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Effect of inhaled fluticasone propionate on laryngotracheal stenosis after balloon dilation: a randomized controlled trial. Eur Arch Otorhinolaryngol 2021; 278:1505-1513. [PMID: 33496811 PMCID: PMC7835446 DOI: 10.1007/s00405-021-06622-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/11/2021] [Indexed: 10/29/2022]
Abstract
PURPOSE Laryngotracheal stenosis describes various airflow compromising conditions leading to laryngeal and tracheal narrowing, including subglottic and tracheal stenosis. Direct laryngobronchoscopy is the diagnostic gold standard for laryngotracheal stenosis. This study aimed to explore the effect of inhaled fluticasone propionate as adjuvant medical therapy in patients with laryngotracheal stenosis after balloon dilation. METHODS This prospective randomized controlled trial was conducted from April 2019 to April 2020. Fourteen adults (≥ 18 years) with laryngotracheal stenosis consented to participate. All patients underwent endoscopic balloon dilation. Seven patients were treated with inhaled fluticasone propionate, and seven acted as controls. Detailed documentation of operative findings and pre- and post-balloon dilation spirometry measurements were recorded. Basic demographic data and operative details, including information about the percentage of laryngotracheal stenosis, distance of laryngotracheal stenosis from the vocal cords, the stenotic segment vertical length, and the largest endotracheal tube used before and after dilation were noted. RESULTS Spirometry measurements were obtained on 34 occasions (17 before and 17 after balloon dilation). The two groups were similar in spirometry values after treatment. Both groups had significantly improved on most spirometry values after balloon dilation. CONCLUSION We found that using inhaled steroids after balloon dilatation in patients with laryngotracheal stenosis had no benefit over non-user patients in spirometry parameters during the short postoperative follow-up. To confirm this outcome, we recommend a large-scale double-blind study with a longer follow-up period.
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Predictive Virtual Patient Modelling of Mechanical Ventilation: Impact of Recruitment Function. Ann Biomed Eng 2019; 47:1626-1641. [PMID: 30927170 DOI: 10.1007/s10439-019-02253-w] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 03/22/2019] [Indexed: 10/27/2022]
Abstract
Mechanical ventilation is a life-support therapy for intensive care patients suffering from respiratory failure. To reduce the current rate of ventilator-induced lung injury requires ventilator settings that are patient-, time-, and disease-specific. A common lung protective strategy is to optimise the level of positive end-expiratory pressure (PEEP) through a recruitment manoeuvre to prevent alveolar collapse at the end of expiration and to improve gas exchange through recruitment of additional alveoli. However, this process can subject parts of the lung to excessively high pressures or volumes. This research significantly extends and more robustly validates a previously developed pulmonary mechanics model to predict lung mechanics throughout recruitment manoeuvres. In particular, the process of recruitment is more thoroughly investigated and the impact of the inclusion of expiratory data when estimating peak inspiratory pressure is assessed. Data from the McREM trial and CURE pilot trial were used to test model predictive capability and assumptions. For PEEP changes of up to and including 14 cmH2O, the parabolic model was shown to improve peak inspiratory pressure prediction resulting in less than 10% absolute error in the CURE cohort and 16% in the McREM cohort. The parabolic model also better captured expiratory mechanics than the exponential model for both cohorts.
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Pan C, Chen L, Zhang YH, Liu W, Urbino R, Ranieri VM, Qiu HB, Yang Y. Physiological Correlation of Airway Pressure and Transpulmonary Pressure Stress Index on Respiratory Mechanics in Acute Respiratory Failure. Chin Med J (Engl) 2017; 129:1652-7. [PMID: 27411451 PMCID: PMC4960953 DOI: 10.4103/0366-6999.185855] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Stress index at post-recruitment maneuvers could be a method of positive end-expiratory pressure (PEEP) titration in acute respiratory distress syndrome (ARDS) patients. However, airway pressure (Paw) stress index may not reflect lung mechanics in the patients with high chest wall elastance. This study was to evaluate the Pawstress index on lung mechanics and the correlation between Pawstress index and transpulmonary pressure (PL) stress index in acute respiratory failure (ARF) patients. METHODS Twenty-four ARF patients with mechanical ventilation (MV) were consecutively recruited from July 2011 to April 2013 in Zhongda Hospital, Nanjing, China and Ospedale S. Giovanni Battista-Molinette Hospital, Turin, Italy. All patients underwent MV with volume control (tidal volume 6 ml/kg) for 20 min. PEEP was set according to the ARDSnet study protocol. The patients were divided into two groups according to the chest wall elastance/respiratory system elastance ratio. The high elastance group (H group, n = 14) had a ratio ≥30%, and the low elastance group (L group, n = 10) had a ratio <30%. Respiratory elastance, gas-exchange, Pawstress index, and PLstress index were measured. Student's t-test, regression analysis, and Bland-Altman analysis were used for statistical analysis. RESULTS Pneumonia was the major cause of respiratory failure (71.0%). Compared with the L group, PEEP was lower in the H group (5.7 ± 1.7 cmH2O vs. 9.0 ± 2.3 cmH2O, P < 0.01). Compared with the H group, lung elastance was higher (20.0 ± 7.8 cmH2O/L vs. 11.6 ± 3.6 cmH2O/L, P < 0.01), and stress was higher in the L group (7.0 ± 1.9 vs. 4.9 ± 1.9, P = 0.02). A linear relationship was observed between the Pawstress index and the PLstress index in H group (R2 = 0.56, P < 0.01) and L group (R2 = 0.85, P < 0.01). CONCLUSION In the ARF patients with MV, Pawstress index can substitute for PLto guide ventilator settings. TRIAL REGISTRATION ClinicalTrials.gov NCT02196870 (https://clinicaltrials.gov/ct2/show/NCT02196870).
