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Savino S, Gaetano S. Functional Phenotyping: A New Role for Electrical Impedance Tomography. Am J Respir Crit Care Med 2024; 209:1291-1292. [PMID: 38457807 PMCID: PMC11146560 DOI: 10.1164/rccm.202402-0328ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 03/06/2024] [Indexed: 03/10/2024] Open
Affiliation(s)
- Spadaro Savino
- Department of Translational Medicine University of Ferrara Ferrara, Italy
| | - Scaramuzzo Gaetano
- Department of Translational Medicine University of Ferrara Ferrara, Italy
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Songsangvorn N, Xu Y, Lu C, Rotstein O, Brochard L, Slutsky AS, Burns KEA, Zhang H. Electrical impedance tomography-guided positive end-expiratory pressure titration in ARDS: a systematic review and meta-analysis. Intensive Care Med 2024; 50:617-631. [PMID: 38512400 PMCID: PMC11078723 DOI: 10.1007/s00134-024-07362-2] [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: 12/16/2023] [Accepted: 02/14/2024] [Indexed: 03/23/2024]
Abstract
PURPOSE Assessing efficacy of electrical impedance tomography (EIT) in optimizing positive end-expiratory pressure (PEEP) for acute respiratory distress syndrome (ARDS) patients to enhance respiratory system mechanics and prevent ventilator-induced lung injury (VILI), compared to traditional methods. METHODS We carried out a systematic review and meta-analysis, spanning literature from January 2012 to May 2023, sourced from Scopus, PubMed, MEDLINE (Ovid), Cochrane, and LILACS, evaluated EIT-guided PEEP strategies in ARDS versus conventional methods. Thirteen studies (3 randomized, 10 non-randomized) involving 623 ARDS patients were analyzed using random-effects models for primary outcomes (respiratory mechanics and mechanical power) and secondary outcomes (PaO2/FiO2 ratio, mortality, stays in intensive care unit (ICU), ventilator-free days). RESULTS EIT-guided PEEP significantly improved lung compliance (n = 941 cases, mean difference (MD) = 4.33, 95% confidence interval (CI) [2.94, 5.71]), reduced mechanical power (n = 148, MD = - 1.99, 95% CI [- 3.51, - 0.47]), and lowered driving pressure (n = 903, MD = - 1.20, 95% CI [- 2.33, - 0.07]) compared to traditional methods. Sensitivity analysis showed consistent positive effect of EIT-guided PEEP on lung compliance in randomized clinical trials vs. non-randomized studies pooled (MD) = 2.43 (95% CI - 0.39 to 5.26), indicating a trend towards improvement. A reduction in mortality rate (259 patients, relative risk (RR) = 0.64, 95% CI [0.45, 0.91]) was associated with modest improvements in compliance and driving pressure in three studies. CONCLUSIONS EIT facilitates real-time, individualized PEEP adjustments, improving respiratory system mechanics. Integration of EIT as a guiding tool in mechanical ventilation holds potential benefits in preventing ventilator-induced lung injury. Larger-scale studies are essential to validate and optimize EIT's clinical utility in ARDS management.
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Affiliation(s)
- Nickjaree Songsangvorn
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Bhumibol Adulyadej Hospital, Bangkok, Thailand
| | - Yonghao Xu
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health 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.
| | - Cong Lu
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - Ori Rotstein
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Arthur S Slutsky
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Karen E A Burns
- Keenan Research Centre for Biomedical Science and the Li Ka Shing Knowledge Institute, 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 and the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
- Department of Physiology, University of Toronto, Toronto, ON, Canada.
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
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Aydeniz E, van Bussel BCT, de Jongh S, Schellens J, Heines SJH, van Kuijk SMJ, Tas J, van Rosmalen F, van der Horst ICC, Bergmans DCJJ. Serial electrical impedance tomography course in different treatment groups; The MaastrICCht cohort. J Crit Care 2024; 80:154506. [PMID: 38113747 DOI: 10.1016/j.jcrc.2023.154506] [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: 06/01/2023] [Revised: 10/16/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE To describe the effect of dexamethasone and tocilizumab on regional lung mechanics over admission in all mechanically ventilated COVID-19 patients. MATERIALS AND METHODS Dynamic compliance, alveolar overdistension and collapse were serially determined using electric impedance tomography (EIT). Patients were categorized into three groups; no anti-inflammatory therapy, dexamethasone therapy, dexamethasone + tocilizumab therapy. The EIT variables were (I) visualized using polynomial regression, (II) evaluated throughout admission using linear mixed-effects models, and (III) average respiratory variables were compared. RESULTS Visual inspection of EIT variables showed a pattern of decreasing dynamic compliance. Overall, optimal set PEEP was lower in the dexamethasone group (-1.4 cmH2O, -2.6; -0.2). Clinically applied PEEP was lower in the dexamethasone and dexamethasone + tocilizumab group (-1.5 cmH2O, -2.6; -0.2; -2.2 cmH2O, -5.1; 0.6). Dynamic compliance, alveolar overdistension, and alveolar collapse at optimal set PEEP did not significantly differ between the three groups. CONCLUSION Optimal and clinically applied PEEP were lower in the dexamethasone and dexamethasone + tocilizumab groups. The results suggest that the potential beneficial effects of these therapies do not affect lung mechanics favorably. However, this study cannot fully rule out any beneficial effect of anti-inflammatory treatment on pulmonary function due to its observational nature.
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Affiliation(s)
- Eda Aydeniz
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Intensive Care Medicine, Laurentius Hospital Roermond, Roermond, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands.
| | - Bas C T van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Sebastiaan de Jongh
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Joep Schellens
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Serge J H Heines
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Jeanette Tas
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, the Netherlands
| | - Frank van Rosmalen
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
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Pavlovsky B, Desprez C, Richard JC, Fage N, Lesimple A, Chean D, Courtais A, Mauri T, Mercat A, Beloncle F. Bedside personalized methods based on electrical impedance tomography or respiratory mechanics to set PEEP in ARDS and recruitment-to-inflation ratio: a physiologic study. Ann Intensive Care 2024; 14:1. [PMID: 38180544 PMCID: PMC10769993 DOI: 10.1186/s13613-023-01228-4] [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: 09/15/2023] [Accepted: 12/10/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Various Positive End-Expiratory Pressure (PEEP) titration strategies have been proposed to optimize ventilation in patients with acute respiratory distress syndrome (ARDS). We aimed to compare PEEP titration strategies based on electrical impedance tomography (EIT) to methods derived from respiratory system mechanics with or without esophageal pressure measurements, in terms of PEEP levels and association with recruitability. METHODS Nineteen patients with ARDS were enrolled. Recruitability was assessed by the estimated Recruitment-to-Inflation ratio (R/Iest) between PEEP 15 and 5 cmH2O. Then, a decremental PEEP trial from PEEP 20 to 5 cmH2O was performed. PEEP levels determined by the following strategies were studied: (1) plateau pressure 28-30 cmH2O (Express), (2) minimal positive expiratory transpulmonary pressure (Positive PLe), (3) center of ventilation closest to 0.5 (CoV) and (4) intersection of the EIT-based overdistension and lung collapse curves (Crossing Point). In addition, the PEEP levels determined by the Crossing Point strategy were assessed using different PEEP ranges during the decremental PEEP trial. RESULTS Express and CoV strategies led to higher PEEP levels than the Positive PLe and Crossing Point ones (17 [14-17], 20 [17-20], 8 [5-11], 10 [8-11] respectively, p < 0.001). For each strategy, there was no significant association between the optimal PEEP level and R/Iest (Crossing Point: r2 = 0.073, p = 0.263; CoV: r2 < 0.001, p = 0.941; Express: r2 < 0.001, p = 0.920; Positive PLe: r2 = 0.037, p = 0.461). The PEEP level obtained with the Crossing Point strategy was impacted by the PEEP range used during the decremental PEEP trial. CONCLUSIONS CoV and Express strategies led to higher PEEP levels than the Crossing Point and Positive PLe strategies. Optimal PEEP levels proposed by these four methods were not associated with recruitability. Recruitability should be specifically assessed in ARDS patients to optimize PEEP titration.
