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Zerbib Y, Schoux R, Richecoeur J, Bradier T, Brault C, Kontar L, Lambour A, Maizel J, Slama M. Effects of Positive End-Expiratory Pressure on Artery Coronary Flow in Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med 2024; 209:598-601. [PMID: 37972356 DOI: 10.1164/rccm.202306-1109le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 11/16/2023] [Indexed: 11/19/2023] Open
Affiliation(s)
- Yoann Zerbib
- Intensive Care Department, Amiens-Picardie University Hospital, Amiens, France; and
| | - Rosalie Schoux
- Intensive Care Department, Amiens-Picardie University Hospital, Amiens, France; and
| | - Jack Richecoeur
- Intensive Care Department, Beauvais Hospital, Beauvais, France
| | - Thomas Bradier
- Intensive Care Department, Beauvais Hospital, Beauvais, France
| | - Clément Brault
- Intensive Care Department, Amiens-Picardie University Hospital, Amiens, France; and
| | - Loay Kontar
- Intensive Care Department, Amiens-Picardie University Hospital, Amiens, France; and
| | - Alexis Lambour
- Intensive Care Department, Amiens-Picardie University Hospital, Amiens, France; and
| | - Julien Maizel
- Intensive Care Department, Amiens-Picardie University Hospital, Amiens, France; and
| | - Michel Slama
- Intensive Care Department, Amiens-Picardie University Hospital, Amiens, France; and
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Sanchez AF, Ambrósio AM, Pinto ACBCF, Pereira MAA, Andrade FSRM, Rodrigues RR, de Carvalho Martins AR, Baroni CO, Ferrante B, Fantoni DT. Effects of a stepwise alveolar recruitment maneuver on lung volume distribution in dogs assessed by computed tomography. Front Vet Sci 2024; 10:1232635. [PMID: 38292132 PMCID: PMC10825017 DOI: 10.3389/fvets.2023.1232635] [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: 05/31/2023] [Accepted: 12/19/2023] [Indexed: 02/01/2024] Open
Abstract
Background Pulmonary atelectasis is a commonly occurs during anesthesia. In these cases, mechanical ventilation (MV) associated with alveolar recruitment maneuvers (ARMs) and positive end-expiratory pressure (PEEP) is indicated to reverse the condition, ensure adequate gas exchange and improve oxygenation. ARMs can trigger volutrauma, barotrauma, and atelectrauma. Therefore, computed tomography (CT) is the gold-standard method for monitoring lung aeration after ARM. Objective To evaluate lung volume distribution after stepwise ARMs using computed tomography (CT). Methods Twelve dogs weighing 24.0 ± 6.0 kg, aged 3 ± 1 years, of both sexes and different breeds, underwent orchiectomy or ovariohysterectomy. The animals were anesthetized and ventilated in volume-controlled mode. ARMs were then initiated by positive end-expiratory pressure (PEEP) titration (5, 10, 15, and 20 cmH2O). CT scans, cardiovascular parameters, and ventilatory mechanics were evaluated at all time points. Data were assessed for normality using the Shapiro-Wilk test and a two-way analysis of variance, followed by a post-hoc Bonferroni test to identify differences between time points. Statistical significance was attributed to a value of p of <0.05. Results CT demonstrated that the ARMs increased ventilation throughout the lung, including the dependent regions, with volumes that increased and decreased proportionally with PEEP titration. When they reached PEEP 10 and 5 cmH2O descending (d), they remained significantly higher than those in PEEP 0 cmH2O (baseline). Static compliance improved about 40% at PEEP 10d and PEEP 5d compared to baseline. There was an increase in heart rate (HR) from PEEP 15 increasing (i) (74.5%) to PEEP 10d (54.8%) compared to baseline. Mean arterial blood pressure (MABP) decreased approximately 9% from PEEP 15i to PEEP 15d compared to baseline. Conclusion Lung attenuation and regional and global volumes assessed by CT showed that maximum pulmonary aeration distribution followed by PEEP titration occurred at PEEP 20 cmH2O, maintaining the lungs normoaerated and without hyperaeration.
