1
|
Benites MH, Zapata-Canivilo M, Poblete F, Labbe F, Battiato R, Ferre A, Dreyse J, Bugedo G, Bruhn A, Costa ELV, Retamal J. Physiological and clinical effects of trunk inclination adjustment in patients with respiratory failure: a scoping review and narrative synthesis. Crit Care 2024; 28:228. [PMID: 38982466 PMCID: PMC11232125 DOI: 10.1186/s13054-024-05010-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 06/27/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND Adjusting trunk inclination from a semi-recumbent position to a supine-flat position or vice versa in patients with respiratory failure significantly affects numerous aspects of respiratory physiology including respiratory mechanics, oxygenation, end-expiratory lung volume, and ventilatory efficiency. Despite these observed effects, the current clinical evidence regarding this positioning manoeuvre is limited. This study undertakes a scoping review of patients with respiratory failure undergoing mechanical ventilation to assess the effect of trunk inclination on physiological lung parameters. METHODS The PubMed, Cochrane, and Scopus databases were systematically searched from 2003 to 2023. INTERVENTIONS Changes in trunk inclination. MEASUREMENTS Four domains were evaluated in this study: 1) respiratory mechanics, 2) ventilation distribution, 3) oxygenation, and 4) ventilatory efficiency. RESULTS After searching the three databases and removing duplicates, 220 studies were screened. Of these, 37 were assessed in detail, and 13 were included in the final analysis, comprising 274 patients. All selected studies were experimental, and assessed respiratory mechanics, ventilation distribution, oxygenation, and ventilatory efficiency, primarily within 60 min post postural change. CONCLUSION In patients with acute respiratory failure, transitioning from a supine to a semi-recumbent position leads to decreased respiratory system compliance and increased airway driving pressure. Additionally, C-ARDS patients experienced an improvement in ventilatory efficiency, which resulted in lower PaCO2 levels. Improvements in oxygenation were observed in a few patients and only in those who exhibited an increase in EELV upon moving to a semi-recumbent position. Therefore, the trunk inclination angle must be accurately reported in patients with respiratory failure under mechanical ventilation.
Collapse
Affiliation(s)
- Martín H Benites
- Unidad de Pacientes Críticos, Clínica Las Condes, Santiago, Chile
- Facultad de Medicina, Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
- Doctorado en Ciencias Médicas, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Fabian Poblete
- Unidad de Pacientes Críticos, Clínica Las Condes, Santiago, Chile
| | - Francisco Labbe
- Unidad de Pacientes Críticos, Clínica Las Condes, Santiago, Chile
| | - Romina Battiato
- Magíster em Bioestadística, Escuela de Salud Pública, Universidad de Chile, Santiago, Chile
| | - Andrés Ferre
- Unidad de Pacientes Críticos, Clínica Las Condes, Santiago, Chile
- Facultad de Medicina, Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
| | - Jorge Dreyse
- Unidad de Pacientes Críticos, Clínica Las Condes, Santiago, Chile
- Facultad de Medicina, Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
| | - Guillermo Bugedo
- Departamento de Medicina Intensiva, Hospital Clínico Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Hospital Clínico Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo L V Costa
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Laboratório de Pneumologia LIM-09, Disciplina de Pneumologia, Heart Institute (Incor), São Paulo, Brazil
- Hospital Sírio-Libanês, Research and Education Institute, São Paulo, Brazil
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Hospital Clínico Pontificia Universidad Católica de Chile, Santiago, Chile.
| |
Collapse
|
2
|
Marini JJ. Detecting end-tidal hyperinflation. Intensive Care Med 2024; 50:752-754. [PMID: 38563895 DOI: 10.1007/s00134-024-07379-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 02/27/2024] [Indexed: 04/04/2024]
|
3
|
Kummer RL, Marini JJ. The Respiratory Mechanics of COVID-19 Acute Respiratory Distress Syndrome-Lessons Learned? J Clin Med 2024; 13:1833. [PMID: 38610598 PMCID: PMC11012401 DOI: 10.3390/jcm13071833] [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: 01/31/2024] [Revised: 03/13/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a well-defined clinical entity characterized by the acute onset of diffuse pulmonary injury and hypoxemia not explained by fluid overload. The COVID-19 pandemic brought about an unprecedented volume of patients with ARDS and challenged our understanding and clinical approach to treatment of this clinical syndrome. Unique to COVID-19 ARDS is the disruption and dysregulation of the pulmonary vascular compartment caused by the SARS-CoV-2 virus, which is a significant cause of hypoxemia in these patients. As a result, gas exchange does not necessarily correlate with respiratory system compliance and mechanics in COVID-19 ARDS as it does with other etiologies. The purpose of this review is to relate the mechanics of COVID-19 ARDS to its underlying pathophysiologic mechanisms and outline the lessons we have learned in the management of this clinic syndrome.