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Affiliation(s)
- Chun Pan
- Department of Critical Care Medicine, Zhongda Hospital, Medical School, Southeast University, Nanjing, Jiangsu 210009, China
| | - Lu Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing 100050, China
| | - Yun-Hang Zhang
- Department of Critical Care Medicine, Zhongda Hospital, Medical School, Southeast University, Nanjing, Jiangsu 210009, China
| | - Wei Liu
- Department of Biopharmaceutics, School of Life Science and Technology, Chinese Pharmaceutical University, Nanjing, Jiangsu 210009, China
| | - Rosario Urbino
- Department of Anesthesiology and Critical Care Medicine, Ospedale S. Giovanni Battista-Molinette, Turin 10126, Italy
| | - V Marco Ranieri
- Department of Anesthesiology and Critical Care Medicine, Ospedale S. Giovanni Battista-Molinette, Turin 10126, Italy
| | - Hai-Bo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, Medical School, Southeast University, Nanjing, Jiangsu 210009, China
| | - Yi Yang
- Department of Critical Care Medicine, Zhongda Hospital, Medical School, Southeast University, Nanjing, Jiangsu 210009, China
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Abstract
PURPOSE OF REVIEW Esophageal pressure measurement well estimates pleural pressure. The interpretation of absolute values is often debated for various reasons, but the changes in pressure measured are considered very accurate provided that a number of precautions are taken. The information provided by these measurements is unique in nature and has an enormous potential to influence management. It allows to study the exact influence of the chest wall and to determine the real lung distending pressure. It is also the only way to quantify respiratory muscle activity and the work of breathing. RECENT FINDINGS The application of esophageal pressure monitoring potentially covers a large field, especially for what concerns mechanical ventilation. This goes from the acute phase of the acute respiratory distress syndrome (ARDS) to weaning and patient-ventilator interactions. During ARDS, recent findings indicate that this measurement may help titrating the level of positive end-expiratory pressure or to determine the well tolerated upper limit of airway pressure. SUMMARY Application of esophageal pressure monitoring is limited by technical issues, the need for background physiological knowledge and the fact that very few studies have assessed a direct influence of this measurement on patients' outcome. The technique is underused in everyday practice.
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Nouraei SM, Patel A, Virk JS, Butler CR, Sandhu GS, Nouraei SAR. Use of pressure-volume loops for physiological assessment of adult laryngotracheal stenosis. Laryngoscope 2013; 123:2735-41. [DOI: 10.1002/lary.24061] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 12/23/2012] [Accepted: 01/25/2013] [Indexed: 11/10/2022]
Affiliation(s)
- S. Mahmoud Nouraei
- Department of Cardiothoracic Surgery; Mazandaran University of Medical Sciences; Sari Iran
- The National Centre for Airway Reconstruction; Department of Otolaryngology, Charing Cross Hospital; London United Kingdom
| | - Anil Patel
- Department of Anaesthesia; University College Hospitals NHS Trust; London United Kingdom
| | - Jag S. Virk
- The National Centre for Airway Reconstruction; Department of Otolaryngology, Charing Cross Hospital; London United Kingdom
| | - Colin R. Butler
- The National Centre for Airway Reconstruction; Department of Otolaryngology, Charing Cross Hospital; London United Kingdom
| | - Guri S. Sandhu
- The National Centre for Airway Reconstruction; Department of Otolaryngology, Charing Cross Hospital; London United Kingdom
| | - S. A. Reza Nouraei
- The National Centre for Airway Reconstruction; Department of Otolaryngology, Charing Cross Hospital; London United Kingdom
- Postgraduate Medical Institute; Anglia Ruskin University; Chelmsford United Kingdom
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Brochard L, Martin GS, Blanch L, Pelosi P, Belda FJ, Jubran A, Gattinoni L, Mancebo J, Ranieri VM, Richard JCM, Gommers D, Vieillard-Baron A, Pesenti A, Jaber S, Stenqvist O, Vincent JL. Clinical review: Respiratory monitoring in the ICU - a consensus of 16. Crit Care 2012; 16:219. [PMID: 22546221 PMCID: PMC3681336 DOI: 10.1186/cc11146] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Monitoring plays an important role in the current management of patients with acute respiratory failure but sometimes lacks definition regarding which 'signals' and 'derived variables' should be prioritized as well as specifics related to timing (continuous versus intermittent) and modality (static versus dynamic). Many new techniques of respiratory monitoring have been made available for clinical use recently, but their place is not always well defined. Appropriate use of available monitoring techniques and correct interpretation of the data provided can help improve our understanding of the disease processes involved and the effects of clinical interventions. In this consensus paper, we provide an overview of the important parameters that can and should be monitored in the critically ill patient with respiratory failure and discuss how the data provided can impact on clinical management.