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Affiliation(s)
- Ana Flávia Sanchez
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Aline Magalhães Ambrósio
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Ana Carolina B. C. Fonseca Pinto
- Department of Veterinary Clinical Sciences, Diagnostic Imaging Purdue University College of Veterinary Medicine, West Lafayette, IN, United States
| | - Marco Aurélio Amador Pereira
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, São Paulo, Brazil
| | | | - Renata Ramos Rodrigues
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, São Paulo, Brazil
| | | | - Carina Outi Baroni
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Bruno Ferrante
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Denise Tabacchi Fantoni
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, São Paulo, Brazil
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Ganeriwal S, Alves Dos Anjos G, Schleicher M, Hockstein MA, Tonelli AR, Duggal A, Siuba MT. Right ventricle-specific therapies in acute respiratory distress syndrome: a scoping review. Crit Care 2023; 27:104. [PMID: 36907888 PMCID: PMC10008150 DOI: 10.1186/s13054-023-04395-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/06/2023] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVE To summarize knowledge and identify gaps in evidence regarding treatment of right ventricular dysfunction (RVD) in acute respiratory distress syndrome (ARDS). DATA SOURCES We conducted a comprehensive search of MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials. STUDY SELECTION Studies were included if they reported effects of treatments on right ventricular function, whether or not the intent was to modify right ventricular function. DATA EXTRACTION Data extraction was performed independently and in duplicate by two authors. Data items included the study design, patient population, type of intervention, comparison group, and RV-specific outcomes. DATA SYNTHESIS Of 1,430 studies screened, 51 studies reporting on 1,526 patients were included. By frequency, the included studies examined the following interventions: ventilator settings (29.4%), inhaled medications (33.3%), extracorporeal life support (13.7%), intravenous or oral medications (13.7%), and prone positioning (9.8%). The majority of the studies were non-randomized experimental studies (53%), with the next most common being case reports (16%). Only 5.9% of studies were RCTs. In total, 27% of studies were conducted with the goal of modifying RV function. CONCLUSIONS Given the prevalence of RVD in ARDS and its association with mortality, the dearth of research on this topic is concerning. This review highlights the need for prospective trials aimed at treating RV dysfunction in ARDS.
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Affiliation(s)
- Simran Ganeriwal
- Department of Internal Medicine, Community Care Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Mary Schleicher
- The Cleveland Clinic Floyd D. Loop Alumni Library, Cleveland Clinic, Cleveland, OH, USA
| | - Maxwell A Hockstein
- Departments of Emergency Medicine and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Adriano R Tonelli
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
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Vedrenne-Cloquet M, Khirani S, Khemani R, Lesage F, Oualha M, Renolleau S, Chiumello D, Demoule A, Fauroux B. Pleural and transpulmonary pressures to tailor protective ventilation in children. Thorax 2023; 78:97-105. [PMID: 35803726 DOI: 10.1136/thorax-2021-218538] [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: 11/30/2021] [Accepted: 06/12/2022] [Indexed: 02/07/2023]
Abstract
This review aims to: (1) describe the rationale of pleural (PPL) and transpulmonary (PL) pressure measurements in children during mechanical ventilation (MV); (2) discuss its usefulness and limitations as a guide for protective MV; (3) propose future directions for paediatric research. We conducted a scoping review on PL in critically ill children using PubMed and Embase search engines. We included peer-reviewed studies using oesophageal (PES) and PL measurements in the paediatric intensive care unit (PICU) published until September 2021, and excluded studies in neonates and patients treated with non-invasive ventilation. PL corresponds to the difference between airway pressure and PPL Oesophageal manometry allows measurement of PES, a good surrogate of PPL, to estimate PL directly at the bedside. Lung stress is the PL, while strain corresponds to the lung deformation induced by the changing volume during insufflation. Lung stress and strain are the main determinants of MV-related injuries with PL and PPL being key components. PL-targeted therapies allow tailoring of MV: (1) Positive end-expiratory pressure (PEEP) titration based on end-expiratory PL (direct measurement) may be used to avoid lung collapse in the lung surrounding the oesophagus. The clinical benefit of such strategy has not been demonstrated yet. This approach should consider the degree of recruitable lung, and may be limited to patients in which PEEP is set to achieve an end-expiratory PL value close to zero; (2) Protective ventilation based on end-inspiratory PL (derived from the ratio of lung and respiratory system elastances), might be used to limit overdistention and volutrauma by targeting lung stress values < 20-25 cmH2O; (3) PPL may be set to target a physiological respiratory effort in order to avoid both self-induced lung injury and ventilator-induced diaphragm dysfunction; (4) PPL or PL measurements may contribute to a better understanding of cardiopulmonary interactions. The growing cardiorespiratory system makes children theoretically more susceptible to atelectrauma, myotrauma and right ventricle failure. In children with acute respiratory distress, PPL and PL measurements may help to characterise how changes in PEEP affect PPL and potentially haemodynamics. In the PICU, PPL measurement to estimate respiratory effort is useful during weaning and ventilator liberation. Finally, the use of PPL tracings may improve the detection of patient ventilator asynchronies, which are frequent in children. Despite these numerous theoritcal benefits in children, PES measurement is rarely performed in routine paediatric practice. While the lack of robust clincal data partially explains this observation, important limitations of the existing methods to estimate PPL in children, such as their invasiveness and technical limitations, associated with the lack of reference values for lung and chest wall elastances may also play a role. PPL and PL monitoring have numerous potential clinical applications in the PICU to tailor protective MV, but its usefulness is counterbalanced by technical limitations. Paediatric evidence seems currently too weak to consider oesophageal manometry as a routine respiratory monitoring. The development and validation of a noninvasive estimation of PL and multimodal respiratory monitoring may be worth to be evaluated in the future.