Collapse
Affiliation(s)
- Rebecca L. Kummer
- Department of Pulmonary and Critical Care Medicine, University of Minnesota School of Medicine, Minneapolis, MN 55455, USA
| | - John J. Marini
- Department of Pulmonary and Critical Care Medicine, Regions Hospital, St. Paul, MN 55101, USA
| |
Collapse
|
4
|
Pearce AK, McGuire WC, Elliott AR, Goligher EC, Prisk GK, Butler JP, Malhotra A. Impact of Supine Versus Semirecumbent Body Posture on the Distribution of Ventilation in Acute Respiratory Distress Syndrome. Crit Care Explor 2023; 5:e1014. [PMID: 38053751 PMCID: PMC10695482 DOI: 10.1097/cce.0000000000001014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023] Open
Abstract
In some patients with acute respiratory distress syndrome (ARDS), a paradoxical improvement in respiratory system compliance (CRS) has been observed when assuming a supine (head of bed [HOB] 0°) compared with semirecumbent (HOB 35-40°) posture. We sought to test the hypothesis that mechanically ventilated patients with ARDS would have improved CRS, due to changes in ventilation distribution, when moving from the semirecumbent to supine position. We conducted a prospective, observational ICU study including 14 mechanically ventilated patients with ARDS. For each patient, ventilation distribution (assessed by electrical impedance tomography) and pulmonary mechanics were compared in supine versus semirecumbent postures. Compared with semirecumbent, in the supine posture CRS increased (33 ± 21 vs. 26 ± 14 mL/cm H2O, p = 0.005), driving pressure was reduced (14 ± 6 vs. 17 ± 7 cm H2O, p < 0.001), and dorsal fraction of ventilation was decreased (48.5 ± 14.1% vs. 54.5 ± 12.0%, p = 0.003). Posture change from semirecumbent to supine resulted in a favorable physiologic response in terms of improved CRS and reduced driving pressure-with a corresponding increase in ventral ventilation, possibly related to reduced ventral overdistension.
Collapse
Affiliation(s)
- Alex K Pearce
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA
| | - W Cameron McGuire
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA
| | - Ann R Elliott
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
- Department of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada
| | - G Kim Prisk
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA
| | - James P Butler
- Department of Environmental Health TH Chan School of Public Health, Boston, MA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, Sleep Medicine, and Physiology, University of California San Diego, La Jolla, CA
| |
Collapse
|
5
|
Duhem H, Terzi N, Segond N, Bellier A, Sanchez C, Louis B, Debaty G, Guérin C. Effect of automated head-thorax elevation during chest compressions on lung ventilation: a model study. Sci Rep 2023; 13:20393. [PMID: 37989865 PMCID: PMC10663599 DOI: 10.1038/s41598-023-47727-z] [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: 04/26/2023] [Accepted: 11/17/2023] [Indexed: 11/23/2023] Open
Abstract
Our goal was to investigate the effects of head-thorax elevation (HUP) during chest compressions (CC) on lung ventilation. A prospective study was performed on seven human cadavers. Chest was automatically compressed-decompressed in flat position and during progressive HUP from 18 to 35°. Lung ventilation was measured with electrical impedance tomography. In each cadaver, 5 sequences were randomly performed: one without CC at positive end-expiratory pressure (PEEP) 0cmH2O, 3 s with CC at PEEP0, 5 or 10cmH2O and 1 with CC and an impedance threshold device at PEEP0cmH2O. The minimal-to-maximal change in impedance (VTEIT in arbitrary unit a.u.) and the minimal impedance in every breathing cycle (EELI) the) were compared between flat, 18°, and 35° in each sequence by a mixed-effects model. Values are expressed as median (1st-3rd quartiles). With CC, between flat, 18° and 35° VTEIT decreased at each level of PEEP. It was 12416a.u. (10,689; 14,442), 11,239 (7667; 13,292), and 6457 (4631; 9516), respectively, at PEEP0. The same was true with the impedance threshold device. EELI/VTEIT significantly decreased from - 0.30 (- 0.40; - 0.15) before to - 1.13 (- 1.70; - 0.61) after the CC (P = 0.009). With HUP lung ventilation decreased with CC as compared to flat position. CC are associated with decreased in EELI.