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Affiliation(s)
- Bertrand Pavlovsky
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France.
| | - Christophe Desprez
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Jean-Christophe Richard
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Nicolas Fage
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Arnaud Lesimple
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Dara Chean
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Antonin Courtais
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, IRCCS (Institute for Treatment and Research, Ca' Granda Maggiore Policlinico Hospital Foundation, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alain Mercat
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
| | - François Beloncle
- Medical Intensive Care Unit, Vent'Lab, Angers University Hospital, University of Angers, 4 Rue Larrey, 49933, Angers Cedex 9, France
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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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Xiao L, Yu K, Yang JJ, Liu WT, Liu L, Miao HH, Li TZ. Effect of individualized positive end-expiratory pressure based on electrical impedance tomography guidance on pulmonary ventilation distribution in patients who receive abdominal thermal perfusion chemotherapy. Front Med (Lausanne) 2023; 10:1198720. [PMID: 37731718 PMCID: PMC10507689 DOI: 10.3389/fmed.2023.1198720] [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: 04/02/2023] [Accepted: 08/15/2023] [Indexed: 09/22/2023] Open
Abstract
Background Electrical impedance tomography (EIT) has been shown to be useful in guiding individual positive end-expiratory pressure titration for patients with mechanical ventilation. However, the appropriate positive end-expiratory pressure (PEEP) level and whether the individualized PEEP needs to be adjusted during long-term surgery (>6 h) were unknown. Meanwhile, the effect of individualized PEEP on the distribution of pulmonary ventilation in patients who receive abdominal thermoperfusion chemotherapy is unknown. The primary aim of this study was to observe the effect of EIT-guided PEEP on the distribution of pulmonary ventilation in patients undergoing cytoreductive surgery (CRS) combined with hot intraperitoneal chemotherapy (HIPEC). The secondary aim was to analyze their effect on postoperative pulmonary complications. Methods A total of 48 patients were recruited and randomly divided into two groups, with 24 patients in each group. For the control group (group A), PEEP was set at 5 cm H2O, while in the EIT group (group B), individual PEEP was titrated and adjusted every 2 h with EIT guidance. Ventilation distribution, respiratory/circulation parameters, and PPC incidence were compared between the two groups. Results The average individualized PEEP was 10.3 ± 1.5 cm H2O, 10.2 ± 1.6 cm H2O, 10.1 ± 1.8 cm H2O, and 9.7 ± 2.1 cm H2O at 5 min, 2 h, 4 h, and 6 h after tracheal intubation during CRS + HIPEC. Individualized PEEP was correlated with ventilation distribution in the regions of interest (ROI) 1 and ROI 3 at 4 h mechanical ventilation and ROI 1 at 6 h mechanical ventilation. The ventilation distribution under individualized PEEP was back-shifted for 6 h but moved to the control group's ventral side under PEEP 5 cm H2O. The respiratory and circulatory function indicators were both acceptable either under individualized PEEP or PEEP 5 cm H2O. The incidence of total PPCs was significantly lower under individualized PEEP (66.7%) than PEEP 5 cm H2O (37.5%) for patients with CRS + HIPEC. Conclusion The appropriate individualized PEEP was stable at approximately 10 cm H2O during 6 h for patients with CRS + HIPEC, along with better ventilation distribution and a lower total PPC incidence than the fixed PEEP of 5 cm H2O.Clinical trial registration: identifier ChiCTR1900023897.
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Affiliation(s)
- Li Xiao
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Kang Yu
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Jiao-Jiao Yang
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Wen-Tao Liu
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Lei Liu
- Department of Science and Technology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Hui-Hui Miao
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Tian-Zuo Li
- Department of Anesthesiology, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
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Byrne DP, Keeshan B, Hosgood G, Adler A, Mosing M. Comparison of electrical impedance tomography and spirometry-based measures of airflow in healthy adult horses. Front Physiol 2023; 14:1164646. [PMID: 37476683 PMCID: PMC10354512 DOI: 10.3389/fphys.2023.1164646] [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: 02/13/2023] [Accepted: 06/26/2023] [Indexed: 07/22/2023] Open
Abstract
Electrical impedance tomography (EIT) is a non-invasive diagnostic tool for evaluating lung function. The objective of this study was to compare respiratory flow variables calculated from thoracic EIT measurements with corresponding spirometry variables. Ten healthy research horses were sedated and instrumented with spirometry via facemask and a single-plane EIT electrode belt around the thorax. Horses were exposed to sequentially increasing volumes of apparatus dead space between 1,000 and 8,500 mL, in 5-7 steps, to induce carbon dioxide rebreathing, until clinical hyperpnea or a tidal volume of 150% baseline was reached. A 2-min stabilization period followed by 2 minutes of data collection occurred at each timepoint. Peak inspiratory and expiratory flow, inspiratory and expiratory time, and expiratory nadir flow, defined as the lowest expiratory flow between the deceleration of flow of the first passive phase of expiration and the acceleration of flow of the second active phase of expiration were evaluated with EIT and spirometry. Breathing pattern was assessed based on the total impedance curve. Bland-Altman analysis was used to evaluate the agreement where perfect agreement was indicated by a ratio of EIT:spirometry of 1.0. The mean ratio (bias; expressed as a percentage difference from perfect agreement) and the 95% confidence interval of the bias are reported. There was good agreement between EIT-derived and spirometry-derived peak inspiratory [-15% (-46-32)] and expiratory [10% (-32-20)] flows and inspiratory [-6% (-25-18)] and expiratory [5% (-9-20)] times. Agreement for nadir flows was poor [-22% (-87-369)]. Sedated horses intermittently exhibited Cheyne-Stokes variant respiration, and a breath pattern with incomplete expiration in between breaths (crown-like breaths). Electrical impedance tomography can quantify airflow changes over increasing tidal volumes and changing breathing pattern when compared with spirometry in standing sedated horses.
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Affiliation(s)
- David P. Byrne
- School of Veterinary Medicine, Murdoch University, Perth, WA, Australia
| | - Ben Keeshan
- Department of Systems and Computer Engineering, Carleton University, Ottawa, ON, Canada
| | - Giselle Hosgood
- School of Veterinary Medicine, Murdoch University, Perth, WA, Australia
| | - Andy Adler
- Department of Systems and Computer Engineering, Carleton University, Ottawa, ON, Canada
| | - Martina Mosing
- Anaesthesiology and Perioperative Intensive Care, Department for Companion Animals and Horses, University of Veterinary Medicine, Vienna, Austria
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Yang L, Li Z, Dai M, Fu F, Möller K, Gao Y, Zhao Z. Optimal machine learning methods for prediction of high-flow nasal cannula outcomes using image features from electrical impedance tomography. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2023; 238:107613. [PMID: 37209577 DOI: 10.1016/j.cmpb.2023.107613] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 04/26/2023] [Accepted: 05/15/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND High-flow nasal cannula (HNFC) is able to provide ventilation support for patients with hypoxic respiratory failure. Early prediction of HFNC outcome is warranted, since failure of HFNC might delay intubation and increase mortality rate. Existing methods require a relatively long period to identify the failure (approximately 12 h) and electrical impedance tomography (EIT) may help identify the patient's respiratory drive during HFNC. OBJECTIVES This study aimed to investigate a proper machine-learning model to predict HFNC outcomes promptly by EIT image features. METHODS The Z-score standardization method was adopted to normalize the samples from 43 patients who underwent HFNC and six EIT features were selected as model input variables through the random forest feature selection method. Machine-learning methods including discriminant, ensembles, k-nearest neighbour (KNN), artificial neural network (ANN), support vector machine (SVM), AdaBoost, xgboost, logistic, random forest, bernoulli bayes, gaussian bayes and gradient-boosted decision trees (GBDT) were used to build prediction models with the original data and balanced data proceeded by the synthetic minority oversampling technique. RESULTS Prior to data balancing, an extremely low specificity (less than 33.33%) as well as a high accuracy in the validation data set were observed in all the methods. After data balancing, the specificity of KNN, xgboost, random forest, GBDT, bernoulli bayes and AdaBoost significantly reduced (p<0.05) while the area under curve did not improve considerably (p>0.05); and the accuracy and recall decreased significantly (p<0.05). CONCLUSIONS The xgboost method showed better overall performance for balanced EIT image features, which may be considered as the ideal machine learning method for early prediction of HFNC outcomes.
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Affiliation(s)
- Lin Yang
- Department of Aerospace Medicine, Fourth Military Medical University, Xi'an, China
| | - Zhe Li
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Meng Dai
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China.
| | - Feng Fu
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China
| | - Knut Möller
- Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
| | - Yuan Gao
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhanqi Zhao
- Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
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9
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Yuan X, Zhang R, Wang Y, Chen D, Chao Y, Xu J, Guo L, Liu A, Xie J, Pan C, Yang Y, Qiu H, Liu L. Effect of EIT-guided PEEP titration on prognosis of patients with moderate to severe ARDS: study protocol for a multicenter randomized controlled trial. Trials 2023; 24:266. [PMID: 37041561 PMCID: PMC10088128 DOI: 10.1186/s13063-023-07280-6] [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: 03/06/2023] [Accepted: 03/27/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Acute respiratory syndrome distress (ARDS) is a clinical common syndrome with high mortality. Electrical impedance tomography (EIT)-guided positive end-expiratory pressure (PEEP) titration can achieve the compromise between lung overdistension and collapse which may minimize ventilator-induced lung injury in these patients. However, the effect of EIT-guided PEEP titration on the clinical outcomes remains unknown. The objective of this trial is to investigate the effects of EIT-guided PEEP titration on the clinical outcomes for moderate or severe ARDS, compared to the low fraction of inspired oxygen (FiO2)-PEEP table. METHODS This is a prospective, multicenter, single-blind, parallel-group, adaptive designed, randomized controlled trial (RCT) with intention-to-treat analysis. Adult patients with moderate to severe ARDS less than 72 h after diagnosis will be included in this study. Participants in the intervention group will receive PEEP titrated by EIT with a stepwise decrease PEEP trial, whereas participants in the control group will select PEEP based on the low FiO2-PEEP table. Other ventilator parameters will be set according to the ARDSNet strategy. Participants will be followed up until 28 days after enrollment. Three hundred seventy-six participants will be recruited based on a 15% decrease of 28-day mortality in the intervention group, with an interim analysis for sample size re-estimation and futility assessment being undertaken once 188 participants have been recruited. The primary outcome is 28-day mortality. The secondary outcomes include ventilator-free days and shock-free days at day 28, length of ICU and hospital stay, the rate of successful weaning, proportion requiring rescue therapies, compilations, respiratory variables, and Sequential Organ Failure Assessment (SOFA). DISCUSSION As a heterogeneous syndrome, ARDS has different responses to treatment and further results in different clinical outcomes. PEEP selection will depend on the properties of patients and can be individually achieved by EIT. This study will be the largest randomized trial to investigate thoroughly the effect of individual PEEP titrated by EIT in moderate to severe ARDS patients to date. TRIAL REGISTRATION ClinicalTrial.gov NCT05207202. First published on January 26, 2022.
