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Fiedler-Kalenka MO, Brenner T, Bernhard M, Reuß CJ, Beynon C, Hecker A, Jungk C, Nusshag C, Michalski D, Weigand MA, Dietrich M. [Focus on ventilation, oxygen therapy and weaning 2022-2024 : Summary of selected intensive care studies]. DIE ANAESTHESIOLOGIE 2024; 73:698-711. [PMID: 39210065 DOI: 10.1007/s00101-024-01455-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/05/2024] [Indexed: 09/04/2024]
Affiliation(s)
- M O Fiedler-Kalenka
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland.
- Translationales Lungenforschungszentrum Heidelberg (TLRC-H), Mitglied des Deutschen Zentrums für Lungenforschung (DZL), Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - T Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine Universität, Düsseldorf, Deutschland
| | - C J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
| | - C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - A Hecker
- Klinik für Allgemein- Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen, Deutschland
| | - C Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - D Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 420, 69120, Heidelberg, Deutschland
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Fawley JA, Tignanelli CJ, Werner NL, Kasotakis G, Mandell SP, Glass NE, Dries DJ, Costantini TW, Napolitano LM. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma clinical protocol for management of acute respiratory distress syndrome and severe hypoxemia. J Trauma Acute Care Surg 2023; 95:592-602. [PMID: 37314843 PMCID: PMC10545067 DOI: 10.1097/ta.0000000000004046] [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: 03/12/2023] [Revised: 04/27/2023] [Accepted: 04/28/2023] [Indexed: 06/15/2023]
Abstract
LEVEL OF EVIDENCE Therapeutic/Care Management: Level V.
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Jimenez JV, Munroe E, Weirauch AJ, Fiorino K, Culter CA, Nelson K, Labaki WW, Choi PJ, Co I, Standiford TJ, Prescott HC, Hyzy RC. Electric impedance tomography-guided PEEP titration reduces mechanical power in ARDS: a randomized crossover pilot trial. Crit Care 2023; 27:21. [PMID: 36650593 PMCID: PMC9843117 DOI: 10.1186/s13054-023-04315-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/11/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND In patients with acute respiratory distress syndrome undergoing mechanical ventilation, positive end-expiratory pressure (PEEP) can lead to recruitment or overdistension. Current strategies utilized for PEEP titration do not permit the distinction. Electric impedance tomography (EIT) detects and quantifies the presence of both collapse and overdistension. We investigated whether using EIT-guided PEEP titration leads to decreased mechanical power compared to high-PEEP/FiO2 tables. METHODS A single-center, randomized crossover pilot trial comparing EIT-guided PEEP selection versus PEEP selection using the High-PEEP/FiO2 table in patients with moderate-severe acute respiratory distress syndrome. The primary outcome was the change in mechanical power after each PEEP selection strategy. Secondary outcomes included changes in the 4 × driving pressure + respiratory rate (4 ΔP, + RR index) index, driving pressure, plateau pressure, PaO2/FiO2 ratio, and static compliance. RESULTS EIT was consistently associated with a decrease in mechanical power compared to PEEP/FiO2 tables (mean difference - 4.36 J/min, 95% CI - 6.7, - 1.95, p = 0.002) and led to lower values in the 4ΔP + RR index (- 11.42 J/min, 95% CI - 19.01, - 3.82, p = 0.007) mainly driven by a decrease in the elastic-dynamic power (- 1.61 J/min, - 2.99, - 0.22, p = 0.027). The elastic-static and resistive powers were unchanged. Similarly, EIT led to a statistically significant change in set PEEP (- 2 cmH2O, p = 0.046), driving pressure, (- 2.92 cmH2O, p = 0.003), peak pressure (- 6.25 cmH2O, p = 0.003), plateau pressure (- 4.53 cmH2O, p = 0.006), and static respiratory system compliance (+ 7.93 ml/cmH2O, p = 0.008). CONCLUSIONS In patients with moderate-severe acute respiratory distress syndrome, EIT-guided PEEP titration reduces mechanical power mainly through a reduction in elastic-dynamic power. Trial registration This trial was prospectively registered on Clinicaltrials.gov (NCT03793842) on January 4th, 2019.
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Affiliation(s)
- Jose Victor Jimenez
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr. Floor 3 Reception C, Ann Arbor, MI, 48109, USA
| | - Elizabeth Munroe
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr. Floor 3 Reception C, Ann Arbor, MI, 48109, USA
| | - Andrew J Weirauch
- UH/CVC Department of Respiratory Care, University of Michigan, Ann Arbor, MI, USA
| | - Kelly Fiorino
- UH/CVC Department of Respiratory Care, University of Michigan, Ann Arbor, MI, USA
| | - Christopher A Culter
- UH/CVC Department of Respiratory Care, University of Michigan, Ann Arbor, MI, USA
| | - Kristine Nelson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr. Floor 3 Reception C, Ann Arbor, MI, 48109, USA
| | - Wassim W Labaki
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr. Floor 3 Reception C, Ann Arbor, MI, 48109, USA
| | - Philip J Choi
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr. Floor 3 Reception C, Ann Arbor, MI, 48109, USA
- UH/CVC Department of Respiratory Care, University of Michigan, Ann Arbor, MI, USA
| | - Ivan Co
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr. Floor 3 Reception C, Ann Arbor, MI, 48109, USA
| | - Theodore J Standiford
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr. Floor 3 Reception C, Ann Arbor, MI, 48109, USA
| | - Hallie C Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr. Floor 3 Reception C, Ann Arbor, MI, 48109, USA
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Robert C Hyzy
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, 1500 E Medical Center Dr. Floor 3 Reception C, Ann Arbor, MI, 48109, USA.