Collapse
Affiliation(s)
- Hélène Duhem
- SAMU 38, Centre Hospitalier Universitaire Grenoble Alpes, 38043, Grenoble, France
- Université de Grenoble-Alpes/CNRS, UMR 5525Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, 38000, Grenoble, France
| | - Nicolas Terzi
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire Grenoble Alpes, 38043, Grenoble, France
| | - Nicolas Segond
- SAMU 38, Centre Hospitalier Universitaire Grenoble Alpes, 38043, Grenoble, France
- Université de Grenoble-Alpes/CNRS, UMR 5525Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, 38000, Grenoble, France
| | - Alexandre Bellier
- Université de Grenoble-Alpes/CNRS, UMR 5525Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, 38000, Grenoble, France
| | - Caroline Sanchez
- Université de Grenoble-Alpes/CNRS, UMR 5525Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, 38000, Grenoble, France
| | - Bruno Louis
- Institut Mondor de Recherches Biomédicales INSERM-UPEC UMR 955 Eq13 - CNRS EMR 7000, 8 rue du Général Sarrail, 94010, Créteil, France
| | - Guillaume Debaty
- SAMU 38, Centre Hospitalier Universitaire Grenoble Alpes, 38043, Grenoble, France.
- Université de Grenoble-Alpes/CNRS, UMR 5525Univ. Grenoble Alpes, CNRS, UMR 5525, VetAgro Sup, Grenoble INP, TIMC, 38000, Grenoble, France.
| | - Claude Guérin
- Institut Mondor de Recherches Biomédicales INSERM-UPEC UMR 955 Eq13 - CNRS EMR 7000, 8 rue du Général Sarrail, 94010, Créteil, France
- Faculté de médecine Lyon Est, Université de Lyon, 8 avenue Rockefeller, 69373, Lyon cedex 08, France
| |
Collapse
|
6
|
Benites MH, Torres D, Poblete F, Labbe F, Bachmann MC, Regueira TE, Soto L, Ferre A, Dreyse J, Retamal J. Effects of changes in trunk inclination on ventilatory efficiency in ARDS patients: quasi-experimental study. Intensive Care Med Exp 2023; 11:65. [PMID: 37755538 PMCID: PMC10533449 DOI: 10.1186/s40635-023-00550-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 09/12/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Trunk inclination from semirecumbent head-upright to supine-flat positioning reduces driving pressure and increases respiratory system compliance in patients with acute respiratory distress syndrome (ARDS). These effects are associated with an improved ventilatory ratio and reduction in the partial pressure of carbon dioxide (PaCO2). However, these physiological effects have not been completely studied, and their mechanisms have not yet been elucidated. Therefore, this study aimed to evaluate the effects of a change in trunk inclination from semirecumbent (45°) to supine-flat (10°) on physiological dead space and ventilation distribution in different lung regions. RESULTS Twenty-two ARDS patients on pressure-controlled ventilation underwent three 60-min steps in which trunk inclination was changed from 45° (baseline) to 10° (intervention) and back to 45° (control) in the last step. Tunk inclination from a semirecumbent (45°) to a supine-flat (10°) position resulted in a higher tidal volume [371 (± 76) vs. 433 (± 84) mL (P < 0.001)] and respiratory system compliance [34 (± 10) to 41 (± 12) mL/cmH2O (P < 0.001)]. The CO2 exhaled per minute improved from 191 mL/min (± 34) to 227 mL/min (± 38) (P < 0.001). Accordingly, Bohr's dead space ratio decreased from 0.49 (± 0.07) to 0.41 (± 0.06) (p < 0.001), and PaCO2 decreased from 43 (± 5) to 36 (± 4) mmHg (p < 0.001). In addition, the impedance ratio, which divides the ventilation activity of the ventral region by the dorsal region ventilation activity in tidal images, dropped from 1.27 (0.83-1.78) to 0.86 (0.51-1.33) (p < 0.001). These results, calculated from functional EIT images, indicated further ventilation activity in the dorsal lung regions. These effects rapidly reversed once the patient was repositioned at 45°. CONCLUSIONS A change in trunk inclination from a semirecumbent (45 degrees) to a supine-flat position (10 degrees) improved Bohr's dead space ratio and reduced PaCO2 in patients with ARDS. This effect is associated with an increase in tidal volume and respiratory system compliance, along with further favourable impedance ventilation distribution toward the dorsal lung regions. This study highlights the importance of considering trunk inclination as a modifiable determinant of physiological parameters. The angle of trunk inclination is essential information that must be reported in ARDS patients.