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Affiliation(s)
- Meryl Vedrenne-Cloquet
- Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France .,Université de Paris Cité, VIFASOM, Paris, France.,Pediatric Non Invasive Ventilation Unit, Necker-Enfants Malades Hospitals, Paris, France
| | - Sonia Khirani
- Pediatric Non Invasive Ventilation Unit, Necker-Enfants Malades Hospitals, Paris, France.,ASV Santé, Genevilliers, France
| | - Robinder Khemani
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
| | - Fabrice Lesage
- Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France
| | - Mehdi Oualha
- Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France
| | - Sylvain Renolleau
- Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France
| | - Davide Chiumello
- Dipartimento di Anestesia, Rianimazione e Terapia del Dolore, Fondazione, IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Alexandre Demoule
- Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France.,UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, Sorbonne Université, INSERM, Paris, France
| | - Brigitte Fauroux
- Université de Paris Cité, VIFASOM, Paris, France.,Pediatric Non Invasive Ventilation Unit, Necker-Enfants Malades Hospitals, Paris, France
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Liu X, Liu X, Meng J, Liu D, Huang Y, Sang L, Xu Y, Xu Z, He W, Chen S, Zhang R, Liu X, Li Y. Electrical impedance tomography for titration of positive end-expiratory pressure in acute respiratory distress syndrome patients with chronic obstructive pulmonary disease. Crit Care 2022; 26:339. [PMCID: PMC9635124 DOI: 10.1186/s13054-022-04201-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
Background Chronic obstructive pulmonary disease (COPD) is one of most common comorbidities in acute respiratory distress syndrome (ARDS). There are few specific studies on the appropriate ventilation strategy for patients with ARDS comorbid with COPD, especially regarding on positive end-expiratory pressure (PEEP) titration. Methods To compare the respiratory mechanics in mechanical ventilated ARDS patients with or without COPD and to determine whether titration of PEEP based on electrical impedance tomography (EIT) is superior to the ARDSnet protocol. This is a single center, perspective, repeated measure study. ARDS patients requiring mechanical ventilation who were admitted to the intensive care unit between August 2017 and December 2020 were included. ARDS patients were divided according to whether they had COPD into a COPD group and a non-COPD group. Respiratory mechanics, gas exchange, and hemodynamics during ventilation were compared between the groups according to whether the PEEP level was titrated by EIT or the ARDSnet protocol. Results A total of twenty-seven ARDS patients including 14 comorbid with and 13 without COPD who met the study eligibility criteria were recruited. The PEEP levels titrated by EIT and the ARDSnet protocol were lower in the COPD group than in the non-COPD group (6.93 ± 1.69 cm H2O vs. 12.15 ± 2.40 cm H2O, P < 0.001 and 10.43 ± 1.20 cm H2O vs. 14.0 ± 3.0 cm H2O, P < 0.001, respectively). In the COPD group, the PEEP level titrated by EIT was lower than that titrated by the ARDSnet protocol (6.93 ± 1.69 cm H2O vs. 10.43 ± 1.20 cm H2O, P < 0.001), as was the global inhomogeneity (GI) index (0.397 ± 0.040 vs. 0.446 ± 0.052, P = 0.001), plateau airway pressure (16.50 ± 4.35 cm H2O vs. 20.93 ± 5.37 cm H2O, P = 0.001), dead space ventilation ratio (48.29 ± 6.78% vs. 55.14 ± 8.85%, P < 0.001), ventilation ratio (1.63 ± 0.33 vs. 1.87 ± 0.33, P < 0.001), and mechanical power (13.92 ± 2.18 J/min vs. 15.87 ± 2.53 J/min, P < 0.001). The cardiac index was higher when PEEP was treated by EIT than when it was titrated by the ARDSnet protocol (3.41 ± 0.50 L/min/m2 vs. 3.02 ± 0.43 L/min/m2, P < 0.001), as was oxygen delivery (466.40 ± 71.08 mL/min/m2 vs. 411.10 ± 69.71 mL/min/m2, P = 0.001). Conclusion Titrated PEEP levels were lower in patients with ARDS with COPD than in ARDS patients without COPD. In ARDS patient comorbid with COPD, application of PEEP titrated by EIT was lower than those titrated by the ARDSnet protocol, which contributed to improvements in the ventilation ratio, mechanical energy, cardiac index, and oxygen delivery with less of an adverse impact on hemodynamics. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04201-y.