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Affiliation(s)
- Xueyan Yuan
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Rui Zhang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yuxuan Wang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Dongyu Chen
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, Jiangsu, China
- Department of Critical Care Medicine, The First People's Hospital of Yancheng, Yancheng, 224000, Jiangsu, China
| | - Yali Chao
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, Jiangsu, China
- Department of Critical Care Medicine, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, 320300, Jiangsu, China
| | - Jingyuan Xu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Lanqi Guo
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Airan Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Chun Pan
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, Jiangsu, China.
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, School of Medicine, Zhongda Hospital, Southeast University, Nanjing, 210009, Jiangsu, China.
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Abstract
Advanced respiratory monitoring involves several mini- or noninvasive tools, applicable at bedside, focused on assessing lung aeration and morphology, lung recruitment and overdistention, ventilation-perfusion distribution, inspiratory effort, respiratory drive, respiratory muscle contraction, and patient-ventilator asynchrony, in dealing with acute respiratory failure. Compared to a conventional approach, advanced respiratory monitoring has the potential to provide more insights into the pathologic modifications of lung aeration induced by the underlying disease, follow the response to therapies, and support clinicians in setting up a respiratory support strategy aimed at protecting the lung and respiratory muscles. Thus, in the clinical management of the acute respiratory failure, advanced respiratory monitoring could play a key role when a therapeutic strategy, relying on individualization of the treatments, is adopted.
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Newly Proposed Diagnostic Criteria for Acute Respiratory Distress Syndrome: Does Inclusion of High Flow Nasal Cannula Solve the Problem? J Clin Med 2023; 12:jcm12031043. [PMID: 36769691 PMCID: PMC9917973 DOI: 10.3390/jcm12031043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 02/03/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a common life-threatening clinical syndrome which accounts for 10% of intensive care unit admissions. Since the Berlin definition was developed, the clinical diagnosis and therapy have changed dramatically by adding a minimum positive end-expiratory pressure (PEEP) to the assessment of hypoxemia compared to the American-European Consensus Conference (AECC) definition in 1994. High-flow nasal cannulas (HFNC) have become widely used as an effective respiratory support for hypoxemia to the extent that their use was proposed in the expansion of the ARDS criteria. However, there would be problems if the diagnosis of a specific disease or clinical syndrome occurred, based on therapeutic strategies.
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12
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Wang Y, Yang Y, Wang DM, Li J, Bao QT, Wang BB, Zhu SJ, Zou L. Different positive end expiratory pressure and tidal volume controls on lung protection and inflammatory factors during surgical anesthesia. World J Clin Cases 2022; 10:12146-12155. [PMID: 36483798 PMCID: PMC9724538 DOI: 10.12998/wjcc.v10.i33.12146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/27/2022] [Accepted: 10/20/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Mechanical ventilation can lead to the severe impairment of the metabolic pathway of alveolar surfactants, inactivating alveolar surfactants and significantly reducing lung-chest compliance. The cardiopulmonary function of elderly patients usually reduced to a certain extent, and there are lung complications after surgical anesthesia, just like lung barotrauma caused by mechanical ventilation, atelectasis and postoperative hypoxemia.
AIM To investigate the effects of different positive end expiratory pressures (PEEPs) and tidal volumes (VTs) on respiratory function, the degree of the inflammatory response and hemodynamic indexes in patients undergoing surgery under general anesthesia.
METHODS A total of 120 patients undergoing surgery for gastric or colon cancer under general anesthesia in Xinghua People's Hospital from January 2017 to January 2021 were randomly divided into Group A and Group B, with 60 cases in each group. The ventilation mode in Group A was VT (6.0 mL/kg) + PEEP (5.0 cmH2O), while that in Group B was VT (6.0 mL/kg) + PEEP (8.0 cmH2O). Blood gas parameters, respiratory mechanical parameters, inflammatory response indicators, hemodynamic indicators and related complications were compared between the two groups.
RESULTS There were no significant differences in PaCO2, PaO2, oxygen or the examined indexes at T0 between group A and group B (P > 0.05). The measured PaO2 value of patients in group A at T3 was higher than that in group B, and the difference was significant (P < 0.05). There were no significant differences in peak airway pressure (Ppeak), mean airway pressure or dynamic pulmonary compliance (Cdyn) at T0 between group A and group B (P > 0.05). The measured Ppeak value of patients in group A at T1 was higher than that in group B, and the difference was significant (P < 0.05). The measured Cdyn value at T1 and T2 was greater than that in group B (P < 0.05). Before surgery, there were no significant differences in tumor necrosis factor-α (TNF-α), interleukin (IL)-6 or IL-10 between group A and group B (P > 0.05). After 4 h, the measured values of TNF-α and IL-6 in group A were lower than those in group B, and the differences were significant (P < 0.05). The IL-10 Level in group A was higher than that in group B (P < 0.05). At T0, there were no significant differences in cardiac output, cardiac index (CI), stroke volume index (SVI) or mean arterial pressure between group A and group B (P > 0.05). The measured values of CI and SVI at T2 in patients in group A were higher than those in group B, and the differences were significant (P < 0.05).
CONCLUSION For patients undergoing surgery for gastric or colon cancer under general anesthesia, the VT (6.0 mL/kg) + PEEP (5.0 cmH2O) regimen was more effective than the VT (6.0 mL/kg) + PEEP (8.0 cmH2O) regimen in protecting the lung function and ventilatory function of patients, and it had better effects on maintaining hemodynamic stability and reducing inflammatory reactions.
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Affiliation(s)
- Yu Wang
- Department of Anesthesia, Xinghua City People's Hospital, Xinghua 225700, Jiangsu Province, China
| | - Yi Yang
- Department of Anesthesiology, Suzhou High-Tech Zone People's Hospital, Suzhou 215011, Jiangsu Province, China
| | - Ding-Mu Wang
- Department of Anesthesia, Xinghua City People's Hospital, Xinghua 225700, Jiangsu Province, China
| | - Jie Li
- Naval Medical Center, Naval Medical University, PLA, Shanghai 200433, China
| | - Quan-Tang Bao
- Department of Anesthesia, Xinghua City People's Hospital, Xinghua 225700, Jiangsu Province, China
| | - Bei-Bei Wang
- Department of Anesthesia, Xinghua City People's Hospital, Xinghua 225700, Jiangsu Province, China
| | - Shu-Jun Zhu
- Department of Anesthesia, Xinghua City People's Hospital, Xinghua 225700, Jiangsu Province, China
| | - Lu Zou
- Department of Anesthesiology, Changzhou Hospital of Traditional Chinese Medicine, Changzhou 213000, Jiangsu Province, China
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13
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Scaramuzzo G, Ronzoni L, Campo G, Priani P, Arena C, La Rosa R, Turrini C, Volta CA, Papi A, Spadaro S, Contoli M. Long-term dyspnea, regional ventilation distribution and peripheral lung function in COVID-19 survivors: a 1 year follow up study. BMC Pulm Med 2022; 22:408. [PMCID: PMC9643983 DOI: 10.1186/s12890-022-02214-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 11/02/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract
Background
Dyspnea is common after COVID-19 pneumonia and can be characterized by a defective CO2 diffusion (DLCO) despite normal pulmonary function tests (PFT). Nevertheless, DLCO impairment tends to normalize at 1 year, with no dyspnea regression. The altered regional distribution of ventilation and a dysfunction of the peripheral lung may characterize dyspnea at 1 year after COVID-19 pneumonia. We aimed at assessing the pattern of airway resistance and inflammation and the regional ventilation inhomogeneity in COVID-19 pneumonia survivors at 12-months after hospital discharge.