Collapse
Affiliation(s)
- Martín H Benites
- Unidad de Pacientes Críticos, Clínica Las Condes, Estoril 450, Santiago, Chile
- Departamento de Epidemiología y Estudios en Salud, Magíster en Epidemiología, Universidad de los Andes, Monseñor Álvaro del Portillo 12455, Santiago, Chile
- Estudiante del Programa Doctorado en Ciencias Médicas, Escuela de Medicina, Pontificia Universidad Católica de Chile, Av. Libertador Bernardo O'Higgins 340, Santiago, Chile
- Facultad de Medicina, Escuela de Medicina, Universidad Finis Terrae, Av. Pedro de Valdivia 1509, Santiago, Chile
| | - David Torres
- Departamento de Epidemiología y Estudios en Salud, Magíster en Epidemiología, Universidad de los Andes, Monseñor Álvaro del Portillo 12455, Santiago, Chile
| | - Fabian Poblete
- Unidad de Pacientes Críticos, Clínica Las Condes, Estoril 450, Santiago, Chile
| | - Francisco Labbe
- Unidad de Pacientes Críticos, Clínica Las Condes, Estoril 450, Santiago, Chile
| | - María C Bachmann
- Estudiante del Programa Doctorado en Ciencias Médicas, Escuela de Medicina, Pontificia Universidad Católica de Chile, Av. Libertador Bernardo O'Higgins 340, Santiago, Chile
- Departamento de Medicina Intensiva, Hospital Clínico Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, Chile
| | - Tomas E Regueira
- Unidad de Pacientes Críticos, Clínica Santa María, Bellavista 415, Santiago, Chile
| | - Leonardo Soto
- Facultad de Medicina, Escuela de Medicina, Universidad Finis Terrae, Av. Pedro de Valdivia 1509, Santiago, Chile
- Unidad de Pacientes Críticos, Clínica Santa María, Bellavista 415, Santiago, Chile
| | - Andrés Ferre
- Unidad de Pacientes Críticos, Clínica Las Condes, Estoril 450, Santiago, Chile
- Facultad de Medicina, Escuela de Medicina, Universidad Finis Terrae, Av. Pedro de Valdivia 1509, Santiago, Chile
| | - Jorge Dreyse
- Unidad de Pacientes Críticos, Clínica Las Condes, Estoril 450, Santiago, Chile
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Hospital Clínico Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago, Chile.
| |
Collapse
|
7
|
Marrazzo F, Spina S, Zadek F, Forlini C, Bassi G, Giudici R, Bellani G, Fumagalli R, Langer T. PEEP Titration Is Markedly Affected by Trunk Inclination in Mechanically Ventilated Patients with COVID-19 ARDS: A Physiologic, Cross-Over Study. J Clin Med 2023; 12:3914. [PMID: 37373608 PMCID: PMC10299565 DOI: 10.3390/jcm12123914] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 06/04/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Changing trunk inclination affects lung function in patients with ARDS. However, its impacts on PEEP titration remain unknown. The primary aim of this study was to assess, in mechanically ventilated patients with COVID-19 ARDS, the effects of trunk inclination on PEEP titration. The secondary aim was to compare respiratory mechanics and gas exchange in the semi-recumbent (40° head-of-the-bed) and supine-flat (0°) positions following PEEP titration. METHODS Twelve patients were positioned both at 40° and 0° trunk inclination (randomized order). The PEEP associated with the best compromise between overdistension and collapse guided by Electrical Impedance Tomography (PEEPEIT) was set. After 30 min of controlled mechanical ventilation, data regarding respiratory mechanics, gas exchange, and EIT parameters were collected. The same procedure was repeated for the other trunk inclination. RESULTS PEEPEIT was lower in the semi-recumbent than in the supine-flat position (8 ± 2 vs. 13 ± 2 cmH2O, p < 0.001). A semi-recumbent position with optimized PEEP resulted in higher PaO2:FiO2 (141 ± 46 vs. 196 ± 99, p = 0.02) and a lower global inhomogeneity index (46 ± 10 vs. 53 ± 11, p = 0.008). After 30 min of observation, a loss of aeration (measured by EIT) was observed only in the supine-flat position (-153 ± 162 vs. 27 ± 203 mL, p = 0.007). CONCLUSIONS A semi-recumbent position is associated with lower PEEPEIT and results in better oxygenation, less derecruitment, and more homogenous ventilation compared to the supine-flat position.