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Felix NS, Maia LA, Rocha NN, Rodrigues GC, Medeiros M, da Silva LA, Baldavira CM, Fernezlian SDM, Eher EM, Capelozzi VL, Malbrain MLNG, Pelosi P, Rocco PRM, Silva PL. Biological impact of restrictive and liberal fluid strategies at low and high PEEP levels on lung and distal organs in experimental acute respiratory distress syndrome. Front Physiol 2022; 13:992401. [PMID: 36388107 PMCID: PMC9663484 DOI: 10.3389/fphys.2022.992401] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 10/13/2022] [Indexed: 11/28/2022] Open
Abstract
Background: Fluid regimens in acute respiratory distress syndrome (ARDS) are conflicting. The amount of fluid and positive end-expiratory pressure (PEEP) level may interact leading to ventilator-induced lung injury (VILI). We therefore evaluated restrictive and liberal fluid strategies associated with low and high PEEP levels with regard to lung and kidney damage, as well as cardiorespiratory function in endotoxin-induced ARDS. Methods: Thirty male Wistar rats received an intratracheal instillation of Escherichia coli lipopolysaccharide. After 24 h, the animals were anesthetized, protectively ventilated (VT = 6 ml/kg), and randomized to restrictive (5 ml/kg/h) or liberal (40 ml/kg/h) fluid strategies (Ringer lactate). Both groups were then ventilated with PEEP = 3 cmH2O (PEEP3) and PEEP = 9 cmH2O (PEEP9) for 1 h (n = 6/group). Echocardiography, arterial blood gases, and lung mechanics were evaluated throughout the experiments. Histologic analyses were done on the lungs, and molecular biology was assessed in lungs and kidneys using six non-ventilated animals with no fluid therapy. Results: In lungs, the liberal group showed increased transpulmonary plateau pressure compared with the restrictive group (liberal, 23.5 ± 2.9 cmH2O; restrictive, 18.8 ± 2.3 cmH2O, p = 0.046) under PEEP = 9 cmH2O. Gene expression associated with inflammation (interleukin [IL]-6) was higher in the liberal-PEEP9 group than the liberal-PEEP3 group (p = 0.006) and restrictive-PEEP9 (p = 0.012), Regardless of the fluid strategy, lung mechanical power and the heterogeneity index were higher, whereas birefringence for claudin-4 and zonula-ocludens-1 gene expression were lower in the PEEP9 groups. Perivascular edema was higher in liberal groups, regardless of PEEP levels. Markers related to damage to epithelial cells [club cell secreted protein (CC16)] and the extracellular matrix (syndecan) were higher in the liberal-PEEP9 group than the liberal-PEEP3 group (p = 0.010 and p = 0.024, respectively). In kidneys, the expression of IL-6 and neutrophil gelatinase-associated lipocalin was higher in PEEP9 groups, regardless of the fluid strategy. For the liberal strategy, PEEP = 9 cmH2O compared with PEEP = 3 cmH2O reduced the right ventricle systolic volume (37%) and inferior vena cava collapsibility index (45%). Conclusion: The combination of a liberal fluid strategy and high PEEP led to more lung damage. The application of high PEEP, regardless of the fluid strategy, may also be deleterious to kidneys.