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Affiliation(s)
- Xuesong Liu
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Xiao Liu
- Department of Critical Care Medicine, Huadu District People’s Hospital, Guangzhou, 510800 China
| | - Jue Meng
- grid.79703.3a0000 0004 1764 3838Department of Respiratory Medicine, Nanhai District People’s Hospital and Sixth Affiliated Hospital of South China University of Technology, Foshan, 528200 Guangdong China
| | - Dongdong Liu
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Yongbo Huang
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Ling Sang
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Yonghao Xu
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Zhiheng Xu
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Weiqun He
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Sibei Chen
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Rong Zhang
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Xiaoqing Liu
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
| | - Yimin Li
- grid.470124.4State Key Lab of Respiratory Diseases, Guangzhou Institute of Respiratory Health, Department of Critical Care Medicine, The First Affiliated Hospital of Guangzhou Medical University, 151 Yanjiang Street West, Guangzhou, 510120 Guangdong China
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Zhang Z, Zhang L, Zhu J, Dong J, Liu H. Effect of electrical impedance-guided PEEP in reducing pulmonary complications after craniotomy: study protocol for a randomized controlled trial. Trials 2022; 23:837. [PMID: 36183099 PMCID: PMC9526950 DOI: 10.1186/s13063-022-06751-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 09/14/2022] [Indexed: 11/10/2022] Open
Abstract
Objective The purpose of this study is to explore whether electrical impedance tomography (EIT)-guided individualized positive end-expiratory pressure (PEEP) can reduce the incidence of pulmonary complications within 1 week following a craniotomy compared with a single PEEP (PEEP = 6 cmH2O) from dura suturing to extubation. Methods A randomized controlled trial will be conducted at the Second Affiliated Hospital of Soochou University. Five hundred forty patients undergoing a craniotomy in the supine position will be randomly allocated into the P6 (PEEP = 6 cmH2O) or Pi (individualized PEEP) group. Both groups of patients will receive a lung recruitment maneuver before suturing the dura. Then, the P6 group will receive 6 cmH2O PEEP, and the Pi group will receive EIT-guided individualized PEEP. The incidence and severity score of pulmonary complications within 1 week following surgery, the lung ultrasound score (LUS), regional cerebral oxygen saturation (rScO2), and PaO2/FiO2 before anesthesia (T0), 10 min after extubation (T1), 24 h after extubation (T2), and 72 h after extubation (T3) will be compared between the two groups. The duration of surgery and anesthesia, the level and duration of PEEP during surgery, the volume of liquid intake and output during surgery, and the postoperative ICU and hospital stays will be recorded. The main outcome of this study will be the incidence of pulmonary complications within 1 week after surgery. Discussion The purposes of this study are to determine whether EIT-guided individualized PEEP from the beginning of dura suturing to extubation reduces the incidence of pulmonary complications within 1 week after a craniotomy compared with a single constant PEEP and to evaluate the length of ICU and hospital stays. If our results are positive, this study will show that EIT-guided individualized PEEP is better than a single constant PEEP and can further improve the prognosis of neurosurgical patients and reduce hospitalization costs, which will promote the wide application of individualized PEEP in clinical anesthesia. Trial registration Chinese Clinical Trial Registry CHiCTR2100051200. Registered on 15 September 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06751-6.
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Affiliation(s)
- Zihao Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, Jiangsu, China
| | - Lianqin Zhang
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, Jiangsu, China
| | - Jiang Zhu
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, Jiangsu, China
| | - Jun Dong
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, Jiangsu, China
| | - Hairui Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, Jiangsu, China.
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Ambrósio AM, Sanchez AF, Pereira MAA, Andrade FSRMD, Rodrigues RR, Vitorasso RDL, Moriya HT, Fantoni DT. Assessment of Regional Ventilation During Recruitment Maneuver by Electrical Impedance Tomography in Dogs. Front Vet Sci 2022; 8:815048. [PMID: 35237676 PMCID: PMC8882687 DOI: 10.3389/fvets.2021.815048] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 12/28/2021] [Indexed: 01/07/2023] Open
Abstract
Background During protective mechanical ventilation, electrical impedance tomography (EIT) is used to monitor alveolar recruitment maneuvers as well as the distribution of regional ventilation. This technique can infer atelectasis and lung overdistention during mechanical ventilation in anesthetized patients or in the ICU. Changes in lung tissue stretching are evaluated by monitoring the electrical impedance of lung tissue with each respiratory cycle. Objective This study aimed to evaluate the distribution of regional ventilation during recruitment maneuvers based on the variables obtained in pulmonary electrical impedance tomography during protective mechanical ventilation, focusing on better lung recruitment associated with less or no overdistention. Methods Prospective clinical study using seven adult client–owned healthy dogs, weighing 25 ± 6 kg, undergoing elective ovariohysterectomy or orchiectomy. The animals were anesthetized and ventilated in volume-controlled mode (7 ml.kg−1) with stepwise PEEP increases from 0 to 20 cmH2O in steps of 5 cmH2O every 5 min and then a stepwise decrease. EIT, respiratory mechanics, oxygenation, and hemodynamic variables were recorded for each PEEP step. Results The results show that the regional compliance of the dependent lung significantly increased in the PEEP 10 cmH2O decrease step when compared with baseline (p < 0.027), and for the nondependent lung, there was a decrease in compliance at PEEP 20 cmH2O (p = 0.039) compared with baseline. A higher level of PEEP was associated with a significant increase in silent space of the nondependent regions from the PEEP 10 cmH2O increase step (p = 0.048) until the PEEP 15 cmH2O (0.019) decrease step with the highest values at PEEP 20 cmH20 (p = 0.016), returning to baseline values thereafter. Silent space of the dependent regions did not show any significant changes. Drive pressure decreased significantly in the PEEP 10 and 5 cmH2O decrease steps (p = 0.032) accompanied by increased respiratory static compliance in the same PEEP step (p = 0.035 and 0.018, respectively). Conclusions The regional ventilation distribution assessed by EIT showed that the best PEEP value for recruitment maintenance, capable of decreasing areas of pulmonary atelectasis in dependent regions promoting less overinflation in nondependent areas, was from 10 to 5 cmH2O decreased steps.