Methods
We followed up at 1-year patients previously admitted to the respiratory units (intensive care or sub-intensive care unit) for COVID-19 acute respiratory failure at 1-year after hospital discharge. PFT (spirometry, DLCO), impulse oscillometry (IOS), measurements of the exhaled nitric oxide (FENO) and Electrical Impedance Tomography (EIT) were used to evaluate lung volumes, CO2 diffusion capacity, peripheral lung inflammation/resistances and the regional inhomogeneity of ventilation distribution. A full medical examination was conducted, and symptoms of new onset (not present before COVID-19) were recorded. Patients were therefore divided into two groups based on the presence/absence of dyspnea (defined as mMRC ≥1) compared to evaluate differences in the respiratory function derived parameters.
Results
Sixty-seven patients were admitted between October and December 2020. Of them, 42/67 (63%) patients were discharged alive and 33 were evaluated during the follow up. Their mean age was 64 ± 11 years and 24/33 (73%) were males. Their maximum respiratory support was in 7/33 (21%) oxygen, in 4/33 (12%) HFNC, in 14/33 (42%) NIV/CPAP and in 8/33 (24%) invasive mechanical ventilation. During the clinical examination, 15/33 (45%) reported dyspnea. When comparing the two groups, no significant differences were found in PFT, in the peripheral airway inflammation (FENO) or mechanical properties (IOS). However, EIT showed a significantly higher regional inhomogeneity in patients with dyspnea both during resting breathing (0.98[0.96–1] vs 1.1[1–1.1], p = 0.012) and during forced expiration (0.96[0.94–1] vs 1 [0.98–1.1], p = 0.045).
Conclusions
New onset dyspnea characterizes 45% of patients 1 year after COVID-19 pneumonia. In these patients, despite pulmonary function test may be normal, EIT shows a higher regional inhomogeneity both during quiet and forced breathing which may contribute to dyspnea.
Clinical trial registration
Clinicaltrials.gov NCT04343053, registration date 13/04/2020.
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14
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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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15
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Jiang H, Han Y, Zheng X, Fang Q. Roles of electrical impedance tomography in lung transplantation. Front Physiol 2022; 13:986422. [PMID: 36407002 PMCID: PMC9669435 DOI: 10.3389/fphys.2022.986422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/25/2022] [Indexed: 11/06/2022] Open
Abstract
Lung transplantation is the preferred treatment method for patients with end-stage pulmonary disease. However, several factors hinder the progress of lung transplantation, including donor shortages, candidate selection, and various postoperative complications. Electrical impedance tomography (EIT) is a functional imaging tool that can be used to evaluate pulmonary ventilation and perfusion at the bedside. Among patients after lung transplantation, monitoring the graft’s pulmonary function is one of the most concerning issues. The feasible application of EIT in lung transplantation has been reported over the past few years, and this technique has gained increasing interest from multidisciplinary researchers. Nevertheless, physicians still lack knowledge concerning the potential applications of EIT in lung transplantation. We present an updated review of EIT in lung transplantation donors and recipients over the past few years, and discuss the potential use of ventilation- and perfusion-monitoring-based EIT in lung transplantation.
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Affiliation(s)
| | | | - Xia Zheng
- *Correspondence: Xia Zheng, ; Qiang Fang,
| | - Qiang Fang
- *Correspondence: Xia Zheng, ; Qiang Fang,
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16
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Slobod D, Leali M, Spinelli E, Grieco DL, Spadaro S, Mauri T. Integrating electrical impedance tomography and transpulmonary pressure monitoring to personalize PEEP in hypoxemic patients undergoing pressure support ventilation. Crit Care 2022; 26:314. [PMID: 36258227 PMCID: PMC9578192 DOI: 10.1186/s13054-022-04198-4] [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: 08/31/2022] [Accepted: 10/12/2022] [Indexed: 11/10/2022] Open
Abstract
Monitoring with electrical impedance tomography (EIT) during a decremental PEEP trial has been used to identify the PEEP that yields the optimal balance of pulmonary overdistension and collapse. This method is based on pixel-level changes in respiratory system compliance and depends on fixed or measured airway driving pressure. We developed a novel approach to quantify overdistension and collapse during pressure support ventilation (PSV) by integrating transpulmonary pressure and EIT monitoring and performed pilot tests in three hypoxemic patients. We report that our experimental approach is feasible and capable of identifying a PEEP that balances overdistension and collapse in intubated hypoxemic patients undergoing PSV.
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Affiliation(s)
- Douglas Slobod
- grid.414818.00000 0004 1757 8749Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto Di Ricovero E Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milan, Italy ,grid.14709.3b0000 0004 1936 8649Department of Critical Care Medicine, McGill University, Montreal, QC Canada
| | - Marco Leali
- grid.4708.b0000 0004 1757 2822Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Elena Spinelli
- grid.414818.00000 0004 1757 8749Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto Di Ricovero E Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milan, Italy
| | - Domenico Luca Grieco
- grid.414603.4Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Savino Spadaro
- grid.8484.00000 0004 1757 2064Anesthesia and Intensive Care Unit, Department of Translational Medicine, University of Ferrara, Ferrara, Italy
| | - Tommaso Mauri
- grid.414818.00000 0004 1757 8749Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto Di Ricovero E Cura a Carattere Scientifico Ca’ Granda, Ospedale Maggiore Policlinico, Via F. Sforza 35, 20122 Milan, Italy ,grid.4708.b0000 0004 1757 2822Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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17
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Yang L, Fu F, Frerichs I, Moeller K, Dai M, Zhao Z. The calculation of electrical impedance tomography based silent spaces requires individual thorax and lung contours. Physiol Meas 2022; 43. [PMID: 35995039 DOI: 10.1088/1361-6579/ac8bc2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/22/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE The present study evaluates the influence of different thorax contours (generic vs individual) on the parameter "silent spaces" computed from electrical impedance tomography (EIT) measurements. APPROACH Six patients with acute respiratory distress syndrome were analyzed retrospectively. EIT measurements were performed and the silent spaces were calculated based on (1) patient-specific contours Sind, (2) generic adult male contours SEidorsA and (3) generic neonate contours SEidorsN. MAIN RESULTS The differences among all studied subjects were 5±6% and 8±7% for Sind vs. SEidorsA, Sind vs. SEidorsN, respectively (median ± interquartile range). Sind values were higher than the generic ones in two patients. SIGNIFICANCE In the present study, we demonstrated the differences in values when the silent spaces were calculated based on different body and organ contours. To our knowledge, this study was the first one showing explicitly that silent spaces calculated with generic thorax and lung contours might lead to results with different locations and values as compared to the calculation with subject-specific models. Interpretations of silent spaces should be proceeded with caution.
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Affiliation(s)
- Lin Yang
- Fourth Military Medical University, Xi'an, Xi'an, 710032, CHINA
| | - Feng Fu
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, Xi'an, 710000, CHINA
| | - Inez Frerichs
- Department of Anaesthesiology and Intensive Care Medicine, University Medical Centre Schleswig-Holstein Campus Kiel, Kiel, Kiel, x, GERMANY
| | - Knut Moeller
- Institute of Technical Medicine, Furtwangen University, Jakob-Kienzle-Strasse 17, Villingen-Schwenningen, D-78054, GERMANY
| | - Meng Dai
- Biomedical Engineering Department, Fourth Military Medical University, 17 Changlex West Road, Xian, Shaanxi 710033, PR CHINA, Xi'an, 710000, CHINA
| | - Zhanqi Zhao
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, Xi'an, 710032, CHINA
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18
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SCARAMUZZO G, OTTAVIANI I, VOLTA CA, SPADARO S. Mechanical ventilation and COPD: from pathophysiology to ventilatory management. Minerva Med 2022; 113:460-470. [DOI: 10.23736/s0026-4806.22.07974-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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19
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Mi L, Chi Y, Yuan S, He H, Long Y, Frerichs I, Zhao Z. Effect of Prone Positioning With Individualized Positive End-Expiratory Pressure in Acute Respiratory Distress Syndrome Using Electrical Impedance Tomography. Front Physiol 2022; 13:906302. [PMID: 35845997 PMCID: PMC9282375 DOI: 10.3389/fphys.2022.906302] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/13/2022] [Indexed: 12/01/2022] Open
Abstract
Background: Positive end-expiratory pressure (PEEP) optimization during prone positioning remains under debate in acute respiratory distress syndrome (ARDS). This study aimed to investigate the effect of prone position on the optimal PEEP guided by electrical impedance tomography (EIT). Methods: We conducted a retrospective analysis on nineteen ARDS patients in a single intensive care unit. All patients underwent PEEP titration guided by EIT in both supine and prone positions. EIT-derived parameters, including center of ventilation (CoV), regional ventilation delay (RVD), percentage of overdistension (OD) and collapse (CL) were calculated. Optimal PEEP was defined as the PEEP level with minimal sum of OD and CL. Patients were divided into two groups: 1) Lower Optimal PEEPPP (LOP), where optimal PEEP was lower in the prone than in the supine position, and 2) Not-Lower Optimal PEEPPP (NLOP), where optimal PEEP was not lower in the prone compared with the supine position. Results: Eleven patients were classified as LOP (9 [8-9] vs. 12 [10-15] cmH2O; PEEP in prone vs. supine). In the NLOP group, optimal PEEP increased after prone positioning in four patients and remained unchanged in the other four patients. Patients in the LOP group had a significantly higher body mass index (26 [25-28] vs. 22 [17-25] kg/m2; p = 0.009) and lower ICU mortality (0/11 vs. 4/8; p = 0.018) compared with the NLOP group. Besides, PaO2/FiO2 increased significantly during prone positioning in the LOP group (238 [170-291] vs. 186 [141-195] mmHg; p = 0.042). CoV and RVD were also significantly improved during prone positioning in LOP group. No such effects were found in the NLOP group. Conclusion: Broad variability in optimal PEEP between supine and prone position was observed in the studied ARDS patients. Not all patients showed decreased optimal PEEP during prone positioning. Patients with higher body mass index exhibited lower optimal PEEP in prone position, better oxygenation and ventilation homogeneity.