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Affiliation(s)
- Laurent Brochard
- Department of Intensive Care, Hôpitaux Universitaires de Genève, Rue
Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland; and Université de
Genève, Switzerland
| | - Greg S Martin
- Division of Pulmonary, Allergy and Critical Care, Emory University School of
Medicine, Grady Memorial Hospital, 615 Michael Street, Suite 205, Atlanta, GA
30322, USA
| | - Lluis Blanch
- Critical Care Center, Corporacio Sanitaria Universitària Parc Tauli,
Universitat Autònoma de Barcelona, 08208 Sabadell, Spain, CIBER Enfermedades
Respiratorias, ISCiii, Madrid, Spain
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa,
San Martino Hospital, Largo Rosanna Benzi 8 16132, Genoa, Italy
| | - F Javier Belda
- Department of Anesthesia and Surgical Critical Care, Hospital Clínico
Universitario, Avda Blasco Ibañez 17, 46010 Valencia, Spain
| | - Amal Jubran
- Division of Pulmonary and Critical Care Medicine, Edward Hines Jr. VA Hospital,
111N, 5th Avenue and Roosevelt Road, Hines, IL 60141, USA
| | - Luciano Gattinoni
- Dipartimento di Anestesiologia, Terapia Intensive e Scienze Dermatologiche, and
Dipartimento do Anestesia, Rianimazione (Intensive e Subintensiva) e Terapia del
Dolore, Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico,
Università degli Studi di Milano, via F, Sforza 35, 20122, Milan, Italy
| | - Jordi Mancebo
- Servicio Medicina Intensiva, Hospital de la Santa Creu i Sant Pau, Carrer St.
Quintí 89, 08041 Barcelona, Spain
| | - V Marco Ranieri
- Department of Anesthesia and Intensive Care Medicine, University of Turin, S.
Giovanni Battista, Molinette Hospital, Corso Dogliotti 14, 10126 Turin, Italy
| | - Jean-Christophe M Richard
- Department of Intensive Care, Hôpitaux Universitaires de Genève, Rue
Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland; and Université de
Genève, Switzerland
| | - Diederik Gommers
- Adult Intensive Care, Erasmus MC, Room H623, 's Gravendijkwal 230, 3015CE
Rotterdam, The Netherlands
| | - Antoine Vieillard-Baron
- Intensive Care Unit, Section Thorax - Vascular disease - Abdomen - Metabolism, CHU
Ambroise Paré, 9 avenue Charles-de-Gaulle, 92104 Boulogne, France
| | - Antonio Pesenti
- Anesthesia and Intensive Care, University of Milan-Bicocca, A.O. Ospedale S.