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Affiliation(s)
- Aline Magalhães Ambrósio
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
- *Correspondence: Aline Magalhães Ambrósio
| | - Ana Flávia Sanchez
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
| | - Marco Aurélio Amador Pereira
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
| | | | - Renata Ramos Rodrigues
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
| | - Renato de Lima Vitorasso
- Laboratory of Biomedical Engineering, Escola Politecnica, University of São Paulo, São Paulo, Brazil
| | - Henrique Takachi Moriya
- Laboratory of Biomedical Engineering, Escola Politecnica, University of São Paulo, São Paulo, Brazil
| | - Denise Tabacchi Fantoni
- Department of Surgery, School of Veterinary Medicine and Animal Science, University of São Paulo, São Paulo, Brazil
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Soares JHN, Braun C, Machado ML, Oliveira RL, Henao-Guerrero N, Countermash-Ott S, Allen IC, Grant DC, Giannella-Neto A. Cardiovascular function, pulmonary gas exchange and tissue oxygenation in isoflurane-anesthetized, mechanically ventilated Beagle dogs with four levels of positive end-expiratory pressure. Vet Anaesth Analg 2021; 48:324-333. [PMID: 33741264 DOI: 10.1016/j.vaa.2021.01.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/07/2021] [Accepted: 01/24/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To compare pulmonary gas exchange, tissue oxygenation and cardiovascular effects of four levels of end-expiratory pressure: no positive end-expiratory pressure (ZEEP), positive end-expiratory pressure (PEEP) of maximal respiratory system compliance (PEEPmaxCrs), PEEPmaxCrs + 2 cmH2O (PEEPmaxCrs+2), PEEPmaxCrs + 4 cmH2O (PEEPmaxCrs+4), in isoflurane-anesthetized dogs. STUDY DESIGN Prospective randomized crossover study. ANIMALS A total of seven healthy male Beagle dogs, aged 1 year and weighing 10.2 ± 0.7 kg (mean ± standard deviation). METHODS The dogs were administered acepromazine and anesthesia was induced with propofol and maintained with isoflurane. Ventilation was controlled for 4 hours with ZEEP, PEEPmaxCrs, PEEPmaxCrs+2 or PEEPmaxCrs+4. Cardiovascular, pulmonary gas exchange and tissue oxygenation data were evaluated at 5, 60, 120, 180 and 240 minutes of ventilation and compared using a mixed-model anova followed by Bonferroni test. p < 0.05 was considered significant. RESULTS Cardiac index (CI) and mean arterial pressure (MAP) were lower in all PEEP treatments at 5 minutes when compared with ZEEP. CI persisted lower throughout the 4 hours only in PEEPmaxCrs+4 with the lowest CI at 5 minutes (2.15 ± 0.70 versus 3.45 ± 0.94 L minute-1 m-2). At 180 and 240 minutes, MAP was lower in PEEPmaxCrs+4 than in PEEPmaxCrs, with the lowest value at 180 minutes (58 ± 7 versus 67 ± 7 mmHg). Oxygen delivery index (DO2I) was lower in PEEPmaxCrs+4 than in ZEEP at 5, 60, 120 and 180 minutes. Venous admixture was not different among treatments. CONCLUSION AND CLINICAL RELEVANCE The use of PEEP caused a transient decrease in MAP and CI in lung-healthy dogs anesthetized with isoflurane, which improved after 60 minutes of ventilation in all levels of PEEP except PEEPmaxCrs+4. A clinically significant improvement in arterial oxygenation and DO2I was not observed with PEEPmaxCrs and PEEPmaxCrs+2 in comparison with ZEEP, whereas PEEPmaxCrs+4 decreased DO2I.
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Affiliation(s)
- Joao H N Soares
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA.