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Affiliation(s)
- Liangyu Mi
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Yi Chi
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Siyi Yuan
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Huaiwu He
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Huaiwu He, ; Yun Long,
| | - Yun Long
- State Key Laboratory of Complex Severe and Rare Disease, Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Huaiwu He, ; Yun Long,
| | - Inéz Frerichs
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center of Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Zhanqi Zhao
- Department of Biomedical Engineering, Fourth Military Medical University, Xi’an, China
- Institute of Technical Medicine, Furtwangen University, VS-Schwenningen, Germany
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20
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Ball L, Scaramuzzo G, Herrmann J, Cereda M. Lung aeration, ventilation, and perfusion imaging. Curr Opin Crit Care 2022; 28:302-307. [PMID: 35653251 PMCID: PMC9178949 DOI: 10.1097/mcc.0000000000000942] [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: 11/03/2022]
Abstract
PURPOSE OF REVIEW Lung imaging is a cornerstone of the management of patients admitted to the intensive care unit (ICU), providing anatomical and functional information on the respiratory system function. The aim of this review is to provide an overview of mechanisms and applications of conventional and emerging lung imaging techniques in critically ill patients. RECENT FINDINGS Chest radiographs provide information on lung structure and have several limitations in the ICU setting; however, scoring systems can be used to stratify patient severity and predict clinical outcomes. Computed tomography (CT) is the gold standard for assessment of lung aeration but requires moving the patients to the CT facility. Dual-energy CT has been recently applied to simultaneous study of lung aeration and perfusion in patients with respiratory failure. Lung ultrasound has an established role in the routine bedside assessment of ICU patients, but has poor spatial resolution and largely relies on the analysis of artifacts. Electrical impedance tomography is an emerging technique capable of depicting ventilation and perfusion at the bedside and at the regional level. SUMMARY Clinicians should be confident with the technical aspects, indications, and limitations of each lung imaging technique to improve patient care.
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Affiliation(s)
- Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS per l’Oncologia e le Neuroscienze, Genoa, Italy
| | - Gaetano Scaramuzzo
- Department of Translational medicine, University of Ferrara, Ferrara, Italy
- Anesthesia and intensive care, Arcispedale Sant’Anna, Ferrara, Italy
| | - Jake Herrmann
- Roy J. Carver Department of Biomedical Engineering, University of Iowa, Iowa City, United States of America
| | - Maurizio Cereda
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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21
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Abstract
OBJECTIVE To describe, through a narrative review, the physiologic principles underlying electrical impedance tomography, and its potential applications in managing acute respiratory distress syndrome (ARDS). To address the current evidence supporting its use in different clinical scenarios along the ARDS management continuum. DATA SOURCES We performed an online search in Pubmed to review articles. We searched MEDLINE, Cochrane Central Register, and clinicaltrials.gov for controlled trials databases. STUDY SELECTION Selected publications included case series, pilot-physiologic studies, observational cohorts, and randomized controlled trials. To describe the rationale underlying physiologic principles, we included experimental studies. DATA EXTRACTION Data from relevant publications were reviewed, analyzed, and its content summarized. DATA SYNTHESIS Electrical impedance tomography is an imaging technique that has aided in understanding the mechanisms underlying multiple interventions used in ARDS management. It has the potential to monitor and predict the response to prone positioning, aid in the dosage of flow rate in high-flow nasal cannula, and guide the titration of positive-end expiratory pressure during invasive mechanical ventilation. The latter has been demonstrated to improve physiologic and mechanical parameters correlating with lung recruitment. Similarly, its use in detecting pneumothorax and harmful patient-ventilator interactions such as pendelluft has been proven effective. Nonetheless, its impact on clinically meaningful outcomes remains to be determined. CONCLUSIONS Electrical impedance tomography is a potential tool for the individualized management of ARDS throughout its different stages. Clinical trials should aim to determine whether a specific approach can improve clinical outcomes in ARDS management.
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Gibot S, Conrad M, Courte G, Cravoisy A. Positive End-Expiratory Pressure Setting in COVID-19-Related Acute Respiratory Distress Syndrome: Comparison Between Electrical Impedance Tomography, PEEP/FiO 2 Tables, and Transpulmonary Pressure. Front Med (Lausanne) 2022; 8:720920. [PMID: 35004712 PMCID: PMC8727370 DOI: 10.3389/fmed.2021.720920] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 11/25/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: The best way to titrate the positive end-expiratory pressure (PEEP) in patients suffering from acute respiratory distress syndrome is still matter of debate. Electrical impedance tomography (EIT) is a non-invasive technique that could guide PEEP setting based on an optimized ventilation homogeneity. Methods: For this study, we enrolled the patients with 2019 coronavirus disease (COVID-19)-related acute respiratory distress syndrome (ARDS), who required mechanical ventilation and were admitted to the ICU in March 2021. Patients were monitored by an esophageal catheter and a 32-electrode EIT device. Within 48 h after the start of mechanical ventilation, different levels of PEEP were applied based upon PEEP/FiO2 tables, positive end-expiratory transpulmonary (PL)/ FiO2 table, and EIT. Respiratory mechanics variables were recorded. Results: Seventeen patients were enrolled. PEEP values derived from EIT (PEEPEIT) were different from those based upon other techniques and has poor in-between agreement. The PEEPEIT was associated with lower plateau pressure, mechanical power, transpulmonary pressures, and with a higher static compliance (Crs) and homogeneity of ventilation. Conclusion: Personalized PEEP setting derived from EIT may help to achieve a more homogenous distribution of ventilation. Whether this approach may translate in outcome improvement remains to be investigated.
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Affiliation(s)
- Sébastien Gibot
- Service de Réanimation Médicale, Hôpital Central, CHRU, Nancy, France
| | - Marie Conrad
- Service de Réanimation Médicale, Hôpital Central, CHRU, Nancy, France
| | - Guilhem Courte
- Service de Réanimation Médicale, Hôpital Central, CHRU, Nancy, France
| | - Aurélie Cravoisy
- Service de Réanimation Médicale, Hôpital Central, CHRU, Nancy, France
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23
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Li Z, Zhang Z, Xia Q, Xu D, Qin S, Dai M, Fu F, Gao Y, Zhao Z. First Attempt at Using Electrical Impedance Tomography to Predict High Flow Nasal Cannula Therapy Outcomes at an Early Phase. Front Med (Lausanne) 2021; 8:737810. [PMID: 34692729 PMCID: PMC8533818 DOI: 10.3389/fmed.2021.737810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/07/2021] [Indexed: 01/21/2023] Open
Abstract
Objective: Spatial and temporal ventilation distributions in patients with acute respiratory failure during high flow nasal cannula (HFNC) therapy were previously studied with electrical impedance tomography (EIT). The aim of the study was to explore the possibility of predicting HFNC failure based on various EIT-derived parameters. Methods: High flow nasal cannula failure was defined reintubation within 48 h after HFNC. EIT was performed with the patients spontaneously breathing in the supine position at the start of HFNC. EIT-based indices (comprising the global inhomogeneity index, center of ventilation, ventilation delay, rapid shallow breathing index, minute volume, and inspiration to expiration time) were explored and evaluated at three time points (prior to HFNC, T1; 30 min after HFNC started, T2; and 1 h after, T3). Results: A total of 46 subjects were included in the final analysis. Eleven subjects had failed HFNC. The time to failure was 27.8 ± 12.4 h. The ROX index (defined as SpO2/FiO2/respiratory rate) for HFNC success patients was 8.3 ± 2.7 and for HFNC failure patients, 6.2 ± 1.8 (p = 0.23). None of the investigated EIT-based parameters showed significant differences between subjects with HFNC failure and success. Further subgroup analysis indicated that a significant difference in ventilation inhomogeneity was found between ARDS and non-ARDS [0.54 (0.37) vs. 0.46 (0.28) as evaluated with GI, p < 0.01]. Ventilation homogeneity significantly improved in ARDS after 60-min HFNC treatment [0.59 (0.20) vs 0.57 (0.19), T1 vs. T3, p < 0.05]. Conclusion: Spatial and temporal ventilation distributions were slightly but insignificantly different between the HFNC success and failure groups. HFNC failure could not be predicted by changes in EIT temporal and spatial indexes of ventilation distribution within the first hour. Further studies are required to predict the outcomes of HFNC.