Collapse
Affiliation(s)
- Francesco Marrazzo
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Stefano Spina
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Francesco Zadek
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (F.Z.); (G.B.)
| | - Clarissa Forlini
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Gabriele Bassi
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Riccardo Giudici
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (F.Z.); (G.B.)
- Department of Anesthesia and Intensive Care 1, Santa Chiara Hospital, APSS Trento, 38122 Trento, Italy
| | - Roberto Fumagalli
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (F.Z.); (G.B.)
| | - Thomas Langer
- Department of Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy; (F.M.); (S.S.); (C.F.); (G.B.); (R.G.); (R.F.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milano, Italy; (F.Z.); (G.B.)
| |
Collapse
|
8
|
Rezoagli E, Bastia L, Brochard L, Bellani G. Physical manoeuvres in patients with ARDS and low compliance: bedside approaches to detect lung hyperinflation and optimise mechanical ventilation. Eur Respir J 2023; 61:61/5/2202169. [PMID: 37208034 DOI: 10.1183/13993003.02169-2022] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 03/30/2023] [Indexed: 05/21/2023]
Affiliation(s)
- Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Co-first authors
| | - Luca Bastia
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
- Co-first authors
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada
- Co-senior authors
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- Co-senior authors
| |
Collapse
|
9
|
Selickman J, Marini JJ. Chest wall loading in the ICU: pushes, weights, and positions. Ann Intensive Care 2022; 12:103. [PMID: 36346532 PMCID: PMC9640797 DOI: 10.1186/s13613-022-01076-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 10/20/2022] [Indexed: 11/11/2022] Open
Abstract
Clinicians monitor mechanical ventilatory support using airway pressures—primarily the plateau and driving pressure, which are considered by many to determine the safety of the applied tidal volume. These airway pressures are influenced not only by the ventilator prescription, but also by the mechanical properties of the respiratory system, which consists of the series-coupled lung and chest wall. Actively limiting chest wall expansion through external compression of the rib cage or abdomen is seldom performed in the ICU. Recent literature describing the respiratory mechanics of patients with late-stage, unresolving, ARDS, however, has raised awareness of the potential diagnostic (and perhaps therapeutic) value of this unfamiliar and somewhat counterintuitive practice. In these patients, interventions that reduce resting lung volume, such as loading the chest wall through application of external weights or manual pressure, or placing the torso in a more horizontal position, have unexpectedly improved tidal compliance of the lung and integrated respiratory system by reducing previously undetected end-tidal hyperinflation. In this interpretive review, we first describe underappreciated lung and chest wall interactions that are clinically relevant to both normal individuals and to the acutely ill who receive ventilatory support. We then apply these physiologic principles, in addition to published clinical observation, to illustrate the utility of chest wall modification for the purposes of detecting end-tidal hyperinflation in everyday practice.
Collapse
Affiliation(s)
- John Selickman
- grid.17635.360000000419368657Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN USA ,grid.415858.50000 0001 0087 6510Department of Critical Care Medicine, Regions Hospital, MS 11203B, 640 Jackson St., St. Paul, MN 55101-2595 USA
| | - John J. Marini
- grid.17635.360000000419368657Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN USA ,grid.415858.50000 0001 0087 6510Department of Critical Care Medicine, Regions Hospital, MS 11203B, 640 Jackson St., St. Paul, MN 55101-2595 USA
| |
Collapse
|
10
|
Bedside Detection of End-Tidal Hyperinflation in Acute Respiratory Distress Syndrome. Ann Am Thorac Soc 2022; 19:1791-1795. [PMID: 35849421 DOI: 10.1513/annalsats.202205-460ps] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
|