| | - Christina Braun
- Anesthesiology and Perioperative Intensive Care, University of Veterinary Medicine Vienna, Vienna, Austria
| | - Marcela L Machado
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Renato L Oliveira
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Natalia Henao-Guerrero
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Sherryl Countermash-Ott
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Irving C Allen
- Department of Biomedical Sciences and Pathobiology, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - David C Grant
- Department of Small Animal Clinical Sciences, Virginia-Maryland College of Veterinary Medicine, Virginia Polytechnic Institute and State University, Blacksburg, VA, USA
| | - Antonio Giannella-Neto
- Laboratory of Pulmonary Engineering, Biomedical Engineering Program/COPPE, Federal University of Rio de Janeiro, Rio de Janeiro, RJ, Brazil
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9
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Schiavon R, Casazza G, Cogliati C. Right Ventricular Longitudinal Strain: A New Prognostic Tool for COVID-19? JACC Cardiovasc Imaging 2020; 13:1859. [PMID: 32762893 PMCID: PMC7334960 DOI: 10.1016/j.jcmg.2020.06.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/03/2020] [Indexed: 12/04/2022]
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10
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Individualized PEEP ventilation between tumor resection and dural suture in craniotomy. Clin Neurol Neurosurg 2020; 196:106027. [PMID: 32673939 DOI: 10.1016/j.clineuro.2020.106027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/03/2020] [Accepted: 06/14/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Atelectasis, which affects oxygenation, is always occurred after craniotomy under general anesthesia. The commonly used protective ventilation strategy, which includes recruitment maneuver and higher level of positive end-expiratory pressure (PEEP), can effectively reduce atelectasis after heart and abdominal surgery, but increase intracranial pressure and reduce cerebral perfusion in patients undergoing craniotomy. We hypothesized individualized PEEP ventilation between tumor resection and dural suture in craniotomy could effectively reduce postoperative atelectasis, improve PaO2/FiO2 ratio, and without reducing the regional cerebral oxygen saturation (rScO2). PATIENTS AND METHODS 96 patients underwent tumor craniotomy in supine position were randomized into the control group (C group) and individualized PEEP group (P group). In the C group, the tidal volume (VT) was set at 8 mL/kg of predicted body weight, but PEEP were not used. In the P group, VT was set at 6 mL/kg of predicted body weight combined with individualized PEEP between tumor resection and dural suture, while in other periods of general anesthesia, VT was set at 8 mL/kg of predicted body weight. PaO2/FiO2 ratio, lung ultrasound score (LUS) and rScO2 were measured before induction, 1 h and 24 h after extubation. RESULTS Individual PEEP in the P group was 7.0 (4.0-9.0). The PaO2/FiO2 ratio and rScO2 in the P group were significantly higher than that of the C group (395 ± 62 vs. 344 ± 40, 67 ± 5 vs. 61 ± 4, respectively, p < 0.05) and the LUS of the experimental group was significantly lower than that of the C group [7.5 (5.3-8.3) vs. 10.0 (9.0-12.0), p < 0.05] 1 h after extubation. CONCLUSION Mechanical ventilation with individualized PEEP between tumor resection and dural suture in craniotomy can reduce atelectasis, improve PaO2/FiO2 ratio and rScO2 1 h after extubation.
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11
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Lemarié J, Maigrat CH, Kimmoun A, Dumont N, Bollaert PE, Selton-Suty C, Gibot S, Huttin O. Feasibility, reproducibility and diagnostic usefulness of right ventricular strain by 2-dimensional speckle-tracking echocardiography in ARDS patients: the ARD strain study. Ann Intensive Care 2020; 10:24. [PMID: 32056017 PMCID: PMC7018922 DOI: 10.1186/s13613-020-0636-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 01/30/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Right ventricular (RV) function evaluation by echocardiography is key in the management of ICU patients with acute respiratory distress syndrome (ARDS), however, it remains challenging. Quantification of RV deformation by speckle-tracking echocardiography (STE) is a recently available and reproducible technique that provides an integrated analysis of the RV. However, data are scarce regarding its use in critically ill patients. The aim of this study was to assess its feasibility and clinical usefulness in moderate-severe ARDS patients. RESULTS Forty-eight ARDS patients under invasive mechanical ventilation (MV) were consecutively enrolled in a prospective observational study. A full transthoracic echocardiography was performed within 36 h of MV initiation. STE-derived and conventional parameters were recorded. Strain imaging of the RV lateral, inferior and septal walls was highly feasible (47/48 (98%) patients). Interobserver reproducibility of RV strain values displayed good reliability (intraclass correlation coefficients (ICC) > 0.75 for all STE-derived parameters) in ARDS patients. ROC curve analysis showed that lateral, inferior, global (average of the 3 RV walls) longitudinal systolic strain (LSS) and global strain rate demonstrated significant diagnostic values when compared to several conventional indices (TAPSE, S', RV FAC). A RV global LSS value > - 13.7% differentiated patients with a TAPSE < vs > 12 mm with a sensitivity of 88% and a specificity of 83%. Regarding clinical outcomes, mortality and cumulative incidence of weaning from MV at day 28 were not different in patients with normal versus abnormal STE-derived parameters. CONCLUSIONS Global STE assessment of the RV was highly achievable and reproducible in moderate-severe ARDS patients under MV and additionally correlated with several conventional parameters of RV function. In our cohort, STE-derived parameters did not provide any incremental value in terms of survival or weaning from MV prediction. Further investigations are needed to evaluate their theranostic usefulness. Trial registration NCT02638844: NCT.