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Affiliation(s)
- Nathane S. Felix
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ligia A. Maia
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Nazareth N. Rocha
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- Department of Physiology and Pharmacology, Biomedical Institute, Fluminense Federal University, Rio de Janeiro, Brazil
| | - Gisele C. Rodrigues
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Mayck Medeiros
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Leticia A. da Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Camila M. Baldavira
- Department of Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Esmeralda M. Eher
- Department of Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Vera L. Capelozzi
- Department of Pathology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Manu L. N. G. Malbrain
- First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Patricia R. M. Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro L. Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- *Correspondence: Pedro L. Silva,
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Boesing C, Graf PT, Schmitt F, Thiel M, Pelosi P, Rocco PRM, Luecke T, Krebs J. Effects of different positive end-expiratory pressure titration strategies during prone positioning in patients with acute respiratory distress syndrome: a prospective interventional study. Crit Care 2022; 26:82. [PMID: 35346325 PMCID: PMC8962042 DOI: 10.1186/s13054-022-03956-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/19/2022] [Indexed: 01/01/2023] Open
Abstract
Background Prone positioning in combination with the application of low tidal volume and adequate positive end-expiratory pressure (PEEP) improves survival in patients with moderate to severe acute respiratory distress syndrome (ARDS). However, the effects of PEEP on end-expiratory transpulmonary pressure (Ptpexp) during prone positioning require clarification. For this purpose, the effects of three different PEEP titration strategies on Ptpexp, respiratory mechanics, mechanical power, gas exchange, and hemodynamics were evaluated comparing supine and prone positioning. Methods In forty consecutive patients with moderate to severe ARDS protective ventilation with PEEP titrated according to three different titration strategies was evaluated during supine and prone positioning: (A) ARDS Network recommendations (PEEPARDSNetwork), (B) the lowest static elastance of the respiratory system (PEEPEstat,RS), and (C) targeting a positive Ptpexp (PEEPPtpexp). The primary endpoint was to analyze whether Ptpexp differed significantly according to PEEP titration strategy during supine and prone positioning. Results Ptpexp increased progressively with prone positioning compared with supine positioning as well as with PEEPEstat,RS and PEEPPtpexp compared with PEEPARDSNetwork (positioning effect p < 0.001, PEEP strategy effect p < 0.001). PEEP was lower during prone positioning with PEEPEstat,RS and PEEPPtpexp (positioning effect p < 0.001, PEEP strategy effect p < 0.001). During supine positioning, mechanical power increased progressively with PEEPEstat,RS and PEEPPtpexp compared with PEEPARDSNetwork, and prone positioning attenuated this effect (positioning effect p < 0.001, PEEP strategy effect p < 0.001). Prone compared with supine positioning significantly improved oxygenation (positioning effect p < 0.001, PEEP strategy effect p < 0.001) while hemodynamics remained stable in both positions. Conclusions Prone positioning increased transpulmonary pressures while improving oxygenation and hemodynamics in patients with moderate to severe ARDS when PEEP was titrated according to the ARDS Network lower PEEP table. This PEEP titration strategy minimized parameters associated with ventilator-induced lung injury induction, such as transpulmonary driving pressure and mechanical power. We propose that a lower PEEP strategy (PEEPARDSNetwork) in combination with prone positioning may be part of a lung protective ventilation strategy in patients with moderate to severe ARDS. Trial registration German Clinical Trials Register (DRKS00017449). Registered June 27, 2019. https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00017449 Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03956-8.
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Lee JWW, Chiew YS, Wang X, Tan CP, Mat Nor MB, Cove ME, Damanhuri NS, Chase JG. Protocol conception for safe selection of mechanical ventilation settings for respiratory failure Patients. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 214:106577. [PMID: 34936946 DOI: 10.1016/j.cmpb.2021.106577] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/17/2021] [Accepted: 12/03/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND AND OBJECTIVE Mechanical ventilation is the primary form of care provided to respiratory failure patients. Limited guidelines and conflicting results from major clinical trials means selection of mechanical ventilation settings relies heavily on clinician experience and intuition. Determining optimal mechanical ventilation settings is therefore difficult, where non-optimal mechanical ventilation can be deleterious. To overcome these difficulties, this research proposes a model-based method to manage the wide range of possible mechanical ventilation settings, while also considering patient-specific conditions and responses. METHODS This study shows the design and development of the "VENT" protocol, which integrates the single compartment linear lung model with clinical recommendations from landmark studies, to aid clinical decision-making in selecting mechanical ventilation settings. Using retrospective breath data from a cohort of 24 patients, 3,566 and 2,447 clinically implemented VC and PC settings were extracted respectively. Using this data, a VENT protocol application case study and clinical comparison is performed, and the prediction accuracy of the VENT protocol is validated against actual measured outcomes of pressure and volume. RESULTS The study shows the VENT protocols' potential use in narrowing an overwhelming number of possible mechanical ventilation setting combinations by up to 99.9%. The comparison with retrospective clinical data showed that only 33% and 45% of clinician settings were approved by the VENT protocol. The unapproved settings were mainly due to exceeding clinical recommended settings. When utilising the single compartment model in the VENT protocol for forecasting peak pressures and tidal volumes, median [IQR] prediction error values of 0.75 [0.31 - 1.83] cmH2O and 0.55 [0.19 - 1.20] mL/kg were obtained. CONCLUSIONS Comparing the proposed protocol with retrospective clinically implemented settings shows the protocol can prevent harmful mechanical ventilation setting combinations for which clinicians would be otherwise unaware. The VENT protocol warrants a more detailed clinical study to validate its potential usefulness in a clinical setting.
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Affiliation(s)
- Jay Wing Wai Lee
- School of Engineering, Monash University Malaysia, Selangor, Malaysia.
| | | | - Xin Wang
- School of Engineering, Monash University Malaysia, Selangor, Malaysia
| | - Chee Pin Tan
- School of Engineering, Monash University Malaysia, Selangor, Malaysia
| | - Mohd Basri Mat Nor
- Kulliyah of Medicine, International Islamic University Malaysia, Pahang, Malaysia
| | - Matthew E Cove
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Health System, Singapore
| | - Nor Salwa Damanhuri
- Faculty of Electrical Engineering, Universiti Teknologi MARA, Cawangan Pulau Pinang, Pulau Pinang, Malaysia
| | - J Geoffrey Chase
- Center of Bioengineering, University of Canterbury, Christchurch, New Zealand
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