Gerardo, Via Pergolesi 33, 20900 Monza, Italy
| | - Samir Jaber
- Department of Critical Care Medicine and Anesthesiology, Saint Eloi University
Hospital and Montpellier School of Medicine, 80 Avenue Augustin Fliche, 34295
Montpellier - Cedex 5, France
| | - Ola Stenqvist
- Department of Anesthesiology and Intensive Care, Sahlgrenska University Hospital,
Bla Straket 5, Gothenburg, SE 413 45, Sweden
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles,
808 route de Lennik, 1070 Brussels, Belgium
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STENQVIST O, GRIVANS C, ANDERSSON B, LUNDIN S. Lung elastance and transpulmonary pressure can be determined without using oesophageal pressure measurements. Acta Anaesthesiol Scand 2012; 56:738-47. [PMID: 22524531 DOI: 10.1111/j.1399-6576.2012.02696.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2012] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The aim of the present study was to demonstrate that lung elastance and transpulmonary pressure can be determined without using oesophageal pressure measurements. METHODS Studies were performed on 13 anesthetized and sacrificed ex vivo pigs. Tracheal and oesophageal pressures were measured and changes in end-expiratory lung volume (ΔEELV) determined by spirometry as the cumulative inspiratory-expiratory tidal volume difference. Studies were performed with different end-expiratory pressure steps [change in end-expiratory airway pressure (ΔPEEP)], body positions and with abdominal load. RESULTS A PEEP increase results in a multi-breath build-up of end-expiratory lung volume. End-expiratory oesophageal pressure did not increase further after the first expiration, constituting half of the change in ΔEELV following a PEEP increase, even though end-expiratory volume continued to increase. This resulted in a successive left shift of the chest wall pressure-volume curve. Even at a PEEP of 12 cmH(2) O did the end-expiratory oesophageal (pleural) pressure remain negative. CONCLUSIONS A PEEP increase resulted in a less than expected increase in end-expiratory oesophageal pressure, indicating that the chest wall and abdomen gradually can accommodate changes in lung volume. The rib cage end-expiratory spring-out force stretches the diaphragm and prevents the lung from being compressed by abdominal pressure. The increase in transpulmonary pressure following a PEEP increase was closely related to the increase in PEEP, indicating that lung compliance can be calculated from the ratio of the change in end-expiratory lung volume and the change in PEEP, ΔEELV/ΔPEEP.
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Affiliation(s)
- O. STENQVIST
- Department of Anesthesiology and Intensive Care; Institute for Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg; Sweden
| | - C. GRIVANS
- Department of Anesthesiology and Intensive Care; Institute for Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg; Sweden
| | - B. ANDERSSON
- Department of Anesthesiology and Intensive Care; Institute for Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg; Sweden
| | - S. LUNDIN
- Department of Anesthesiology and Intensive Care; Institute for Clinical Sciences; Sahlgrenska Academy; University of Gothenburg; Gothenburg; Sweden
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The chest wall. Crit Care Med 2012; 40:2258-9. [DOI: 10.1097/ccm.0b013e318256b974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Richard JCM, Marini JJ. Transpulmonary pressure as a surrogate of plateau pressure for lung protective strategy: not perfect but more physiologic. Intensive Care Med 2012; 38:339-41. [DOI: 10.1007/s00134-012-2492-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2011] [Accepted: 01/09/2012] [Indexed: 01/19/2023]
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Owens RL, Malhotra A, Eckert DJ, White DP, Jordan AS. The influence of end-expiratory lung volume on measurements of pharyngeal collapsibility. J Appl Physiol (1985) 2009; 108:445-51. [PMID: 19940097 DOI: 10.1152/japplphysiol.00755.2009] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Changes in end-expiratory lung volume (EELV) affect upper airway stability. The passive pharyngeal critical pressure (Pcrit), a measure of upper airway collapsibility, is determined using airway pressure drops. The EELV change during these drops has not been quantified and may differ between obese obstructive sleep apnea (OSA) patients and controls. Continuous positive airway pressure (CPAP)-treated OSA patients and controls were instrumented with an epiglottic catheter, magnetometers (to measure change in EELV), and a nasal mask/pneumotachograph. Subjects slept supine in a head-out plastic chamber in which the extrathoracic pressure could be lowered (to raise EELV) while on nasal CPAP. The magnitude of EELV change during Pcrit measurement (sudden reductions of CPAP for 3-5 breaths each minute) was assessed at baseline and with EELV increased approximately 500 ml. Fifteen OSA patients and 7 controls were studied. EELV change during Pcrit measurement was rapid and pressure dependent, but similar in OSA and control subjects (74 +/- 36 and 59 +/- 24 ml/cmH(2)O respectively, P = 0.33). Increased lung volume (mean +521 ml) decreased Pcrit by a similar amount in OSA and control subjects (-3.1 +/- 1.7 vs. -3.9 +/- 1.9 cmH(2)O, P = 0.31). Important lung volume changes occur during passive Pcrit measurement. However, on average, there is no difference in lung volume change for a given CPAP change between obese OSA subjects and controls. Changes in lung volume alter Pcrit substantially. This work supports a role for lung volume in the pathogenesis of OSA, and lung volume changes should be a consideration during assessment of pharyngeal mechanics.
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Affiliation(s)
- Robert L Owens
- Sleep Disorders Research Program, Div. of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA.
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Should we worry about chest wall influence on airway pressures during mechanical ventilation?*. Crit Care Med 2008; 36:3100-1. [DOI: 10.1097/ccm.0b013e31818c1095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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