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Affiliation(s)
- Jérémie Lemarié
- Service de Réanimation Médicale, Hôpital Central, CHRU de Nancy, 29 rue du Maréchal de Lattre de Tassigny, 54000, Nancy, France.
| | - Charles-Henri Maigrat
- Service de Cardiologie, Institut Lorrain du Cœur et des Vaisseaux, CHRU de Nancy, 54511, Vandoeuvre-lès-Nancy, France
| | - Antoine Kimmoun
- Service de Médecine Intensive et Réanimation, Institut Lorrain du Cœur et des Vaisseaux, CHRU de Nancy, 54511, Vandoeuvre-lès-Nancy, France
| | - Nathalie Dumont
- Plateforme d'Aide à la Recherche Clinique, Bâtiment Recherche, CHRU de Nancy, 54511, Vandoeuvre-lès-Nancy, France
| | - Pierre-Edouard Bollaert
- Service de Réanimation Médicale, Hôpital Central, CHRU de Nancy, 29 rue du Maréchal de Lattre de Tassigny, 54000, Nancy, France
| | - Christine Selton-Suty
- Service de Cardiologie, Institut Lorrain du Cœur et des Vaisseaux, CHRU de Nancy, 54511, Vandoeuvre-lès-Nancy, France
| | - Sébastien Gibot
- Service de Réanimation Médicale, Hôpital Central, CHRU de Nancy, 29 rue du Maréchal de Lattre de Tassigny, 54000, Nancy, France
| | - Olivier Huttin
- Service de Cardiologie, Institut Lorrain du Cœur et des Vaisseaux, CHRU de Nancy, 54511, Vandoeuvre-lès-Nancy, France
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12
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Li J, Wu X, Liu H, Huang Y, Liu Y, Xie H, Dong J. The effects of protective lung ventilation on regional cerebral oxygen saturation in intracranial tumor operation during dura opening: study protocol for a randomized controlled trial. Trials 2020; 21:149. [PMID: 32033612 PMCID: PMC7006087 DOI: 10.1186/s13063-019-4025-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/21/2019] [Indexed: 12/03/2022] Open
Abstract
Objective The objective of this trial is to investigate the effects of protective lung ventilation on regional cerebral oxygen saturation (rSO2) during dura opening, that is from Ta (after dura opening) to Tb (before dura closing), in patients undergoing intracranial tumor surgery. Methods This is a randomized controlled trial which will be carried out at the Second Affiliated Hospital of Soochow University. Fifty-four patients undergoing intracranial tumor surgery will be randomly allocated to the control group (C group) or the protective lung ventilation group (P group). In the C group, the tidal volume (VT) will be set at 8 ml/kg of predicted body weight, but positive end-expiratory pressure (PEEP) and recruitment maneuvers will not be used. In the P group, VT will be set at 6 ml/kg of predicted body weight combined with individualized PEEP during dura opening, while in other periods of general anesthesia, VT will be set at 8 ml/kg of predicted body weight. The level of rSO2, partial pressures of oxygen and carbon dioxide, oxygenation index, lactic acid level in arterial blood, and mean arterial pressure will be compared before anesthesia (T0), before dura opening (T1), after dura closing (T2), and 24 h after surgery (T3). Lung ultrasound scores will be measured at T0 and T3. The degree of brain relaxation at T1 and T2 will be evaluated by the surgeon using the brain relaxation scale. The amount of vasoactive drugs used and blood loss will be recorded during surgery. The duration of operation and reoperation rate will be recorded. The primary outcome of this study is the changes in rSO2 within 24 h postoperatively. Discussion This study aims to determine whether protective lung ventilation during dura opening can improve rSO2 and the state of pulmonary ventilation in patients undergoing intracranial tumor surgery, and to investigate whether this strategy affects the degree of brain tissue swelling and the reoperation rate after operation. If our results are positive, this study will show that protective lung ventilation during dura opening can be used effectively and safely in neurosurgical patients undergoing craniotomy for tumor resection. Trial registration Chinese Clinical Trial Registry, ChiCTR1900025632. Registered on 3 September 2019. chictr.org.cn.
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Affiliation(s)
- Jinlu Li
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, Jiangsu, China
| | - Xuemei Wu
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, Jiangsu, China
| | - Hairui Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, Jiangsu, China.
| | - Ying Huang
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, Jiangsu, China
| | - Yueqin Liu
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, Jiangsu, China
| | - Hong Xie
- Department of Anesthesiology, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, Jiangsu, China
| | - Jun Dong
- Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, 1055 Sanxiang Road, Suzhou, 215004, Jiangsu, China
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13
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Lam NN, Hung TD, Hung DK. Impact of “opening the lung” ventilatory strategy on burn patients with acute respiratory distress syndrome. Burns 2019; 45:1841-1847. [DOI: 10.1016/j.burns.2019.05.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 05/22/2019] [Accepted: 05/24/2019] [Indexed: 02/07/2023]
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Komorowski M, Lemyze M. Informing future intensive care trials with machine learning. Br J Anaesth 2019; 123:14-16. [PMID: 31076087 DOI: 10.1016/j.bja.2019.03.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 03/28/2019] [Indexed: 12/16/2022] Open
Affiliation(s)
- Matthieu Komorowski
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK; Intensive Care Unit, Charing Cross Hospital, London, UK.