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Affiliation(s)
- Zhe Li
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiyun Zhang
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qian Xia
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Danling Xu
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Shaojie Qin
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Meng Dai
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China
| | - Feng Fu
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China
| | - Yuan Gao
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhanqi Zhao
- Department of Biomedical Engineering, Fourth Military Medical University, Xi'an, China.,Institute of Technical Medicine, Furtwangen University, Villingen-Schwenningen, Germany
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24
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Scaramuzzo G, Spadaro S, Spinelli E, Waldmann AD, Bohm SH, Ottaviani I, Montanaro F, Gamberini L, Marangoni E, Mauri T, Volta CA. Calculation of Transpulmonary Pressure From Regional Ventilation Displayed by Electrical Impedance Tomography in Acute Respiratory Distress Syndrome. Front Physiol 2021; 12:693736. [PMID: 34349666 PMCID: PMC8327175 DOI: 10.3389/fphys.2021.693736] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 06/14/2021] [Indexed: 01/21/2023] Open
Abstract
Transpulmonary driving pressure (DPL) corresponds to the cyclical stress imposed on the lung parenchyma during tidal breathing and, therefore, can be used to assess the risk of ventilator-induced lung injury (VILI). Its measurement at the bedside requires the use of esophageal pressure (Peso), which is sometimes technically challenging. Recently, it has been demonstrated how in an animal model of ARDS, the transpulmonary pressure (PL) measured with Peso calculated with the absolute values method (PL = Paw—Peso) is equivalent to the transpulmonary pressure directly measured using pleural sensors in the central-dependent part of the lung. We hypothesized that, since the PL derived from Peso reflects the regional behavior of the lung, it could exist a relationship between regional parameters measured by electrical impedance tomography (EIT) and driving PL (DPL). Moreover, we explored if, by integrating airways pressure data and EIT data, it could be possible to estimate non-invasively DPL and consequently lung elastance (EL) and elastance-derived inspiratory PL (PI). We analyzed 59 measurements from 20 patients with ARDS. There was a significant intra-patient correlation between EIT derived regional compliance in regions of interest (ROI1) (r = 0.5, p = 0.001), ROI2 (r = −0.68, p < 0.001), and ROI3 (r = −0.4, p = 0.002), and DPL. A multiple linear regression successfully predicted DPL based on respiratory system elastance (Ers), ideal body weight (IBW), roi1%, roi2%, and roi3% (R2 = 0.84, p < 0.001). The corresponding Bland-Altmann analysis showed a bias of −1.4e-007 cmH2O and limits of agreement (LoA) of −2.4–2.4 cmH2O. EL and PI calculated using EIT showed good agreement (R2 = 0.89, p < 0.001 and R2 = 0.75, p < 0.001) with the esophageal derived correspondent variables. In conclusion, DPL has a good correlation with EIT-derived parameters in the central lung. DPL, PI, and EL can be estimated with good accuracy non-invasively combining information coming from EIT and airway pressure.
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Affiliation(s)
- Gaetano Scaramuzzo
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Savino Spadaro
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andreas D Waldmann
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Stephan H Bohm
- Department of Anesthesiology and Intensive Care Medicine, Rostock University Medical Center, Rostock, Germany
| | - Irene Ottaviani
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Federica Montanaro
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Lorenzo Gamberini
- Department of Anaesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Elisabetta Marangoni
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplant, University of Milan, Milan, Italy
| | - Carlo Alberto Volta
- Department of Translational Medicine and for Romagna, University of Ferrara, Ferrara, Italy
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25
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Pelosi P, Ball L, Barbas CSV, Bellomo R, Burns KEA, Einav S, Gattinoni L, Laffey JG, Marini JJ, Myatra SN, Schultz MJ, Teboul JL, Rocco PRM. Personalized mechanical ventilation in acute respiratory distress syndrome. Crit Care 2021; 25:250. [PMID: 34271958 PMCID: PMC8284184 DOI: 10.1186/s13054-021-03686-3] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 07/08/2021] [Indexed: 01/22/2023] Open
Abstract
A personalized mechanical ventilation approach for patients with adult respiratory distress syndrome (ARDS) based on lung physiology and morphology, ARDS etiology, lung imaging, and biological phenotypes may improve ventilation practice and outcome. However, additional research is warranted before personalized mechanical ventilation strategies can be applied at the bedside. Ventilatory parameters should be titrated based on close monitoring of targeted physiologic variables and individualized goals. Although low tidal volume (VT) is a standard of care, further individualization of VT may necessitate the evaluation of lung volume reserve (e.g., inspiratory capacity). Low driving pressures provide a target for clinicians to adjust VT and possibly to optimize positive end-expiratory pressure (PEEP), while maintaining plateau pressures below safety thresholds. Esophageal pressure monitoring allows estimation of transpulmonary pressure, but its use requires technical skill and correct physiologic interpretation for clinical application at the bedside. Mechanical power considers ventilatory parameters as a whole in the optimization of ventilation setting, but further studies are necessary to assess its clinical relevance. The identification of recruitability in patients with ARDS is essential to titrate and individualize PEEP. To define gas-exchange targets for individual patients, clinicians should consider issues related to oxygen transport and dead space. In this review, we discuss the rationale for personalized approaches to mechanical ventilation for patients with ARDS, the role of lung imaging, phenotype identification, physiologically based individualized approaches to ventilation, and a future research agenda.
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Affiliation(s)
- Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy.
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy
| | - Carmen S V Barbas
- Pneumology and Intensive Care Medicine, University of São Paulo, São Paulo, Brazil
- Adult Intensive Care Unit, Albert Einstein Hospital, São Paulo, Brazil
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Australia
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Unity Health Toronto-St. Michael's Hospital, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - Sharon Einav
- Intensive Care Unit of the Shaare Zedek Medical Medical Centre, Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Luciano Gattinoni
- Department of Anaesthesiology, Emergency, and Intensive Care Medicine, University of Göttingen, Göttingen, Germany
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, University Hospital Galway, and School of Medicine, National University of Ireland, Galway, Ireland
| | - John J Marini
- University of Minnesota and Regions Hospital, St. Paul, MN, USA
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Marcus J Schultz
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Jean Louis Teboul
- Service de Médecine Intensive-Réanimation, Hôpital Bicêtre, Inserm UMR S_999, AP-HP Université Paris-Saclay, Le Kremlin-Bicêtre, France
| | - 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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26
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Personalized Positive End-Expiratory Pressure and Tidal Volume in Acute Respiratory Distress Syndrome: Bedside Physiology-Based Approach. Crit Care Explor 2021; 3:e0486. [PMID: 34278316 PMCID: PMC8280087 DOI: 10.1097/cce.0000000000000486] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES: Positive end-expiratory pressure and tidal volume may have a key role for the outcome of patients with acute respiratory distress syndrome. The variety of acute respiratory distress syndrome phenotypes implies personalization of those settings. To guide personalized positive end-expiratory pressure and tidal volume, physicians need to have an in-depth understanding of the physiologic effects and bedside methods to measure the extent of these effects. In the present article, a step-by-step physiologic approach to select personalized positive end-expiratory pressure and tidal volume at the bedside is described. DATA SOURCES: The present review is a critical reanalysis of the traditional and latest literature on the topic. STUDY SELECTION: Relevant clinical and physiologic studies on positive end-expiratory pressure and tidal volume setting were reviewed. DATA EXTRACTION: Reappraisal of the available physiologic and clinical data. DATA SYNTHESIS: Positive end-expiratory pressure is aimed at stabilizing alveolar recruitment, thus reducing the risk of volutrauma and atelectrauma. Bedside assessment of the potential for lung recruitment is a preliminary step to recognize patients who benefit from higher positive end-expiratory pressure level. In patients with higher potential for lung recruitment, positive end-expiratory pressure could be selected by physiology-based methods balancing recruitment and overdistension. In patients with lower potential for lung recruitment or in shock, positive end-expiratory pressure could be maintained in the 5–8 cm H2O range. Tidal volume induces alveolar recruitment and improves gas exchange. After setting personalized positive end-expiratory pressure, tidal volume could be based on lung inflation (collapsed lung size) respecting safety thresholds of static and dynamic lung stress. Positive end-expiratory pressure and tidal volume could be kept stable for some hours in order to allow early recognition of changes in the clinical course of acute respiratory distress syndrome but also frequently reassessed to avoid crossing of safety thresholds. CONCLUSIONS: The setting of personalized positive end-expiratory pressure and tidal volume based on sound physiologic bedside measures may represent an effective strategy for treating acute respiratory distress syndrome patients.
