, Burlington, Vermont, United States
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Lee JE, Kim HY, Lee KW, Kim GS. Second-generation supraglottic airway in laparoscopic donor nephrectomy. Sci Rep 2023; 13:8406. [PMID: 37225750 DOI: 10.1038/s41598-023-34691-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 05/05/2023] [Indexed: 05/26/2023] Open
Abstract
Supraglottic airway (SGA) may have advantages over endotracheal tube (ETT) regarding laryngospasm, coughing, sore throat, and hemodynamic changes; however, studies on the use of SGA in laparoscopic donor nephrectomy (LDN) are lacking. Here, we aimed to confirm the safety and feasibility of second-generation SGA in LDN and compare them with those of ETT. Enrolled adult donors (aged > 18 years) who underwent LDN between August 2018 and November 2021 were divided into two groups-ETT vs. SGA. Airway pressure, lung compliance, desaturation, and hypercapnia were recorded during surgery. After propensity score matching for baseline characteristics and surgical duration, 82 and 152 donors were included in the ETT and SGA groups, respectively, and their outcomes were compared. The peak airway pressure was lower in the SGA group than in the ETT group 5 min after pneumoperitoneum. Dynamic lung compliance was higher in the SGA group than in the ETT group during surgery. There were no cases of intraoperative desaturation, hypercapnia, or postoperative aspiration pneumonitis. The use of second-generation SGA, a safe alternative to ETT for LDN, resulted in reduced airway resistance and increased lung compliance, which suggests its benefits for airway management in kidney donors.
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Affiliation(s)
- Ja Eun Lee
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ha Yeon Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Kyo Won Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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50
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Wahlster S, Sharma M, Taran S, Town JA, Stevens RD, Cinotti R, Asehoune K, Pelosi P, Robba C. Utilization of mechanical power and associations with clinical outcomes in brain injured patients: a secondary analysis of the extubation strategies in neuro-intensive care unit patients and associations with outcome (ENIO) trial. Crit Care 2023; 27:156. [PMID: 37081474 PMCID: PMC10120226 DOI: 10.1186/s13054-023-04410-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/20/2023] [Indexed: 04/22/2023] Open
Abstract
BACKGROUND There is insufficient evidence to guide ventilatory targets in acute brain injury (ABI). Recent studies have shown associations between mechanical power (MP) and mortality in critical care populations. We aimed to describe MP in ventilated patients with ABI, and evaluate associations between MP and clinical outcomes. METHODS In this preplanned, secondary analysis of a prospective, multi-center, observational cohort study (ENIO, NCT03400904), we included adult patients with ABI (Glasgow Coma Scale ≤ 12 before intubation) who required mechanical ventilation (MV) ≥ 24 h. Using multivariable log binomial regressions, we separately assessed associations between MP on hospital day (HD)1, HD3, HD7 and clinical outcomes: hospital mortality, need for reintubation, tracheostomy placement, and development of acute respiratory distress syndrome (ARDS). RESULTS We included 1217 patients (mean age 51.2 years [SD 18.1], 66% male, mean body mass index [BMI] 26.3 [SD 5.18]) hospitalized at 62 intensive care units in 18 countries. Hospital mortality was 11% (n = 139), 44% (n = 536) were extubated by HD7 of which 20% (107/536) required reintubation, 28% (n = 340) underwent tracheostomy placement, and 9% (n = 114) developed ARDS. The median MP on HD1, HD3, and HD7 was 11.9 J/min [IQR 9.2-15.1], 13 J/min [IQR 10-17], and 14 J/min [IQR 11-20], respectively. MP was overall higher in patients with ARDS, especially those with higher ARDS severity. After controlling for same-day pressure of arterial oxygen/fraction of inspired oxygen (P/F ratio), BMI, and neurological severity, MP at HD1, HD3, and HD7 was independently associated with hospital mortality, reintubation and tracheostomy placement. The adjusted relative risk (aRR) was greater at higher MP, and strongest for: mortality on HD1 (compared to the HD1 median MP 11.9 J/min, aRR at 17 J/min was 1.22, 95% CI 1.14-1.30) and HD3 (1.38, 95% CI 1.23-1.53), reintubation on HD1 (1.64; 95% CI 1.57-1.72), and tracheostomy on HD7 (1.53; 95%CI 1.18-1.99). MP was associated with the development of moderate-severe ARDS on HD1 (2.07; 95% CI 1.56-2.78) and HD3 (1.76; 95% CI 1.41-2.22). CONCLUSIONS Exposure to high MP during the first week of MV is associated with poor clinical outcomes in ABI, independent of P/F ratio and neurological severity. Potential benefits of optimizing ventilator settings to limit MP warrant further investigation.
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Affiliation(s)
- Sarah Wahlster
- Neurocritical Care, Department of Neurology, Harborview Medical Center, University of Washington, Box 359702, 325 9th Avenue, WA, 98104-2499, Seattle, USA.
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, USA.
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, USA.
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, USA
| | - Shaurya Taran
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - James A Town
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, USA
| | - Robert D Stevens
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Raphaël Cinotti
- Department of Anesthesiology and Critical Care, CHU Nantes, Nantes Université, Nantes, France
| | - Karim Asehoune
- Department of Anesthesiology and Critical Care, CHU Nantes, Nantes Université, Nantes, France
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, 10 Largo Rosanna Benzi, 16100, Genoa, Italy
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