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15
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Orde S, Slama M, Yastrebov K, Mclean A, Huang S. Subjective right ventricle assessment by echo qualified intensive care specialists: assessing agreement with objective measures. Crit Care 2019; 23:70. [PMID: 30845976 PMCID: PMC6407213 DOI: 10.1186/s13054-019-2375-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 02/21/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Right ventricle (RV) size and function assessment by echocardiography (echo) is a standard tool in the ICU. Frequently subjective assessment is performed, and guidelines suggest its utility in adequately trained clinicians. We aimed to compare subjective (visual) assessment of RV size and function by ICU physicians, with advanced qualifications in echocardiography, vs objective measurements. METHODS ICU specialists with a qualification in advanced echocardiography reviewed 2D echo clips from critically ill patients on mechanical ventilation with PaO2:FiO2 < 300. Subjective assessments of RV size and function were made independently using a three-class categorical scale. Agreement (B-score) and bias (p value) were analysed using objective echo measurements. RV size assessment included RV end-diastolic area (EDA) and diameters. RV function assessment included fractional area change, S', TAPSE and RV free wall strain. Binary and ordinal analysis was performed. RESULTS Fifty-two clinicians reviewed 2D images from 80 patients. Fair agreement was seen with objective measures vs binary assessment of RV size (RV EDA 0.26 [p < 0.001], RV dimensions 0.29 [p = 0.06]) and function (RV free wall strain 0.27 [p < 0.001], TAPSE 0.27 [p < 0.001], S' 0.29 [p < 0.001], FAC 0.31 [p = 0.16]). However, ordinal data analysis showed poor agreement with RV dimensions (0.11 [p = 0.06]) and RV free wall strain (0.14 [p = 0.16]). If one-step disagreement was allowed, agreement was good (RV dimensions 0.6 [p = 0.06], RV free wall strain 0.6 [p = 0.16]). Significant overestimation of severity of abnormalities was seen with subjective assessment vs RV EDA, TAPSE, S' and fractional area change. CONCLUSION Subjective (visual) assessment of RV size and function, by ICU specialists trained in advanced echo, can be fairly reliable for the initial exclusion of significant RV pathology. It seems prudent to avoid subjective RV assessment in isolation.
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Affiliation(s)
- Sam Orde
- Nepean Hospital, Sydney, NSW Australia
| | - Michel Slama
- Medical ICU, Amiens University Hospital, Amiens, France
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Bonizzoli M, Cipani S, Lazzeri C, Chiostri M, Ballo P, Sarti A, Peris A. Speckle tracking echocardiography and right ventricle dysfunction in acute respiratory distress syndrome: A pilot study. Echocardiography 2018; 35:1982-1987. [DOI: 10.1111/echo.14153] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 08/23/2018] [Accepted: 09/03/2018] [Indexed: 12/24/2022] Open
Affiliation(s)
- Manuela Bonizzoli
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - Simone Cipani
- Intensive Care Unit; Ospedale Santa Maria Nuova; Florence Italy
| | - Chiara Lazzeri
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | - Marco Chiostri
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
| | | | - Armando Sarti
- Intensive Care Unit; Ospedale Santa Maria Nuova; Florence Italy
| | - Adriano Peris
- Intensive Care Unit and Regional ECMO Referral centre; Azienda Ospedaliero-Universitaria Careggi; Florence Italy
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17
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Conditional Hemodynamic Tolerance to Decremental Recruitment of the “Open Lung”*. Crit Care Med 2018; 46:1694-1695. [DOI: 10.1097/ccm.0000000000003304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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18
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Marini JJ. Should we titrate positive end-expiratory pressure based on an end-expiratory transpulmonary pressure? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:391. [PMID: 30460265 DOI: 10.21037/atm.2018.08.22] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Arguments continue to swirl regarding the need for and best method of positive end-expiratory pressure (PEEP) titration. An appropriately conducted decremental method that uses modest peak pressures for the recruiting maneuver (RM), a lung protective tidal excursion, relatively small PEEP increments and appropriate timing intervals is currently the most logical and attractive option, particularly when the esophageal balloon pressure (Pes) is used to calculate transpulmonary driving pressures relevant to the lung. The setting of PEEP by the Pes-guided end-expiratory pressure at the 'polarity transition' point of the transmural end-expiratory pressure is quite relevant to the locale of the esophageal balloon catheter. Its desirability, however, is limited by its tendency to encourage PEEP levels that are higher than most other PEEP titration methods. These Pes-set PEEP values promote higher mean airway pressures and are likely to be unnecessary when small tidal driving pressures are in use. Because high airway pressures increase global lung stress and risk hemodynamic compromise, the Pes-determined PEEP would seem associated with a relatively high hazard to benefit ratio for many patients.
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Affiliation(s)
- John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN, USA
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