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27
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Fogagnolo A, Montanaro F, Al-Husinat L, Turrini C, Rauseo M, Mirabella L, Ragazzi R, Ottaviani I, Cinnella G, Volta CA, Spadaro S. Management of Intraoperative Mechanical Ventilation to Prevent Postoperative Complications after General Anesthesia: A Narrative Review. J Clin Med 2021; 10:jcm10122656. [PMID: 34208699 PMCID: PMC8234365 DOI: 10.3390/jcm10122656] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 06/09/2021] [Accepted: 06/15/2021] [Indexed: 01/02/2023] Open
Abstract
Mechanical ventilation (MV) is still necessary in many surgical procedures; nonetheless, intraoperative MV is not free from harmful effects. Protective ventilation strategies, which include the combination of low tidal volume and adequate positive end expiratory pressure (PEEP) levels, are usually adopted to minimize the ventilation-induced lung injury and to avoid post-operative pulmonary complications (PPCs). Even so, volutrauma and atelectrauma may co-exist at different levels of tidal volume and PEEP, and therefore, the physiological response to the MV settings should be monitored in each patient. A personalized perioperative approach is gaining relevance in the field of intraoperative MV; in particular, many efforts have been made to individualize PEEP, giving more emphasis on physiological and functional status to the whole body. In this review, we summarized the latest findings about the optimization of PEEP and intraoperative MV in different surgical settings. Starting from a physiological point of view, we described how to approach the individualized MV and monitor the effects of MV on lung function.
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Affiliation(s)
- Alberto Fogagnolo
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
- Correspondence:
| | - Federica Montanaro
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
| | - Lou’i Al-Husinat
- Department of Clinical Sciences, Faculty of Medicine, Yarmouk University, Irbid 21163, Jordan;
| | - Cecilia Turrini
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
| | - Michela Rauseo
- Department of Anesthesia and Intensive Care, University of Foggia, 71122 Foggia, Italy; (M.R.); (L.M.); (G.C.)
| | - Lucia Mirabella
- Department of Anesthesia and Intensive Care, University of Foggia, 71122 Foggia, Italy; (M.R.); (L.M.); (G.C.)
| | - Riccardo Ragazzi
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
| | - Irene Ottaviani
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
| | - Gilda Cinnella
- Department of Anesthesia and Intensive Care, University of Foggia, 71122 Foggia, Italy; (M.R.); (L.M.); (G.C.)
| | - Carlo Alberto Volta
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
| | - Savino Spadaro
- Department of Translation Medicine and for Romagna, Section of Anesthesia and Intensive Care, University of Ferrara, 44121 Ferrara, Italy; (F.M.); (C.T.); (R.R.); (I.O.); (C.A.V.); (S.S.)
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28
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Scaramuzzo G, Gamberini L, Tonetti T, Zani G, Ottaviani I, Mazzoli CA, Capozzi C, Giampalma E, Bacchi Reggiani ML, Bertellini E, Castelli A, Cavalli I, Colombo D, Crimaldi F, Damiani F, Fusari M, Gamberini E, Gordini G, Laici C, Lanza MC, Leo M, Marudi A, Nardi G, Papa R, Potalivo A, Russo E, Taddei S, Consales G, Cappellini I, Ranieri VM, Volta CA, Guerin C, Spadaro S. Sustained oxygenation improvement after first prone positioning is associated with liberation from mechanical ventilation and mortality in critically ill COVID-19 patients: a cohort study. Ann Intensive Care 2021; 11:63. [PMID: 33900484 PMCID: PMC8072095 DOI: 10.1186/s13613-021-00853-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 04/10/2021] [Indexed: 01/02/2023] Open
Abstract
Background Prone positioning (PP) has been used to improve oxygenation in patients affected by the SARS-CoV-2 disease (COVID-19). Several mechanisms, including lung recruitment and better lung ventilation/perfusion matching, make a relevant rational for using PP. However, not all patients maintain the oxygenation improvement after returning to supine position. Nevertheless, no evidence exists that a sustained oxygenation response after PP is associated to outcome in mechanically ventilated COVID-19 patients. We analyzed data from 191 patients affected by COVID-19-related acute respiratory distress syndrome undergoing PP for clinical reasons. Clinical history, severity scores and respiratory mechanics were analyzed. Patients were classified as responders (≥ median PaO2/FiO2 variation) or non-responders (< median PaO2/FiO2 variation) based on the PaO2/FiO2 percentage change between pre-proning and 1 to 3 h after re-supination in the first prone positioning session. Differences among the groups in physiological variables, complication rates and outcome were evaluated. A competing risk regression analysis was conducted to evaluate if PaO2/FiO2 response after the first pronation cycle was associated to liberation from mechanical ventilation. Results The median PaO2/FiO2 variation after the first PP cycle was 49 [19–100%] and no differences were found in demographics, comorbidities, ventilatory treatment and PaO2/FiO2 before PP between responders (96/191) and non-responders (95/191). Despite no differences in ICU length of stay, non-responders had a higher rate of tracheostomy (70.5% vs 47.9, P = 0.008) and mortality (53.7% vs 33.3%, P = 0.006), as compared to responders. Moreover, oxygenation response after the first PP was independently associated to liberation from mechanical ventilation at 28 days and was increasingly higher being higher the oxygenation response to PP. Conclusions Sustained oxygenation improvement after first PP session is independently associated to improved survival and reduced duration of mechanical ventilation in critically ill COVID-19 patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00853-1.
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Affiliation(s)
- Gaetano Scaramuzzo
- Department of Translational Medicine and for Romagna, University of Ferrara & Azienda Ospedaliero-Universitaria S. Anna, Via Aldo Moro, 8 Cona, 44121, Ferrara, Italy
| | - Lorenzo Gamberini
- Department of Anaesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Tommaso Tonetti
- Alma Mater Studiorum, Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Università di Bologna, Bologna, Italy
| | - Gianluca Zani
- Department of Anesthesia and Intensive Care, Santa Maria Delle Croci Hospital, Ravenna, Italy
| | - Irene Ottaviani
- Department of Translational Medicine and for Romagna, University of Ferrara & Azienda Ospedaliero-Universitaria S. Anna, Via Aldo Moro, 8 Cona, 44121, Ferrara, Italy
| | - Carlo Alberto Mazzoli
- Department of Anaesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Chiara Capozzi
- Cardio-Anesthesiology Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | | | - Maria Letizia Bacchi Reggiani
- Department of Clinical, Integrated and Experimental Medicine (DIMES), Statistical Service, Alma Mater University, S. Orsola-Malpighi Hospital Bologna, Bologna, Italy
| | - Elisabetta Bertellini
- Department of Anaesthesiology, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy
| | - Andrea Castelli
- Cardio-Anesthesiology Unit, Cardio-Thoracic-Vascular Department, S.Orsola Hospital, University of Bologna, Bologna, Italy
| | - Irene Cavalli
- Alma Mater Studiorum, Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Università di Bologna, Bologna, Italy
| | - Davide Colombo
- Anaesthesia and Intensive Care Department, SS. Trinità Hospital, ASL, Novara, Italy.,Translational Medicine Department, Eastern Piedmont University, Novara, Italy
| | | | - Federica Damiani
- Department of Anaesthesia, Intensive Care and Pain Therapy, Imola Hospital, Imola, Italy
| | - Maurizio Fusari
- Department of Anesthesia and Intensive Care, Santa Maria Delle Croci Hospital, Ravenna, Italy
| | - Emiliano Gamberini
- Anaesthesia and Intensive Care Unit, M. Bufalini Hospital, Cesena, Italy
| | - Giovanni Gordini
- Department of Anaesthesia, Intensive Care and Prehospital Emergency, Ospedale Maggiore Carlo Alberto Pizzardi, Bologna, Italy
| | - Cristiana Laici
- Anesthesia and Intensive Care Unit of Transplant, Department of Organ Failures and Transplants, Azienda Ospedaliero-Universitaria Di Bologna (IRCCS), Bologna, Italy
| | - Maria Concetta Lanza
- Department of Anesthesia and Intensive Care, G.B. Morgagni-Pierantoni Hospital, Forlì, Italy
| | - Mirco Leo
- Department of Anaesthesia and Intensive Care, Azienda Ospedaliera SS. Antonio E Biagio E Cesare Arrigo, Alessandria, Italy
| | - Andrea Marudi
- Department of Anaesthesiology, University Hospital of Modena, Via del Pozzo 71, 41100, Modena, Italy
| | - Giuseppe Nardi
- Department of Anaesthesia and Intensive Care, Infermi Hospital, Rimini, Italy
| | - Raffaella Papa
- Anaesthesia and Intensive Care Unit, Santa Maria Annunziata Hospital, Firenze, Italy
| | - Antonella Potalivo
- Department of Anaesthesia and Intensive Care, Infermi Hospital, Rimini, Italy
| | - Emanuele Russo
- Anaesthesia and Intensive Care Unit, M. Bufalini Hospital, Cesena, Italy
| | - Stefania Taddei
- Anaesthesia and Intensive Care Unit, Bentivoglio Hospital, Bentivoglio, Bologna, Italy
| | - Guglielmo Consales
- Department of Critical Care Section of Anesthesiology and Intensive Care, Azienda USL Toscana Centro, Prato, Italy
| | - Iacopo Cappellini
- Department of Critical Care Section of Anesthesiology and Intensive Care, Azienda USL Toscana Centro, Prato, Italy
| | - Vito Marco Ranieri
- Alma Mater Studiorum, Dipartimento di Scienze Mediche e Chirurgiche, Anesthesia and Intensive Care Medicine, Policlinico di Sant'Orsola, Università di Bologna, Bologna, Italy
| | - Carlo Alberto Volta
- Department of Translational Medicine and for Romagna, University of Ferrara & Azienda Ospedaliero-Universitaria S. Anna, Via Aldo Moro, 8 Cona, 44121, Ferrara, Italy
| | - Claude Guerin
- Médecine Intensive-Réanimation Groupement Hospitalier Edouard Herriot, Université de Lyon Faculté de Médecine Lyon-Est, Lyon, Institut Mondor de Recherches Biomédicales, Créteil, France
| | - Savino Spadaro
- Department of Translational Medicine and for Romagna, University of Ferrara & Azienda Ospedaliero-Universitaria S. Anna, Via Aldo Moro, 8 Cona, 44121, Ferrara, Italy.
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29
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Spinelli E, Colussi G, Dal Santo G, Scotti E, Marongiu I, Garbelli E, Mazzucco A, Dondossola D, Maia R, Battistin M, Biancolilli O, Rosso L, Gatti S, Mauri T. Atelectasis, Shunt, and Worsening Oxygenation Following Reduction of Respiratory Rate in Healthy Pigs Undergoing ECMO: An Experimental Lung Imaging Study. Front Physiol 2021; 12:663313. [PMID: 33897471 PMCID: PMC8063114 DOI: 10.3389/fphys.2021.663313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 03/04/2021] [Indexed: 12/21/2022] Open
Abstract
Rationale: Reducing the respiratory rate during extracorporeal membrane oxygenation (ECMO) decreases the mechanical power, but it might induce alveolar de-recruitment. Dissecting de-recruitment due to lung edema vs. the fraction due to hypoventilation may be challenging in injured lungs. Objectives: We characterized changes in lung physiology (primary endpoint: development of atelectasis) associated with progressive reduction of the respiratory rate in healthy animals on ECMO. Methods: Six female pigs underwent general anesthesia and volume control ventilation (Baseline: PEEP 5 cmH2O, Vt 10 ml/kg, I:E = 1:2, FiO2 0.5, rate 24 bpm). Veno-venous ECMO was started and respiratory rate was progressively reduced to 18, 12, and 6 breaths per minute (6-h steps), while all other settings remained unchanged. ECMO blood flow was kept constant while gas flow was increased to maintain stable PaCO2. Measurements and Main Results: At Baseline (without ECMO) and toward the end of each step, data from quantitative CT scan, electrical impedance tomography, and gas exchange were collected. Increasing ECMO gas flow while lowering the respiratory rate was associated with an increase in the fraction of non-aerated tissue (i.e., atelectasis) and with a decrease of tidal ventilation reaching the gravitationally dependent lung regions (p = 0.009 and p = 0.018). Intrapulmonary shunt increased (p < 0.001) and arterial PaO2 decreased (p < 0.001) at lower rates. The fraction of non-aerated lung was correlated with longer expiratory time spent at zero flow (r = 0.555, p = 0.011). Conclusions: Progressive decrease of respiratory rate coupled with increasing CO2 removal in mechanically ventilated healthy pigs is associated with development of lung atelectasis, higher shunt, and poorer oxygenation.
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Affiliation(s)
- Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giulia Colussi
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Gaia Dal Santo
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Eleonora Scotti
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ines Marongiu
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Erica Garbelli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alessandra Mazzucco
- Thoracic Surgery and Lung Transplantation Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Dondossola
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,General and Liver Transplant Surgery Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Raquel Maia
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Intensive Care Medicine, Hospital Professor Doutor Fernando Fonseca, Amadora, Portugal
| | - Michele Battistin
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Osvaldo Biancolilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Rosso
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.,Thoracic Surgery and Lung Transplantation Unit, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Gatti
- Center for Preclinical Research, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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30
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Tas J, van Gassel RJJ, Heines SJH, Mulder MMG, Heijnen NFL, Acampo-de Jong MJ, Bels JLM, Bennis FC, Koelmann M, Groven RVM, Donkers MA, van Rosmalen F, Hermans BJM, Meex SJ, Mingels A, Bekers O, Savelkoul P, Oude Lashof AML, Wildberger J, Tijssen FH, Buhre W, Sels JWEM, Ghossein-Doha C, Driessen RGH, Kubben PL, Janssen MLF, Nicolaes GAF, Strauch U, Geyik Z, Delnoij TSR, Walraven KHM, Stehouwer CDA, Verbunt JAMCF, Van Mook WNKA, van Santen S, Schnabel RM, Aries MJH, van de Poll MCG, Bergmans D, van der Horst ICC, van Kuijk S, van Bussel BCT. Serial measurements in COVID-19-induced acute respiratory disease to unravel heterogeneity of the disease course: design of the Maastricht Intensive Care COVID cohort (MaastrICCht). BMJ Open 2020; 10:e040175. [PMID: 32994259 PMCID: PMC7526030 DOI: 10.1136/bmjopen-2020-040175] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 07/30/2020] [Accepted: 08/19/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The course of the disease in SARS-CoV-2 infection in mechanically ventilated patients is unknown. To unravel the clinical heterogeneity of the SARS-CoV-2 infection in these patients, we designed the prospective observational Maastricht Intensive Care COVID cohort (MaastrICCht). We incorporated serial measurements that harbour aetiological, diagnostic and predictive information. The study aims to investigate the heterogeneity of the natural course of critically ill patients with a SARS-CoV-2 infection. METHODS AND ANALYSIS Mechanically ventilated patients admitted to the intensive care with a SARS-CoV-2 infection will be included. We will collect clinical variables, vital parameters, laboratory variables, mechanical ventilator settings, chest electrical impedance tomography, ECGs, echocardiography as well as other imaging modalities to assess heterogeneity of the course of a SARS-CoV-2 infection in critically ill patients. The MaastrICCht is also designed to foster various other studies and registries and intends to create an open-source database for investigators. Therefore, a major part of the data collection is aligned with an existing national intensive care data registry and two international COVID-19 data collection initiatives. Additionally, we create a flexible design, so that additional measures can be added during the ongoing study based on new knowledge obtained from the rapidly growing body of evidence. The spread of the COVID-19 pandemic requires the swift implementation of observational research to unravel heterogeneity of the natural course of the disease of SARS-CoV-2 infection in mechanically ventilated patients. Our study design is expected to enhance aetiological, diagnostic and prognostic understanding of the disease. This paper describes the design of the MaastrICCht. ETHICS AND DISSEMINATION Ethical approval has been obtained from the medical ethics committee (Medisch Ethische Toetsingscommissie 2020-1565/3 00 523) of the Maastricht University Medical Centre+ (Maastricht UMC+), which will be performed based on the Declaration of Helsinki. During the pandemic, the board of directors of Maastricht UMC+ adopted a policy to inform patients and ask their consent to use the collected data and to store serum samples for COVID-19 research purposes. All study documentation will be stored securely for fifteen years after recruitment of the last patient. The results will be published in peer-reviewed academic journals, with a preference for open access journals, while particularly considering deposition of the manuscripts on a preprint server early. TRIAL REGISTRATION NUMBER The Netherlands Trial Register (NL8613).
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Affiliation(s)
- Jeanette Tas
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Rob J J van Gassel
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Serge J H Heines
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Mark M G Mulder
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Nanon F L Heijnen
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Melanie J Acampo-de Jong
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Julia L M Bels
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Frank C Bennis
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Marcel Koelmann
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Rald V M Groven
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Moniek A Donkers
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Frank van Rosmalen
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Biomedical Engineering, Maastricht University, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Ben J M Hermans
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Steven Jr Meex
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Alma Mingels
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Otto Bekers
- Department of Clinical Chemistry, Central Diagnostic Laboratory, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Paul Savelkoul
- Department of Medical Microbiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Astrid M L Oude Lashof
- Department of Medical Microbiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Joachim Wildberger
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Radiology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Fabian H Tijssen
- Department of Anesthesiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Wolfgang Buhre
- Department of Anesthesiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Jan-Willem E M Sels
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Chahinda Ghossein-Doha
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Rob G H Driessen
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Pieter L Kubben
- Department of Neurosurgery, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Marcus L F Janssen
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Gerry A F Nicolaes
- Department of Biochemistry, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ulrich Strauch
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Zafer Geyik
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Thijs S R Delnoij
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Cardiology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Kim H M Walraven
- Department of Pulmonology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Coen DA Stehouwer
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Jeanine A M C F Verbunt
- Department of Rehabilitation Medicine, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Walther N K A Van Mook
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Susanne van Santen
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ronny M Schnabel
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Marcel J H Aries
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, The Netherlands
| | - Marcel C G van de Poll
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, The Netherlands
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Dennis Bergmans
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Sander van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Bas C T van Bussel
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
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